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REGISTRATION FORM 2018-2019
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Family Address
Primary Family Address
Family Name
Envelope Number
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
Deceased
Yes
No
E-mail
Marital Status
Married
Divorced
Separated
Single
Widower
Religion
Cell Phone
Mother / Guardian
Maiden Name
Name
Deceased
Yes
No
E-mail
Marital Status
Married
Divorced
Separated
Single
Widow
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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Child 1
Is your child a New or Returning Student to our program?
New Student
Returning Student
Name
Gender
Male
Female
Date of Birth
Place of Birth
City & State
Religious Education Grade
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Grade in Fall 2018
School Grade
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
School Grade in Fall 2018
School
School District
Medical/Learning Data: Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services
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
Grades 1-5 - Wednesdays, 3:30 - 5:00 pm
Grades 6-8 - Wednesdays, 6:30 - 8:00 pm
Child 2
Is your child a New or Returning Student to our program?
New Student
Returning Student
Name
Gender
Male
Female
Date of Birth
Place of Birth
City & State
Religious Education Grade
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Grade in Fall 2018
School Grade
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
School Grade in Fall 2018
School
School District
Medical/Learning Data: Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services
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
Grades 1-5 - Wednesdays, 3:30 - 5:00 pm
Grades 6-8 - Wednesdays, 6:30 - 8:00 pm
Child 3
Is your child a New or Returning Student to our program?
New Student
Returning Student
Name
Gender
Male
Female
Date of Birth
Place of Birth
City & State
Religious Education Grade
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Grade in Fall 2018
School Grade
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
School Grade in Fall 2018
School
School District
Medical/Learning Data: Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services
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
Grades 1-5 - Wednesdays, 3:30 - 5:00 pm
Grades 6-8 - Wednesdays, 6:30 - 8:00 pm
Child 4
Is your child a New or Returning Student to our program?
New Student
Returning Student
Name
Gender
Male
Female
Date of Birth
Place of Birth
City & State
Religious Education Grade
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Grade in Fall 2018
School Grade
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
School Grade in Fall 2018
School
School District
Medical/Learning Data: Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services
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
Grades 1-5 - Wednesdays, 3:30 - 5:00 pm
Grades 6-8 - Wednesdays, 6:30 - 8:00 pm
Child 5
Is your child a New or Returning Student to our program?
New Student
Returning Student
Name
Gender
Male
Female
Date of Birth
Place of Birth
City & State
Religious Education Grade
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Grade in Fall 2018
School Grade
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
School Grade in Fall 2018
School
School District
Medical/Learning Data: Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services
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
Grades 1-5 - Wednesdays, 3:30 - 5:00 pm
Grades 6-8 - Wednesdays, 6:30 - 8:00 pm
Document Uploads
File Uploads
Add files
Drop files anywhere to add
Please upload any documents required by the office with this form. (Birth cert, Baptism cert, Custody docs, etc.)
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Emergency Contact / Doctor
Emergency Contact Name
Relationship
Emergency Contact Phone
Doctor's Name
Doctor's Phone
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Terms & Conditions
In case of accident or illness, I request that the representative of the parish catechetical program contact me, If I am unable to be reached, I hereby authorize this representative to call the physician indicated above and to follow the physician's instructions. If it is impossible to contact this physician, the representative of the parish catechetical program may make whatever arrangements seem necessary. I agree to assume the financial responsibility for any diagnosis, treatment and/or medication deemed necessary. To the best of my knowledge all information given is accurate and complete. I hereby consent to, and authorize the necessary procedures that been stated above.
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
Total Cap
Total Choices
Late Fee
Early Bird Discount
Late Fee Date
A Late Fee of $30.00 will be added after May 24, 2018
Total Normal
Total Amount
Verification
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SUBMIT FORM AND PAY