ST. JOHN ONLINE REGISTRATION FORM 2010 - 2011

GRADE ________________                                                    DATE ______________________

CHILD'S FULL NAME _________________________________________________________________

NAME CHILD GOES BY________________________________________                      SEX ___________

BIRTH DATE _____________________  BIRTH PLACE ______________________________________

RELIGION _______________________       PARISH IN WHICH REGISTERED (CHECK ONE)
      ______ St. John (Valdosta)                 ______ Queen of Peace (Lakeland)       ______St. Patrick (Moody)
      ______ St. Margaret Mary (Adel)      ______ St. Mary (Nashville)                   ______ Other ___________

DATE OF BAPTISM _____________       PARISH/CITY_______________________________________

DATE OF 1ST EUCHARIST ____________  PARISH/CITY ____________________________________

DATE OF CONFIRMATION ___________  PARISH/CITY ____________________________________

RANK IN FAMILY 1 2 3 4 5 _____              # BROTHERS ______                # SISTERS ______

IN WHICH PUBLIC SCHOOL DISTRICT  DO YOU LIVE? (CHECK ONE)
     _____  Valdosta    _____Lowndes     _____ Brooks     _____  Cook     _____Berrien     _____ Other ___________________________

ETHNIC BACKGROUND (CHECK ONE)  _____ EUROPEAN  _____ BLACK   _____WHITE

   _____HISPANIC   _____ASIAN   _____AM/INDIAN   _____OTHER _______________

MOTHER'S NAME ___________________________  MAIDEN NAME ____________________

ADDRESS ___________________________________________________________________________

HOME PHONE # _____________________   E-MAIL ADDRESS____________________________

WORKPLACE ______________________________ WORK PHONE # _________________________

JOB TITLE _________________________   RELIGION _________________________________

RELATIONSHIP TO CHILD (CHECK ONE)       _____NATURAL      _____ STEP      _____ ADOPTIVE 
                                                                                                  _____ GUARDIAN   _____ GRANDPARENT   _____ OTHER

FATHER'S NAME ________________________________________________________________

ADDRESS ________________________________________________________________________

HOME PHONE # _____________________   E-MAIL ADDRESS____________________________

WORKPLACE ______________________________ WORK PHONE # _________________________

JOB TITLE _________________________   RELIGION _________________________________

RELATIONSHIP TO CHILD (CHECK ONE)   _____NATURAL         _____ STEP     _____ ADOPTIVE                                     
                                                                                               _____GUARDIAN    _____ GRANDPARENT   _____ OTHER

CHILD LIVES WITH _____________________________________________________________

DOES THE CHILD HAVE ANY SPECIAL NEEDS? __________________________________

REFERRED BY __________________________________________________________________