Confirmation Registration

PRIMARY PARENT / GUARDIAN

Last Name: REQUIRED Please fill out this field. Please enter valid data.
First Name: REQUIRED Please fill out this field. Please enter valid data.
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.
Phone: REQUIRED Please fill out this field. Please enter valid data.
Email REQUIRED Please fill out this field. Please enter an email address.
Religious Affiliation: REQUIRED Please fill out this field.
Language(s)/Idioma(s): REQUIRED Only English/Sólo inglés Only Spanish/Sólo español English and Spanish/Inglés y español Please fill out this field.
Persons Authorized to Pick Up Child: REQUIRED Please fill out this field.
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SECONDARY PARENT / GUARDIAN

Last Name: REQUIRED Please fill out this field. Please enter valid data.
First Name: REQUIRED Please fill out this field. Please enter valid data.
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.
Phone: REQUIRED Please fill out this field. Please enter valid data.
Email REQUIRED Please fill out this field. Please enter an email address.
Religious Affiliation: REQUIRED Please fill out this field.
Language(s)/Idioma(s) REQUIRED Only English/Sólo inglés Only Spanish/Sólo español English and Spanish/Inglés y español Please fill out this field.

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CHILD'S INFORMATION:

Please select the Year your child is joining: REQUIRED 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.
Grade in School: REQUIRED Please fill out this field.
Allergies/Medical Conditions: Please enter valid data.
Date of Baptism: REQUIRED Please fill out this field. Please enter a date.
Church Name/Address: REQUIRED Please fill out this field. Please enter valid data.

Language(s)/Idioma(s) REQUIRED Only English/Sólo inglés Only Spanish/Sólo español English and Spanish/Inglés y español Please fill out this field.

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Who will be the primary contact: REQUIRED Please fill out this field.

Emergency Contact: Other than Parent

Last Name: REQUIRED Please fill out this field. Please enter valid data.
First Name: REQUIRED Please fill out this field. Please enter valid data.
Email: REQUIRED Please fill out this field. Please enter valid data.
Phone: REQUIRED Please fill out this field. Please enter valid data.
Relationship to Child: REQUIRED Please fill out this field. Please enter valid data.

Contracts:

I understand that either myself or my spouse has to attend parent classes while my child attends his/her First Communion classes.
I agree: REQUIRED Yes Please fill out this field.
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We at St. Rose of Lima Church are committed to your child’s safety and well-being. There are daily reports of child abuse, both sexual and other forms in our society. Therefore, we recognize how important it is to “empower” our children and young people with the knowledge and understanding of ways to keep themselves and others safe from potential harm. The Empowering God’s Children and Young People© Safety Program is provided by the Archdiocese of Los Angeles as an ongoing effort to educate children and young people through classroom lessons and activities on ways to maintain their own personal safety. It is based on catechetical principals to help them know they are loved by God and that He wants them to be healthy and safe. The Empowering God’s Children and Young People© Safety Program will be presented to our students during the upcoming year of study. Parents/guardians seeking additional information regarding this program or who would like to review the materials/videos, may contact Nicole Pizano at [email protected]. I understand that for my child to participate in the Empowering God’s Children and Young People© Safety Program, I need to provide permission. I am specifically giving permission for the Empowering God Children and Young People© Safety Program to be presented to my child(ren).
I agree: REQUIRED Yes Please fill out this field.
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I give permission for my child to be photographed and/or videotaped for future promotional materials including website postings. I do so without expectation of compensation and with the understanding that these photographs and video images will be used exclusively by St. Rose of Lima for its publications, website, and publicity purposes.
I agree: REQUIRED Yes Please fill out this field.
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In the event of illness or injury, I do hereby consent to whatever treatment and hospital care are considered necessary in the best judgment of the attending physician, surgeon, or dentist and performed by or under the supervision of the facility furnishing services. I fully understand that students are to abide by all rules and regulations governing conduct and safety while attending Faith Formation classes and that any violation of these rules and regulations may result in the violator being removed from the program.
I agree: REQUIRED Yes Please fill out this field.
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Notes

*Birth Certificate and Baptism Certificate must be uploaded here: Click to Upload Documents
*Denial of Registration if this request is not followed
*Only Upload Files Once

I Agree to provide all requested information in a timely manner. Please select this field.

Registration Fee:

Registration Subtotal:200.0