Blessed Sacrament Sunday School
152 W. 71 Street
New York, NY 10023
ph: 212-877-3111
fax: 212-799-6233
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Registration Form
REGISTRATION: SUNDAY RELIGIOUS EDUCATION CLASSES 2011-2012
PLEASE PRINT CLEARLY
STUDENT’S NAME: ____________________________________________________________________________________
ADDRESS:___________________________________________________________________________APT:_____________
ADDRESS MAIL TO: (name of addressee)___________________________________________________________________
CITY: _________________________________ STATE: ___________________ ZIP: ________________________
PHONE: __________________________________ CELL:___________________________________________
PARENT'S EMAIL: _____________________________________________________________________________________
SEPT. 2011 GRADE: ______________ AGE: ________ DATE OF BIRTH: ____________________________________
BIRTHPLACE:___________________________________ SCHOOL:___________________________________________
FATHER’S NAME: _______________________________ RELIGION:__________________________________________
BUSINESS PHONE: _____________________________ PLACE OF BUSINESS:_________________________________
MOTHER’S NAME: ______________________________ RELIGION:__________________________________________
MOTHER’S MAIDEN NAME: ____________________________________________
BUSINESS PHONE: _____________________________ PLACE OF BUSINESS:_________________________________
(if applicable) CUSTODIAL PARENT OR LEGAL GUARDIAN:
____________________________________________________________________________________________________
HAS THE STUDENT BEEN BAPTIZED? YES ______ NO ______
CHURCH_________________________________________________DATE__________________
(name of church, city, state)
***PLEASE ATTACH A COPY OF YOUR CHILD’S BAPTISMAL CERTIFICATE IF NOT ALREADY ON FILE IN THE RELIGIOUS EDUCATION OFFICE
HAS THE STUDENT RECEIVED THE FOLLOWING SACRAMENTS?
FIRST COMMUNION: YES______ NO______ CHURCH:_____________________________________________________
RECONCILIATION: YES______ NO______ CHURCH:____________________________________________________
CONFIRMATION: YES______ NO______ CHURCH:_____________________________________________________
DID THE STUDENT ATTEND SUNDAY SCHOOL AT BLESSED SACRAMENT LAST YEAR?
________YES ________NO
STUDENT INFORMATION RECORD
Name: ______________________________________________
Special Medical Conditions:
_______________________________________________________________________________
_______________________________________________________________________________
Procedures to be followed if the above condition presents an emergency:
_______________________________________________________________________________
_______________________________________________________________________________
Any special request for the dismissal of the child after class should be made on this form:
_____________________________________________________________________________________________________
IN CASE OF AN EMERGENCY
Persons To Contact If Parent/Legal Guardian Cannot Be Reached:
Name: ________________________________________ Relationship: ______________________
Phone #: ______________________________ Additional Phone #: ______________________
Address: ________________________________________________________________________
Doctor for Emergency: _____________________________________________________________
Phone: __________________________________________________________________________
Address: ________________________________________________________________________
In case of accident or illness, I request that the representative of the parish catechetical program contact me. If I am unable to be reached, I hereby authorize this representative to call the physician indicated and to follow the physician’s instructions. If it is impossible to contact this physician, the representative of the parish catechetical program may make whatever arrangements seem necessary. I agree to assume the financial responsibility for any diagnosis, treatment and/or medication deemed necessary.
To the best of my knowledge all information given is accurate and complete. I hereby consent to, and authorize the necessary procedures that have been stated above.
Parent/Guardian Signature: _______________________________________________
Date: __________________________________________
Copyright 2011 Blessed Sacrament Sunday School. All rights reserved.
152 W. 71 Street
New York, NY 10023
ph: 212-877-3111
fax: 212-799-6233
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