Confirmation Registration

Student Information

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

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

Grade of Student REQUIRED Please fill out this field.

Session REQUIRED 1st year 2nd year Please fill out this field.

Mother's Information

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.

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

Father's Information

First Name Please enter valid data.

Last Name Please enter valid data.

Phone Number Please enter a phone number.

Email Please enter an email address.

Student Information

School Attending REQUIRED Please fill out this field. Please enter valid data.

Home 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.

Gender REQUIRED Please fill out this field.

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

Place of Birth (city, state) REQUIRED Please fill out this field. Please enter valid data.

Baptized at St Perpetua REQUIRED Yes No Please fill out this field.

Name of Church, City and State Please enter valid data.

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

First Eucharist at St Perpetua REQUIRED Yes No Please fill out this field.

Name of Church, City and State Please enter valid data.

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

Mother's Religion REQUIRED Catholic Other Please fill out this field.

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

Father's Religion Catholic Other

Registered in Parish REQUIRED Yes No Please fill out this field.

Child's image may appear on St. Perpetura materials (website, bulletin)? REQUIRED Yes No Please fill out this field.

Volunteer Buyout ($150) REQUIRED Yes No Please fill out this field.

St. Perpetua Church