St. James, Our Lady of Refuge, and St. Therese CCD Registration

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Parish Name: REQUIRED Please fill out this field.
Family Last Name REQUIRED Please fill out this field. Please enter valid data.
Street 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.
Father's Name: Please enter valid data.
Father's Email: REQUIRED Please fill out this field. Please enter an email address.
Father's Phone Number REQUIRED

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Father's Religion REQUIRED Please fill out this field. Please enter valid data.
Mother's Name: REQUIRED Please fill out this field. Please enter valid data.
Mother's Email REQUIRED Please fill out this field. Please enter an email address.
Mother's Maiden Name: Please enter valid data.
Mother's Phone Number REQUIRED

Please fill out this field. Please enter a phone number.
Mother's Religion REQUIRED Please fill out this field. Please enter valid data.
- How many students are you registering? REQUIRED Please fill out this field.
- 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.
  - Catholic? REQUIRED Yes No Please fill out this field.
  - Gender: REQUIRED Male Female Please fill out this field.
  - Birthdate REQUIRED Please fill out this field. Please enter a date.
  - Grade Level REQUIRED Please fill out this field. Please enter valid data.
  - Sacrament Details (please check all that apply) REQUIRED Baptism Eucharist Reconciliation Confirmation Please fill out this field.
  - Please list relevant Sacrament dates:
  - Does this student have special needs (medical, learning disabilities, physical disabilities)?
- Student 2
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Catholic? REQUIRED Yes No Please fill out this field.
  - Gender: REQUIRED Male Female Please fill out this field.
  - Birthdate REQUIRED Please fill out this field. Please enter a date.
  - Grade Level REQUIRED Please fill out this field. Please enter valid data.
  - Sacrament Details (please check all that apply) REQUIRED Baptism Eucharist Reconciliation Confirmation Please fill out this field.
  - Please list relevant Sacrament dates:
  - Does this student have special needs (medical, learning disabilities, physical disabilities)?
- Student 3
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Catholic? REQUIRED Yes No Please fill out this field.
  - Gender: REQUIRED Male Female Please fill out this field.
  - Birthdate REQUIRED Please fill out this field. Please enter a date.
  - Grade Level REQUIRED Please fill out this field. Please enter valid data.
  - Sacrament Details (please check all that apply) REQUIRED Baptism Eucharist Reconciliation Confirmation Please fill out this field.
  - Please list relevant Sacrament dates:
  - Does this student have special needs (medical, learning disabilities, physical disabilities)?
- Student 4
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Catholic? REQUIRED Yes No Please fill out this field.
  - Gender: REQUIRED Male Female Please fill out this field.
  - Birthdate REQUIRED Please fill out this field. Please enter a date.
  - Grade Level REQUIRED Please fill out this field. Please enter valid data.
  - Sacrament Details (please check all that apply) REQUIRED Baptism Eucharist Reconciliation Confirmation Please fill out this field.
  - Please list relevant Sacrament dates:
  - Does this student have special needs (medical, learning disabilities, physical disabilities)?
- Student 5
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Catholic? REQUIRED Yes No Please fill out this field.
  - Gender: REQUIRED Male Female Please fill out this field.
  - Birthdate REQUIRED Please fill out this field. Please enter a date.
  - Grade Level REQUIRED Please fill out this field. Please enter valid data.
  - Sacrament Details (please check all that apply) REQUIRED Baptism Eucharist Reconciliation Confirmation Please fill out this field.
  - Please list relevant Sacrament dates:
  - Does this student have special needs (medical, learning disabilities, physical disabilities)?
- Student 6
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Catholic? REQUIRED Yes No Please fill out this field.
  - Gender: REQUIRED Male Female Please fill out this field.
  - Birthdate REQUIRED Please fill out this field. Please enter a date.
  - Grade Level REQUIRED Please fill out this field. Please enter valid data.
  - Sacrament Details (please check all that apply) REQUIRED Baptism Eucharist Reconciliation Confirmation Please fill out this field.
  - Please list relevant Sacrament dates:
  - Does this student have special needs (medical, learning disabilities, physical disabilities)?
- Student 7
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Catholic? REQUIRED Yes No Please fill out this field.
  - Gender: REQUIRED Male Female Please fill out this field.
  - Birthdate REQUIRED Please fill out this field. Please enter a date.
  - Grade Level REQUIRED Please fill out this field. Please enter valid data.
  - Sacrament Details (please check all that apply) REQUIRED Baptism Eucharist Reconciliation Confirmation Please fill out this field.
  - Please list relevant Sacrament dates:
  - Does this student have special needs (medical, learning disabilities, physical disabilities)?
- Student 8
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Catholic? REQUIRED Yes No Please fill out this field.
  - Gender: REQUIRED Male Female Please fill out this field.
  - Birthdate REQUIRED Please fill out this field. Please enter a date.
  - Grade Level REQUIRED Please fill out this field. Please enter valid data.
  - Sacrament Details (please check all that apply) REQUIRED Baptism Eucharist Reconciliation Confirmation Please fill out this field.
  - Please list relevant Sacrament dates:
  - Does this student have special needs (medical, learning disabilities, physical disabilities)?
- Student 9
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Catholic? REQUIRED Yes No Please fill out this field.
  - Gender: REQUIRED Male Female Please fill out this field.
  - Birthdate REQUIRED Please fill out this field. Please enter a date.
  - Grade Level REQUIRED Please fill out this field. Please enter valid data.
  - Sacrament Details (please check all that apply) REQUIRED Baptism Eucharist Reconciliation Confirmation Please fill out this field.
  - Please list relevant Sacrament dates:
  - Does this student have special needs (medical, learning disabilities, physical disabilities)?
- Student 10
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Catholic? REQUIRED Yes No Please fill out this field.
  - Gender: REQUIRED Male Female Please fill out this field.
  - Birthdate REQUIRED Please fill out this field. Please enter a date.
  - Grade Level REQUIRED Please fill out this field. Please enter valid data.
  - Sacrament Details (please check all that apply) REQUIRED Baptism Eucharist Reconciliation Confirmation Please fill out this field.
  - Please list relevant Sacrament dates:
  - Does this student have special needs (medical, learning disabilities, physical disabilities)?
PARENT/GUARDIAN PERMISSION & LIABILITY WAIVER

