Name of Person Submitting Information

	Title Bro.Dea.Rev.Sis.	First Name 	Last Name 
           

Student Information

       First Name 	Last Name

   Date of Birth 	Age 	  Grade 	School 

List of Student's Accomplishments / Comments

Father's Information                                                                  

            Name 	   
         Address 
            City 
             Zip 
      Home Phone 

Mother's Information

	    Name 

	 Address 

	    City 

	     Zip 

      Home Phone 

Guardian's Information

            Name 
         Address 
            City 
             Zip 
      Home Phone 

Student lives with

Both Parents     Father     Mother     Guardian     Other     (please explain) 

* - Please include the name of parents), even if not in home, and of 
    stepparents, presently living with child.