2009—2010 REGISTRATION FOR ST. JOSEPH RELIGIOUS EDUCATION PROGRAMS by DerrellAcrey

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									             2009—2010 REGISTRATION FOR ST. JOSEPH RELIGIOUS EDUCATION PROGRAMS (Please Print)

Registrant's Last Name______________________
Mailing Address____________________________________________________________________________

  PRIMARY CONTACT INFORMATION                                      EMERGENCY MEDICAL TREATMENT                                                                                   Permission to Use
      Please list all numbers that apply.        In the event of an emergency, I hereby give permission to transport my                                                           Student Photos:
  FILL IN THE CIRCLE NEXT TO THE #               child(ren) to a hospital for emergency medical or surgical treatment. I
   YOU WISH TO DESIGNATE AS YOUR                 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::
    PRIMARY TELEPHONE CONTACT.
                                                                                                                                                                            You have my permission to
                                                 Alternate Name_______________________________________________                                                              use student(s) photos for
ο Home___________________________                                                                                                                                           commercial purposes
ο Cell ___________________________               Phone Number_______________________________________________
                                                                                                                                                                            (ex: advertising an event in
ο Work___________________________                Relationship to Child___________________________________________                                                           flyers, on the web, etc).
ο Other___________________________
-----------------------                          Family Doctor________________________________________________
ο I give permission to be included                                                                                                                                          Initials__________________
                                                 Doctor’s Phone_______________________________________________
   on a telephone tree.
                                                 __________________________________________________________________
e-mail ____________________________              Custodial Parent/Guardian Signature                      Date


                                                                        (!) Sacraments                              X Sacrament                          For each child, X the column(s) corresponding to the
             List ONLY those children                                                                                                                          programs(s) for which you are enrolling.
             whom you are enrolling.                                  Already Celebrated                            Registration


                                                                                 1st Rec.

                                                                                            1st Comm.

                                                                                                        Confirm.

                                                                                                                   1st Rec.

                                                                                                                              1st. Comm

                                                                                                                                          Confirm.
                                                                       Baptism
                                                                                                                                                                                                 TIME
                                                                                                                                                           CCD (grade)           TYME            AFTER
                                                                                                                                                                                                 TYME
                                                M
               CHILD’S NAME                     / Birth
First        Middle Initial             Last    F Date      School    ! ! ! !                                      X          X           X          1    2    3   4    5    6   7    8     9   10    11    12

                                                                      " " " "
                                                                      " " " "
                                                                      " " " "
                                                                      " " " "
List any medical or learning problems for above students. Also list any special placement requests/needs.
Family Status                                                                                 FEES
                                                                                              C.C.D./T.Y.M.E* (gr. 1 - 8)
                                       Father                           Mother
                                                                                                      1 Child                     $ 60
Name                                                                                                  2 Children                  $100
                                                                                                      3 or More                   $140                 $ ______
Religion/                                                                                     *Early Bird Discount:
Church of Membership                                                                          Deduct $10/child from above fees if completed
                                                                                              registration forms & half or full payment
Occupation/Employer
                                                                                              are postmarked by August 31.                             $______
Additional contact                                                                            TAT: Time After T.Y.M.E. (gr. 9 – 12)
Information                                                                                   Please complete separate Time After T.Y.M.E.
                                                                                              Registration Sheet and transfer fee totals here.
                                                                                              # of Workshops

Marital Status: Check    □    Single       □    Married    □   Single          □   Married            Youth 1                   ______@ $15 =          $______
all that apply
                         □    Separated    □    Divorced   □   Separated       □   Divorced           Youth 2                   ______@ $15 =          $______
                         □    Remarried    □    Annulled   □   Remarried       □   Annulled
                                                                                                      Youth 3                   ______@ $15 =          $______
Legal Custody of         □ Sole             □ Joint        □ Sole              □ Joint        Sacraments
Child(ren)
                                                                                                      1st Reconciliation        ______@ $15 =          $______
Physical Placement
                                                                                                      1st Communion             ______@ $15 =          $______
Name of Stepparent                                                                                    Confirmation              ______@ $50 =          $______

                                                                                                                        TOTAL FEES                     $______
FEE PAYMENT RECORD (Office Use Only)
                               Check # /                         Staff       Input on
    Date       Amt. Paid                    Balance Due
                                Cash                            Initials    Computer

                                                                                                                PAYMENT SCHEDULE (choose one):

                                                                                                      #         Prepay in full @ registration

                                                                                                      #         1/2 @ registration and
                                                                                                                1/2 @ semester (1/15)

                                                                                                      #         Financial Aid ( Minimum required payment of $15.00)
              Verify Parish Registration
                                                                        Revised April 2008

								
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