St. John Preschool Registation Form

Child’s Full Name REQUIRED Please fill out this field. Please enter valid data.

Date of Birth REQUIRED Please fill out this field. Please enter a date.

Gender REQUIRED Male Female Please fill out this field.

Which class are you interested in? REQUIRED JrK MWF TTh Please fill out this field.

Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Home/Cell phone REQUIRED Please fill out this field. Please enter a phone number.

Parent E-Mail REQUIRED Please fill out this field. Please enter an email address.

Allow for text messaging REQUIRED Yes No Please fill out this field.

Father's Information

Father’s Name Please enter valid data.

Father’s Employer Please enter valid data.

Father's Work phone Please enter valid data.

Father's Home/Cell phone Please enter a phone number.

Mother's Information

Mother’s Name Please enter valid data.

Mother’s Employer Please enter valid data.

Mother's Work phone Please enter valid data.

Mother's Home/Cell phone Please enter a phone number.

Marital Status REQUIRED Married Separated Divorced Single Other Please fill out this field.

If other, please specify Please enter valid data.

With whom does the child reside? REQUIRED Please fill out this field. Please enter valid data.

Are you aware of any learning difficulties your child may have? REQUIRED Please fill out this field. Please enter valid data.

If yes, please explain: Please enter valid data.

Does your child have any fears? REQUIRED Please fill out this field. Please enter valid data.

Other information we should know:

Siblings REQUIRED Please fill out this field.
Sibling 1
- Name of Sibling REQUIRED Please fill out this field. Please enter valid data.
- Age REQUIRED Please fill out this field. Please enter an integer (number).
Sibling 2
- Name of Sibling REQUIRED Please fill out this field. Please enter valid data.
- Age REQUIRED Please fill out this field. Please enter an integer (number).
Sibling 3
- Name of Sibling REQUIRED Please fill out this field. Please enter valid data.
- Age REQUIRED Please fill out this field. Please enter an integer (number).
Sibling 4
- Name of Sibling REQUIRED Please fill out this field. Please enter valid data.
- Age REQUIRED Please fill out this field. Please enter an integer (number).
Sibling 5
- Name of Sibling REQUIRED Please fill out this field. Please enter valid data.
- Age REQUIRED Please fill out this field. Please enter an integer (number).
Sibling 6
- Name of Sibling REQUIRED Please fill out this field. Please enter valid data.
- Age REQUIRED Please fill out this field. Please enter an integer (number).
Sibling 7
- Name of Sibling REQUIRED Please fill out this field. Please enter valid data.
- Age REQUIRED Please fill out this field. Please enter an integer (number).
Sibling 8
- Name of Sibling REQUIRED Please fill out this field. Please enter valid data.
- Age REQUIRED Please fill out this field. Please enter an integer (number).

Emergency Contact 1

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Relationship REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact 2

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Relationship REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact 3

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Relationship REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact 4

First Name Please enter valid data.

Last Name Please enter valid data.

Phone Number Please enter a phone number.

Relationship Please enter valid data.

St. John the Baptist & St. Joseph Churches

A Pastorate of the Diocese of Lafayette-in-Indiana

St. John Preschool Registation Form