Confirmation I / (8th grade ONLY) Registration

This page is for Confirmation I / 8th grade registration ONLY
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- Parent First Name REQUIRED Please fill out this field. Please enter valid data.
- Parent Last Name REQUIRED Please fill out this field. Please enter valid data.
- Mothers Maiden Name REQUIRED Please fill out this field. Please enter valid data.
- Student First Name REQUIRED Please fill out this field. Please enter valid data.
- Student Last Name (if different from parent) REQUIRED Please fill out this field. Please enter valid data.
- Address REQUIRED Please fill out this field.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Parent Email REQUIRED Please fill out this field. Please enter an email address.
- Student Date of Birth (ie 01-01-05) REQUIRED Please fill out this field. Please enter valid data.
- Student City and State of Birth REQUIRED Please fill out this field. Please enter valid data.
- New to St. Bart's Faith Formation Program? REQUIRED Please fill out this field. Please enter valid data.
- Student Date of Baptism (ie 01-01-05) REQUIRED Please fill out this field. Please enter valid data.
- Church of Baptism REQUIRED Please fill out this field. Please enter valid data.
- Student City and State of Baptism REQUIRED Please fill out this field. Please enter valid data.
- Student Date of First Eucharist (ie 01-01-05) REQUIRED Please fill out this field. Please enter valid data.
- Church of First Eucharist, (Please include city) REQUIRED Please fill out this field. Please enter valid data.
- School Students Attends REQUIRED Please fill out this field. Please enter valid data.
- Commitment: We, the parents or guardians of the participant(s) above, give our permission to participate in all activities of Faith Formation. We accept to help our son/daughter to participate actively, cooperate and follow the directions of their Catechists. We agree that if our son/daughter were to have an accident as a result of participation in Catechesis, including transportation (which is not caused by negligence of the parish or their representatives), the necessary resources for care, hospital, medical and other expenses or payments will be made against the insurance company that represents us.
- Electronic Signature REQUIRED Please fill out this field. Please enter valid data.
- Electronic Signature (Your full name) REQUIRED MOTHER FATHER GUARDIAN Please fill out this field.
- Consent for image publication REQUIRED Yes, I give permission to have my child’s picture on the St. Bartholomew's Catholic Church Website, www.barts.org, and/or in Parish publications and/or displays. Children will not be identified by name. No, I do not give me permission Please fill out this field.
- Electronic Signature (Your full name) REQUIRED Please fill out this field. Please enter valid data.
- Electronic Signature REQUIRED MOTHER FATHER GUARDIAN Please fill out this field.
- EMERGENCY CONTACT NAME REQUIRED Please fill out this field. Please enter valid data.
- EMERGENCY CONTACT NUMBER REQUIRED Please fill out this field. Please enter valid data.
- List any allergy reactions to medications, foods, Insects REQUIRED Please fill out this field. Please enter valid data.
- Current medication(s) REQUIRED Please fill out this field. Please enter valid data.
- Any other special medical issues to be aware of? REQUIRED Please fill out this field. Please enter valid data.
- Any other special learning or physical needs? REQUIRED Please fill out this field. Please enter valid data.
- Physician Name REQUIRED Please fill out this field. Please enter valid data.
- Physician Phone Number REQUIRED Please fill out this field. Please enter valid data.
- Dentist Name REQUIRED Please fill out this field. Please enter valid data.
- Dentist Phone Number REQUIRED Please fill out this field. Please enter valid data.
- Medical Insurance Carrier REQUIRED Please fill out this field. Please enter valid data.
- Medical Insurance Card Number REQUIRED Please fill out this field. Please enter valid data.
- I, the parent/legal guardian of the student mentioned above, give the OFFICE OF FAITH FORMATION OF ST. BARTHOLOMEW'S the authorization to contact the contacts mentioned above. I understand and assume all responsibility for emergency care and for transport of the student mentioned above.
- Electronic Signature (Your full name) REQUIRED Please fill out this field. Please enter valid data.
- Electronic Signature Title REQUIRED Please fill out this field.
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