PRIMARY HOUSEHOLD PARENT/GUARDIAN INFORMATION

1.  Father / Male Guardian ___________________________________________________________
                                                                              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.     
Cell Phone Number: _____________________________    Pager Number: ______________________
Work Number: __________________________________   Email Address: ______________________
Employer:  _____________________________________   Occupation: _________________________
Employer Address: __________________________________________________________________
 
Residential Address:
_________________________________________________________________________
   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__________________________________________________________________
 
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.