Our Lady of Grace Parish Youth Ministry - Confirmation Year 2 Registration - 2022-2023
Annual Tuition Fee: $170. (Please note that there will be an additional cost (TBD) for the mandatory Year 2 Confirmation Retreat.

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Email *
CANDIDATE INFORMATION
Candidate Last Name *
Candidate First Name *
Candidate Full Mailing Address *
Candidate Date of Birth *
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Gender *
Home Phone # *
Cell Phone #
OK to text Candidate? *
Candidate email address *
High School attending *
Grade in Fall *
Any special needs, allergies or medications? Please note Yes or No and describe further if Yes. *
PARENT/LEGAL GUARDIAN INFORMATION
Mother's (or Legal Guardian) First and Last Name *
Mother's (or Legal Guardian) Mailing Address (if different from candidate)
Mother's (or Legal Guardian) Cell Phone *
Mother's (or Legal Guardian) Home Phone (if different from candidate)
Mother's (or Legal Guardian) Work Phone *
Mother's (or Legal Guardian) Email address *
Mother's (or Legal Guardian) Religion *
Father's First and Last Name *
Father's Mailing Address (if different from candidate)
Father's Cell Phone *
Father's Home Phone (if different from candidate)
Father's Work Phone *
Father's Email Address *
Father's Religion *
CANDIDATE BAPTISM INFORMATION
Is Candidate Baptized? *
If Baptized, date of Baptism
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If Baptized, Church name and city
If Baptized, I will submit a copy of the Baptism Certificate by: *
Has Candidate received First Holy Communion? *
EMERGENCY INFORMATION (Two Contacts Required)
Emergency Contact #1 First and Last Name *
Emergency Contact #1 Relationship to Student *
Emergency Contact #1 Cell Phone # *
Emergency Contact #2 First and Last Name *
Emergency Contact #2 Relationship to Student *
Emergency Contact #2 Cell Phone # *
IN THE EVENT OF A MAJOR EARTHQUAKE OR MEDICAL EMERGENCY, I AUTHORIZE THE ABOVE-NAMED EMERGENCY CONTACTS TO PICK UP MY CHILD, IF I AM UNABLE TO DO SO.  BY TYPING MY NAME AND DATING BELOW, I AFFIRM THIS AUTHORIZATION.
EN CASO DE UN TERREMOTO O EMERGENCIA MEDICA, LA PERSONA MENCIONADA ARRIBA TIENE LA AUTORIZACION DE REGOGER A MI NINO/NINA DEL LAS ESCUAELA SI ES IMPOSIBLE PARA MI HACERLO. PONGA MI NOMBRE PARA CONFIRMAR LA AUTORIZACION.
Parent/Legal Guardian Name *
Date of Signature *
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PHOTO RELEASE
I GIVE MY PERMISSION FOR MY CHILD TO BE PHOTOGRAPHED FOR THE FOLLOWING PURPOSES: FOR STUDENT RECORDS, FOR USE IN CLASS PROJECTS, FOR PARISH BULLETIN BOARDS AND FOR YOUTH MINISTRY SOCIAL MEDIA PAGES (Facebook, Instagram, etc.) (Child will not be identified by name.) BY TYPING MY NAME AND DATING BELOW, I AUTHORIZE THIS RELEASE.
DOY PERMISO PARA QUE MI NINO/NINA SEA FOTOGRAFIADO/A PARA LO SIGUIENTE: PARA LOS RECORDS DEL ESTUDIATE, PARA USO EN PROYECTOS DE LA CLASE, Y POR ANUNCIOS DE LA PARROQUIA Y LOS RADIO SOCIALES (Facebook, Instagram, etc.). (MI NINO/NINA NO SERA IDENTIFICADOS/AS POR NOMBRE.) PONGA MI NOMBRE PARA CONFIRMAR LA AUTORIZACION.
Parent/Legal Guardian Name *
Date of Signature *
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I will submit payment of $160 by: *
Required
Our Lady of Grace Youth Ministry Contact Information
Jesse Rodriguez, Director of Religious Education/Youth Minister, Our Lady of Grace Parish, 5001 White Oak Ave. Encino, CA 91316 - (818)342-4686 - dre@ourladyofgrace.org
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