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Registration Form

- Registration

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- Today's Date REQUIRED Please fill out this field. Please enter a date.
- Select one of the following: REQUIRED Please fill out this field.
- Family Last Name REQUIRED Please fill out this field. Please enter valid data.
- Street Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Family Email Please enter an email address.
- Head of Household 1
  
  Title REQUIRED Mr Miss Ms Mrs Please fill out this field.
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Maiden Name (if female) Please enter valid data.
  
  Primary Phone Number REQUIRED
  
  Please fill out this field. Please enter a phone number.
  
  Marital Status REQUIRED Single Married Separated Divorced Widowed Please fill out this field.
  
  Date of Birth (mm/dd/yyyy) REQUIRED Please fill out this field. Please enter a date.
  
  Religion REQUIRED Please fill out this field. Please enter valid data.
  
  Sacraments Received REQUIRED Baptism Eucharist Confirmation None Please fill out this field.
  
  Place of Employment Please enter valid data.
  
  Work Phone Number
  
  Please enter a phone number.
- Head of Household 2
  
  Title Mr Miss Ms Mrs
  
  First Name Please enter valid data.
  
  Last Name Please enter valid data.
  
  Maiden Name (if female) Please enter valid data.
  
  Relationship to Head of Household 1 Please enter valid data.
  
  Phone Number
  
  Please enter a phone number.
  
  Date of Birth (mm/dd/yyyy) Please enter a date.
  
  Religion Please enter valid data.
  
  Sacraments Received Baptism Eucharist Confirmation None
  
  Place of Employment Please enter valid data.
  
  Work Phone Number
  
  Please enter a phone number.
- Do you reside at the address? REQUIRED Full Time Part Time Please fill out this field.
- Emergency Contact Information REQUIRED Please fill out this field.
  
  Emergency Contact 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED
  
  Please fill out this field. Please enter a phone number.
  
  This person's relationship to Head of Household: REQUIRED Please fill out this field. Please enter valid data.
- Children under the age of 18 who currently live with you. REQUIRED Please fill out this field.
  
  Child/Student 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth (mm/dd/yyyy) REQUIRED Please fill out this field. Please enter a date.
  
  Age REQUIRED Please fill out this field. Please enter an integer (number).
  
  Gender REQUIRED Male Female Please fill out this field.
  
  Religion REQUIRED Please fill out this field. Please enter valid data.
  
  Sacraments Received REQUIRED Baptism Eucharist Confirmation None Please fill out this field.
  
  Name of School REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Level REQUIRED Please fill out this field.
  
  Session Option REQUIRED Please fill out this field.
  
  Any special needs of which we should be aware? Allergies Disabilities Other
  
  Please specify
  
  Primary person to whom you are allowing your child(ren) to be released: REQUIRED Please fill out this field. Please enter valid data.
  
  Alternate person to whom you are allowing your child(ren) to be released: REQUIRED Please fill out this field. Please enter valid data.
  
  SAFE ENVIRONMENT / ABUSE PREVENTION CLASSES
  
  Each year our Diocese requires that we educate our Parish children regarding abuse prevention and personal safety. Children are taught at age-appropriate levels and from the “Sanctity of Life” point of view. The “Opt-Out Form” is to be completed only if you would NOT like your child to participate in this class.
  
  Choose one: REQUIRED I am requesting an Opt-Out Form I am not requesting an Opt-Out Form Please fill out this field.
  
  Child/Student 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth (mm/dd/yyyy) REQUIRED Please fill out this field. Please enter a date.
  
  Age REQUIRED Please fill out this field. Please enter an integer (number).
  
  Gender REQUIRED Male Female Please fill out this field.
  
  Religion REQUIRED Please fill out this field. Please enter valid data.
  
  Sacraments Received REQUIRED Baptism Eucharist Confirmation None Please fill out this field.
  
  Name of School REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Level REQUIRED Please fill out this field.
  
  Session Option REQUIRED Please fill out this field.
  
  Any special needs of which we should be aware? Allergies Disabilities Other
  
  Please specify
  
  Primary person to whom you are allowing your child(ren) to be released: REQUIRED Please fill out this field. Please enter valid data.
  
