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Family Information

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Father's Name*

First Last

Father's Phone*

Mother's Name*

First Last Maiden

Mother's Phone*

Status of Parents*

Are parents registered at Holy Child Parish?*

At what parish are the parents registered?

Name(s) of person(s) to receive mailed information*

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Name(s) of person(s) to receive electronic information*

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Name	Email	Text Message Address

Emergency Contact Name*

First Last

Relationship to Child*

Contact's Phone Number*

How many children do you want to register?*

Please enter a number from 1 to 7.

Student Information*

First	Last	Grade	Date of Birth

Do any of the students have any medical conditions we need to know?

Please include the name of the student and medical condition if applicable