Mother Teresa Academy
PRIMARY HOUSEHOLD PARENT/GUARDIAN INFORMATION
1. Father / Male Guardian ___________________________________________________________
Last Name First Name M.I.
Last Name First Name M.I.
Cell Phone Number: _____________________________ Pager Number: ______________________
Work Number: __________________________________ Email Address: ______________________
Employer: _____________________________________ Occupation: _________________________
Employer Address: __________________________________________________________________
2. Mother / Female Guardian ________________________________________________________
Last Name First Name M.I.
Last Name First Name M.I.
Cell Phone Number: _____________________________ Pager Number: ______________________
Work Number: __________________________________ Email Address: ______________________
Employer: _____________________________________ Occupation: _________________________
Employer Address: __________________________________________________________________
Residential Address:
_________________________________________________________________________
House # Street City/State/Zip Apt. #
House # Street City/State/Zip Apt. #
Mailing Address (if different from above)__________________________________________________
Home Phone # ______________________________
Religion __________ Parish: ______________________________________
Child’s Name __________________________ Date of Birth ___/__/ will be enrolling for
Nickname (if any) _______________________________________
PreK (3yr) half day First Grade
Kindergarten Second Grade
PreK (4yr) full day
Name of School Last Attended__________________________________________________________
Address and Phone__________________________________________________________________
Address and Phone__________________________________________________________________
Is English the only language spoken at home? _____yes ______no
If no, what other language does your family speak? _________________________________________
Any legal custodial restrictions? ______ Yes ______ No If yes, please attach court documents.
Please list two people Mother Teresa Academy may contact regarding your child in the event you cannot
be reached.
Name Name
Address Address
Daytime Phone # Daytime Phone #
Enclosed is my $100 (per family) non-refundable retaining fee.
Parent Statement:
I certify that the above information is true and correct.
Parent Signature: __________________________________________ Date: __________________
(Please check off each item as attached.)
_____ Copy of updated Immunization Records
_____ Copy of Birth Certificate
_____ Copy of Annual Physical Form
_____ Copy of Baptismal Certificate
Please list any special needs or concerns that we might need to know about your child/children (speech,
physical therapy, severe allergies, etc):
_________________________________________________________________________________
Referred by: _______________________________________________________________________
If you would like more information regarding our programs, please contact Joyce Maddalone at 857-2288.