St. Hyacinth Confirmation Registration

YOUTH INFORMATION: This information is used periodically by our staff to contact your child.

Name Nick Name ______

(Full name as it appears on Baptismal Certificate)

Address

Date of Birth ______(month/day/year) Age: ______Grade in Fall 2016 ______

Sex: M or F School Attending ______

Home Phone: Youth Cell Number ______

Youth E-Mail Address:______

Please indicate the forms of communication we are allowed to use with your child:

Cell Phone: ____ Texting: _____ Facebook: _____ Email: _____ None: _____

BAPTISM: Please provide a copy of your child's Baptismal Certificate

Date of Baptism: Parish of Baptism: ______

Parish of Baptism Address: ______

PARENT INFORMATION: This information is used periodically by our staff to contact you.

Father's Name: ______Cell No. ______

E-Mail ______Work No. ______

Mother's Name ______Cell No. ______

E-Mail ______Work No. ______

Stepfather ______Stepmother ______

Primary residence is with: (check one) _____ Father _____ Mother _____ Both

Are there any circumstances we should be aware of? (e.g., guardianship, divorce, living with relatives, special needs) ______

NON-PARENT EMERGENCY CONTACT:

Name ______Number ______Relation ______

Please continue on Back

VIDEO/PHOTOGRAPHY CONSENT: As parent/guardian, i understand that promotional pictures and videos (individual and group) will be taken during this event. I give permission for my son's/daughter's picture/video to be used for promotional materials (newsletter, web page, calendars, power point, video etc.) in highlighting the event.

______

Signature (Parent/Guardian) Date

TUITION IS DUE WITH REGISTRATION

$200 per child

Includes Books, Bible, Retreat, Retreat Activities, Transportation to Retreat, T-Shirt

______

OFFICE USE ONLY:

Date Received: ______Amount Paid $______