Confirmation Registration Form 2021

CONFIRMATION YEAR: *

2021--Confirmation Preparation begins fall 2019
CANDIDATE'S FIRST NAME: *
CANDIDATE'S LAST NAME: *
MIDDLE NAME:
Nick Name AKA:
Date of Birth: *

Month Day Year
GENDER: *
CANDIDATE'S EMAIL ADDRESS: *
HOME NUMBER: (xxx-xxx-xxxx) *
TEEN'S CELL NUMBER: (xxx-xxx-xxxx)
ADDRESS: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
CANDIDATE LIVES WITH *

Both Parents Mother Father Stepmother Stepfather Grandparent(s) Guardian

Medical Information
Is this candidate in good health and able to participate in all activities in the Confirmation process? *

Yes No (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:

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

Month Day Year
Date of DPT

Month Day Year
Date of Tetanus Booster

Month Day Year
ALLERGIES or ILLNESSES

Hay Fever Asthma Sulfa Nuts Penicillin Gluten
Treatment: If any of the above is a yes, please state how the child has been (should be) treated and with what medication.

Emergency Contacts
In case of an emergency, besides you, who should we contact?
Emergency Contact's First and Last Name: *
Relationship to Candidate: *
Primary Phone Number: *

Area Code Phone Number
Secondary Phone Number:

Area Code Phone Number
Secondary Emergency Contact's First and Last Name:
Relationship to Candidate:
Primary Phone Number:

Area Code Phone Number
Secondary Phone Number:

Area Code Phone Number
Holy Family Confirmation, Eden Center 1520 Fremont Ave. South Pasadena. CA 91030 Mailing Address: 1527 Fremont Ave. South Pasadena, CA 626.403.6128 youthministry.holyfamily.org
Should be Empty:

Family Information