As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“participant”). I would like my CHILD to participate in the above-named ACTIVITY. In exchange, and for said consideration, as parent or legal guardian, I agree to defend and fully indemnify the above-named PARISH/SCHOOL and Diocese against any claim which results from the intentional or negligent actions taken of my CHILD during the above-namedACTIVITY. I further agree to fully indemnify and hold harmless the PARISH/SCHOOLand Diocese against any claim or cause of action whatsoever brought by my CHILD or his/her parent/legal guardian against the PARISH/SCHOOL which arose out of the above identified ACTIVITY, regardless of whether such claim results from the negligence of the PARISH/SCHOOL, its employees or volunteers or the negligence of individuals or companies not a party to this agreement.Further, for said consideration, I hereby release and discharge the Diocese, its agents, servants, and employees, including the PARISH/SCHOOL, their employee(s), agents and representatives (parties being released) of and from all claims, demands, causes of action, and expenses arising out of or in any way connected with the employee of the PARISH/School.I certify that I understand this agreement and the risks and hazards associated with the ACTIVITY described above that my CHILD will be participating in. I further understand that I had the opportunity to fully discuss this agreement with a representative of the PARISH/SCHOOL to clarify any concerns or questions about the activity or this agreement that I may have had.PHOTO/VIDEO CONSENT: As a parent/guardian, I understand that photos/video of my child may betaken during this activity. I give permission for the taking of my child’s photo or video and for use of the resulting images and video for promotional purposes of the Diocese. This may include the right to use them in print, online, in social media, and in press releases.
I Agree Please select this field.

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three catholic parishes & Mission

refugio & Woodsboro, texas

St. James, Our Lady of Refuge, and St. Therese CCD Registration

PARENT/GUARDIAN PERMISSION & LIABILITY WAIVER