St. Patrick Church

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STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

REGISTRATION FORM 2022-2023

Registration Payment

$75.00

Participant Information

First Name: *

Last Name: *

Age: *

Address: *

City: *

State: *

Zip Code: *

DOB: *

School Attending: *

Grade: *

T-Shirt Size: *

Does your son have special needs, conditions, allergies, etc. that we should be aware of?

Child lives with: *

If other, explain relationship:

Parent Information

Mother's Name: *

Occupation: *

Religion: *

Cell #: *

Email: *

Father's Name: *

Occupation: *

Religion: *

Cell #: *

Email: *

Legal Guardian Name:

Religion:

Cell #:

Email:

Emergency Contact Information

Emergency Contact Name: *

In the event of an emergency we will first contact the parents or guardians. Please provide contact information for someone else if unable to reach the above individuals.

Relationship: *

Cell #: *

Video and Photography Consent

This allows you, the parent/guardian, to identify how images of your child may or may not be used for purposes of print, on-line class recording, social media communication or promotion. In any print, digital and on-line postings, your child will never be identified by written caption without specific written consent of the parent. Your child will never be “tagged” in any posting through social media.

Video and Photography Consent: *

The Diocese of Laredo has taken this step-in order to be in compliance with federal legislation for child protection, including The Children’s On-line Privacy Protection Act (COPPA http://www.ftc.gov/os/1999/9910/64fr59888.htm) and The Children's Internet Protection Act (CIPA https://www.fcc.gov/consumers/guides/childrens-internet-protection-act)

Person filling out this form

Your First Name: *

Your Last Name: *

Your Address: *

If different than above

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *