ST.

FRANCIS XAVIER RELIGIOUS EDUCATION REGISTRATION

2010 - 2011
Please fill out 1 form per child

Students Name _____________________________________________________________Birthdate ________________________

First

Middle

Last

School attending ______________________________________________________________ Grade_________________

Sacraments student has already received: Baptism _________ Eucharist _________ Reconciliation ______ Confirmation ______
Please list: Any Allergirs (especially food allergies) __________________________________________________________________
Any special needs ___________________________________________________________________________________
Misc. _____________________________________________________________________________________________
Parent/Guardian Information:
Mothers Name _________________________________________________________________ Religion _________________
Address _________________________________________________________________________________________________
Telephone: (h) ____________________________________ _________________________________ (w) _________________
E-Mail ___________________________________________________________________________________________________
Fathers Name _______________________________________________________________ Religion _____________________
Address _________________________________________________________________________________________________
Telephone: (h) ____________________________________ _________________________________ (w) _________________
E-Mail ___________________________________________________________________________________________________
Student lives with: ______ Mother _______ Father __________ Both ________Other

IN CASE OF EMERGENCY-CONTACT INFORMATION

Please list names
andName
grades
of siblings in the RE Program
Emergency
Contact
_________________________________________________
Phone # _________________________
Relationship to Student _______________________________________________________

ST. FRANCIS XAVIER RELIGIOUS EDUCATION REGISTRATION

2010 - 2011
Please list name/grades of any siblings in the RE program

Name ______________________________________________________________________ Grade __________________________

Name ______________________________________________________________________ Grade ___________________________
Name ______________________________________________________________________ Grade ____________________________
Name _______________________________________________________________________ Grade ____________________________

Parent Volunteers
_______________ Teacher Grade _____________
_______________ Teachers Aid Grade _______________
_______________ Parking Assistant
_______________ Other ________________________________________________________________________

1 Child
2 Children
3 Children
Non Parishioners

$25.00
$35.00
$40.00
$50.00

Check # _______________
Cash _______________