EmailMe Form - Confirmation Ministry Registration

Student's Name *

First Middle Last

Grade in School this Fall *

Birth Date *

MM / DD / YYYY

Birth Place (city/state) *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Student's Cell Phone if they have one:

### - ### - ####

Student's Home Phone if there is one

### - ### - ####

Has the student been baptized? *

Yes

No

If baptized, date of baptism

MM / DD / YYYY

If baptized, baptismal place: Church, City/State

Father's Name *

First Last

Mother's Name *

First Last

Father's Cell Phone *

### - ### - ####

Mother's Cell Phone *

### - ### - ####

If the pastor or group leader needs to contact a parent, who should they call? *

Mother

Father

Either One

Parent's Email for future contact *

Parent's Marital Status *

Married

Separated

Divorced/Single

During the week (on Wednesday)
the student is living at: *

Parent's Home

Mother's Home

Father's Home

Confirmation evening begins with pizza. What would be your preferrence? Check one *

Cheese Only

Sausage w/cheese

Pepperoni w/cheese

Sausage & Pepperoni w/cheese