STUDENT INFORMATION

Student Name (Nombre del estudiante: Nombre de pila, Segundo, Apellido) *

First

Middle

Last

Address (Dirreccion: Ciudad, Estado, Codigo Postal) *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone (Telefono Casa) *

Family Email (Correo Electronico de la Familia) *

Student Email (Correo Electronico del estudiante) *

Language Spoken at home (Idioma en casa) *

Student lives with (Estudiante vive con) *

Mother/Madre
Father/Padre
Guardian/Guardian

If appropriate, attach custody paperwork / Si corresponde, adjunte la documentacion de custodia

Birthday (Fecha de nacimiento) *

Place of Birth (Lugar de nacimiento) *

Sex (sexo) *

Current Grade (Grado en el otoño) *

9th
10th
11th
12th

School (Nombre de la escuela) *

Any physical or learning problems (Problemas de aprendizaje) *

If Yes, please explain / Explicar *

Did child attend religious education classes last year / Asistio a clases de educacion religiosa el ano pasado *

If Yes, at which church / En que iglesia *

Received Sacraments / Sacramentos Recibidos *

None
Baptism / Bautismo
Confession
1st Communion

Approx. Date Baptism Received (Aproximado fecha bautismo recibido) *

Church Name & Address where received (Nombre de la iglesia y direccion recibido) *

***A copy of the baptismal certificate is required for the Youth Ministry Office (Se requiere una copia del certificado bautismal para la Oficina del Ministerio de la Juventud)

Approx. Date Confession Received (Aproximado fecha confesión recibido) *

Church Name & Address where received (Nombre de la iglesia y direccion recibido) *

Approx. Date 1st Communion Received (Aproximado fecha primera comunión recibido) *

Church Name & Address where received (Nombre de la iglesia y direccion recibido) *

***A copy of the confirmation certificate is required for the Youth Ministry Office (Se requiere una copia del certificado primera comunión para la Oficina del Ministerio de la Juventud)

Do you have another student to register? / ¿Tienes otro estudiante para inscribirte?

SECOND STUDENT'S INFORMATION

Student Name (Nombre del estudiante: Nombre de pila, Segundo, Apellido) *

First

Middle

Last

Birthday (Fecha de nacimiento) *

Place of Birth (Lugar de nacimiento) *

Sex (sexo) *

Current Grade (Grado en el otoño) *

9th
10th
11th
12th

School (Nombre de la escuela) *

Received Sacraments (2nd Student) / Sacramentos Recibidos (2o Estudiante) *

None
Baptism / Bautismo
Confession
1st Communion

Approx. Date Baptism Received (Aproximado fecha bautismo recibido) *

Church Name & Address where received (Nombre de la iglesia y direccion donde recibidas) *

***A copy of the baptismal certificate is required for the Youth Ministry Office (Se requiere una copia del certificado bautismal para la Oficina del Ministerio de la Juventud)

Approx. Date Confession Received (Aproximado fecha confesión recibido) *

Church Name & Address where received (Nombre de la iglesia y direccion donde recibidas) *

Approx. Date 1st Communion Received (Aproximado fecha primera comunión recibido) *

Church Name & Address where received (Nombre de la iglesia y direccion donde recibidas) *

***A copy of the confirmation certificate is required for the Youth Ministry Office (Se requiere una copia del certificado primera comunión para la Oficina del Ministerio de la Juventud)

PARENT/GUARDIAN INFORMATION

Mother's Full Maiden Name (Nombre de soltera de la Madre) *

First

Middle

Last

Cell Phone *

Religion *

Marital Status (Estado Civil) *

Single (Soltera)
Married (Casada)
Widowed (Viuda)
Separated (Separada)
Divorced (Divorciada)

Remarried? (volver a casarse?)

Yes / Sí
No

Husband's Name (if remarried) - (Nombre de esposo - no el padre) *

First

Last

Father's Name (Nombre de Padre)

First

Last

Cell Phone

Religion

Marital Status (Estado Civil)

Single (Soltera)
Married (Casada)
Widowed (Viuda)
Separated (Separada)
Divorced (Divorciada)

Remarried? (volver a casarse?)

