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St.Theresa PSR Registration 2016-2017 (Registro parroquial para la escuela de religión)
Please complete all information....you may bring payment ($30 per child) to Orientation on 8/28/16 @ 9:00 AM. Please contact Mrs. Wadsworth (samanthawads@gmail.com) if you need to make financial arrangements.
Family Last Name (Apellido de Familia)
Your answer
Father's Name (Nombre de padre)
Your answer
Mother's Name (Nombre de Madre)
Your answer
Children live with? (niños/as viven con)
If other, please explain....
Your answer
If parents are separated/divorced are there custody issues the teacher should be aware of? (Si los padres están separados/divorciados, hay algo de la custodia que la maestra debe estar enterada?)
If yes, please explain..(Si es si, por favor explique)
Your answer
Religion of Father (Religión de Padre)
Your answer
Religion of Mother (Religión de Madre)
Your answer
Father's Address (Dirección del Padre)
Your answer
Father's Cell Phone # (Padre Teléfono de celular)
Your answer
Father's Home Phone # (Padre Teléfono de casa)
Your answer
Father Work Phone # (Padre Teléfono de trabajo)
Your answer
Father's Email address (Correo elextronico)
Your answer
Mother's Address (Dirección de la Madre)
Please type "same" if this applies.
Your answer
Mother's Cell Phone # (MadreTeléfono de celular)
Your answer
Mother's Home Phone # (Madre Teléfono de casa)
Your answer
Mother's Work Phone #
Your answer
Mother's Email address (Correo elextronico)
Your answer
We are registered members of St. Theresa and have completed Parish Census Information. (Estamos registrados en la Iglesia Catolica de St. Theresa y llenamos una tarjeta de registro):
1. Student's Full Name (Nombre del estudiante)
Please note there are enough spaces here to register 6 students (marked by numbers 1-6, each number represents THAT child only) once you have completed the number of students in your family, simply scroll past the rest to finish the form. Please complete all information for every child.
Your answer
1. Male or Female (Hombre o Mujer)
1. School Attending (Nombre de escuela)
Your answer
1. Grade (Grado)
Your answer
1. Date of Birth (Fecha de Nacimento)
Your answer
1. Baptized? (date/parish) Bautizado (fecha ylugar)
Your answer
1. First Penance (date/parish) Primera confesion (fecha y lugar)
Your answer
1. First Communion (date/parish) Primera Comunion (fecha y lugar)
Your answer
1. Confirmation (date/parish) Confirmacion (fecha ylugar)
Your answer
1. Please list any allergies (alergias)/special needs/social concerns (Preocupacianes especiales) /any other concerns for this child
Your answer
2. Student's Full Name (Nombre del estudiante)
Your answer
2. Male or Female (Hombre o Mujer)
2. School Attending (Nombre de escuela)
Your answer
2. Grade (Grado)
Your answer
2. Date of Birth (Fecha de Nacimento)
Your answer
2. Baptized? (date/parish) Bautizado (fecha ylugar)
Your answer
2. First Penance (date/parish) Primera confesion (fecha y lugar)
Your answer
2. First Communion (date/parish) Primera Comunion (fecha y lugar)
Your answer
2. Confirmation (date/parish) Confirmacion (fecha ylugar)
Your answer
2. Please list any allergies (alergias)/special needs/social concerns (Preocupacianes especiales) /any other concerns for this child
Your answer
3. Student's Full Name (Nombre del estudiante)
Your answer
3. Male or Female (Hombre o Mujer)
3. School Attending (Nombre de escuela)
Your answer
3. Grade (Grado)
Your answer
3. Date of Birth (Fecha de Nacimento)
Your answer
3. Baptized? (date/parish) Bautizado (fecha ylugar)
Your answer
3. First Penance (date/parish) Primera confesion (fecha y lugar)
Your answer
3. First Communion (date/parish) Primera Comunion (fecha y lugar)
Your answer
3. Confirmation (date/parish) Confirmacion (fecha ylugar)
Your answer
3. Please list any allergies (alergias)/special needs/social concerns (Preocupacianes especiales) /any other concerns for this child
Your answer
4. Student's Full Name (Nombre del estudiante)
Your answer
4. Male or Female (Hombre o Mujer)
4. School Attending (Nombre de escuela)
Your answer
4. Grade (Grado)
Your answer
4. Date of Birth (Fecha de Nacimento)
Your answer
4. Baptized? (date/parish) Bautizado (fecha ylugar)
Your answer
4. First Penance (date/parish) Primera confesion (fecha y lugar)
Your answer
4. First Communion (date/parish) Primera Comunion (fecha y lugar)
Your answer
4. Confirmation (date/parish) Confirmacion (fecha ylugar)
Your answer
4. Please list any allergies (alergias)/special needs/social concerns (Preocupacianes especiales) /any other concerns for this child
Your answer
5. Student's Full Name (Nombre del estudiante)
Your answer
5. Male or Female (Hombre o Mujer)
5. School Attending (Nombre de escuela)
Your answer
5. Grade (Grado)
Your answer
5. Date of Birth (Fecha de Nacimento)
Your answer
5. Baptized? (date/parish) Bautizado (fecha ylugar)
Your answer
5. First Penance (date/parish) Primera confesion (fecha y lugar)
Your answer
5. First Communion (date/parish) Primera Comunion (fecha y lugar)
Your answer
5. Confirmation (date/parish) Confirmacion (fecha ylugar)
Your answer
5. Please list any allergies (alergias)/special needs/social concerns (Preocupacianes especiales) /any other concerns for this child
Your answer
6. Student's Full Name (Nombre del estudiante)
Your answer
6. Male or Female (Hombre o Mujer)
6. School Attending (Nombre de escuela)
Your answer
6. Grade (Grado)
Your answer
6. First Communion (date/parish) Primera Comunion (fecha y lugar)
Your answer
6. Date of Birth (Fecha de Nacimento)
Your answer
6. Baptized? (date/parish) Bautizado (fecha ylugar)
Your answer
6. First Penance (date/parish) Primera confesion (fecha y lugar)
Your answer
6. Confirmation (date/parish) Confirmacion (fecha ylugar)
Your answer
6. Please list any allergies (alergias)/special needs/social concerns (Preocupacianes especiales) /any other concerns for this child
Your answer
Emergency Contact & Phone #'s
Your answer
Family Physician & Phone #
Your answer
Health Insurance Provider
Your answer
Contract/Policy #
Your answer
In case my child needs medical attention, I authorize a representative of St. Theresa Catholic Church to act on my behalf: En caso de que mi niño/a necesite atención medica, autorizo un representante de la Iglesia Católica de St. Theresa a actuar en mi favor:
Electronic Signature
Please type the name of the parent or guardian completing this form.
Your answer
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