Registration

Student Information Record

Name	Date of Birth:
Address:	Phone:
Father's Name:	Business Phone/Beeper:
Business Address:
Mother's Name:	Business Phone/Beeper:
Business Address:
Legal Guardian's Name:	Business Phone/Beeper:
Business Address:
Special Medical Conditions:
Procedures to be followed if the condition presents an emergency:
Any special requests for the dismissal of the child should be made on this form:

In Case of Emergency Persons to Contact If Parent/Legal Guardian Cannot Be Reached
Name:	Phone/Beeper
Address:
Relationship:
Doctor for emergency:	Phone/Beeper:
Address:
In case of accident or illness, I request that the representative of the parish catechetical program contact me. If I am unable to be reached, I hereby authorize this representative to call the physician indicated and to follow the physician's instructions. If it is impossible to contact this physician, the representative of the parish catechetical program may make whatever arrangements seem necessary. I agree to assume the financial responsibility for any diagnosis, treatment, and/or medication deemed necessary. To the best of my knowledge all information given is accurate and complete. I hereby consent to, and authorize the necessary procedures that have been stated above.

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