- CATECHISM INSCRIPTION FORM 2023-2024
  OFFICE OF RELIGIOUS EDUCATION ST. EMYDIUS CATHOLIC CHURCH
  10900 CALIFORNIA ave. lynwood ca, 90262 tel. (310)639-1249 ext.229
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  PARENTS/TUTOR INFORMATION
  
  Name of the Father: REQUIRED
  Father's Last and First Name
  Please fill out this field. Please enter valid data.
  
  Name of the Mother: REQUIRED
  Mother's Maiden Last and First Name
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  Address: REQUIRED
  Number and Street Name
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  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.
  
  Cellphone#: REQUIRED Maximum 20 characters
  Cellphone
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  Home Phone REQUIRED Maximum 20 characters
  Home Phone
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  Emergency Phone REQUIRED Maximum 20 characters
  Emergency Phone
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  Contact this Person in case of Emergency REQUIRED
  Contact Person in case of Emergency
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  Emergency Phone REQUIRED Maximum 20 characters
  Emergency Phone
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  Contact this Person in case of Emergency
  Contact Person in case of Emergency
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  Married through Catholic Church? REQUIRED
  Selection One
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  Status REQUIRED
  Selection One
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  STUDENT(S) INFORMATION
  
  Name of the child: REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth: REQUIRED Please fill out this field. Please enter a date.
  
  Age REQUIRED Please fill out this field. Please enter an integer (number).
  
  School: 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.
  
  Grade: REQUIRED Please fill out this field. Please enter valid data.
  
  Gender REQUIRED Please fill out this field.
  
  Baptized? REQUIRED Please fill out this field.
  
  Living Arrangements REQUIRED Please fill out this field.
  
  Are there any custody issues or restraining order in place? (If "Yes" email [email protected] a copy of the most recent court order(s)) REQUIRED
  Selection One
  Please fill out this field.
  
  Given the nature of the program, does your child have any physical, mental, emotional, cognitive, or other limitations? REQUIRED
  Selection One
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  If "Yes" what type of restriction does your child have or what adjustment(s) will be needed?
  
  Cathecism Group (Office Use Only) Please enter valid data.
  
  Comments:
  
  Parents or Guardian Signature REQUIRED
  Just type your name or initials
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  Name of Person who filled out form REQUIRED Please fill out this field. Please enter valid data.
  
  Date REQUIRED Please fill out this field. Please enter a date.
  
  Submit
  
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