Boys Lock In - St. Thomas Chaldean Catholic Church

Son's Name(Required)

First Last

Date of Birth(Required)

Address(Required)

Street Address City State ZIP Code

High School Attending(Attended)(Required)

Grade in High School(Required)

9th Grade

10th Grade

11th Grade

12th Grade

Any Medical Conditions (if none please type none)(Required)

Any Allergies/Food Restrictions (if none please type none)(Required)

Are there any medications your son needs to take that we should keep track of? (Please include time, dosage, etc)(If none please type none)(Required)

Parent Name(Required)

First Last

Parent Cell Phone Number(Required)

Parent Email(Required)

Secondary Emergency Contact Name(Required)

First Last

Emergency Contact Cell Phone(Required)

Emergency Contact Relationship To Student(Required)

Signature of Parent(Required)

First Last

Date of Signature(Required)

Total Per Person

Price:

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

If you would ike to help St. Thomas out and pay for the 3.5% credit card processing fees please click YES below

YES

CC Processing Fees

Price: $0.00

Total