Religious Education Registration Form

Religious Education Registration Form
Student 1 *

First Name Middle Name Last Name
Birth Date *

Month Day Year
Grade *
Student 2

First Name Middle Name Last Name
Birth Date

Month Day Year
Grade
Student 3

First Name Middle Name Last Name
Birth Date

Month Day Year
Grade
Student 4

First Name Middle Name Last Name
Birth Date

Month Day Year
Grade
Family Information
Mother's Name

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Father's Name

First Name Last Name
Address (if different from Mother's)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone in case of emergency (if different)

Area Code Phone Number
Preferred Family Email Address *

Payment

1 Parent Guide + 1 Student Activity Book $ 30.00

1 Parent Guide + 2 Student Activity Books $ 45.00

1 Parent Guide + 3 Student Activity Books $ 60.00

1 Parent Guide + 4 Student Activity Books $ 75.00

I have a student in First Communion Prep Class $ 25.00

Quantity

I have a student in Confirmation Class $ 25.00

Quantity

I would like you to mail me my books $ 4.00

price per family

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

Notes
Should be Empty: