2019 - 2020 St. Teresa Church Religious Education Registration
Event Timing: September 29, 2019 - May 31, 2020
Grades K-5: Saturdays
Grades 6-8: Sundays
Address: 141 Henry Street, New York, NY 10002
Contact us at (212) 233-0233 or StTeresaYouthNY@gmail.com
Email address *
First Name of Student *
Your answer
Last Name of Student *
Your answer
Date of Birth *
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School Grade in September 2019 *
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
College
Grade
Name of School Child Attends *
Your answer
Last Grade completed in Religious Education *
None
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Grade
Name of Parish Where Completed:
Your answer
Name of Church where student was Baptized:
Your answer
Baptism Year:
Your answer
Name of Church where student received First Communion :
Your answer
First Communion Year:
Your answer
Is the student preparing for a communion if so what year of preparation are they in: *
Is the student preparing for a confirmation if so what year of preparation are they in: *
Is the student is interested in joining the following Youth Ministry Programs *
Required
Is your family registered at St. Teresa Church? *
Name of Parent / Guardian (Last Name, First Name) *
Your answer
Home Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Primary Phone Number *
Your answer
Secondary Phone Number
Your answer
Email *
Your answer
Does student have any allergies or health issues: *
If so, please provide details below:
Your answer
Does the Student carry an Epi Pen: *
Does the Student have an IEP (Individualized Education Plan) *
If so, please provide details below:
Your answer
Any Special needs or relevant information that you would like us to know:
Your answer
Dietary restrictions *
Emergency Contact ( Last Name, First Name) *
Your answer
Relationship to Student: *
Your answer
Emergency Contact Phone Number *
Your answer
Who is allowed to pick up Student: (Please provide full name and contact phone numbers) *
Your answer
Electronic Signature (Last Name, First Name) *
Your answer
Date of Registration *
MM
/
DD
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YYYY
I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document. *
Required
Z. I understand that checking this box I attest that our family will donate $25.00 per semester toward the religious instruction of my child. *
Required
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