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Religious Education Registration

- Religious Education

St. Benedict Religious Education Registration 2018-19
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- Registered in this parish? REQUIRED Yes No Please fill out this field.
- Family Information
  
  Family Name REQUIRED Please fill out this field. Please enter valid data.
  
  Address 1 REQUIRED Please fill out this field. Please enter valid data.
  
  Address 2 Please enter valid data.
  
  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.
  
  Father's Name & Religion REQUIRED Please fill out this field. Please enter valid data.
  
  Mother's Name & Mother's Maiden Name & Religion REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Please fill out this field. Please enter a phone number.
  
  Secondary Phone Number Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Emergency Contact (First and Last Name): REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact Relationship REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Children to Register REQUIRED Please fill out this field.
  
  Child 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Birthdate (mm/dd/yy) REQUIRED Please fill out this field. Please enter valid data.
  
  Gender REQUIRED Male Female Please fill out this field.
  
  Grade REQUIRED Please fill out this field.
  
  Sacraments Completed REQUIRED Baptism Eucharist Reconciliation Confirmation None Please fill out this field.
  
  Class Preference
  
  Child 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Birthdate (mm/dd/yy) REQUIRED Please fill out this field. Please enter valid data.
  
  Gender REQUIRED Male Female Please fill out this field.
  
  Grade REQUIRED Please fill out this field.
  
  Sacraments Completed REQUIRED Baptism Eucharist Reconciliation Confirmation None Please fill out this field.
  
  Class Preference
  
  Child 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Birthdate (mm/dd/yy) REQUIRED Please fill out this field. Please enter valid data.
  
  Gender REQUIRED Male Female Please fill out this field.
  
  Grade REQUIRED Please fill out this field.
  
  Sacraments Completed REQUIRED Baptism Eucharist Reconciliation Confirmation None Please fill out this field.
  
  Class Preference
  
  Child 4
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Birthdate (mm/dd/yy) REQUIRED Please fill out this field. Please enter valid data.
  
  Gender REQUIRED Male Female Please fill out this field.
  
  Grade REQUIRED Please fill out this field.
  
  Sacraments Completed REQUIRED Baptism Eucharist Reconciliation Confirmation None Please fill out this field.
  
  Class Preference
- Additional Details
  
  Special Needs/Medication
  Please list child's name & needs. Send procedure plan to parish office if needed. Please include anything we may need to know about your child (ren) such as allergies, special learning needs, health conditions or family situations we should be aware of (for each child). This information will only be shared with the child's catechist.
  
  Check here if parents are divorced
  
  Child resides with: Mother & Father Mother Father Other
  
  Who is the custodial parent?
  May non-custodial parent receive reports on child? Please respond below.
  Please enter valid data.
  
  Media Release
  Would you please give your permission for your child's picture and name to appear in St. Benedict's media releases such as St. Benedict's website, Facebook page, parish bulletin, parish videos and other parish media releases?
  Yes No
  
  Parent Signature REQUIRED
  I acknowledge that as the parent/guardian, this information will be submitted to the parish for use in registration.*
  Yes Please fill out this field.
  
  Payment Information
  Checks and Credit Cards are accepted. Checks can be made payable to St. Benedict Church If you would like to pay by credit/debit card (MasterCard, Visa, Discover). Please call the parish office with your credit card information at 812-232-8421 extension 10
  
  NOTE: SECOND GRADE ONLY: A baptismal certificate is required for second grade students who are preparing for First Communion. If baptized at St. Benedict, please indicate the year of baptism. If baptized at another church, please indicate on the registration form. You will need to provide a copy of the baptismal certificate as soon as possible after the beginning of the school year. Information needed: Date of baptism, Name of Church, City/Town/State, Father's Name, Mother's Maiden Name. If all information is not entered on the actual certificate, please provide the additional information. Please inform Rita if your child has not been baptized.
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