Confirmation Registration Form Confirmation Registration (1) Student InformationStudent Name* First Last Preferred Name / Nickname Preferred Name/Nickname Student's Cell Phone Number Student's Email Address* * Please note, students will not be contacted without an adult on copy to ensure safe environment protocol.Date of Birth* Church of Baptism* Date of Baptism* Month Day Year Church of First Eucharist* Date of First Eucharist* Month Day Year School Attending the Fall* Grade in the Fall*910Home Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneParent InformationMother's Name* First Maiden Name Last Mother's Cell PhoneMother's Email Address Father's Name* First Last Father's Cell PhoneFather's Email Address Emergency Contact InformationName* First Last Phone*Relationship* Medical Conditions/Allergies/Educational NeedsIs your family registered at Immaculate Conception Parish?* Registered NOT registered If not, at what parish are you registered? Service and Volunteer ConsentPermission to participate in service and volunteer opportunities related to Immaculate Conception Confirmation Classes from June 1, 2021 until June 1, 2023. I understand that events may take place away from church grounds and this form will serve as a medical release for my child. I further consent to my child's participation with regard to transportation, i.e. parish van, chartered bus, or car.* I consent to the above Parent Name* Photo/Video and Online Learning ConsentPhotographs and/or videos of minors are taken periodically for use in parish publications. In checking "I agree" you are acknowledging this and granting permission to Immaculate Conception Faith Formation to use photos and videos of your child and their names in print/electronic publications and displays.* I agree I DO NOT agree Virtual On-Line Learning Permission: If necessary, my child has my permission to participate with on-line Catechesis with Immaculate Conception. I understand that a subsequent email will be forwarded providing the dates and times of the sessions.* I give permission. I DO NOT give permission. Parent Name* Other CommentsIs there anything else you would like to add?PaymentPlease indicate your method of payment.* Cash/Check (Please mail or drop in the rectory door mail slot at Parish Office.) Online payment (Once you submit this form you will receive a pop up that will provide a link to pay online.) FEE FOR THE TWO YEAR PROGRAM IS $125. Registration and Fee are due July 31, 2021. Please note, registration is not complete without payment. Late registrations will be handles on an individual basis. (If student fee presents a hardship, please call the IC Youth Office, 637-2375).