REGISTRATION FORM

- Faith Formation

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- Head of Household
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Street address 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.
- Mother's Information
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Mother's Maiden Name REQUIRED Please fill out this field. Please enter valid data.
  
  Mother's Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Mother's Email REQUIRED Please fill out this field. Please enter an email address.
- Father's Information
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Father's Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Father's Email REQUIRED Please fill out this field. Please enter an email address.
- We are currently members of St. Patrick/St. Anthony Church REQUIRED Please fill out this field.
- If you answered "no" above: What is your home parish? Please enter valid data.
- Name of Emergency Contact and relationship to child REQUIRED Please fill out this field. Please enter valid data.
- Emergency contact phone # REQUIRED Please fill out this field. Please enter valid data.
- Name of 2nd Emergency Contact and relationship to child (or NONE) REQUIRED Please fill out this field. Please enter valid data.
- 2nd Emergency contact phone # (or NA) REQUIRED Please fill out this field. Please enter valid data.
- Names and relationship of people (other than parents) authorized to pick up your child(ren). PLEASE ADD PHONE#
- Number of children to register REQUIRED Please fill out this field.
  
  Name of 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.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Child resides with: REQUIRED Please fill out this field.
  
  Grade in school REQUIRED Please fill out this field.
  
  School attending REQUIRED Please fill out this field. Please enter valid data.
  
  Baptism- Church & date REQUIRED Please fill out this field. Please enter valid data.
  
  1st Reconciliation & 1 Communion Church(es) or Not recieved REQUIRED Please fill out this field. Please enter valid data.
  
  Please list any food allergies, health issues or special needs OR write "None" REQUIRED Please fill out this field.
  
  Name of 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.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Child resides with: REQUIRED Please fill out this field.
  
  Grade in school REQUIRED Please fill out this field.
  
  School attending REQUIRED Please fill out this field. Please enter valid data.
  
  Baptism- Church & date REQUIRED Please fill out this field. Please enter valid data.
  
  1st Reconciliation & 1 Communion Church(es) or Not recieved REQUIRED Please fill out this field. Please enter valid data.
  
  Please list any food allergies, health issues or special needs OR write "None" REQUIRED Please fill out this field.
  
  Name of 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.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Child resides with: REQUIRED Please fill out this field.
  
  Grade in school REQUIRED Please fill out this field.
  
  School attending REQUIRED Please fill out this field. Please enter valid data.
  
  Baptism- Church & date REQUIRED Please fill out this field. Please enter valid data.
  
  1st Reconciliation & 1 Communion Church(es) or Not recieved REQUIRED Please fill out this field. Please enter valid data.
  
  Please list any food allergies, health issues or special needs OR write "None" REQUIRED Please fill out this field.
  
  Name of 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.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Child resides with: REQUIRED Please fill out this field.
  
  Grade in school REQUIRED Please fill out this field.
  
  School attending REQUIRED Please fill out this field. Please enter valid data.
  
  Baptism- Church & date REQUIRED Please fill out this field. Please enter valid data.
  
  1st Reconciliation & 1 Communion Church(es) or Not recieved REQUIRED Please fill out this field. Please enter valid data.
  
  Please list any food allergies, health issues or special needs OR write "None" REQUIRED Please fill out this field.
  
  Name of child 5
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Child resides with: REQUIRED Please fill out this field.
  
  Grade in school REQUIRED Please fill out this field.
  
  School attending REQUIRED Please fill out this field. Please enter valid data.
  
  Baptism- Church & date REQUIRED Please fill out this field. Please enter valid data.
  
  1st Reconciliation & 1 Communion Church(es) or Not recieved REQUIRED Please fill out this field. Please enter valid data.
  
  Please list any food allergies, health issues or special needs OR write "None" REQUIRED Please fill out this field.
  
  Name of child 6
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Child resides with: REQUIRED Please fill out this field.
  
  Grade in school REQUIRED Please fill out this field.
  
  School attending REQUIRED Please fill out this field. Please enter valid data.
  
  Baptism- Church & date REQUIRED Please fill out this field. Please enter valid data.
  
  1st Reconciliation & 1 Communion Church(es) or Not recieved REQUIRED Please fill out this field. Please enter valid data.
  
  Please list any food allergies, health issues or special needs OR write "None" REQUIRED Please fill out this field.
  
  Name of child 7
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Child resides with: REQUIRED Please fill out this field.
  
  Grade in school REQUIRED Please fill out this field.
  
  School attending REQUIRED Please fill out this field. Please enter valid data.
  
  Baptism- Church & date REQUIRED Please fill out this field. Please enter valid data.
  
  1st Reconciliation & 1 Communion Church(es) or Not recieved REQUIRED Please fill out this field. Please enter valid data.
  
  Please list any food allergies, health issues or special needs OR write "None" REQUIRED Please fill out this field.
  
  Name of child 8
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Child resides with: REQUIRED Please fill out this field.
  
  Grade in school REQUIRED Please fill out this field.
  
  School attending REQUIRED Please fill out this field. Please enter valid data.
  
  Baptism- Church & date REQUIRED Please fill out this field. Please enter valid data.
  
  1st Reconciliation & 1 Communion Church(es) or Not recieved REQUIRED Please fill out this field. Please enter valid data.
  
  Please list any food allergies, health issues or special needs OR write "None" REQUIRED Please fill out this field.
- I give permission to use my child(rens) photo(s) for (please check ALL that apply) REQUIRED Bulletin boards & class projects Parish bulletin or Newsletter (print & digital) Parish website I do not want my child(rens) photo used without permission Please fill out this field.
- PLEASE NOTE: If your children attend, or are involved in, a "group event" their picture may appear in a "group photo" and may be posted on our parish or diocese's website or newsletter...however we will not post names unless permission is given for 1st names only.
  ****We also may not have control over others taking photos at group events and St. Patrick/St. Anthony's will not be held responsible or liable for these photos if shared in any way. ***
- I have read, understand & agree with the above statement on photos of my child(ren) Please select this field.
- Please check all that apply - I am interested in: REQUIRED Learning about becoming a catechist or an assistant Helping with events or special projects I am sorry but can not help at this time. Please fill out this field.
- Comments, questions or concerns?
- "E-Signature" (Please type your name confirming you are the person filling out this form) REQUIRED Please fill out this field. Please enter valid data.
- REGISTATION FEE:
  
  Parishioners who use envelopes: No Charge (except Confirmation fee)
  
  Parishioners who DO NOT use envelopes: $25/child; $45 family max
  
  First Reconciliation/First Eucharist: NO additional fee
  
  Confirmation year (10th grade) $20 additional fee (supports retreat costs)
  
  IF YOU CHOOSE TO MAKE PAYMENT ONLINE, choose amount(s) below and click "PAY NOW".
  
  IF YOU CHOOSE TO SEND A CHECK (or pay with cash) then click "PAY LATER" and send or drop off check payable to St. Patrick-St. Anthony.
  
  PLEASE KNOW that NO child will be denied because of financial difficulties. This will remain confidential.
  
  Your form will be submitted when you make your "pay" option.
- PAYMENTS (please indicate the amount(s) below): REQUIRED
  0.0 – FREE - Have envelopes
  25.0 – 1 child
  45.0 – 2 or more children (family max is $45)
  20.0 – CONFIRMATION FEE (additional 1 child)
  40.0 – CONFIRMATION FEE (additional 2 children) Please fill out this field.
Total:

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St Patrick -
St Anthony Church

Chadwicks, ny

REGISTRATION FORM