Religious Education Registration

The student(s) your are registering live with

Street Address REQUIRED Please fill out this field. 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.

Email REQUIRED Please fill out this field. Please enter an email address.

Home Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Father's Work Phone Number Please enter a phone number.

Father's Cell Phone Number Please enter a phone number.

Mother's Work Phone Number Please enter a phone number.

Mother's Cell Phone Number Please enter a phone number.

Father's Religion REQUIRED Please fill out this field. Please enter valid data.

Mother's Religion REQUIRED Please fill out this field. Please enter valid data.

If students are not living with both mother and father, please complete this section.

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.
Birth Date REQUIRED Please fill out this field. Please enter valid data.
Gender REQUIRED Male Female Please fill out this field.
Grade for the 2017-2018 School Year REQUIRED Please fill out this field.
Name of school Please enter valid data.
Is this child experiencing physical or emotional difficulties, a learning disability, hyperactivity, etc.? REQUIRED Yes No Please fill out this field.
If yes, explain below (please list any special services your child is receiving from their school or through private counseling). Please do not use just initials in describing any difficulties. List any medications they may be taking for these difficulties.
Please be assured this information will be kept confidential.
Class Time

Child 2

First Name Please enter valid data.

Last Name Please enter valid data.
Birth Date Please enter valid data.
Gender Male Female
Grade for the 2017-2018 School Year
Name of school Please enter valid data.
Is this child experiencing physical or emotional difficulties, a learning disability, hyperactivity, etc.? Yes No
If yes, explain below (please list any special services your child is receiving from their school or through private counseling). Please do not use just initials in describing any difficulties. List any medications they may be taking for these difficulties.
Please be assured this information will be kept confidential.
Class Time

Child 3

First Name Please enter valid data.

Last Name Please enter valid data.
Birth Date Please enter valid data.
Gender Male Female
Grade for the 2017-2018 School Year
Name of school Please enter valid data.
Is this child experiencing physical or emotional difficulties, a learning disability, hyperactivity, etc.? Yes No
If yes, explain below (please list any special services your child is receiving from their school or through private counseling). Please do not use just initials in describing any difficulties. List any medications they may be taking for these difficulties.
Please be assured this information will be kept confidential.
Class Time

Child 4

First Name Please enter valid data.

Last Name Please enter valid data.
Birth Date Please enter valid data.
Gender Male Female
Grade for the 2017-2018 School Year
Name of school Please enter valid data.
Is this child experiencing physical or emotional difficulties, a learning disability, hyperactivity, etc.? Yes No
If yes, explain below (please list any special services your child is receiving from their school or through private counseling). Please do not use just initials in describing any difficulties. List any medications they may be taking for these difficulties.
Please be assured this information will be kept confidential.
Class Time

Child 5

First Name Please enter valid data.

Last Name Please enter valid data.
Birth Date Please enter valid data.
Gender Male Female
Grade for the 2017-2018 School Year
Name of school Please enter valid data.
Is this child experiencing physical or emotional difficulties, a learning disability, hyperactivity, etc.? Yes No
If yes, explain below (please list any special services your child is receiving from their school or through private counseling). Please do not use just initials in describing any difficulties. List any medications they may be taking for these difficulties.
Please be assured this information will be kept confidential.
Class Time