Saint Hedwig Parish School

32 Golden Hill Street ~~ Naugatuck, Connecticut

203-729-2403

Preschool Registration Form ($35.00 fee)

Please Choose Program:

            ___  PreK 3 Program (Tu,Th)             ___  PreK 4 Program (Mon, Wed, Fri)

            ___ PreK 5 Day (1/2 day)                   ___ PreK 5 Day (full day)

Child’s Full Name:  __________________________________________  M/F:  _______

last Name                              first Name                         middle name                    sex

Home Address:  _________________________________________________________

City/State:  ____________________________________________ Zip:  ____________

Home Phone:  ____________________                    Cell Phone:  ___________________

Ethnic Group:  (√ all that apply)      ___  African American

                                                            ___  Hispanic

                                                            ___  Native American

                                                            ___  Asian

                                                            ___  White

                                                            ___  Multi-Racial

Birthplace:  ____________________________________ Date of Birth:  _____________

                                City                                         State/Country                                                     (copy of certificate)

Father’s Full Name:  _____________________________ Religion:  ________________

                                                                                        Occupation:  ________________

Mother’s Full Name:______________________________ Religion: ________________

                                                                                         Occupation: ________________

Pupil lives with:           ___ Parents

                                    ___ Mother

                                    ___ Father

                                    ___ Other:____________________________

(please explain)

Language Spoken at Home:  ___  English     ___  Other __________________________

(please explain)

Baptism Date:  ________________   Parish:  __________________________________

(please provide copy of certificate)

Parish in which you are registered:  __________________________________________