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Saint Eugene Parish - Registration Form
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Family Address
Primary Family Address
Family Name
Address
Primary E-mail
This will be the main e-mail address we will use to communicate with your family.
Primary Phone
This will be the main phone number we will use to communicate with your family.
Number of Children
1
2
3
4
5
Number of Children you will be registering today
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Father / Guardian
Name
Living Status
Living
Deceased
E-mail
Marital Status
Married
Divorced
Separated
Single
Widower
Religion
Cell Phone
Mother / Guardian
Maiden Name
Name
Living Status
Living
Deceased
E-mail
Marital Status
Married
Divorced
Separated
Single
Widower
Religion
Cell Phone
Custody Information
Are there any custody issues we should be made aware of? If there is a custody agreement please send a copy to the Religious Education Department.
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Page Break
Child 1
Name
Gender
Male
Female
Date of Birth
Place of Birth
City & State
Religious Education Grade
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Grade in Fall 2017
School Grade
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
School Grade in Fall 2017
School
School District
Medical/Learning Data: Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services
Does your child have medication that needs to be carried/administered during PREP? If your child carries an Epipen, they must be able to self administer.
Individualized Education Program (IEP)
No
Yes
*As defined by Individuals with Disabilities Education Act (IDEA), the term "child with a disability" means a child: "with mental retardation, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities and who, by reason thereof, needs special education and related services."
Child 1 Sacraments
If registering for first time your Child's Baptismal Certificate must be submitted to the office.
Date of Baptism
Church of Baptism
Church Name, City & State
Date of Reconciliation
Church of Reconciliation
Church Name, City & State
Date of First Communion
Church of First Communion
Church Name, City & State
Child 1 Session Choice
Child 1 Session Choice
Sunday 9:00-10:00 am (Grades 1-2)
Sunday 11:00-12:00 pm (Grades 3-4)
Sunday 10:00-11:15 pm (Grades 3-4)
Monday & Tuesday 4:45-6:15 pm (Grades 5-8)
Sunday 10:00-11:15 pm (Grades 5-8)
Wednesday 6:45-8:00 pm (Grades 5-8)
Child 2
Name
Gender
Male
Female
Date of Birth
Place of Birth
City & State
Religious Education Grade
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Grade in Fall 2017
School Grade
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
School Grade in Fall 2017
School
School District
Medical/Learning Data: Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services
Does your child have medication that needs to be carried/administered during PREP? If your child carries an Epipen, they must be able to self administer.
Individualized Education Program (IEP)
No
Yes
*As defined by Individuals with Disabilities Education Act (IDEA), the term "child with a disability" means a child: "with mental retardation, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities and who, by reason thereof, needs special education and related services."
Child 2 Sacraments
If registering for first time your Child's Baptismal Certificate must be submitted to the office.
Date of Baptism
Church of Baptism
Church Name, City & State
Date of Reconciliation
Church of Reconciliation
Church Name, City & State
Date of First Communion
Church of First Communion
Church Name, City & State
Child 2 Session Choice
Child 2 Session Choice
Sunday 9:00-10:00 am (Grades 1-2)
Sunday 11:00-12:00 pm (Grades 3-4)
Sunday 10:00-11:15 pm (Grades 3-4)
Monday & Tuesday 4:45-6:15 pm (Grades 5-8)
Sunday 10:00-11:15 pm (Grades 5-8)
Wednesday 6:45-8:00 pm (Grades 5-8)
Child 3
Name
Gender
Male
Female
Date of Birth
Place of Birth
City & State
Religious Education Grade
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Grade in Fall 2017
School Grade
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
School Grade in Fall 2017
School
School District
Medical/Learning Data: Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services
Does your child have medication that needs to be carried/administered during PREP? If your child carries an Epipen, they must be able to self administer.
Individualized Education Program (IEP)
No
Yes
*As defined by Individuals with Disabilities Education Act (IDEA), the term "child with a disability" means a child: "with mental retardation, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities and who, by reason thereof, needs special education and related services."
Child 3 Sacraments
If registering for first time your Child's Baptismal Certificate must be submitted to the office.
