Old Mission San Juan Bautista Religious Education Registration Form Office Phone: (831) 623‐4178
[email protected] Today's Date:______________________________Amount Paid:____________________________Installments:____________________________ RCIA: 1st Yr [ ] 2nd Yr [ ] Birth Certificate [ ]
1st Communion: 1st Yr [ ] 2nd Yr [ ] Baptism Certificate [ ]
Confirmation: 1st Yr [ ] 2nd Yr [ ] Baptism/1st Comm. Certificate [ ]
Family Name / Apellido Children's Names / Nombre de Estudiantes e‐mail address / enviar electronica:___________________________________________________________________________________ ________ Parent/Guardian/Nombre de Padre Information:
Last Name/Apellido
Father/Padre [ ]
First Name/Nombre
Guardian/Custodio [ ]
Religion (optional)
Phone/Telefono
Address / Physical Address Domicilio / Apartado Postal
Parent/Guardian/Pariente/Custodio:
Last Name/Apellido
Mother/Madre [ ]
First Name/Nombre
Guardian/Custodio [ ]
Religion (optional)
Phone/Telefono
Mailing Address ONLY if parents / guardians have seperate addresses / include physical address when address is a P.O. Box. Emergency information ONLY if different from Parent /Guardian Information above: Informacion de presona solamente si los parientes no pueden responder en una emergencia: Person to Call/ Contacto
Phone / Numero
Names/Phone numbers of individuals who are permitted to pick up child:
1
Nombre y telefono de personas que usted confia llevarse sus ninos. 1.________________________________________ Name/Nombre Phone/Telefono Relationship:______________________________ Pariente/Amigo
2.________________________________________ Name/Nombre Phone/Telefono Relationship:______________________________ Pariente/Amigo
3.________________________________________ Name/Nombre Phone/Telefono Relationship:______________________________ Pariente/Amigo
4.________________________________________ Name/Nombre Phone/Telefono Relationship:______________________________ Pariente/Amigo
Children's Information: 1.________________________________________________________________________________________________________ Last Name/Apellido First Name/Nombre Grade/Grado Age/Edad ________________________________________________________________________________________________________ Date of Birth/Fecha de Nacimiento Place of Birth/Donde Nacio Sacraments Received:
Date / Church / Place of Baptism / Fecha de Bautismo/Iglesia de Bautismo
Date / Church / Place of 1st Communion / Fecha de Primera Comunion/Iglesia de Comunion
Date / Church / Place of Confirmation / Fecha de Confirmacion 2.________________________________________________________________________________________________________ Last Name/Apellido First Name/Nombre Grade/Grado Age/Edad ________________________________________________________________________________________________________ Date of Birth/Fecha de Nacimiento Place of Birth/Donde Nacio Sacraments Received:
2
__________________________________________________________________________________________________________ Date / Church / Place of Baptism / Fecha de Bautismo/Iglesia de Bautismo
Date / Church / Place of 1st Communion / Fecha de Primera Comunion/Iglesia de Comunion
Date / Church / Place of Confirmation / Fecha de Confirmacion 3.________________________________________________________________________________________________________ Last Name/Apellido First Name/Nombre Grade/Grado Age/Edad ________________________________________________________________________________________________________ Date of Birth/Fecha de Nacimiento Place of Birth/Donde Nacio Sacraments Received: __________________________________________________________________________________________________________ Date / Church / Place of Baptism / Fecha de Bautismo/Iglesia de Bautismo Date / Church / Place of 1st Communion / Fecha de Primera Comunion/Iglesia de Comunion Date / Church / Place of Confirmation / Fecha de Confirmacion
Family Medical Information: ___________________________________________________________________________________________ Family Physician/Medico Phone/Numero
___________________________________________________________________________________________ Family Dentist/Dientista Phone/Numero Allergies/Alergias: [ ] YES/Si [ ] NO List of Allergies/Lista de Alergias:
Is you child on Medications?
[ ] YES
[ ] NO
List of Medicatons:____________________________ 3
Other Special Needs/Otras Necesidades:______________________________________________________ __________________________________________________________________________________________ Should it be necessary for my child to have medical treatment, I, Hereby give Old Mission San Juan Bautista Teaching Center Personnel permission to use their judgment in obtaining medical services for my child, and I give permission to the physician selected by the personnel to render medical treatment deemed necessary and appropriate. I agree that in the event my child or children, is or are injured as a result of his/her participating in the religious education program, recourse for the payment of any resulting hospital, medical or related costs and expenses will first be had against any accident, hospital or medical insurance, or any available benefit plan of mine or my spouse.
Parent/Guardian Signature
Date
Si es necesario parami nino recibir tratamiento medico, yo, Por estemedio da a Mision San Juan Bautista Departa mento de educacion religios el permiso de Personal de usar su juicio en la obtencion de servicios medicos para mi nino, Y doy el permiso al medico seleccionado por el personal para dar medico el tratamiento juzgo necesario y apropiado. Estoy de acuerdo que tal como resulto despues mi nino o ninos, son heridos a comsecuencia de su participación en el programa de educación religioso, recurso para el pago de cualquier hospital que resulta, medico o los gastos relacionados y los gastos serán primero cotra cualquier accidente, hospital o seguro medico, o cualquier plan de beneficios disponible mío o mi cónyuge.
Firma
Fecha
Volunteer / Donations for Religious Education Program: 4
Please check one of the following areas where you are interested in helping us. [ ] Contribution to our Scholarship Fund [ ] Catechist for 1st through 5th grade (Wednesday afternoons 2:00 pm ‐ 3:30 pm) [ ] Catechist for 6th through 9th grades (Thursday, twice a month 7:00 pm ‐ 8:30 pm) [ ] Be a helper for Catechist Wednesday afternoons, or Thursday evenings [ ] Fundraisers for 1st and 2nd Year : Parking Cars [ ] ***************************************************************************************************
****THIS SPACE IS FOR OFFICE USE ONLY****
Please make checks payable to: Old Mission San Juan Bautista
Registration Fees One Child
$45 :___________________________________
Two Children
$60 :___________________________________
Three Children
$70 :___________________________________
Retreat Fees First Eucharist Retreat Fee
$20 :___________________________________
1st Yr Confirmation Retreat Fee
$20 :___________________________________
2nd Yr Confirmation Retreat Fee St Francis Retreat Center
$50 :
Total Due:____________________________________
Amt Paid:__________________ Baptism Certificate: [ ] Received
Cash:_____________ Check#_____________Installments: Not received: [ ] 5
Date rec'd: ________
RCIA: Birth Certificate: [ ] Received Notes:
Not received: [ ]
6
Date rec'd: ________