Registration

Online Registration (Non-PayPal Pmt)

New & Returning Students 2022-2023
Student(s) Information
Student(s) Last Name

K-7th Grade Rel Ed Child(ren) and Sacrament(s) Received: *

Rows	First Name	Gender	Grade	Attended last year?	Birth Date mm/dd/yy	Baptism	Holy Communion
Child #1
Child #2
Child #3
Child #4

New or Returning Student in need of BaptismNew or Returning Student in need of First Holy Communion (1st-7th grades) must have at least two years of continuous formation before admittance to First Holy Communion.
Notes:
Use this note box to include other important notes for us, if needed.
PARENT/GUARDIAN INFORMATION:
Father's Name*

First NameLast Name
Cell Phone #*

Area CodePhone Number
Mother's Name*

First NameLast Name
Cell Phone #*

Area CodePhone Number
Family E-mail*
YesNo
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Emergency Contact
Contact Name*

First NameLast Name
Relation to Student
Cell Phone #*

Area CodePhone Number
Adults allowed to pickup student (not applicable in a distance learning year): :
MEDICAL INFORMATION
Primary Doctor

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical Concerns
Insurance Company
Card A/O Group #
Parent Signature
YesNo
YES - I CAN make such video conferencing applications (e.g., Zoom) available to my child under my supervision)NO - I CANNOT make such video conferencing applications (e.g., Zoom) available to my child under my supervision)
By signing below, I request the above-named participant be allowed to attend church-related activities with the St Dominics Catholic church. I, the parent/guardian of the above-named student do hereby give permission for him/her to attend Faith Formation/Sacramental Preparation Classes and to be treated for a medical emergency in my absence while participating in the faith formation program. The adult supervisor may act as an agent in my absence.
Name Signing

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Forms Needed For New Students:

Each of following forms/certificates needs to be submitted:
- New families are asked to complete a New Family Registration form.
Please download this form, fill out and upload in Family Registration field below:

New Parishioner Registration Form (pdf)

Or go visit shorturl.at/nqGX0 to download it.
- Birth Certificate
- Baptism Certificate
- Holy Communion Certificate (if any)
New Parishioner Registration Form

Browse Files
1 per family Cancelof
Child's Birth Certificate (s)

Browse Files
You can add more than one certificate at a time if more than 1 child. (up to 4 files) Cancelof
Baptism Certificate (s)

Browse Files
You can add more than one certificate at a time if more than 1 child. (up to 4 files) Cancelof
Holy Communion Certificate(s) - if any.

Browse Files
You can add more than one certificate at a time if more than 1 child. (up to 4 files) Cancelof
Payments Other than PayPal
Personal CheckOnline Giving (Through St. Dominic's Parish Website)Cash
By clicking Submit, your registration will be submitted for processing. You may submit payment by a personal check. If paying by check, please make your check payable to St. Dominic's Church. You may mail your check to St. Dominic's Church, Attn: Deacon Errol Kissinger, 475 East I St., Benicia, CA 94510 or drop-off your check at our parish office Tue-Fri, 9:00 AM-12:00PM. If paying by cash, please pay at the parish office.
For more than 1 student please calculate fees below.

Fees:

- Base Tuition $90 (per student)

- Sacrament Tuition $30 (only additive in a sacrament year)

- Teacher's Child(ren): Fee Waived

- Teacher's Aide: 50% Fee Waived

(example: Student 1 first Grade ($90) + Student 2nd grade plus holy Communion ($90+$30) + Student 3 6th Grade ($90) = 90 + 120 + 90 = $300

Check may be made by US Postal Mail addressed to :

St. Dominic’s Church

Attn: Rel Ed

475 East I Street,

Benicia, CA 94510

For any further questions, please email D. Errol at ekissinger@stdombenicia.org .
Should be Empty:

Online Registration (Non-PayPal Pmt)

Student(s) Information

PARENT/GUARDIAN INFORMATION:

Emergency Contact

MEDICAL INFORMATION

Parent Signature

Forms Needed For New Students:

Payments Other than PayPal