RELIGIOUS EDUCATION REGISTRATION

FORM FOR NEW STUDENTS IN OUR PROGRAM

Date: ____________

(We need the following information for permanent church record books. Please fill out entire form. Thank you.)

Student’s Last Name: _______________________________________

First Name: _______________________________________

Middle Name: _______________________________________

Nick Name: _______________________________________

Street Address: _______________________________________

City, Zip: _______________________________________

Telephone: _________E-Mail Address_________________

Father/Guardian’s Name: _____________________________________

Father’s Address

(If Different From Student): __________________________________

Mother/Guardian’s Name: ____________________________________

Mother’s Maiden Name: _____________________________________

Mother’s Address

(If Different From Student): __________________________________

Student is a Member of which Parish: ___________________________

Student’s Current Grade at School: ____________________________

Student’s Current Grade at CCD: ______________________________

Student’s Birth date: ________________________________________

Church of Baptism: _________________________________________

City, State of Baptism: ______________________________________

Date of Baptism: ___________________________________________

Church of First Communion: _________________________________

City, State of First Communion: _______________________________

Date of First Communion: ___________________________________

In Case of Emergency Call: __________________________________

Telephone: __________________________________

Student’s Siblings living at home: _____________________________

_________________________________________________________

Does Student have any Special Needs, Diet, Allergies, Disabilities?

_____________________________________________________________________________________________________________

OFFICE USE ONLY:

Registration Fee Amount: _______ Date Received: ________Cash/Check (Circle One) Check Number: ________