St. Ann Religious Education Registration Form (1) Name of Student*Date of Birth:*Grade:*School:Sacraments:*Indicate which sacrament(s) your child has received by clicking on the appropriate box(es): Baptism Reconciliation Eucharist Is the Mother a baptized Catholic?*YesNoIs the Mother registered at St. Ann?*YesNoIs the Father a baptized Catholic?*YesNoIs the Father registered at St. Ann?*YesNoMother's Name:*Mother's Maiden Name:*Father's Name:*Child's Social Security Number*Home Address (Street Address, Apt. # if applicable)*City, State, Zip Code*Chronic Conditions (e.g., epilepsy, diabetes, etc.):*Allergies/Medications:*Other Information We Should Know About Your Child:*Parent/Guardian Place of Employment:*Parent/Guardian Primary Phone Number:*Parent/Guardian Secondary Phone Number:Email Address for Notifications of Changes/Cancellations:*Emergency Contact Name:*Emergency Contact Cell Phone Number:*Name of Medical Insurance Co.:*Policy Number:*Member's Name:*Member's Phone Number:*Member's Birth Date:*Member's Social Security Number:*Please note that some hospitals will not treat without the member's social security number.Name of Family Doctor:Phone Number of Family Doctor:Signature - use cursor to sign your name below:*Today's Date:*
