<p> Beckman Catholic High School Application for Admission Please return completed form to Beckman Catholic High School</p><p>______Date</p><p>STUDENT’S NAME ______Last First Middle Name I PLAN TO ATTEND BECKMAN: YES______NO______UNDECIDED______</p><p>Date of Birth ______Gender: M F Grade (2016-2017) ______</p><p>Student’s Email ______Student Cell Phone ______</p><p>Street Address ______Home Phone ______</p><p>City/State ______Zip Code ______</p><p>Lives with: ______Relationship (Mother/Father) ______</p><p>Current School ______Parish ______</p><p>Public High School District ______Resident School District (if different)______</p><p>Mother’s Name ______Employer ______</p><p>Address and Phone (if different than above) ______</p><p>Preferred E-mail ______Work # ______Cell #______</p><p>Father’s Name ______Employer ______</p><p>Address and Phone (if different than above) ______</p><p>Preferred E-mail ______Work # ______Cell # ______</p><p>WILL THE STUDENT BE IN BAND? YES______NO______</p><p>______Signature of Mother</p><p>______Signature of Father</p><p>Beckman Catholic High School 1325 9th St SE Dyersville, IA 52040 Phone: (563)875-7188 Fax: (563)875-7242 [email protected] or [email protected] </p>