RE Information Card

Religious Education On-line New Student Information Card

* Indicates required field

Child's Name (First, Middle, Last) *

Birthdate *

Street Address *

City & Zip Code *

Child lives with: *

Public school child attends *

Father's Name (First, Last) *

Father's Religion *

Father's Work # *

Mother's Name (First, Last) *

Mother's Religion *

Mother's Work # *

Child's Baptismal Date *

Baptismal Church *

Baptismal Church Address *

First Communion Date *

First Communion Church *

First Communion Church Address *

Emergency Medical Information

Please list any important health or learning information concerning your child. For example: allergic (food, medication,environmental) reactions, learning disabilities, diabetes, vision or hearing impairment, physical disabilities that would preclude climbing stairs, etc. *

Emergency contact phone numbers if parents cannot be reached at home or at work.

Emergency Contact #1 (First & Last Name) *

Phone # of Contact #1 *

#1's Relationship to student *

Emergency Contact #2 (First & Last Name) *

Phone # of Conact #2 *

#2's Relationship to Student *

I give permission for my child to receive emergency treatment if I or my designated emergency contacts cannot be reached at the above telephone numbers.

Parent's Name (First & Last) *

Date (MM/DD/YYYY) *

Submit