FAMILY (LAST) NAME: Date:
Parent(s) (Guardian's) Mailing Name:
Address : Town: Zip:
Home Telephone # : e-mail :
Father's First Name: Father's Work Phone # :
Mother's First Name: Maiden Name: Mother's Work Phone:
Emergency Contact : Emergency Phone:

STUDENT'S INFORMATION:
Child 1 Last Name: First Name: Date of Birth:
Male Female
School: School Grade (Fall '09): Rel. Ed. Grade:
Child 2 Last Name: First Name: Date of Birth:
Male Female
School: School Grade (Fall '09): Rel. Ed. Grade:
Class Time Preference: (please note the day and time preferred):
    1st Choice: 2nd Choice:

Fee: $50 per student BEFORE July 1, 2009; tuition is $75 per student after July 1, 2009

(make checks payable to Survival Fund of St. Jeremiah - write Religious Ed in the memo line)
Tuition Fee presents financial hardship (please check if appropriate)
Please add my donation to the Religious Education Program. Amount: $

TENTATIVE Class Times  (Subject to availability of teacher)