Today's date:_____________ ____Grade English, Thrusday
September 2011 - May 2012 Fees: $65/1 Child,
$85/2 Children
$100/3 Children
St. Cyprian Parish Catechetical Program Registration Form
PLEASE PRINT CLEARLY.
Child’s Name: _____________________________________________________________ Grade: ______
Last First Middle
Address: _______________________________________________________________________________
Street/Apt. Number City Zip Code
Home phone: _____________________ Cell:
(Area Code) (Area Code) Currently Attending
Age: ______ Date of Birth: _____________________ Place of Birth _____________________________
Father’s Name: _______________________________________ Work Phone: ______________________
(Area Code)
Mother’s Name: ______________________________________ Work Phone: ______________________
(Area Code)
Mother’s e-mail: ______________________________ Father’s e-mail: _________________________
In case of an emergency, who can pick up your child? Please provide the information:
Person Name: _______________________________________ Phone Number: ___________________
(Area Code)
PLEASE NOTE: There is a two-year preparation period prior to celebrating First Communion. Grade 2 is minimum age for
First Communion; Grade 8, for Confirmation.
Our program depends on volunteer help, and each family is asked to contribute whetever it can.
Teacher/Catechist____ Aide____ Music____ Retreats____
Craft Preparation____ Office Help____ Baking____ Other_______________
CONFIDENTIAL
Does you son or daughter have any special needs?_________
Diagnosis or nature of the differences that your child/children have:______________________________________
This is to meet the needs of your family.
Parent/Guardian’s Signature: _______________________________________ Date __________________
For office use only:
Amount paid: __________
Date:______________________ D.C.M Approval