Name*

Address 1

Address 2

City

State

Zip/Postal Code

Applicant lives with...
Mother & FatherMotherMother & StepfatherFatherFather & StepmotherGuardianOther

Date of Birth

Religious Affiliation

Church/Parish Name

Pastor

Last School Attended & Grade Completed

In which public high school district do you reside?

If the applicant is not in a Catholic school, does he or she attend a Parish School of Religion (PSR) program?
YesNo

Co-Curriculars: Activities, clubs, athletics, leadership positions and awards (with grade level):

Other hobbies, interests or talents: