Rock StEdY Registration Form

Date REQUIRED Please fill out this field. Please enter a date.

Disciple's Name

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

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

Program Options Regular Class Attendance HomeSchool Hybrid (combination of attendance and handouts at home)

Grade Going In To REQUIRED Please fill out this field.

Did your Disciple attend Religious Education Classes last year? Yes No

At what church or school? Please enter valid data.

Mother's Name REQUIRED Please fill out this field. Please enter valid data.

Father's 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.

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

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

Baptism (Date and Place) Please enter valid data.

First Reconciliation (Date and Place) Please enter valid data.

First Holy Communion (Date and Place) Please enter valid data.

Emergency Contact - Name and Phone Number Please enter valid data.

Allergies/Medical Conditions/Physical Restrictions/Special Needs?

For Venture, Vision and Spirit (4th Grade and up) Groups Only. My Disciple can leave the Parish Hall without supervision after class. Yes No

All Disciples in Groups Promise and Good News (Kinder - 3rd) must be signed in and out by a Parent.

I give permission to St. Edward Church to photograph my Disciple during church related activities. We also request permission to use those photos on our website, bulletin boards, newsletters, etc. Yes No

Are you a registered member of St. Edward Parish? Yes No

If no, at what Parish are you registered at? Please enter valid data.

PARENTAL PERMISSION AND RELEASE AND WAIVER OF LIABILITY
I agree to have my Disciple participate in the parish religious education program.

On behalf of the above named Disciple, I do herby release, waive, indemnify, hold harmless and defend the Roman Catholic Bishop of Las Cruces, and his successors, the Diocese of Las Cruces, St. Edward Parish, its officers, directors and agents, volunteers, chaperones, and/or representatives thereof from all damages and/or liability arising from or in connection with any activities undertaken as part of in relation to the Spiritual Formation program(s) of St. Edward, San Jose, Our Lady of Grace, Cristo Rey or the Diocese of Las Cruces.

St. Edward Roman Catholic Church

Carlsbad, New Mexico

Rock StEdY Registration Form

Spiritual Formation Registration