Religious Education Program

Religious Education Program
Title
First
Last
Suffix
Date of Birth

MonthDayYear
Place of Birth:
Ethnic Background:
Grade in School:
Grade for Religious Ed:
Sacraments Received:
Title
First
Last
Suffix
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number Main:

Area CodePhone Number
Phone Number Cell:

Area CodePhone Number
Phone Number Work:

Area CodePhone Number
Legal Guardian:

First NameLast Name
Legal Guardian's Phone Number

Area CodePhone Number
Registered Member of St. John de LaSalle?
Is your child currently taking medications for a chronic condition?
Please identify the medication and course of action should your child become ill during class:
Physician's Name:

First NameLast Name
Physician's Phone Number

Area CodePhone Number
Physician's Address:
Medical Insurance Company:
Insurance number:
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship:
Medical Release and Notice of Release of Liability
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