20162017 REGISTRATION FOR ST.

STEPHEN RELIGIOUS EDUCATION PROGRAMS (Please Print)

Registrant's Last Name____________________
PRIMARY CONTACT INFORMATION
Please list all numbers that apply.
FILL IN THE CIRCLE NEXT TO THE # YOU
WISH TO DESIGNATE AS YOUR PRIMARY
TELEPHONE CONTACT.
Home___________________________
Cell ___________________________
Work___________________________
Other___________________________
e-mail ____________________________

Mailing Address______________________________________________________________________
Street

City

EMERGENCY MEDICAL TREATMENT

In the event of an emergency, I hereby give permission to transport my
child(ren) to a hospital for emergency medical or surgical treatment. I
wish to be advised prior to any further treatment by the hospital or
doctor. If you are unable to reach me at the above numbers, contact::

Phone Number_______________________________________________
Relationship to Child___________________________________________
Family Doctor________________________________________________
Doctors Phone_______________________________________________

Sacraments
Already Celebrated

Confirm.

1st Rec

1st Comm

School

1st Comm.

Birth
Date

1st Rec.

M/F

X
Sacrament
Registration

Baptism

CHILDS NAME
Last

You have my permission to

use student(s) photos for
commercial purposes
(ex: promoting an event on
flyers, parish websites, news
articles)
Initials________________

__________________________________________________________________
Custodial Parent/Guardian Signature
Date

List ONLY those children whom you are enrolling

Middle Initial

Zip

Permission to Use
Student Photos:

Alternate Name_______________________________________________

()

First

State

List any medical or learning accommodations needed for above students. Also list any special placement requests/needs.

For each child, X the column(s)

corresponding to the programs(s) for
which you are enrolling.

CCD (grade)

TYME

Family Status

FEES

Father

Mother

C.C.D./T.Y.M.E* (gr. 1 - 8)

Name

1 Child
2 Children
3 or More

Religion
Church of Membership
Occupation

$ 85
$135
$185

$ _______

*Early Bird Discount:

Deduct $20/child from above fees if completed

registration forms & half or full payment are
postmarked by August 31.

Employer
Additional contact
Information
Marital Status: Check
all that apply

$_______

Single
Separated
Remarried

Sole

Legal Custody of
Child(ren)

Married
Divorced
Annulled

Joint

Single
Separated
Remarried

Sole

Married
Divorced
Annulled

Joint

Sacramental Preparation:
1st Reconciliation/1st Communion
per child______@ $30

$_______

Physical Placement
TOTAL FEES
Name of Stepparent

FEE PAYMENT RECORD (Office Use Only)

Date

Amt. Paid

Check # /
Cash

Balance Due

Staff
Initials

Input on
Computer

Verify Parish Registration

Revised July 2016

PAYMENT SCHEDULE (choose one):

Prepay in full @ registration

1/2 @ registration and

1/2 on January 15

$_______