CCD Registration

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CCD Online Registration Form

Religious Education Online Registration Form
St. Elizabeth Ann Seton Church

Student Information

Student Name * Primer-Apellido Y Nombre

First

Last

Student Age * Anos

Date of Birth * Fecha Nacimaiento

YYYY

Last Grade Completed in CCD (if any) Apellido grado completocn

Name of Church where Completed Nombre de la Iglesia Donde complete

Sacraments

Baptism Date Dato Bautismo

YYYY

Name of Church (Need copy of baptismal certificate) Iglesia- necesitar pirata certificado

First Communion *

Yes

Name of Church Nombre de la Iglesia Donde complete

Family Information

Family Name * Nombre Familia

Mother * Madre

Father * Padre

Address * Direcion

Street Address
Address Line 2
City	State / Province / Region
Postal / Zip Code	Country

Home Phone * Telephono casa

###

####

Mobile Phone Cellular

###

####

Email

Special Health Needs

Does your child have any allergies or health issues? * Necesitades salud especial

Yes

If Yes please list here

Does your child carry an epi pen? *

Yes

Does your child have an IEP? *

Yes

Other relevant special needs or information

Emergency Information & Medical Waiver

By giving my electronic signature below, I do hereby give my permission as the parent or guardian of the above mentioned student to be treated for a medical emergency in my absence while participating in the St. Elizabeth Ann Seton religious education program. The director or volunteers may act as an agent in my absence. In case of an accident I do not hold the Diocese of Palm Beach, the parish or its staff or the adult volunteers responsible.

*Type your Full Name Here to agree to the above paragraph.

Emergency Contacts

In case you can not be reached in the event of an emergency, whom should be contacted?

Name *

First

Last

Home Phone *

###

####

Mobile Phone

###

####

Relationship to child

Parent Pick-up Release Form

We realize there may be times when someone other than yourself may have to pick up your child after CCD class. If you are not able to send a note or notify us, please list all the persons that are allowed to pick up your child from CCD (including yourself)

Primary Pickup Person *

First

Last

Alternate Pickup Person 1

First

Last

Alternate Pickup Person 2

First

Last

Alternate Pickup Person 3

First

Last

* Student pickup and drop off are in the main church parking lot. No one is to park in the CCD center except CCD teachers. Please follow this rule for the safety of our children and tell all those other than yourself who will be picking up your child. Thank you for your cooperation in this safety matter.

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