Saint Paul Chong Hasang Office of Religious Education

CCD Registration

Date: _________________

All NEW Registrants AND First Communion Students must attach a copy of Birth and Baptism Certificates.
All Confirmation Students must attach a copy of Birth, Baptism, and First Communion Certificates.

FAMILY INFORMATION:

Are You A Registered Member of Saint Paul Chong Hasang Parish?        Yes [     ]    No [     ]  

FAMILY NAME:  _________________________

FATHER’S NAME: _________________________________________ RELIGION: ____________________
                                                                              RANK IF MILITARY
PHONE: WORK   __________________   CELL   ________________  EMAIL:  ______________________

MOTHER’S NAME:  ________________________________________ RELIGION: ____________________
                                                                             RANK IF MILITARY
PHONE: WORK ________________ CELL   ________________    EMAIL  ______________________

MOTHER’S MAIDEN NAME:  ________________________

STREET ADDRESS (Family):  ______________________________________________________

CITY:  _______________STATE:  _____ ZIP CODE:  __________ HOME PHONE:  ____________   

LEGAL GUARDIAN, if different from above:

NAME:  ___________________________________________ RELATIONSHIP:  ________________ 

STREET ADDRESS:  ________________________________________________________________    

CITY:  __________________STATE:  _____ ZIP CODE:  __________ HOME PHONE: ________________   

PHONE:  WORK ___________________ CELL _________________    EMAIL   ______________________

IN CASE OF EMERGENCY

EMERGENCY CONTACT NAME:  ______________________   PHONE:  _____________________
(Other than parent)

PHYSICIAN: __________________________ PHONE #:  ______________ HOSPITAL: ______________ 

PERMISSION TO TRANSPORT TO HOSPITAL YES [   ] NO [   ]  

Signature   ___________________________________________

Please Make Checks Payable To:  St. Paul Chong Hasang Catholic Church

Office Use Only   

Date:  ________________________________

Total Amount Due:   _____________________                      Total Amount Paid:  _____________________

Cashier:  ______________________________                     Paid By:   Check  [   ]        # _____________