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

STUDENT'S INFORMATION:
Last Name: First Name: Date of Birth:
Male Female
School: School Grade (Fall '07): Rel. Ed. Grade:
Class Time Preference: (please note the day and time preferred):
    1st Choice: 2nd Choice:

All efforts will be made to place your child in your first choice of day and time. Siblings will be scheduled for classes in the
same slot if noted. Children of catechists will be assigned classes that coincide with their parent's teaching schedule.

Fee: $50 per student BEFORE July 1, 2008; tuition is $60 per student after July 1, 2008

(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)