ST. HELENA RELIGIOUS EDUCATION PROGRAM REGISTRATION FORM

ST. HELENA RELIGIOUS EDUCATION PROGRAM REGISTRATION FORM

Emergency Information
Parents/Guardians,

We have adopted the following procedures in caring for you child(ren). Who is allowed to pick up your child(ren) on Monday night in your absence? These people will also be called if we cannot reach you in the event that your child becomes ill or injured.
Emergency Contact 1*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Emergency Contact 2

First NameLast Name
Phone Number
Please enter a valid phone number.
Emergency Contact 3

First NameLast Name
Phone Number
Please enter a valid phone number.
If none of the above answer, we will call an ambulance, if necessary and take your child to Nemours Hospital for Children.
Medical Insurance: Name of Company ID # Group #

Additional Children
Child 2's Legal Full Name

First NameMiddle NameLast Name
Gender

MaleFemale
Child's Date of Birth

MonthDayYear
Date
School
Grade
Grade in Religious Ed Class
Student was Baptized on Date at Church Name in City, State
Student received Reconciliation on Date at Church Name in City, State
Student received Eucharist on Date at Church Name in City, State
Please indicate any medical/learning problems the student has:
Does the child take any medications regularly? Please list:
Please indicate any allergies, especially to food:
Child 3's Legal Full Name

First NameMiddle NameLast Name
Gender

MaleFemale
Child's Date of Birth

MonthDayYear
Date
School
Grade
Grade in Religious Ed Class
Student was Baptized on Date at Church Name in City, State
Student received Reconciliation on Date at Church Name in City, State
Student received Eucharist on Date at Church Name in City, State
Please indicate any medical/learning problems the student has:
Does the child take any medications regularly? Please list:
Please indicate any allergies, especially to food:
Child 4's Legal Full Name

First NameMiddle NameLast Name
Gender

MaleFemale
Child's Date of Birth

MonthDayYear
Date
School
Grade
Grade in Religious Ed Class
Student was Baptized on Date at Church Name in City, State
Student received Reconciliation on Date at Church Name in City, State
Student received Eucharist on Date at Church Name in City, State
Please indicate any medical/learning problems the student has:
Does the child take any medications regularly? Please list:
Please indicate any allergies, especially to food:

Signature and Submit
Would you like to receive email updates for St. Helena via Flock Notes?*

YesNo
Would you like to register as a parishioner at St. Helena? (If yes, we will send a registration link via email.)*

YesNo
Signature*

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