2019 - 2020 Saint David Catholic Church

Registration CCD

PLEASE PRINT LEDGIBLY: This form cannot be processed, unless all information is provided.

Today’s Date: ____________________________	SAINT DAVID C.C.D. OFFICE - 954-475-1521

SAINT DAVID CHURCH OFFICE - 954-475-8046

Family Last Name (with whom student lives):_________________________________________

Street Address ________________________________City________________ Zip___________

Home Number_______________________________________

Email address: ______________________________________

Parent/Guardians

I, ______________, am interested in being considered as a Religious Education volunteer for: Teacher__Aide___Other:__

Names of Children Registering for CCD:

1.____________________ 2. ____________________ 3. ____________________ 4____________________

STUDENT HEALTH EMERGENCY INFORMATION

EMERGENCY CONTACT: (Please write other than parent/guardian names as Emergency Contact)

1._______________________________ CELL: __________________ HOME: __________________

2._______________________________ CELL: __________________ HOME: __________________

3._______________________________ CELL: __________________ HOME: __________________

Indicate Special Health Concerns: ______________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Physician: ___________________________________ Phone: (____) ________________________

Hospital of Choice: _____________________________ Phone: (____) ________________________

Address: _________________________________________________________________________

I, the undersigned, do hereby authorize officials of Saint David Religious Education Department to contact directly the person named on this form and do authorize the named physician or his/her designee to render such treatment as may be deemed necessary in an emergency, for the health of said student. In the event that physicians or other person listed on this form cannot be contacted, the Religious Education Department officials are herby authorized to take whatever action deemed necessary in their judgment for the health of the aforesaid student. I will not hold Saint David Catholic Church financially responsible for the emergency care and/or transportation for said students.

Parent/Guardian Signature:_______________________________________Date:__________________

Father:

Parent/Guardian Name: ___________________

Relationship to Child: ________________________

Occupation: _______________________________

Cell Phone: (______) ______________________

Work Phone: (______) _____________________

E-mail Address: ____________________________

Religion: __________Marital Status: ___________

Mother:

Parent/Guardian Name: ___________________

(1ST and last name)

Relationship to Child: ________________________

Occupation: _______________________________

Cell Phone: (______) ______________________

Work Phone: (______) _____________________

E-mail Address: ____________________________

Religion: __________Marital Status: ___________

Tuition and Fees (per year)	Office Use Only

One Child:	_______________________	Number of Children enrolled: ___________

Two Children: _______________________	Tuition$: __________ AMT Paid: ________

Three or more Children: _______________	Sacrament Fees $: __________________

$50 Confirmation Fee: ________________	Amount Due: _______________

$30 Communion Fee: ________________	Check#:___________Cash:_____________

Initials: _______________________

STUDENT INFORMATION

FIRST STUDENT REGISTRATION FEE - $ 180.00

CHILD’S NAME: ____________________________________________________________ SEX: _____________

C.C.D. SESSION: TUESDAY (CIRCLE ONE) 3:30 - 4:30pm (K-4) OR 6:30 - 7:30pm (K-8)

UPCOMING SCHOOL GRADE: ______________ C.C.D. GRADE: ____________ (OFFICE USE ONLY)

BIRTH DATE: _____/_____/_____	BAPTIZED CATHOLIC: YES NO (CIRCLE ONE)

A COPY OF THE CHILD’S BAPTISMAL CERTIFICATE ATTACHED IS MANDATORY

DATE OF BAPTISM _____/_____/_____ NAME AND ADDRESS OF CHURCH _________________________________

HAS THIS CHILD RECEIVED FIRST PENANCE? YES NO (CIRCLE ONE)

DATE: _____/_____/_____ NAME OF CHURCH ___________________________________________________

HAS THIS CHILD RECEIVED FIRST COMMUNION? YES NO (CIRCLE ONE) PLEASE ATTACH CERTIFICATE

DATE: _____/_____/_____ NAME OF CHURCH____________________________________________________

ANY HEALTH PROBLEMS: ___________________________ ANY LEARNING PROBLEMS: _________________________

SECOND CHILD - $105.00

CHILD’S NAME: ____________________________________________________________ SEX: _____________

C.C.D. SESSION: TUESDAY (CIRCLE ONE) 3:30 - 4:30pm (K-4) OR 6:30 - 7:30pm (K-8)

UPCOMING SCHOOL GRADE: ______________ C.C.D. GRADE: ____________ (OFFICE USE ONLY)

BIRTH DATE: _____/_____/_____	BAPTIZED CATHOLIC: YES NO (CIRCLE ONE)

A COPY OF THE CHILD’S BAPTISMAL CERTIFICATE ATTACHED IS MANDATORY

DATE OF BAPTISM _____/_____/_____ NAME AND ADDRESS OF CHURCH _________________________________

HAS THIS CHILD RECEIVED FIRST PENANCE? YES NO (CIRCLE ONE)

DATE: _____/_____/_____ NAME OF CHURCH ___________________________________________________

HAS THIS CHILD RECEIVED FIRST COMMUNION? YES NO (CIRCLE ONE) PLEASE ATTACH CERTIFICATE

DATE: _____/_____/_____ NAME OF CHURCH____________________________________________________

ANY HEALTH PROBLEMS: ___________________________ ANY LEARNING PROBLEMS: _________________________

THIRD CHILD - $105.00

CHILD’S NAME: ____________________________________________________________ SEX: _____________

C.C.D. SESSION: TUESDAY (CIRCLE ONE) 3:30 - 4:30pm (K-4) OR 6:30 - 7:30pm (K-8)

UPCOMING SCHOOL GRADE: ______________ C.C.D. GRADE: ____________ (OFFICE USE ONLY)

BIRTH DATE: _____/_____/_____	BAPTIZED CATHOLIC: YES NO (CIRCLE ONE)

A COPY OF THE CHILD’S BAPTISMAL CERTIFICATE ATTACHED IS MANDATORY

DATE OF BAPTISM _____/_____/_____ NAME AND ADDRESS OF CHURCH _________________________________

HAS THIS CHILD RECEIVED FIRST PENANCE? YES NO (CIRCLE ONE)

DATE: _____/_____/_____ NAME OF CHURCH ___________________________________________________

HAS THIS CHILD RECEIVED FIRST COMMUNION? YES NO (CIRCLE ONE) PLEASE ATTACH CERTIFICATE

DATE: _____/_____/_____ NAME OF CHURCH____________________________________________________

ANY HEALTH PROBLEMS: ___________________________ ANY LEARNING PROBLEMS: _________________________

I and my student have reviewed, read and gone onto the Saint David CCD web page to read the handbook. I, as parent/guardian, and my student agree to abide by the rules and regulations of Saint David Church Religious Education Program.

FAMILY INFORMATION

Pat Potenza

2019-03-29

Paula

Saint David Catholic Church