  Alternate person to whom you are allowing your child(ren) to be released: REQUIRED Please fill out this field. Please enter valid data.
  
  SAFE ENVIRONMENT / ABUSE PREVENTION CLASSES
  
  Each year our Diocese requires that we educate our Parish children regarding abuse prevention and personal safety. Children are taught at age-appropriate levels and from the “Sanctity of Life” point of view. The “Opt-Out Form” is to be completed only if you would NOT like your child to participate in this class.
  
  Choose one: REQUIRED I am requesting an Opt-Out Form I am not requesting an Opt-Out Form Please fill out this field.
  
  Child/Student 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth (mm/dd/yyyy) REQUIRED Please fill out this field. Please enter a date.
  
  Age REQUIRED Please fill out this field. Please enter an integer (number).
  
  Gender REQUIRED Male Female Please fill out this field.
  
  Religion REQUIRED Please fill out this field. Please enter valid data.
  
  Sacraments Received REQUIRED Baptism Eucharist Confirmation None Please fill out this field.
  
  Name of School REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Level REQUIRED Please fill out this field.
  
  Session Option REQUIRED Please fill out this field.
  
  Any special needs of which we should be aware? Allergies Disabilities Other
  
  Please specify
  
  Primary person to whom you are allowing your child(ren) to be released: REQUIRED Please fill out this field. Please enter valid data.
  
  Alternate person to whom you are allowing your child(ren) to be released: REQUIRED Please fill out this field. Please enter valid data.
  
  SAFE ENVIRONMENT / ABUSE PREVENTION CLASSES
  
  Each year our Diocese requires that we educate our Parish children regarding abuse prevention and personal safety. Children are taught at age-appropriate levels and from the “Sanctity of Life” point of view. The “Opt-Out Form” is to be completed only if you would NOT like your child to participate in this class.
  
  Choose one: REQUIRED I am requesting an Opt-Out Form I am not requesting an Opt-Out Form Please fill out this field.
  
  Child/Student 4
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth (mm/dd/yyyy) REQUIRED Please fill out this field. Please enter a date.
  
  Age REQUIRED Please fill out this field. Please enter an integer (number).
  
  Gender REQUIRED Male Female Please fill out this field.
  
  Religion REQUIRED Please fill out this field. Please enter valid data.
  
  Sacraments Received REQUIRED Baptism Eucharist Confirmation None Please fill out this field.
  
  Name of School REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Level REQUIRED Please fill out this field.
  
  Session Option REQUIRED Please fill out this field.
  
  Any special needs of which we should be aware? Allergies Disabilities Other
  
  Please specify
  
  Primary person to whom you are allowing your child(ren) to be released: REQUIRED Please fill out this field. Please enter valid data.
  
  Alternate person to whom you are allowing your child(ren) to be released: REQUIRED Please fill out this field. Please enter valid data.
  
  SAFE ENVIRONMENT / ABUSE PREVENTION CLASSES
  
  Each year our Diocese requires that we educate our Parish children regarding abuse prevention and personal safety. Children are taught at age-appropriate levels and from the “Sanctity of Life” point of view. The “Opt-Out Form” is to be completed only if you would NOT like your child to participate in this class.
  
  Choose one: REQUIRED I am requesting an Opt-Out Form I am not requesting an Opt-Out Form Please fill out this field.
  
  Child/Student 5
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth (mm/dd/yyyy) REQUIRED Please fill out this field. Please enter a date.
  
  Age REQUIRED Please fill out this field. Please enter an integer (number).
  
  Gender REQUIRED Male Female Please fill out this field.
  
  Religion REQUIRED Please fill out this field. Please enter valid data.
  
  Sacraments Received REQUIRED Baptism Eucharist Confirmation None Please fill out this field.
  
  Name of School REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Level REQUIRED Please fill out this field.
  
  Session Option REQUIRED Please fill out this field.
  
  Any special needs of which we should be aware? Allergies Disabilities Other
  
  Please specify
  
  Primary person to whom you are allowing your child(ren) to be released: REQUIRED Please fill out this field. Please enter valid data.
  
