Religious Ed Registration

Primary Parent/Guardian First and Last Name REQUIRED Please fill out this field. Please enter valid data.

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

Primary 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.

Parent/Guardian First and Last Name Please enter valid data.

Phone Number Please enter a phone number.

Child's Full Name REQUIRED Please fill out this field. Please enter valid data.

Child's Grade in the Fall (select one) REQUIRED PreK Kindergarten 1st 2nd / Sacramental Preparation 3rd 4th 5th 6th 7th Please fill out this field.

Sacraments Child has received (select all that apply) Baptism 1st Reconciliation 1st Eucharist Confirmation

Please list any medical conditions/allergies/current medications/learning challenges or IEP

Name of Emergency Contact (other than parent/guardian) REQUIRED Please fill out this field. Please enter valid data.

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

Name of Child's Physician REQUIRED Please fill out this field. Please enter valid data.

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

Preferred Hospital REQUIRED Please fill out this field. Please enter valid data.

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

If I, primary parent/guardian or the emergency contact cannot be reached at the time of the emergency, and if immediate observation or treatment of my child is urgent, in the judgment of the Holy Name Religious Education administration, I hereby authorize and direct that my child (properly accompanied) be taken to the physician or hospital of choice.

I Agree Please select this field.