Yes / Sí
No

Wife's Name (if remarried) - (Nombre de esposo - no el madre) *

First

Last

RELEASE FORMS

SAFETY

As the participant, I agree to follow all procedures, safety precautions, and rules and regulations set forth by the Diocese and the Parish.

PHOTO, PRESS, AUDIO, AND ELECTRONIC MEDIA RELEASE

I authorize the Catholic Diocese of Arlington, its parishes, its schools and/or the Arlington Catholic Herald to use and publish my child’s photograph, video and/or audio recording along with their name identifying them for educational, news stories, illustration and/or marketing purposes.

I authorize St. Leo the Great to add my child(ren)'s email address to Flocknote for distribution of weekly communications regarding RCIT.

Print Full Name *

DIOCESE OF ARLINGTON PERMISSION FOR EMERGENCY CARE

Student Name (Nombre del estudiante: Nombre de pila, Segundo, Apellido) *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Home Email

Birthdate

Multiple Choice *

Female
Male

Father's Name *

First

Last

Father's Work Phone

Father's Cell Phone *

Father's Email *

Mother's Name *

First

Last

Mother's Work Phone

Mother's Cell Phone *

Mother's Email *

Person(s) OR Agency Having Legal Custody (if not parents)*

*Appropriate custody paperwork must be turned in

Address

Address Line 1

Address Line 2

City

State

Zip Code

ALLERGIES (if any)

Environmental (i.e. pollen, dust)

Any Medications

Food

Does your child have an EPI-pen?

Do they know how to administer it to themselves?

Actions taken in response to allergies

Student's Doctor

Doctor's Phone

MEDICATIONS

Please list any prescription or doctor prescribed over the counter medications your child is using

Drug Name

Dosage

Drug Name

Dosage

In case there are additional drugs, please mention the drug name and its dosage below:

HISTORY

Medical History (be specific)

Mental Health Information (be specific)

Physician and Medical Insurance

Primary Healthcare Provider

Phone

Insurance Company

Policy Number

Date of Last Tetanus Shot *

Emergency Contact

Name *

First

Last

Relationship

Phone *

Name *

First

Last

Relationship

Phone *

I agree to pick up my sick or injured child in a timely manner when contacted. If I cannot be reached, the above emergency contacts can be called to pick up my child. Additionally, if I cannot be contacted in an emergency, the Youth Ministry office has my permission to take my child to the emergency room of the nearest hospital and I hereby authorize its medical staff to provide treatment which a physician deems necessary for the well-being of my child.

I certify that the information provided in this document is true and accurate to the best of my knowledge.

Printed Name

Today's Date

REGISTRATION FEE

Parishoner

1 Student: $125

2 Students: $150

3+ Students: $175

Non-Parishoner

1 Student: $200

2 Students: $250

3+ Students: $300

(Our online payment system is 100% safe and secure. We do NOT store any of your credit card information. We respect your privacy!)

Are you a Parishioner of St. Leo the Great Catholic Church

Would you like to pay the registration fee online right now? *

Yes, I'll pay right now with a credit card.
No, I'll give you a check. (Please choose if you need to defer payment at this time)

Total: *

1 Student - $175
2 Students - $200

Total: *

1 Student - $225
2 Students - $275

Total

$ 0.00

Stripe Credit Card *

Credit Card field is disabled, Stripe payments are not enabled in the form settings.

BILLING DETAILS
Our online payment system is 100% safe and secure. We do NOT store any of your credit card information. We respect your privacy!

OCIT Registration 2022-2023

STUDENT INFORMATION

SECOND STUDENT'S INFORMATION

PARENT/GUARDIAN INFORMATION

RELEASE FORMS

SAFETY

PHOTO, PRESS, AUDIO, AND ELECTRONIC MEDIA RELEASE

DIOCESE OF ARLINGTON PERMISSION FOR EMERGENCY CARE

ALLERGIES (if any)

MEDICATIONS

HISTORY

REGISTRATION FEE

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