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

Number students being registered REQUIRED Please fill out this field.
Child's Information 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.
- Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- Age REQUIRED Please fill out this field. Please enter valid data.
- Grade Level
- Gender REQUIRED Male Female Please fill out this field.
- Sacramental Information
- *Please submit the Baptism Certificate to the parish office of children preparing for 1st Communion or Confirmation*
- Baptism Date REQUIRED Please fill out this field. Please enter valid data.
- Church of Baptism 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.
- _____________________________________________________
Child's Information 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.
- Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- Age REQUIRED Please fill out this field. Please enter valid data.
- Grade Level
- Gender REQUIRED Male Female Please fill out this field.
- Sacramental Information
- *Please submit the Baptism Certificate to the parish office of children preparing for 1st Communion or Confirmation*
- Baptism Date REQUIRED Please fill out this field. Please enter valid data.
- Church of Baptism 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.
- _____________________________________________________
Child's Information 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.
- Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- Age REQUIRED Please fill out this field. Please enter valid data.
- Grade Level
- Gender REQUIRED Male Female Please fill out this field.
- Sacramental Information
- *Please submit the Baptism Certificate to the parish office of children preparing for 1st Communion or Confirmation*
- Baptism Date REQUIRED Please fill out this field. Please enter valid data.
- Church of Baptism 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.
- _____________________________________________________
Child's Information 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.
- Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- Age REQUIRED Please fill out this field. Please enter valid data.
- Grade Level
- Gender REQUIRED Male Female Please fill out this field.
- Sacramental Information
- *Please submit the Baptism Certificate to the parish office of children preparing for 1st Communion or Confirmation*
- Baptism Date REQUIRED Please fill out this field. Please enter valid data.
- Church of Baptism 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.
- _____________________________________________________
Child's Information 5
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- Age REQUIRED Please fill out this field. Please enter valid data.
- Grade Level
- Gender REQUIRED Male Female Please fill out this field.
- Sacramental Information
- *Please submit the Baptism Certificate to the parish office of children preparing for 1st Communion or Confirmation*
- Baptism Date REQUIRED Please fill out this field. Please enter valid data.
- Church of Baptism 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.
- _____________________________________________________

Parent / Guardian Information

Relationship REQUIRED Please fill out this field.

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

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

Address - Street 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.

Relationship REQUIRED Please fill out this field.

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

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

Address - Street 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.

Emergency Contact

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

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

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

Relationship to child Please enter valid data.

Please list any special information we should know (allergies, medical conditions, medicines).

Please answer these survey questions?

What are your child's strengths as a learner?

What are your child's needs as a learner?

What do you hope for your child this year?

What do you hope for your family this year?

Information provided on this form will be held in strict confidence.

May we share the information on this form with your child's catechist REQUIRED yes no Please fill out this field.

How Many Children Have you Registered for CCD Today REQUIRED Please fill out this field.

Christ the Divine Shepherd
Penn Hills/Pitcairn/Monroeville

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