Faith Formation Registration

Student Information
Please fill out the entire form. Put NA if not applicable.
Student's Name*
First Middle Last
Date of Birth*
Month
Day
Year
Please check the Sacraments that your child has already received:*
- Baptism
- Penance
- Eucharist
- Confirmation
- None of the above
Parish of Baptism*
Address*
City State ZIP Code
If child is to receive First Penance or First Eucharist this year somewhere other than Prince of Peace Parish, please indicate where:*
School Presently Attending*
Grade Level*
Please list any learning disabilities:*
Pick Up/Drop Off
Please list the names of the individual(s) who will be responsible for bringing your child to and from Religious Education below.
Name*
First Last
Phone*
Name*
First Last
Phone*

Mother Information
Name*
First Middle Last
Maiden Name*
Last
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Work Phone*
Cell Phone*
Do you want to receive CCD information via email?*
- Yes
- No
Email*
Religion*
Parish/Church*
Marital Status*
- Single
- Married
- Separated
- Divorced
- Widowed
Please select one
Name of Spouse*
First Last

Father Information
Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Work Phone*
Cell Phone*
Do you want to receive CCD information via email?*
- Yes
- No
Email*
Religion*
Parish/Church*
Marital Status*
- Single
- Married
- Separated
- Divorced
- Widowed
Please select one
Name of Spouse*
First Last

Secondary Contacts
If parents cannot be reached, we will call the following secondary contacts.
Secondary Contact #1*
First Last
Relationship*
Address*
Street Address Address Line 2 City State ZIP Code
Best Phone Number to Reach Them*
Secondary Contact #2*
First Last
Relationship*
Address*
Street Address Address Line 2 City State ZIP Code
Best Phone Number to Reach Them*

Seeking Medical Attention
In case of accident or serious illness, I request the school to contact me or my designate. If this cannot be done, I autorise the school to call the physician or dentist listed on this card and to follow his/her instructions. If the physician or dentist named cannot be reached, the school may seek medical services that seem necessary. I also realize that the school does not assume responsibility for the payment of medical expenses.*
- Yes, I understand and agree.
Please Enter Your Full Name*
By entering your name, you are agreeing that you are in fact, the parent or guardian of said child.
Today's Date*
Month
Day
Year
In the event emergency treatment is needed, I give the hospital, its authorized personnel and/or physician permission to treat my son/daughter as necessary.*
- Yes, I understand and agree.
- No, I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring medical treatment, I wish the school authorities to take no action.
- No, I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring medical treatment, I wish the school authorities to take no action BUT I HAVE SPECIFIC REQUESTS.
Please Enter Your Full Name*
By entering your name, you are agreeing that you are in fact, the parent or guardian of said child.
Today's Date*
Month
Day
Year
Emergency Medical Consent Given
Allergies*
Medical Issues*
Taking Medication*
- Yes
- No
What Medications and for what reason?*
Medication will be administered at school only according to current school policies.
Physician/Clinic*
Phone*
Dentist/Hospital Preference*
Phone*
Medical Consent Not Given
Specific Requests*

Step 1 of 5

Student Information

Pick Up/Drop Off

Mother Information

Father Information

Secondary Contacts

Seeking Medical Attention

Emergency Medical Consent Given

Medical Consent Not Given