Confirmation Preparation Program
Wednesdays from 6:15 to 8:00 pm
Meeting Dates
January 7, 14, 21, 28, February 4, 11, March 4, 11, 18, 25
Location
Assumption BVM Parish: 3516 E Monroe Rd, Midland, MI 48642
Leaders
Christine Sellnow, Kathy Russell, Bailey Delaney
To which church does your family belong?
*
Please Select
Blessed Sacrament
Assumption
Our Lady of Grace
St. Brigid
St. Agnes
Other
None
Name of Child
*
First Name
Last Name
Age/Date of Birth
*
Where was your child baptized?
*
What year was your child baptized?
*
Has your child completed his/her First Reconciliation?
*
Please Select
Yes
No
Unsure
Has your child completed his/her First Eucharist?
*
Please Select
Yes
No
Unsure
Allergies
*
Medical Conditions
*
Medicines child is currently taking
*
Medicines that need to be dispensed during this activity must be given to the designated supervisor in its original container with directions and dosage.
Name of Child 2
First Name
Last Name
Age of Child 2/Date of Birth
Where was your child baptized?
What year was your child baptized?
Has your child completed his/her First Reconciliation?
Please Select
Yes
No
Unsure
Has your child completed his/her First Eucharist?
Please Select
Yes
No
Unsure
Allergies of Child 2
Medical Conditions of Child 2
Medicines Child 2 is currently taking
Permission to Participate
I, the parent of the child(ren) listed, request that Blessed Sacrament Parish and Assumption BVM Parish allow my son(s)/daughter(s) to participate in the activity described above. I give permission for my child(ren) to participate in the Confirmation Preparation Program. In consideration for my child(ren)'s participation, I hereby release, save harmless and indemnify Blessed Sacrament Parish, Assumption BVM Parish, St. Brigid Parish, its employees, volunteers, agents and any sponsors or benefactors from any and all liability. I understand that my son(s)/daughter(s) will be under the supervision of the designated leaders on the stated dates and that all parish rules will be in effect. I understand and agree that, if my son(s)/daughter(s) violates a parish rule, he/she/they will be sent home.
Parent/Guardian Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Alternate Emergency Phone Number
*
Please enter a valid phone number.
Medical Release
In case emergency medical treatment is necessary and I am not available to give consent, I authorize the adult advisor in charge to consent to any necessary examination, anesthetic, medical diagnosis, surgery or treatment, and/or hospital care to be rendered to the above-named minor(s) under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine in the state of Michigan.
Medical Insurance Carrier
*
Policy Contract Number
*
Family Physician
*
Parent/Guardian Signature
*
Submit
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