Middle School Ministry Registration Form 2018-19

Medical Information
YesNo (Please submit statement below)
If no, please submit a statement indicating the limitation or serious medial condition(s).
MEDICATION: Please list any medication(s) that might need to be administered. Name of medication (over-the-counter and/or prescriptions) including dosage and frequency.
Please list any notable operations or serious Injuries: (Please include dates)
Please list any special dietary needs:
Please describe any learning issues:
Date of most recent physical exam:

MonthDayYear
Name of Physician/Clinic:
Physician/Clinic Address:
Physician/Clinic Phone Number: (xxx-xxx-xxx)
Family Health Insurance Company:
Policy Number:
Date of DPT Booster

MonthDayYear
Date of DPT

MonthDayYear
Date of Tetanus Booster

MonthDayYear
Hay FeverAsthmaSulfaNutsPenicillinGlutenOther
Treatment: If any of the above is a yes, please state how the child has been (should be) treated and with what medication.

Sacramental Information
DATE OF BAPTISM:

MonthDayYear
CHURCH OF BAPTISM:
Address for Church of Baptism:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Upload a copy of the Baptismal Certificate

Upload a File

Cancelof
DATE OF FIRST EUCHARIST:

MonthDayYear
CHURCH OF FIRST EUCHARIST:
Address for Church of First Eucharist:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Upload a copy of first Eucharist certificate

Browse Files
First Eucharist Certificate Cancelof
LAST GRADE OF RELIGIOUS EDUCATION:
HOME PARISH:*
Please see schedule as they change each month. We also participate in Family Faith Formation sessions once a month.

Family Information