CCD online registration form

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

Parents/Guardians REQUIRED Please fill out this field. Please enter valid data.

Mother's maiden name REQUIRED Please fill out this field. Please enter valid data.

Are you registered parishoners of St. Dom's? REQUIRED Yes No Please fill out this field.

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.

Home Phone Please enter a phone number.

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

Text? REQUIRED Yes No Please fill out this field.

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

Individuals who may pick up my children (other than parents):

Name and relation to children: Please enter valid data.

Child Information

Names, DOB, Age and Grades of Children (Grades K through 8)

Name, Birthday/year, Grade, Age REQUIRED Please fill out this field. Please enter valid data.

Name, Birthday/year, Grade, Age Please enter valid data.

Children baptized at St. Dominic's? REQUIRED Yes No Please fill out this field.

If Yes, please put Date of Baptism (at least the year). If No, please state date and parish. REQUIRED Please fill out this field. Please enter valid data.

Emergency Information:

Do any children have allergies? Yes No

If so, which child and what allergy? Please enter valid data.

Do any children have any learning or physical disabilities? REQUIRED Yes No Please fill out this field.

If so, which child and what disability? Please enter valid data.

In an EMERGENCY, if parents cannot be reached, call: REQUIRED Please fill out this field. Please enter valid data.

Legal Information: Please check if applicable. Describe/attatch documentation if necessary.

Marital Status Married Divorced Single

Custody issues, transportation permissions? REQUIRED Yes No Please fill out this field.

Court orders restricting contact with child? REQUIRED Yes No Please fill out this field.

Child has IEP? REQUIRED Yes No Please fill out this field.

Attendance issues impacting participation? Yes No

CCD begins Sunday, September 9, 2018 from 9:00-10:15 AM in the St. Dominic Parish Center.
Questions? Give us a call (330) 783-1900 ext 247, or send an email to jacqueline.conigliaro@gmail.com.

St. Dominic Parish

Youngstown, Ohio

CCD online registration form

2018 - 2019 St. Dominic's CCD Registration