Parent InformationLast Name:(Required)Father’s Name(Required)Mother’s Name:(Required)Please Enter Address Below(Required) Address Number and Street City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Email (For All Main Communication During The Year)(Required) Home PhoneFather's Cell PhoneMother's Cell PhoneEmergency Contact Person:(Required)Emergency PhoneChild(ren) InformationHow Many Children Will Be Registered This Year(Required) 1 2 3 4 Child 1 First Name(Required)Child 1 - Date of Birth(Required) Child 1 - Grade in September(Required) PLEASE NOTE: When a Grade Has Reached Capacity, It Will No Longer Appear In The Drop Down List.SELECT CHILD'S CURRENT GRADE1st Grade2nd Grade3rd Grade4th Grade5th GradeDoes your child have a learning disability? If so please explain.Does your child have a food allergy? If so, indicate child and type of alergy.Child 2 First Name(Required)Child 2 - Date of Birth(Required) Child 2 - Grade in September(Required) PLEASE NOTE: When a Grade Has Reached Capacity, It Will No Longer Appear In The Drop Down List.SELECT CHILD'S CURRENT GRADE1st Grade2nd Grade3rd Grade4th Grade5th GradeDoes your child have a learning disability? If so please explain.Does your child have a food allergy? If so, indicate child and type of alergy.Child 3 First Name(Required)Child 3 - Date of Birth(Required) Child 3 - Grade in September(Required) PLEASE NOTE: When a Grade Has Reached Capacity, It Will No Longer Appear In The Drop Down List.SELECT CHILD'S CURRENT GRADE1st Grade2nd Grade3rd Grade4th Grade5th GradeDoes your child have a learning disability? If so please explain.Does your child have a food allergy? If so, indicate child and type of alergy.Child 4 First Name(Required)Child 4 - Date of Birth(Required) Child 4 - Grade in September(Required) PLEASE NOTE: When a Grade Has Reached Capacity, It Will No Longer Appear In The Drop Down List.SELECT CHILD'S CURRENT GRADE1st Grade2nd Grade3rd Grade4th Grade5th GradeDoes your child have a learning disability? If so please explain.Does your child have a food allergy? If so, indicate child and type of alergy.Touching Safety ProgramOur parish will be presenting a Child Abuse Prevention Program called the “Touching Safety Program” to all the children and youth enrolled in our parish programs. It is provided by St. Thomas Chaldean Diocese and is a part of our ongoing effort to help create and maintain a safe environment for children and to protect all children from sexual abuse. This educational program is mandated by the Conference of Catholic Bishops. As a parent you have a right to choose whether your child participates. If you have any question about the program you may contact your pastor. Touching Safety Program (Similar to Protecting God's Children)(Required) (YES) I give my permission to have my child participate in this safety program (NO) I decline to have my child participate in this safety program Credit Card PaymentSubtotal $0.00 If you like to cover the credit card processing fees of 3.5% please click on the box below YES CC Processing Fees Price: $0.00 Total Credit Card(Required) American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 Security Code Cardholder Name
