628 Middle School Ministry 2024-2025 Registration Form

628 Middle School Ministry

2024-2025
Student Registration
Student Information
Student Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Age*
Gender*
School Attending*
Grade in School 2024-2025
Please list any medical conditions, allergies, or special needs for this teen*
I give permission to The Holy Name of Jesus to publish photos of my child in church related social media.*
Student email
Student Cell Phone

Area CodePhone Number
Student Sacraments
Has teen been Baptized?*

YesNo
Has teen received First Holy Communion?*

YesNo
Student 2 Information
Student #2 Information
Student Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Age
Gender
Grade in School 2024-2025
School Attending
Please list any medical conditions, allergies, or special needs for this teen
I give permission to The Holy Name of Jesus to publish photos of my child in church related social media.
Student email
example@example.com
Student Cell Phone

Area CodePhone Number
Student Sacraments
Has teen been Baptized?

YesNo
Has teen received First Holy Communion?

YesNo
Parent/Guardian Information
Mother's Information
Mother's Name*

First NameLast Name
Mother's Maiden Name*
Phone Number*

Area CodePhone Number
E-mail Address*
example@example.com
Fathers's Information
Father's Name*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail Address*
example@example.com
Address (where child primarily resides)*

Street Address

Street Address Line 2

CityState

Zip Code
Primary language spoken in the home*
Are you registered parishioners at The Holy Name of Jesus?*
Emergency Contact (If Parent/Guardian cannot be reached)*
Relationship to Student*
Emergency Phone Number*

Area CodePhone Number
Today's Date*

MonthDayYear
Date
PAYMENT

$60.00 per student

My Products

1st Pre-Teen - 628 Middle School Ministry$60.00

(Non-Sac.)

2nd Pre-Teen - 628 Middle School Ministry$40.00

Discount for 2nd child (Non-Sac.)

Total $0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

ACH Bank Transfer

Payment options are not available at this time. We will email you with a link to the payment portal when available. Thank You.
Should be Empty:

628 Middle School Ministry

Student Registration

Student 2 Information

Parent/Guardian Information

PAYMENT

Payment Methods