CHILD'S LAST NAME:
*
CHILD'S FIRST NAME:
*
CHILD'S MIDDLE NAME:
AKA:
Date of Birth:
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
GENDER:
*
Please Select
Female
Male
CHILD'S EMAIL ADDRESS: (to be used for MSM communication only)
*
ADDRESS:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
HOME NUMBER: (xxx-xxx-xxxx)
*
CHILD LIVES WITH:
*
Both Parents
Mother
Father
Stepmother
Stepfather
Grandparent(s)
Guardian
Other
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Family Information
MOTHER'S FIRST NAME:
*
MOTHER'S LAST NAME:
*
MOTHER'S FAITH TRADITION:
*
Please Select
Roman Catholic
Other
MOTHER'S EMAIL:
*
CELL PHONE NUMBER
-
Area Code
Phone Number
WORK PHONE NUMBER
-
Area Code
Phone Number
FATHER'S FIRST NAME:
*
FATHER'S LAST NAME:
*
FATHER'S FAITH TRADITION:
*
Please Select
Roman Catholic
Other
WORK PHONE: (xxx-xxx-xxxx)
CELL PHONE: (xxx-xxx-xxxx)
FATHER'S EMAIL:
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Medical Information
Is this child in good health and able to participate in all activities in Middle School Ministry?
*
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
Date Picker Icon
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 Picker Icon
Date of DPT
-
Month
-
Day
Year
Date Picker Icon
Date of Tetanus Booster
-
Month
-
Day
Year
Date Picker Icon
ALLERGIES or ILLNESSES
Hay Fever
Asthma
Sulfa
Nuts
Penicillin
Gluten
Other
Treatment: If any of the above is a yes, please state how the child has been (should be) treated and with what medication.
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Sacramental Information
DATE OF BAPTISM:
-
Month
-
Day
Year
Date Picker Icon
CHURCH OF BAPTISM:
Address for Church of Baptism:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Upload a copy of the Baptismal Certificate
DATE OF FIRST EUCHARIST:
-
Month
-
Day
Year
Date Picker Icon
CHURCH OF FIRST EUCHARIST:
Address for Church of First Eucharist:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Upload a copy of first Eucharist certificate
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First Eucharist Certificate
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LAST GRADE OF RELIGIOUS EDUCATION:
HOME PARISH:
*
MSM SESSION:
Please see schedule as they change each month. We also participate in Family Faith Formation sessions once a month.
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School Information
MIDDLE SCHOOL:
*
GRADE IN 9/2021
*
Please Select
6th
7th
8th
PLEASE LIST ALL EXTRACURRICULAR ACTIVITIES:
*
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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
Heading
Submit
Should be Empty: