SOR &amp; CGS Registration &amp; Payments

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Family Information
Family Last Name REQUIRED Please fill out this field. Please enter valid data.
Family 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.
Family Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Registered Parish Please enter valid data.
_____________________________________
Father'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.
- Fathers Email REQUIRED Please fill out this field. Please enter an email address.
- Fathers Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Fathers Religion Please enter valid data.
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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.
- Mothers Email REQUIRED Please fill out this field. Please enter an email address.
- Mothers Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Mothers Religion Please enter valid data.
- Mother's Maiden Name REQUIRED Please fill out this field. Please enter valid data.
____________________________________
Emergency Information
- Insurance Company REQUIRED Please fill out this field. Please enter valid data.
- Insurance Policy Number REQUIRED Please fill out this field. Please enter valid data.
- Hospital Preference REQUIRED Please fill out this field. Please enter valid data.
- In the event of illness or injury, I do hereby consent to whatever x-ray examination, anesthetic, medical, surgical, dental diagnosis or treatment and hospital care are considered necessary in the best judgment of the attending physician, surgeon or dentist and performed by or under the supervision of the medical staff of the hospital or facility furnishing medical or dental services. I fully understand that students are to abide by all rules and regulations governing conduct and safety while attending the Queen of the Holy Rosary School of Religion Program and related activities. Any violation of these rules and regulations may result in that individual being sent home.
  I Agree Please select this field.
- ---------------------------
- Emergency Contact Name 1 REQUIRED Please fill out this field. Please enter valid data.
- Relationship 1 REQUIRED Please fill out this field. Please enter valid data.
- Phone Number 1 REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- ---------------------------
- Emergency Contact Name 2 REQUIRED Please fill out this field. Please enter valid data.
- Relationship 2 REQUIRED Please fill out this field. Please enter valid data.
- Phone Number 2 REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
_____________________________________
- Number of Children Registering REQUIRED Please fill out this field.
- Child 1
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Date of Birth REQUIRED Please fill out this field. Please enter a date.
  - Grade REQUIRED Please fill out this field.
  - Gender REQUIRED Please fill out this field.
  - Child Lives With REQUIRED Please fill out this field.
  - If other - please describe Please enter valid data.
  - Baptized Catholic REQUIRED Yes No Please fill out this field.
  - Baptized Other
    What denomination?
    Please enter valid data.
  - First Reconciliation REQUIRED Yes No Please fill out this field.
  - First Communion REQUIRED Yes No Please fill out this field.
  - Disability or Learning Difficulties? REQUIRED Yes No Please fill out this field.
  - Describe
    If yes, please describe the disability(s) or learning difficulties.
  - May We Use Child's Picture? REQUIRED
    May we use your child's picture(s) for publicity?
    Yes No Please fill out this field.
- Child 2
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Date of Birth REQUIRED Please fill out this field. Please enter a date.
  - Grade REQUIRED Please fill out this field.
  - Gender REQUIRED Please fill out this field.
  - Child Lives With REQUIRED Please fill out this field.
  - If other - please describe Please enter valid data.
  - Baptized Catholic REQUIRED Yes No Please fill out this field.
  - Baptized Other
    What denomination?
    Please enter valid data.
  - First Reconciliation REQUIRED Yes No Please fill out this field.
  - First Communion REQUIRED Yes No Please fill out this field.
  - Disability or Learning Difficulties? REQUIRED Yes No Please fill out this field.
  - Describe
    If yes, please describe the disability(s) or learning difficulties.
  - May We Use Child's Picture? REQUIRED
    May we use your child's picture(s) for publicity?
    Yes No Please fill out this field.
- Child 3
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Date of Birth REQUIRED Please fill out this field. Please enter a date.
  - Grade REQUIRED Please fill out this field.
  - Gender REQUIRED Please fill out this field.
  - Child Lives With REQUIRED Please fill out this field.
  - If other - please describe Please enter valid data.
  - Baptized Catholic REQUIRED Yes No Please fill out this field.
  - Baptized Other
    What denomination?
    Please enter valid data.
  - First Reconciliation REQUIRED Yes No Please fill out this field.
  - First Communion REQUIRED Yes No Please fill out this field.
  - Disability or Learning Difficulties? REQUIRED Yes No Please fill out this field.
  - Describe
    If yes, please describe the disability(s) or learning difficulties.
  - May We Use Child's Picture? REQUIRED
    May we use your child's picture(s) for publicity?
    Yes No Please fill out this field.
- Child 4
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Date of Birth REQUIRED Please fill out this field. Please enter a date.
  - Grade REQUIRED Please fill out this field.
  - Gender REQUIRED Please fill out this field.
  - Child Lives With REQUIRED Please fill out this field.
  - If other - please describe Please enter valid data.
  - Baptized Catholic REQUIRED Yes No Please fill out this field.
  - Baptized Other
    What denomination?
    Please enter valid data.
  - First Reconciliation REQUIRED Yes No Please fill out this field.
  - First Communion REQUIRED Yes No Please fill out this field.
  - Disability or Learning Difficulties? REQUIRED Yes No Please fill out this field.
  - Describe
    If yes, please describe the disability(s) or learning difficulties.
  - May We Use Child's Picture? REQUIRED
    May we use your child's picture(s) for publicity?
    Yes No Please fill out this field.
- Child 5
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Date of Birth REQUIRED Please fill out this field. Please enter a date.
  - Grade REQUIRED Please fill out this field.
  - Gender REQUIRED Please fill out this field.
  - Child Lives With REQUIRED Please fill out this field.
  - If other - please describe Please enter valid data.
  - Baptized Catholic REQUIRED Yes No Please fill out this field.
  - Baptized Other
    What denomination?
    Please enter valid data.
  - First Reconciliation REQUIRED Yes No Please fill out this field.
  - First Communion REQUIRED Yes No Please fill out this field.
  - Disability or Learning Difficulties? REQUIRED Yes No Please fill out this field.
  - Describe
    If yes, please describe the disability(s) or learning difficulties.
  - May We Use Child's Picture? REQUIRED
    May we use your child's picture(s) for publicity?
    Yes No Please fill out this field.
- Child 6
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Date of Birth REQUIRED Please fill out this field. Please enter a date.
  - Grade REQUIRED Please fill out this field.
  - Gender REQUIRED Please fill out this field.
  - Child Lives With REQUIRED Please fill out this field.
  - If other - please describe Please enter valid data.
  - Baptized Catholic REQUIRED Yes No Please fill out this field.
  - Baptized Other
    What denomination?
    Please enter valid data.
  - First Reconciliation REQUIRED Yes No Please fill out this field.
  - First Communion REQUIRED Yes No Please fill out this field.
  - Disability or Learning Difficulties? REQUIRED Yes No Please fill out this field.
  - Describe
    If yes, please describe the disability(s) or learning difficulties.
  - May We Use Child's Picture? REQUIRED
    May we use your child's picture(s) for publicity?
    Yes No Please fill out this field.
- Child 7
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Date of Birth REQUIRED Please fill out this field. Please enter a date.
  - Grade REQUIRED Please fill out this field.
  - Gender REQUIRED Please fill out this field.
  - Child Lives With REQUIRED Please fill out this field.
  - If other - please describe Please enter valid data.
  - Baptized Catholic REQUIRED Yes No Please fill out this field.
  - Baptized Other
    What denomination?
    Please enter valid data.
  - First Reconciliation REQUIRED Yes No Please fill out this field.
  - First Communion REQUIRED Yes No Please fill out this field.
  - Disability or Learning Difficulties? REQUIRED Yes No Please fill out this field.
  - Describe
    If yes, please describe the disability(s) or learning difficulties.
  - May We Use Child's Picture? REQUIRED
    May we use your child's picture(s) for publicity?
    Yes No Please fill out this field.
- Child 8
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Date of Birth REQUIRED Please fill out this field. Please enter a date.
  - Grade REQUIRED Please fill out this field.
  - Gender REQUIRED Please fill out this field.
  - Child Lives With REQUIRED Please fill out this field.
  - If other - please describe Please enter valid data.
  - Baptized Catholic REQUIRED Yes No Please fill out this field.
  - Baptized Other
    What denomination?
    Please enter valid data.
  - First Reconciliation REQUIRED Yes No Please fill out this field.
  - First Communion REQUIRED Yes No Please fill out this field.
  - Disability or Learning Difficulties? REQUIRED Yes No Please fill out this field.
  - Describe
    If yes, please describe the disability(s) or learning difficulties.
  - May We Use Child's Picture? REQUIRED
    May we use your child's picture(s) for publicity?
    Yes No Please fill out this field.
____________________________________
Baptismal Certificate(s) REQUIRED All children being registered have baptismal certificate(s) on file at QHR School of Religion I will email or mail copy of my child(ren)'s baptismal certificate(s) to QHR School of Religion before SOR begins. Not Applicable Please fill out this field.
____________________________________
Fees
- Convenience Fee Payment Type REQUIRED
  A convenience fee is required and different depending on your payment type. How are you paying for this - Electronic Check or Credit Card?
  Please fill out this field.
- Registration Fee REQUIRED Please fill out this field.
- Needing 1st Reconciliation & 1st Communion REQUIRED Please fill out this field.
- No. of Children for Confirmation REQUIRED Please fill out this field.
- _____________________________________
  
  Please review fees before proceeding to payment.

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Queen of the Holy Rosary - Wea	Parish	School
22779 Metcalf Rd.	p. (913) 533-2464	p. (913) 533-2462
Bucyrus, KS 66013	e. parish@qhrwea.org	e. nick@qhrwea.org