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St. Mary-St. Michael School
14 Seymour Avenue   Derby, CT 06418
203-735-6471
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Request Admissions Information

Complete the following form to request information about enrolling.
Use the Tab key or the mouse to move from field to field. Do not hit the Enter key while entering data.

Family Info  
Family Last Name: Address:
Father/Guardian: City:  State:  Zip:
Mother/Guardian:   Home Phone:
Catholic: Yes  No Email:
 Student Info - Enter below your students' information and the grades in which they would enroll:
 Student First Name
Student Last Name Date of Birth Sex Grade
 
 
 
 
 
 
  Please send me a registration information packet.     Please have someone from the school contact me.

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