Catechesis of the Good Shepherd

STUDENT #1

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

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

Check One: REQUIRED Male Female Please fill out this field.

On August 1, 2020, my/our child's age is: REQUIRED Please fill out this field. Please enter valid data.

Check One: REQUIRED My/Our child WAS Baptized My/Our child WAS NOT Baptized Please fill out this field.

Does your child have any health or special needs of which we need to be aware? If none, state so. REQUIRED Please fill out this field.

STUDENT #2 (if applicable)

First Name Please enter valid data.

Last Name Please enter valid data.

Check One: Male Female

On August 1, 2020, my/our child's age is: Please enter valid data.

Check One: My/Our child WAS Baptized My/Our child WAS NOT Baptized

Does your child have any health or special needs of which we need to be aware? If none, state so.

FAMILY INFORMATION

FATHER

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

Last 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.

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

Email REQUIRED Please fill out this field. Please enter an email address.

MOTHER

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

Last 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.

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

Email REQUIRED Please fill out this field. Please enter an email address.

Have you completed the Protecting God's Children workshop? REQUIRED Yes No Please fill out this field.

Program Fees - check the appropriate box REQUIRED 70 – 1 Child 140 – 2 Children Please fill out this field.