St. Patrick Church

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

REGISTRATION FORM 2023-2024

Annual Membership Fee + T-Shirt and Prayer Book

$75.00

Registrant Information

First Name: *

Last Name: *

Age: *

Address: *

City: *

State: *

Zip Code: *

DOB: *

School Attending: *

Grade: *

T-Shirt Size: *

Special need or condition:

Let us know if your daughter has any special need or condition.

Child lives with: *

Other:

Parent Information

Mother First Name: *

Mother Last Name: *

Occupation: *

Home #:

Cell #: *

Work #: *

Email: *

Father First Name: *

Father Last Name: *

Occupation: *

Home #:

Cell #: *

Work #: *

Email: *

Emergency Contact Information

Emergency Contact Name: *

Relationship: *

Home #:

Cell #: *

Signature: *

Date: *

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)

Payer Information

First Name: *

Last Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *