Faith Formation Registration Please indicate in which household the child primarily resides:*Please choose one:MotherFatherBothOther (please explain below)We require both custodial parent information. Please explain: Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Primary Family Email:* Mother's Information* First Last Mother's Cell Phone*Primary Cell Phone*Mother's cell phone*Mother's Email - if different than primary Father's Information* First Last Father's cell phone*Father's cell phone*Father's Information Father's Information is required if joint custody, otherwise enter NA. Mother's Information Mother's Information is required if joint custody, otherwise enter NA. Father's Name:* Father's Cell PhoneMother's Name:* Mother's Cell PhoneFather's Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Father's Email - if different than primary Mother's Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Other Information: (if residing with child)Relationship to child: Full Name:* First Middle Last Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Section B - Student InformationChild's Name:* First Last Child's Grade (in Sept. 2022)* School Child Attends (in Sept 2022)* ALLERGIES: Please indicate if your child has a severe, life threatening allergy.* Yes No If so, please explain:SPECIAL NEEDS: Please indicate if your child has an IEP or receive any special education services.* Yes No If so, please explain:Would you like to add another child?Please select to add another child?* Yes No Second Child's Name: First Last Second Child's Grade (in Sept. 2022) School Second Child Attends (in Sept 2022) ALLERGIES: Please indicate if your Second child has a severe, life threatening allergy. Yes No If so, please explain:SPECIAL NEEDS: Please indicate if your Second child has an IEP or receive any special education services. Yes No If so, please explain:Would you like to add a Third child?Please select to add a third child?* Yes No Third Child's Name: First Last Third Child's Grade (in Sept. 2022) School Third Child Attends (in Sept 2022) ALLERGIES: Please indicate if your Third child has a severe, life threatening allergy. Yes No If so, please explain:SPECIAL NEEDS: Please indicate if your Third child has an IEP or receive any special education services. Yes No If so, please explain:Would you like to add a Fourth child?Please select to add a fourth child?* Yes No Fourth Child's Name: First Last Fourth Child's Grade (in Sept. 2022) School Fourth Child Attends (in Sept 2022) ALLERGIES: Please indicate if your Fourth child has a severe, life threatening allergy. Yes No If so, please explain:SPECIAL NEEDS: Please indicate if your Fourth child has an IEP or receive any special education services. Yes No If so, please explain:Would you like to add a Fifth child?Please select to add a fifth child?* Yes No Fifth Child's Name: First Last Fifth Child's Grade (in Sept. 2022) School Fifth Child Attends (in Sept 2022) ALLERGIES: Please indicate if your Fifrth child has a severe, life threatening allergy. Yes No If so, please explain:SPECIAL NEEDS: Please indicate if your Fifth child has an IEP or receive any special education services. Yes No If so, please explain:Additional CommentsStart-up MeetingStart-up Meeting choice:*Please choose from:Please contact the Catholic Education Office for more information.Disclaimer• I hereby grant permission for publication of group (two or more persons) photo(s) taken at church events to be used for church publications only. I've read the terms above and:* I agree I disagree Optional Information Release PermissionThis request is pertaining only for families whose children are in grades 5-8 I grant permission for my contact information to be shared with the Diocese to receive information on upcoming Diocesan events and activities. PaymentOptions*Option 1 - Submit payment online (Vanco)Option 2 - Submit cash or checkOption 3 - Request consideration for payment waiver due to hardship.1 child - $125.00, 2 children - $175.00, 3 or more children - $225.00Disclaimer* I acknowledge my registration will not be processed until my payment is received.
