Waterloo Catholics

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High School Confirmation Registration for current 10th & 11th grade students

- Sacraments

- Student's Name (As it appears on their birth certificate)
  
  Student's First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Middle Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Youth's Date of Birth (Month, Day, Year) REQUIRED Please fill out this field. Please enter a date.
- City & State of Birth (or list country if out of the USA) REQUIRED Please fill out this field. Please enter valid data.
- Youth's 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.
- 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.
  
  Maiden Name REQUIRED Please fill out this field. Please enter valid data.
  
  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.
- Father's Info
  
  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
  
  Please enter a phone number.
  
  Email
  This will be used to communicate about the program.
  Please enter an email address.
- What cell phone number can we use to send text messages about program updates? REQUIRED
  This will be used to communicate about the program.
  
  Please fill out this field. Please enter a phone number.
- Language in which you wish to receive information from us: REQUIRED Please fill out this field.
- Parish where you belong? REQUIRED Please fill out this field.
- If you do not belong to a Waterloo parish, please type the name of your parish? Please enter valid data.
- What school does your child attend? REQUIRED Please fill out this field. Please enter valid data.
- Current Grade of Student REQUIRED Please fill out this field. Please enter valid data.
- Baptismal Information
  
  Is your child baptized? REQUIRED Yes No Please fill out this field.
  
  Church where student was baptized REQUIRED
  If child was not baptized in a Waterloo or Cedar Falls parish, a Baptism certificate is required.
  Please fill out this field. Please enter valid data.
  
  City and state where baptized REQUIRED Please fill out this field. Please enter valid data.
  
  Date of baptism (month or year would be helpful if you don't know exact date) REQUIRED Please fill out this field. Please enter valid data.
- Parental Consent & Releases
  
  Media Consent & Release
  
  I understand that, unless I indicate otherwise, I give permission for the Waterloo Area Pastorate to use video, photographs, or similar items in which my child/children might appear, or statements made by them, on display on the parish website, parish bulletin, or parish social media. Note: no children’s names will be published without specific prior consent.
  
  Sepcific Medical Matters
  I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.
- Emergency Medical Treatment
  
  Item A - Emergency Medical Treatment:
  
  In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:
  
  Name, Relationship & Phone: REQUIRED Please fill out this field. Please enter valid data.
  
  Item B- Other Medical Treatment
  In the event it comes to the attention of the parish/school, its officers, directors and agents, and the Archdiocese of Dubuque, chaperones, or representatives associated with the activity that my child becomes ill with symptoms such as vomiting, sore throat, fever, diarrhea, I want to be notified.
  
  I wish to be informed if my youth becomes ill (sore throat, vomiting, fever, diarrhea, etc). REQUIRED No Yes Please fill out this field.
  
  On-site Nonprescription Medication Permission
  
  I hereby grant permission for nonprescription medication (such as ibuprofen, Tylenol, throat lozenges, etc.) to be given to my child in the event a condition arises after my child is already in attendance at the on site program.
  
  I give permission to allow my youth to have nonprescription medication if needed. REQUIRED Yes No Please fill out this field.
- Fee for preparation materials35.0
Total:

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