St. Elizabeth/ St. Mark CCD Registration Form

Family Information

Student's Name

First Name*

Last Name*

Mother's Name

First Name*

Last Name*

Father's Name

First Name*

Last Name*

Address

Street 1*

Street 2

City*

State*

Zip*

Home Phone

Cell Phone

E-mail

What Parish is your Family Registered at?

Student's Information

Child's Date of Birth	//
Place of Birth
Age
Grade
Date of Baptism	//
Church of Baptism
If new to the program,	Please send a copy of Baptismal Certificate to stelizabethbearcreek@outlook.com or bring a copy into the Parish office.
School Child Attending

Emergency Contact Information

Name

First Name

Last Name

Relationship

Phone

Does your child have any food allergies?

Agree & Sign

Message

In the event of an emergency, in which I cannot be contacted, emergency staff may take appropriate action to best serve the interest of the child. Therefore, in consideration of your acceptance of this registration, i hereby for myself, my heirs, and assignees waive any and all claims for damages which i might have against St. Elizabeth-St. Mark Parish Community for any and all injuries suffered by my child.

Electronic Signature

First Name

Last Name

Date