SACRED HEART EDUCATIONAL CENTER
at the ACADEMY OF THE HOLY FAMILY 54 WEST MAIN STREET BALTIC, CT 06330 (860) 822-8241 (860) 822-8242
FAX (860) 822-1318
Last Name First Name
Telephone
Address
City State Zip
Birth Date
,
Social Security
Father's Name
Address
City State Zip
Mother's Name
Address
City State Zip
Or
Guardian's Name
Address
City State Zip
Applicant's Place of Work Telephone
Address
City State Zip
Please list below any medical problems that we should know about:
Please select the courses you would like to participate in. You can select no more than two classes for Summer term
Name of the school you attend:
Town:
Name of School Guidance Counselor:
Current Grade (or last grade completed)
