Beckman Catholic High School

Beckman Catholic High School Application for Admission Please return completed form to Beckman Catholic High School

______Date

STUDENT’S NAME ______Last First Middle Name I PLAN TO ATTEND BECKMAN: YES______NO______UNDECIDED______

Date of Birth ______Gender: M F Grade (2016-2017) ______

Student’s Email ______Student Cell Phone ______

Street Address ______Home Phone ______

City/State ______Zip Code ______

Lives with: ______Relationship (Mother/Father) ______

Current School ______Parish ______

Public High School District ______Resident School District (if different)______

Mother’s Name ______Employer ______

Address and Phone (if different than above) ______

Preferred E-mail ______Work # ______Cell #______

Father’s Name ______Employer ______

Address and Phone (if different than above) ______

Preferred E-mail ______Work # ______Cell # ______

WILL THE STUDENT BE IN BAND? YES______NO______

______Signature of Mother

______Signature of Father

Beckman Catholic High School 1325 9th St SE Dyersville, IA 52040 Phone: (563)875-7188 Fax: (563)875-7242 [email protected] or [email protected]