Youth Religious Education Registration

Parent/Guardian Email Address REQUIRED Please fill out this field. Please enter valid data.

First Name of Student REQUIRED Please fill out this field. Please enter valid data.

Last Name of Student REQUIRED Please fill out this field. Please enter valid data.

Student Date of Birth REQUIRED Please fill out this field. Please enter valid data.

Student's School Grade as of September 2022 REQUIRED Please fill out this field.

Last Grade Student Completed in Religious Education REQUIRED Please fill out this field.

Name of Parish Where Completed: REQUIRED Please fill out this field. Please enter valid data.

Name of Church where student was Baptized: REQUIRED Please fill out this field. Please enter valid data.

Baptism Year: REQUIRED Please fill out this field. Please enter valid data.

Name of Church where student received First Communion: REQUIRED Please fill out this field. Please enter valid data.

First Communion Year: REQUIRED Please fill out this field. Please enter valid data.

Is the student preparing for First Communion? If so, what year of preparation are they in: REQUIRED Please fill out this field.

Is the student preparing for Confirmation? if so, what year of preparation are they in: REQUIRED Please fill out this field.

Is the student interested in joining the following Youth Ministry Programs? REQUIRED Altar Serving Reading at Mass as a Lector or Commentator Youth Ushers Choir None Please fill out this field.

Is your family registered at Our Lady of Lourdes Church? REQUIRED Yes No Please fill out this field.

Name of Parent / Guardian (Last Name, First Name) REQUIRED Please fill out this field. Please enter valid data.

Home 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. Please enter valid data.

Zip Code Please enter valid data.

Primary Phone Number REQUIRED Please fill out this field. Please enter valid data.

Secondary Phone Number Please enter valid data.

Does student have any allergies or health issues? REQUIRED Yes No Please fill out this field.

If so, please provide details below:

Does the Student carry an Epi Pen? REQUIRED Yes No Please fill out this field.

Does the Student have an IEP (Individualized Education Plan)? REQUIRED Yes No Please fill out this field.

If so, please provide details below:

Any Special needs or relevant information that you would like us to know?

Dietary Restrictions? REQUIRED Please fill out this field.

Emergency Contact ( Last Name, First Name) REQUIRED Please fill out this field. Please enter valid data.

Relationship to Student: REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact Phone Number REQUIRED Please fill out this field. Please enter valid data.

Who is allowed to pick up Student: (Please provide full name and contact phone numbers) REQUIRED Please fill out this field.

Electronic Signature (Last Name, First Name) REQUIRED Please fill out this field. Please enter valid data.

Date of Registration REQUIRED Please fill out this field. Please enter valid data.

I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document REQUIRED I hereby grant permission to the student I am registering to participate in Religious Education this year. Please fill out this field.

Youth Religious Education Registration

2022-2023 Our Lady of Lourdes Youth Religious Education Registration

Contact

Mass Times