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EARLY CHILDHOOD PROGRAM REGISTRATION

registER for pRESCHOOL & KINDERGARTEN

PLEASE COMPLETE THE FORM BELOW TO
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  STUDENT NAME
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth Please enter valid data.
  
  Sex Male Female
  
  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.
  
  Phone REQUIRED Please fill out this field. Please enter valid data.
  
  Ethnicity REQUIRED Please fill out this field.
  
  Place of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Students must be 3 years old by October 1 for Prek-3.
  Students must be 4 years old by October 1 for Prek-4.
  Studetns must be 5 years old by October 1 for Kindergarten.
  
  Entering grade REQUIRED Please fill out this field.
  
  From School Please enter valid data.
  
  MOTHER
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Maiden Name REQUIRED Please fill out this field. Please enter valid data.
  
  Address (if different from above) 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.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Phone Number REQUIRED Please fill out this field. Please enter a phone number.
  
  Religion REQUIRED Please fill out this field. Please enter valid data.
  
  Ethnicity REQUIRED Please fill out this field.
  
  Occupation Please enter valid data.
  
  Business Address 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.
  
  FATHER
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Address (if different from above) 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.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Phone Number REQUIRED Please fill out this field. Please enter a phone number.
  
  Religion REQUIRED Please fill out this field. Please enter valid data.
  
  Ethnicity REQUIRED Please fill out this field.
  
  Occupation Please enter valid data.
  
  Business Address 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.
  
  Emergency Contact Information
  Please list two contacts in addtion to the Parent Contact information provided.
  
  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.
  
  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.
  
  PHYSICIAN INFORMATION
  
  Student Physician REQUIRED Please fill out this field. Please enter valid data.
  
  Phone REQUIRED Please fill out this field. Please enter valid data.
  
  Hospital child should be taken to if Parent not available. REQUIRED Please fill out this field. Please enter valid data.
  
  Allergies and other Medical Conditions REQUIRED Please fill out this field. Please enter valid data.
  
  Please explain if necessary
  
  PAYMENT INFORMATION
  
  My FACTS tuition account will be listed under the following name: REQUIRED Please fill out this field. Please enter valid data.
  
  I am a parishioner at: REQUIRED Please fill out this field. Please enter valid data.
  
  I agree that registration fees are non refundable.
  
  REGISTRATION FEE250.0
  
  TECHNOLOGY FEE - To Be Determined
  
  PARENT AMBASSADOR COUNCIL DUES
  
  I Agree Please select this field.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Total:
  
  Submit
  
  Proceed to Payment
  
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Our Lady of Mercy Academy

Park Ridge, NJ

EARLY CHILDHOOD PROGRAM REGISTRATION

registER for pRESCHOOL & KINDERGARTEN

PLEASE COMPLETE THE FORM BELOW TO