St Cyprian PSR Registration
Please submit each student individually. Thank you!
Student's Name *
Student's Birth Date *
MM
/
DD
/
YYYY
Student's Home Address *
 Name and Primary Phone Number *
Name and Secondary Phone Number
Mother's First and Last Name and (Maiden Name)
Father's First and Last Name
Primary Email Address
Grade *
Are you registered at St. Cyprian?
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List any medical conditions the staff needs to be aware of
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