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Main Phone: 914-961-1076 Fax: 914-961-4765 FAMILY NAME ==> Will be assigned by office CHILD'S NAME Family E-Mail Required Date of Birth _______________ PREP Grade in Sep 2020 _____ Mother’s Name Public School ___________________ Grade - Sept 2020 _____ Mother’s Maiden Name Sex _____ Male _____ Female Age as of 9/1/2020 _____ Mother’s Occupation Child Lives With: _____ Mom & Dad _____ Mom _____ Dad Father’s Name _____ Other Specify : ___________________ Father’s Occupation SACRAMENTAL INFORMATION Family Street Address Where was your child baptized? Family City, State Zip ___ Baptized at ICA ___ Baptismal Certificate Submitted Home Phone ___ Baptized Elsewhere ___ Baptismal Certificate Submitted Mom’s Cell Phone Church Name & Location ______________________________ Mom’s Work Phone _____ My child needs to be baptized Mom’s Email Required Where did your child celebrate 1 st Holy Communion? Dad’s Cell Phone ___ Received at ICA _____ Communion Certificate Submitted Dad’s Work Phone ___ Received Elsewhere _____ Communion Certificate Submitted Dad’s Email Required _____ My child attended Religious Education elsewhere last year IN AN EMERGENCY CONTACT Church Name & Location ______________________________ (If parents cannot be reached.) Name #1 EDUCATIONAL / MEDICAL INFORMATION Phone #1 Indicate all that apply Name #2 My child has _____ IEP _____ 504 Plan Phone #2 My child has _____ ADD _____ ADHD _____ LD Name #3 Provide documentation so we may best instruct your child Phone #3 Does your child need any accommodations? ___ Yes ___ No My child has ___Food Allergies ___Asthma ___Diabetes ___Other What Session? For Office Use Only! Please explain _______________________________ ___ TUE 4:15 PM ___ WED 4:15 PM REGISTER Before July 1 for the session you want! ___ WED 6:45 PM 2020-21 ICA PREP REGISTRATION 53 Winter Hill Road Tuckahoe, NY 10707 Sr. Cora Ext. 215 [email protected] Maddy Ext. 216 [email protected] Josie Ext. 217 [email protected]