  Alternate person to whom you are allowing your child(ren) to be released: REQUIRED Please fill out this field. Please enter valid data.
  
  SAFE ENVIRONMENT / ABUSE PREVENTION CLASSES
  
  Each year our Diocese requires that we educate our Parish children regarding abuse prevention and personal safety. Children are taught at age-appropriate levels and from the “Sanctity of Life” point of view. The “Opt-Out Form” is to be completed only if you would NOT like your child to participate in this class.
  
  Choose one: REQUIRED I am requesting an Opt-Out Form I am not requesting an Opt-Out Form Please fill out this field.
  
  Child/Student 6
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth (mm/dd/yyyy) REQUIRED Please fill out this field. Please enter a date.
  
  Age REQUIRED Please fill out this field. Please enter an integer (number).
  
  Gender REQUIRED Male Female Please fill out this field.
  
  Religion REQUIRED Please fill out this field. Please enter valid data.
  
  Sacraments Received REQUIRED Baptism Eucharist Confirmation None Please fill out this field.
  
  Name of School REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Level REQUIRED Please fill out this field.
  
  Session Option REQUIRED Please fill out this field.
  
  Any special needs of which we should be aware? Allergies Disabilities Other
  
  Please specify
  
  Primary person to whom you are allowing your child(ren) to be released: REQUIRED Please fill out this field. Please enter valid data.
  
  Alternate person to whom you are allowing your child(ren) to be released: REQUIRED Please fill out this field. Please enter valid data.
  
  SAFE ENVIRONMENT / ABUSE PREVENTION CLASSES
  
  Each year our Diocese requires that we educate our Parish children regarding abuse prevention and personal safety. Children are taught at age-appropriate levels and from the “Sanctity of Life” point of view. The “Opt-Out Form” is to be completed only if you would NOT like your child to participate in this class.
  
  Choose one: REQUIRED I am requesting an Opt-Out Form I am not requesting an Opt-Out Form Please fill out this field.
- Other adults (18+) living with you: REQUIRED Please fill out this field.
  
  Adults (over 18) 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth (mm/dd/yyyy) REQUIRED Please fill out this field. Please enter valid data.
  
  Gender Male Female
  
  Religion REQUIRED Please fill out this field. Please enter valid data.
  
  Sacraments Received REQUIRED Baptism Eucharist Confirmation None Please fill out this field.
  
  Relationship to Head of Household 1 REQUIRED Please fill out this field. Please enter valid data.
  
  Adults (over 18) 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth (mm/dd/yyyy) REQUIRED Please fill out this field. Please enter valid data.
  
  Gender Male Female
  
  Religion REQUIRED Please fill out this field. Please enter valid data.
  
  Sacraments Received REQUIRED Baptism Eucharist Confirmation None Please fill out this field.
  
  Relationship to Head of Household 1 REQUIRED Please fill out this field. Please enter valid data.
- Other Pertinent Information Regarding the Safety of Minors
  
  PERMISSION FOR USE OF INFORMATION OR IMAGE OF A MINOR IN MEDIA
  
  I hereby give permission for the Diocese of Pensacola-Tallahassee and any of its affiliated organizations, including but not limited to the Catholic Compass, to use my child’s name and/or photograph(s) for promotional, news or public relations purposes in print and/or electronic media.
  Please note that all use of images and/or names will comply with privacy and use policies of the Diocese of Pensacola-Tallahassee as published at www.ptdiocese.org. Names of minors are not published electronically in conjunction with their photographs.
  
  By selecting the “I ACCEPT” box, you are signing this agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting “I ACCEPT” you consent to be legally bound by this Agreements terms and conditions.
  
  Choose One: REQUIRED I have no children in Religious Education I accept (Signature required below) I decline (Signature required below) Please fill out this field.
  
  Electronic Signature of Parent/Legal Guardian Please enter valid data.
  
  Our family attends Mass Daily Weekly Occasionally Rarely
  
  Our children participation in RE during last school year: Weekly Occasionally Rarely Did not participate in RE last year.
  
  Occasion to volunteer Teach RE Occasionly sub in class Provide food Arts/Crafts
Submit

Our Lady of Victory Catholic Church

Crestview, FL

Registration Form