Re-Registration Form

Sacred Heart Villa Re-Registration Form

2025-2026
Email of Person Completing This Form
example@example.com
The child will be enrolled in: (Check the appropriate program)

Toddler (Turns 2 by August 1)Pre-K 3 (Turns 3 by August 1)Pre-K 4 (Turns 4 by August 1)
Child's Name

First Name Middle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender
Male or Female
Date of Birth

MonthDayYear
A copy of the child's birth certificate must be submitted to the school office.
CIty of Birth
Nationality
Child's Parish
Child's Religion
Date of Baptism
A copy of the Baptismal Certificate needs to be presented to the school office.
Custody of the Child
Documentation must be submitted to the school office.
Mother's Name

First Name Maiden Name Last Name
Mother's Preferred Title
Dr. ~ Mrs. ~ Ms. ~ Miss
Mother's Cell Phone Number
Please enter a valid phone number.
Mother's Email
example@example.com
Mother's Religion
Mother's Parish
Martial Status
Married ~ Single ~ Separated ~ Divorced ~ Remarried
Mother's Address -- (If not same as child, indicate your address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Occupation
Mother's Employer
Mother's Employer's Phone Number
Please enter a valid phone number.
Mother's Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Name

First NameLast Name
Father's Cell Phone Number
Please enter a valid phone number.
Father's Email
example@example.com
Father's Religion
Father's Parish
Father's Marital Status
Married ~ Single ~ Separated ~ Divorced ~ Remarried
Father's Preferred Title
Dr. ~ Mr. ~ Military or Civil Service Title
Father's Address -- (If not same as child, indicate your address.)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Occupation
Name of Father's Employer
Father's Employer's Phone Number
Please enter a valid phone number.
Father's Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Informaiton

First NameLast Name
Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Cell Phone
Please enter a valid phone number.
Relation to the Child
Emergency Contact Information

First NameLast Name
Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Cell Phone
Please enter a valid phone number.
Relation to the Child
Authorization for Emergency Medical Care: I understand that I will be notified at once in case of emergency with my child, and I will make arrangements for medical care of my child with the physican or hospital of my choice. If I cannot be reached to make necessary arrangements, or in a critical emergencey requiring medical care, I authorize: Sacred Heart Villa, 2108 Macklind Ave., St. Louis, MO 63110 to contact the following below:
Signature*

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Physician name

First NameLast Name
Physician Phone Number
Please enter a valid phone number.
Preferred Hospital
Hospital Phone Number
Please enter a valid phone number.
Acknowledgements: Check to confirm

I have been informed of the required health and safety inspections and forms are available for review.When my child is ill, I understand and agree that she/he may not be accepted for care or remain in care.I have been notified that I may request an initial enrollment form any time there after whether there are children currently enrolled in or attending the facility for whom an immunization exemption has been filed.My child is in good health, is able to participate in group care, has no special health or mental requirements.
My child is able to participate in group care but has special health or mental requirements listed below
List any allergies, special medical conditions including chronic health problems, vision/auditory/speech issues, etc.
Parent Signature *

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Date

MonthDayYear
Date
Person Responsible for Tuition Payments

First Name Middle NameLast Name
Preferred Title
Dr. ~ Mr. ~ Mrs. ~ Miss ~ Ms.
Relationship to the Child
Phone Number
Please enter a valid phone number.

Payment*

Registration Fee (Non-refundable)

$180.00 Quantity

Processing Fee

$6.00 Quantity

Total

$0.00

Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Sacred Heart Villa Re-Registration Form