Faith Formation Registration

Faith Formation Registration

Fill out the form carefully for registration
Mother Full Name

First NameLast Name
Mother Maiden Name
Mother Email
example@example.com
Mother Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Father Full Name

First NameLast Name
Father Email
example@example.com
Father Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name
Not a parent
Emergency Contact Number
Format: (000) 000-0000.
Is this your first year of Faith Formation at St. Rita?
Registered Parishioner at
Please indicate your frequency of Mass attendance as a family (parent & child together)
According to St. Rita policy, all children are required to be signed out by an approved person. Please list any persons who have permission to release your child from our care.

Child #3 - Student Name

First NameMiddle NameLast Name
Relationship to you:
Allergies, Medications or other pertinent comments:
Family Physician
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health Insurance Company
Policy #
Group #
Contract #
Register another Child?
Does child #4 have the same physician?
Does child #4 have the same insurance coverage?

Child #4 - Student Name

First NameMiddle NameLast Name
Relationship to you:
Allergies, Medications or other pertinent comments:
Family Physician
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health Insurance Company
Policy #
Group #
Contract #
Register another Child?
Does child #5 have the same insurance coverage?
Child #5 - Student Name
Relationship to you:
Allergies, Medications or other pertinent comments:
Family Physician
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health Insurance Company
Policy #
Contract #
Signature
Would you like to prepay?
prevnext( X )
How many students?
$30.00 Quantity

How many students making a sacrament this year?
$20.00 Quantity

Total

$0.00
Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info
Should be Empty:

Medical Treatment Authorization