Date of Baptism
Church of Baptism
Church Name, City & State
Date of Reconciliation
Church of Reconciliation
Church Name, City & State
Date of First Communion
Church of First Communion
Church Name, City & State
Child 3 Session Choice
Child 3 Session Choice
Sunday 9:00-10:00 am (Grades 1-2)
Sunday 11:00-12:00 pm (Grades 3-4)
Sunday 10:00-11:15 pm (Grades 3-4)
Monday & Tuesday 4:45-6:15 pm (Grades 5-8)
Sunday 10:00-11:15 pm (Grades 5-8)
Wednesday 6:45-8:00 pm (Grades 5-8)
Child 4
Name
Gender
Male
Female
Date of Birth
Place of Birth
City & State
Religious Education Grade
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Grade in Fall 2017
School Grade
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
School Grade in Fall 2017
School
School District
Medical/Learning Data: Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services
Does your child have medication that needs to be carried/administered during PREP? If your child carries an Epipen, they must be able to self administer.
Individualized Education Program (IEP)
No
Yes
*As defined by Individuals with Disabilities Education Act (IDEA), the term "child with a disability" means a child: "with mental retardation, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities and who, by reason thereof, needs special education and related services."
Child 4 Sacraments
If registering for first time your Child's Baptismal Certificate must be submitted to the office.
Date of Baptism
Church of Baptism
Church Name, City & State
Date of Reconciliation
Church of Reconciliation
Church Name, City & State
Date of First Communion
Church of First Communion
Church Name, City & State
Child 4 Session Choice
Child 4 Session Choice
Sunday 9:00-10:00 am (Grades 1-2)
Sunday 11:00-12:00 pm (Grades 3-4)
Sunday 10:00-11:15 pm (Grades 3-4)
Monday & Tuesday 4:45-6:15 pm (Grades 5-8)
Sunday 10:00-11:15 pm (Grades 5-8)
Wednesday 6:45-8:00 pm (Grades 5-8)
Child 5
Name
Gender
Male
Female
Date of Birth
Place of Birth
City & State
Religious Education Grade
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Grade in Fall 2017
School Grade
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
School Grade in Fall 2017
School
School District
Medical/Learning Data: Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services
Does your child have medication that needs to be carried/administered during PREP? If your child carries an Epipen, they must be able to self administer.
Individualized Education Program (IEP)
No
Yes
*As defined by Individuals with Disabilities Education Act (IDEA), the term "child with a disability" means a child: "with mental retardation, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities and who, by reason thereof, needs special education and related services."
Child 5 Sacraments
If registering for first time your Child's Baptismal Certificate must be submitted to the office.
Date of Baptism
Church of Baptism
Church Name, City & State
Date of Reconciliation
Church of Reconciliation
Church Name, City & State
Date of First Communion
Church of First Communion
Church Name, City & State
Child 5 Session Choice
Child 5 Session Choice
Sunday 9:00-10:00 am (Grades 1-2)
Sunday 11:00-12:00 pm (Grades 3-4)
Sunday 10:00-11:15 pm (Grades 3-4)
Monday & Tuesday 4:45-6:15 pm (Grades 5-8)
Sunday 10:00-11:15 pm (Grades 5-8)
Wednesday 6:45-8:00 pm (Grades 5-8)
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Emergency Contact / Doctor
Emergency Contact Name
Relationship
Emergency Contact Phone
Doctor's Name
Doctor's Phone
Terms & Conditions
I understand that in the case of injury or illness, every effort will be made to contact me in a medical emergency. In the event I cannot be reached, I give permission to parish staff to secure all proper and necessary treatment for my child(ren). I understand that no liability is assumed by the church or the Archdiocese for claims that may arise.
I agree
Parental Consent for Medical Care: In case of an emergency, I give permission for my child to receive emergency medical treatment and, if necessary, be transported to the nearest medical facility.
I agree
I understand that photos of my child(ren) may be taken and used in Parish publications including web and print media.
I agree
Late Fee Date
Late Fee
A late fee of $25 will be added after July 31st, 2017
Total Amount
Verification
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