Faith Formation Registration - St. Mary's Swormville

Please indicate in which household the child primarily resides:*

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 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 Phone

Mother's Name:*

Mother's Cell Phone

Father's Address

Street Address Address Line 2 City State ZIP Code

Father's Email - if different than primary

Mother's Address

Street Address Address Line 2 City State ZIP Code

Other Information: (if residing with child)

Relationship to child:

Full Name:*

First Middle Last

Address:*

Street Address Address Line 2 City State ZIP Code

Section B - Student Information

Child's Name:*

First Last

Child's Grade (in Sept. 2020)*

School Child Attends (in Sept 2020)*

Start-up Meeting choice:*

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. 2020)

School Second Child Attends (in Sept 2020)

Second Child Start-up Meeting choice:*

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. 2020)

School Third Child Attends (in Sept 2020)

Third Child Start-up Meeting choice:*

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. 2020)

School Fourth Child Attends (in Sept 2020)

Fourth Child Start-up Meeting choice:*

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. 2020)

School Fifth Child Attends (in Sept 2020)

Fifth Child Start-up Meeting choice:*

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 Comments

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