Immaculate
(Please Print and Then Fill Out)
Registration
School Year _________
Mailing Address:
______________________________________________
_____________________________________________________________
Home Phone__________________ Gender
____________
Email Address
________________________________________________
Person responsible for child’s
Religious Training ___________________
Mother’s Maiden Name
________________________________________
Student Lives with
_____________________________________________
Date of Birth _____________ Age
_____ Grade Level ________________
Baptism Date, Name of Church and
Address _______________________
_____________________________________________________________
1st
Communion Date, Name of Church and city _____________________
Emergency Phone Numbers
_____________________________________
Relationship to Child
__________________________________________
Health
Problems, Allergies, Learning Disabilities or
other information we should have about your child:
Approved Discipline check all that
apply: Write Prayers _______
Time Out _____ Call Home ________
Chores________
*************************************************************
Number of children registered in the
program _____
Registration Fee
$_______
Confirmation $20
$_______
Reconciliation and First Communion $20
$_______
Total Fee
$_______
No child would ever be prohibited from
involvement in the program for financial reasons.
If there is a problem, please see Kathleen Deglomine
or call me at 726-8111(Office) or 432-6131(Cell).
The fees charged by the program are a
small contribution to the total cost of running
this program, the majority of the cost is born by the parish as a whole.