Date received _______________

                                                                                    Surname ___________________

 

Sacred Heart/ St. Benedict Catholic Community

2002-2003

 

Household Surname ___________________    Address _________________________________

 

 Home Phone _________________________    Email ___________________________________

 

Relationship

First name

Last name

Date of Birth

Grade

02-03

Gender

Head of Household

 

 

 

 

 

Spouse

 

 

 

 

 

Youth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Parental/ Guardian Information

 

Relationship to Child ____________________           Name ___________________________________________

                                                                                                                First                                                       last

Business _______________________________      Business Phone __________________________________

 

Cell / Pager_____________________________        Religion _________________________________________

 

Registered at Sacred Heart/St. Benedict Parish?            __ Yes    __ No     Envelope number ___________________

 

                                                                                **************************

 

Relationship to Child ____________________           Name ___________________________________________

                                                                                                                First                                                       last

Business _______________________________      Business Phone ___________________________________

 

Cell/ Pager______________________________       Religion _________________________________________

 

Registered at Sacred Heart/St. Benedict Parish?            __ Yes    __ No     Envelope number ___________________

 

 

************************

 

Parent/Guardian not living in household        

 

Name ______________________________               Relationship to child ________________________________

 

Address __________________________________________________           Phone # _____________________

 

 

 

When sending mail, address to: (Circle One)

 

                                Mr./Mrs.                Mr.          Mrs.          Ms.         Miss        Dr. /Mrs.             Other _______________

 

Children’s Information

 

Name ___________________________________________________              Nickname ___________________

First                                       Middle                                   Last

 

Mother’s Maiden Name _____________________________________              School attending______________

 

BIRTH

                Date __/__/__      Location ______________________            City/State _________________________

 

BAPTISM

                Date __/__/__      Church _______________________            City/State _________________________

 

COMMUNION

                Date __/__/__      Church _______________________            City/State _________________________

 

CONFIRMATION

                Date __/__/__      Church _______________________            City/State _________________________

 

My child is:           ___ New   ___ Returning   What was the last year attended Religious Education? ____________

 

Health problems ___________________________________________________________________________

 

Other considerations  _______________________________________________________________________

 

 
CHILD’S PLACEMENT     Grade _____        A   B   C Level     1    2    3    4    5                      RCIA

*******************

 

 

Name __________________________________________________                Nick name _____________________

First                                       Middle                                   Last

 

Mother’s Maiden Name ____________________________________                 School attending________________

 

BIRTH

                Date __/__/__                      Location ______________________            City/State _____________________

 

BAPTISM

                Date __/__/__                      Church  ______________________              City/State _____________________

 

COMMUNION

                Date __/__/__                      Church  ______________________              City/State _________________________

 

CONFIRMATION

                Date __/__/__                      Church  ______________________              City/State _________________________

 

My child is:           ___ New   ___ Returning                   What was the last year attended Religious Education? ____________

 

Health problems _________________________________________________________________________________

 

Other considerations _____________________________________________________________________________

 

 

CHILD'S PLACEMENT                     Grade _____        A   B   C Level     1    2    3    4    5                      RCIA

 

 

 

 

Emergency Information

 

In the event of an emergency, if you are unable to reach me, please contact the following:

 

Name _______________________________________          Relationship to child _______________________

 

Address _____________________________________         Phone number ____________________________

 

Health Insurance Co. ___________________________           Policy # _________________________________

 

Physician’s name ______________________________          Phone # _________________________________

 

In the event of a medical emergency, I hereby give permission to those in charge to request medical treatment for my child, in the event that I cannot be reached at the above listed phone listed phone numbers.

 

Signed (Parent/Guardian): _________________________________________  Date _____________________________

 

 

 

 

 

 

Office Use Only

 

Placement                                                                                             Date __________________

            Elementary                                                                                          

                        Tuesday           Thursday          Saturday                       Received by ____________

            Junior High

                        Level 1 Level 2                                                             Bapt. Cert.______________

            Senior High

                        Level 1 Level 2 Level 3 Level 4 CMS __________________

            RCIA adapted for children

 

Registration fee             $25.00             ________                    Assessment 1   __________

                                                                                                                                    Date

Tuition                          ______            ________                    Assessment 2   __________

                                                                                                                                    Date

Sac. Prep                     $30.00             ________                    Assessment 3   __________

                                                                                                                                    Date

Total                                                   ________                    Level 4 Interview ________

                                                                                                                                        Date

Paid ___________      Cash    Check # ________      MO      Conf. Interview  _________

                                                                                                                                    Date

Amount            ___________              Date     _____________

 

Amount            ___________              Date     _____________

 

Amount            ___________              Date     _____________