OFFICE USE (CIRCLE) ST. MARY’S ________________

Reg fee $50 $60 $65 $75 _____ RELIGIOUS EDUCATION CLASS CHOICE

FHC fee – Level 2: $15

NEW REGISTRATION LEV_____DAY_____

Paid Y N Cash Check 2008-2009 2ND CHOICE______

Reg by______Date_______ _____I can volunteer in the program

Parish we currently attend______________________________

Year registered in Parish___________________

STUDENT INFORMATION

First Name___________________________________Nickname________________________Birthdate ___/___/_____

Last Name_____________________________________________________ Sex M F

Baptism___/___/___ Church Name_________________________Full Address_____________________________zip__________

(CHILD WILL BE PLACED ON CLASS LIST ONLY IF BAPTISMAL CERTIFICATE IS ATTACHED TO THIS FORM)

Communion___/___/___Church Name__________________________Full Address______________________________________

Penance ___/___/____ Church Name___________________________ Baptismal verified by staff _________(initial)

School Child Attends _______________________________ Grade in Sept. 08______ Rel Ed Grade Level________

Circle Rel Ed or Catholic School Grades completed 1 2 3 4 5 6 7 8 (applies to 2nd level & up)

Special Medical Condition__________________________________________________________________________________

Procedure to follow if condition presents an emergency____________________________________________________________

Learning Disability (Confidential) List ADD, ADHD, reading_______________________________________________________

FAMILY INFORMATION Family Name__________________________________Child Lives With____________________

Father’s First Name_______________________________Last Name_______________________________________Religion_____

Date of Birth ___/___/___ Occupation_________________________________________ Work Phone/Cell__________________

Mother’s First Name______________________________ Last Name______________________________________ Religion_____

Date of Birth ___/___/___ Occupation__________________________________________Work Phone /Cell__________________

Family e mail address__________________________________________________________________________________

Marital Status of Parents _____________________ (Child’s) Mother’s Maiden Name_______________________________

Church-Place/Date of Marriage: _______________________________________Address_______________________________________________Date__________

Family Address______________________________________________________________________________________________

Home Telephone No._________________________ Unlisted? Y N Cell No. for Emergency_____________________________

Emergency Contact______________________________________________Phone No.___________________

Step Parent Name____________________________________________Date of Birth___/___/___ Religion__________________

OTHER HOUSEHOLD MEMBERS - INCLUDE ADULTS & CHILDREN NOT LISTED ABOVE:

Name Religion M/F Birthdate Baptized FHC Confirm Occupation

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Medical Information:

Doctor/Phone______________________________________________ Dentist/Phone__________________________________

Hospital______________________________________ I hereby give permission for my child to receive emergency medical attention_________________________________________________(Parent signature)