Registration form 2015-2016 with Spanish.pub

St. Paul Catholic Church
Sacramental Registration 2015-2016
Sacrament(s) To Be Celebrated:
⃞ First Eucharist
⃞ Confirmation
Child’s Last Name:
(Nombre del Niño)
(Primera Comunión)
(Confirmación)
Child’s Information (Informacion del Niño)
Full Name:
(Nombre completo)
_________
First and Middle (Primero y Segundo Nombre)
Address:
(Dirección)
Date of Birth:
(Fecha de Nacimiento)
City/State of Birth:
(Ciudad y Estado de Nacimiento)
Grade:
___
School:
(Grado escolar)
___
(Nombre de la Escuela)
Parent Information (Información de los padres)
Father’s Full Name:
(Nomdre complete del padre)
Phone:
(Teléfono)
Email:
(Correo electrónico)
Mother’s Full Name/Maiden Name:
(Nombre complete de la madre/ de soltera)
Phone:
Email:
(Teléfono)
(Correo electrónico)
Baptism Information (Información de Bautismo)
Date of Baptism:
(Fecha de Bautismo)
Name of church where baptized:
(Iglesia de Bautismo)
Address:
Baptismal Name:
(Nombre de bautismo)
(Dirección/Ciudad/Estado/Codigo postal de la iglesia del Bautismo)
If your child was not baptized at St. Paul Church, please attach copy of Baptismal Certificate
Si el niño no fue bautizado en la iglesia San Pablo favor de proporcionar una copia del certificado de bautismo
Office Use Only:
Date Received:
Baptism Info Verified:
Sacrament Fee $25: Ck#
Parish Registration Verified:
Cash
Confirmation Information
Name:
____
Sponsor:
____
2015-2016. Paul Parish
EMERGENCY MEDICAL AUTHORIZATION/PERMISSION FORM
Only one medical form needed for all children.
Name[s] of Child[ren]:
________________________________________________________________________
Parent Name: ______________________________________________________
Emergency phone number where parent can be reached _______________________________
Purpose – to enable parents and guardians to authorize the provision of emergency treatment for children whom
become ill or injured while under PSR authority, when parents or guardians cannot be reached.
Name of Relative or Childcare Provider FOR EMERGENCY CONTACT:
_________________________________________________________ Relationship
Phone
TO GRANT CONSENT:
I hereby give consent for the following medical care providers and local hospital to be called:
Physician: ________________________________________________ Phone
Dentist: __________________________________________________ Phone
Hospital: _________________________________________________ Phone
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1)
the administration of any treatment deemed necessary by above named doctors, or, in the event the designated
preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to
any hospital reasonably accessible.
This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or
dentists, concurring in the necessity for such surgery are obtained prior to the performance of such surgery.
Facts concerning the child’s medical history, including allergies, medications being taken and any physical impairment to which we and a physician should be alerted:
_________________________________________________________________________________________
_________________________________________________________________________________________
Special Needs:
________________________________________________________________________________
PERMISSION RELEASE:
Permission for my child’s picture to be taken and used in brochures, video, CD/DVDs, websites, etc. for publicity
use only.
I grant permission
Date: ____________
I do NOT grant permission
Signature of Parent/Guardian________________________________