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Kindergarten Interest Form

2016-2017 Academic Year

Child’s Name:____________________________________________________________

Parent(s) Name(s):________________________________________________________

Address:________________________________________________________________

Phone Number: (Primary) _________________________ (Alt)_____________________

E-Mail:__________________________________________________________________

Catholic Y_____ N_____

St. Therese Parish Member Y_____ N_____

Other Child(ren) at St. Therese School Y_____ N_____

Has your child ever been recommended and/or evaluated for special needs? Y_____ N_____

Has your child ever received services for special needs? Y _____ N ______

If Yes, please submit a copy of the evaluation or an explanation

Interest Form is also available for submission online at www.sttheresenorth.org

Living a Faith, Building a Future

Statement of Non-Discrimination

St. Therese School admits students of any sex, race, color, national and/or ethnic origin to all the rights,

privileges, programs, and activities accorded to students of the school. Diocesan policy 300.2

Thank you for your interest in St. Therese School, we look forward to contacting you . For additional infor-

mation, or to schedule a tour, please contact Teri Jo Garitz, Executive Secretary, at 816-741-5400 ext. 106.

www.sttheresenorth.org