Registered Parishionerof :

St John Francis Regis

St Catherine of Alexandria

Student Information

Returning Student

New Student

Place of Baptism

St John Francis Regis

St Catherine of Alexandria

Student Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

MM

DD

YYYY

Gender

Male

Female

Child lives with:

Father

Mother

Both Parents

Legal Guardian

PARENTS INFORMATION

Parents are:

Married

Single Parent

Widowed

Divorced

Custody Arrangement

Mother's Name

First Name

Last Name

Phone

(###)

###

####

Step-Mom

If applicable

First Name

Last Name

Phone

(###)

###

####

Father's Name

First Name

Last Name

Phone

(###)

###

####

Step-Father

If applicable

First Name

Last Name

Phone

(###)

###

####

Photograph / Video / Audio / Media Consent

I consent to and authorize the Roman Catholic Diocese of Lafayette and all entities, representatives, employees and agents operating under its authority to record, use, edit, reproduce, and/or publish photographs, video, audio, and/or other media that may portray and'or relate to the aforementioned minor child, his/her image, likeness and/or voice, without compensation. I understand that these materials maybe used in various print and electronic media, including but not limited to the Diocesan website and the Diocesan publication, Acadiana Catholic, and/or for other endeavors related to Diocesan interests. I understand that the Diocese may use and/or publish materials relating to said minor child in any manner the Diocese deems appropriate in order to promote and/or publicize its programs, or for other lawful purpose. This authorization shall not expire and will remain effective indefinitely until rescinded in writing.

I DO GIVE permission

I DO NOT GIVE permission