Copy of K (Youth) Religious Education Registration

Join the Parish

Student's Full Name

Date of Birth

Age

Sex

Female

Male

Gender

Home Address

City

State

Zip

Home (Cell) Phone

Student Email Address

Church/Parish (current)

Baptized

Church/Parish baptized

1st Holy Communion (date, church)

Student is enrolling into

Student email

Parent 1 Full Name

Parent 1 Religion

Parent 1 Contact Info (Cell/Email)

Parent 2 Full Name

Parent 2 Religion

Parent 2 Contact Info (Email/Cell Phone)

Photo and video release authorization

Medical emergency (allergies or problems)

Specific medical information

Emergency Contact Name and Phone

Authorized person (s) to pick up student

Are there any physical or mental limitation you would like us to be aware of

Parent agrees

Parent date

Student agrees

Student date