| St. Joseph Catholic Church

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

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

Street Address REQUIRED Please fill out this field. Please enter an integer (number).

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.

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

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

Children's Information:

Number of Children REQUIRED Please fill out this field.
Child 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.
- Age (Required) REQUIRED Please fill out this field. Please enter valid data.
- Birthdate mm/dd/yyyy REQUIRED Please fill out this field. Please enter valid data.
Child 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.
- Age (Required) REQUIRED Please fill out this field. Please enter valid data.
- Birthdate mm/dd/yyyy REQUIRED Please fill out this field. Please enter valid data.
Child 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.
- Age (Required) REQUIRED Please fill out this field. Please enter valid data.
- Birthdate mm/dd/yyyy REQUIRED Please fill out this field. Please enter valid data.
Child 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.
- Age (Required) REQUIRED Please fill out this field. Please enter valid data.
- Birthdate mm/dd/yyyy REQUIRED Please fill out this field. Please enter valid data.

Current Grade REQUIRED Kindergarten First Second Third Fourth Fifth Please fill out this field.

Medical Information/Release

Do any of your children have severe allergies that we need to now about? (Environmental, food, medications, chemical)? REQUIRED No Yes Please fill out this field.

If yes please explain and give childs name if registering more than one child. Please enter valid data.

Do any of your children have a medical condition the we may need to administer medication for? No Yes

If yes please explain and give childs name if registering more than one child. Please enter valid data.

Do any of your children have significant emotional, behavioral and/or physical concerns or limitations? No Yes

If yes please explain and give childs name if registering more than one child. Please enter valid data.

In the event your child requires medical attention, we will attempt to notify the parents at the number provided above. If the parent cannot be reached, please leave an alternate number to reach the parent or someone else.

Alternate Contact Name Please enter valid data.

Alternate Contact Phone Number Please enter valid data.

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

Pediatrician Address REQUIRED Please fill out this field. Please enter valid data.

Pediatrician Phone REQUIRED Please fill out this field. Please enter valid data.

If there is a medical emergency situation where I cannot be reached according to the instructions provided, I hereby grant permission to the staff at St. Joseph's to provide transportation to proper medical treatment for my child(ren). REQUIRED I Agree Please fill out this field.

Publicity - Photos will be taken during VBS. May we have permission to use your child(ren) photo for church bulletin boards, presentations, our web site, Catholic Free Press or local newspaper?

Choose One I grant permission I do not grant permission

Email (for confirmation Please enter an email address.

St. Joseph's Catholic Church

10 H. Putnam Rd. Ext. Charlton, MA

Rev. Robert Grattaroti, Pastor
Rev. Charles Monroe, Senior Priest

Registration Form

August 3-7th (9-3Mon-Thur, 9-2Fri)

Mandatory Totus Tuus Release Form
Please print and bring on first day