Summer / Fall Registration REQUIRED Summer Fall Please fill out this field.

Student Information

Last Name REQUIRED Please fill out this field. Please enter valid data.

First Name REQUIRED Please fill out this field. Please enter valid data.

Middle 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.

Home Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Birth Date REQUIRED Please fill out this field. Please enter a date.

Grade REQUIRED Please fill out this field. Please enter an integer (number).

Cell Phone Number Please enter a phone number.

Email Please enter an email address.

Last Grade Completed Here At St. Theresa Please enter an integer (number).

Family Information

Mothers Name Please enter valid data.

Work Phone Please enter a phone number.

Fathers Name Please enter valid data.

Work Phone Please enter a phone number.

Legal Guardian, If Different Than Above Please enter valid data.

Home Phone Please enter a phone number.

Emergency Contacts

Emergency Contact REQUIRED Please fill out this field. Please enter valid data.

Emergency Phone REQUIRED Please fill out this field. Please enter a phone number.

Relationship REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact REQUIRED Please fill out this field. Please enter valid data.

Emergency Phone REQUIRED Please fill out this field. Please enter a phone number.

Relationship REQUIRED Please fill out this field. Please enter valid data.

Health Information

Does your child have learning needs? REQUIRED Yes No Please fill out this field.

Classification? If Yes please explain:

Other Learning Needs? If Yes please explain:

Does your child have any medical conditions? REQUIRED Yes No Please fill out this field.

Medical conditions? If Yes please explain:

Are there any other special instructions? REQUIRED Yes No Please fill out this field.

Special instructions? If Yes please explain:

(I.e. dismissal, transportation, etc.)

Are there any custodial issues? REQUIRED Yes No Please fill out this field.

Custodial issues? If Yes please explain:

Promotional Release

I also consent to the use of any videotapes and/or photographs in which my child may appear by the Diocese of Trenton and/or the parish. I understand that these materials are being used for promotion of the parish Religious Education programs and/or activities, which may include recruitment and fundraising efforts.

Promotional Release Electronic Parent / Legal Guardian Signature: REQUIRED Please fill out this field. Please enter valid data.

Date REQUIRED Please fill out this field. Please enter a date.

We have received / (downloaded below) a copy of the Children's Faith Formation Hand book and we agree and will abide by all the requirements found in the handbook. I will support and help my child understand what is required to ensure their compliance with the Parish of St. Theresa Children's Faith formation Program.

Electronic Parent / Legal Guardian Signature: REQUIRED Please fill out this field. Please enter valid data.

Date REQUIRED Please fill out this field. Please enter a date.

Parent / Legal Guardian Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Parent / Legal Guardian Email REQUIRED Please fill out this field. Please enter an email address.

The Parish of St. Theresa

Student Summer / Fall Re-Registration Form

Student Information

Family Information

Emergency Contacts

Health Information

Documents