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Catholic School
Ansonia, CT

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ACCENT

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# of Children

Child (1) First name*

Last name*

DOB*

Grade:*

Child (2) First Name

Last Name

DOB:

Grade:

Child (3) First Name

Last Name

DOB:

Grade:

I need:*

Before Care

After Care

Both

Guardian Name(s):*

Guardian(s) Phone #:*

Emergency Contact Name:*

Emergency Contact Phone #:*

Any Allergies/Emergency Medical Information? (Please list child's name and describe below)

Catholic School

51 North Cliff Street
Ansonia, CT 06401
(203) 734-0855

© 2025 by Assumption School

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