628 Middle School Ministry 2025-26 Registration Form

Student Information

Student Name*

First NameMiddle NameLast Name

Date of Birth*

MonthDayYear

Age*

Gender*

School Attending*

Grade in School 2025-26

Please list any medical conditions, allergies, or special needs for this teen*

I give permission to The Holy Name of Jesus to publish photos of my child in church related social media.*

Student email

Student Cell Phone

Area CodePhone Number

Student Sacraments

YesNo

This is a non-sacramental program for children who have received the sacrament of First Communion. If your child has not received this sacrament, please use the following link to register to the appropriate program.

https://pci.jotform.com/form/251808059004150

YESNO

Student Name

First NameMiddle NameLast Name

Date of Birth

MonthDayYear

Age

Gender

Grade in School 2025-2026

School Attending

Please list any medical conditions, allergies, or special needs for this teen

I give permission to The Holy Name of Jesus to publish photos of my child in church related social media.

Student email

example@example.com

Student Cell Phone

Area CodePhone Number

Student Sacraments

YesNo

This is a non-sacramental program for children who have received the sacrament of First Communion. If your child has not received this sacrament, please use the following link to register to the appropriate program.

https://pci.jotform.com/form/251808059004150

Mother's Information

Mother's Name*

First NameLast Name

Mother's Maiden Name*

Phone Number*

Area CodePhone Number

E-mail Address*

example@example.com

Fathers's Information

Father's Name*

First NameLast Name

Phone Number*

Area CodePhone Number

E-mail Address*

example@example.com

Address (where child primarily resides)*

Street Address

Street Address Line 2

CityState

Zip Code

Primary language spoken in the home*

Are you registered parishioners at The Holy Name of Jesus?*

Emergency Contact (If Parent/Guardian cannot be reached)*

Relationship to Student*

Emergency Phone Number*

Area CodePhone Number

Suggested Offering, to offset cost of materials, activities & other. (Please feel free to select any of the suggested amounts).

628 - Option #1 $60.00

628 - Option #2$40.00

628 - Option #3$20.00

628 - Hospitality$20.00

Monetary donations are welcome and the dropping off of treats is appreciated. (Ex. Pizza, beverage, donuts, etc.) Thank you in advance.

Quantity

Total $0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

ACH Bank Transfer

Today's Date*

Date

628 Middle School Ministry Non-Sacramental Program

Student #2 Information

Parent/Guardian Information

DONATION

Payment Methods