FATHER EDWARD W. TROIKE LEADERSHIP PROGRAM-2010

CATHEDRAL PREPARATORY SEMINARY

56-25 92^nd Street Elmhurst NY 11373

1-718-592-6800 x120

PLEASE PRINT

NAME______________________________________TELEPHONE # ___________________________

Last First

ADDRESS _________________________________________________________________________

Number (apt. no.) Town State Zip

PARISH _________________ SCHOOL _________________ GRADE (as of 9/2010)_________________

AGE _____________________________ DATE OF BIRTH ________________________________

FATHER’S NAME ______________ BUSINESS TEL. No. _____________________________

MOTHER’S NAME ____________________BUSINESS TEL. No. _____________________________

RELIGIOUS DENOMINATION_____________________________

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EMERGENCY HOME CONTACT

In case of an emergency, when the parents cannot be contacted, please contact:

NAME ____________________________________RELATIONSHIP __________________________

TELEPHONE No(s). _______________________________________________________________

Take to hospital (check one) Yes __________ No __________ or other instructions:

___________________________________________________________________________________

It is understood that in the final disposition of an emergency case, the judgement of the school authorities will prevail. The recommendation of the parent as indicated above, will be respected as far as possible.

Is there any medical problem or disability the school should be aware of? _______________

_________________________________________________________________________________________

___________________________________________________

Parent’s Signature

---------------------------------------------------------------------------ELEMENTARY SCHOOL CHARACTER RECOMMENDATION: PRESENT GRADE ________________

MOST RECENT REPORT CARD GRADES:

RELIGION GRADE *___________________ READING ____________ VOCABULARY _______________

*(If in Catholic School)

COMPREHENSION ______________ MATH _______________ ENGLISH ___________________

CHARACTER RECOMMENDATION: ______________________________________________________________

_____________________________________________________ Principal’s or Teacher’s Signature