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Middle School Catechism Registration
Welcome to Middle School Program Registration!
If you have any questions or encounter problems with the registration process,
please feel free to e-mail:
rhoda@stmichaellivermore.com
Student's Name
*
Date of Birth
*
Grade Level
*
A
6th Grade
B
7th Grade
C
8th Grade
D
Others
School
*
Has the teen been baptized?
*
A
Yes
B
No
Has the teen received First Communion?
*
A
Yes
B
No
Are you a parishioner of St. Michael?
*
A
Yes
B
No
Home Address
*
Student's Mobile Number
Student's E-mail address
Mother's Name
*
Mother's Phone Number
*
Mother's E-mail Address
*
Father's Name
*
Father's Phone Number
*
Father's E-mail address
*
Who is the primary contact?
*
A
Mother
B
Father
C
Both
D
Other
Medical Conditions, Allergies or Special Needs
*
Emergency Contact Information (Name and Phone Number)
*
Insurance and Doctor Information
*
"By providing this information, you authorize parish staff and designated event leaders to utilize this medical data strictly for safety accommodations and emergency care during Sacrament preparation activities."
*
A
I AUTHORIZED
B
I DO NOT AUTHORIZE
Photo/Media Release Information
*
A
I hereby GRANT
B
I hereby DECLINE
Parental Permission and Acknowledgement
*
A
I AGREE
B
I DO NOT AGREE
RELEASE WAIVER LIABILITY
*
A
I have read the agreement, understand and AGREE everything written above
B
I DO NOT AGREE with what is written above
Name of Child
*
I certify that all the information provided on this form is true, correct, and complete to the best of my knowledge. Furthermore, I have read, understand, and agree to adhere to the policies, requirements, and guidelines of the St. Michael Youth Ministry program.
*
A
I AGREE
B
I DO NOT AGREE
Parent's Signature
*
Signature
Printed Name
*
Today's Date
*
Submit
