Confirmation Request Form

- Youth & Young Adults

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- St. Joseph’s Confirmation
  Sacramental Request Form 2021-2022
- Child Name (Last, First, Middle) Please enter valid data.
- Mailing Address - Street (Apt. or Lot #) Please enter valid data.
- Mailing Address - City, State, Zip Code Please enter valid data.
- Home Phone Please enter valid data.
- Cell Phone - Mother Please enter valid data.
- Cell Phone - Father Please enter valid data.
- Email Address Please enter valid data.
- Date of Birth Please enter valid data.
- City & State of Birth Please enter valid data.
- Father’s Full Name (Birth Father or Legally Adoptive Father) Please enter valid data.
- Mother’s Full Name (Birth Mother or Legally Adoptive Mother) INCLUDE MAIDEN NAME Please enter valid data.
- Baptismal Information:
  
  Date of Baptism/Year of Baptism Please enter valid data.
  
  Name of the Baptismal Church Please enter valid data.
  
  Address of the Baptismal Church – Street Please enter valid data.
  
  Address of Baptismal Church – City, State, Zip Code Please enter valid data.
  
  For any child NOT baptized at St. Joseph Parish: Please submit a copy of your child’s baptismal certificate to the Religious Education Office at St. Joseph. Parish. If you do not have a copy of the Baptismal Certifcate you must obtain proof of baptism in order to receive the sacrament. Please do so as soon as possible and have it sent to the Religious Education office at St. Joseph Parish.
- 2021-2022 Grade: Please enter valid data.
- Registered Member of St. Joseph Parish? REQUIRED Please fill out this field.
- Registered Member of: (list Parish if not St. Joseph) *You must obtain a letter of permission in order to receive the sacrament of communion with us. Please gather this letter as soon as possible from your home parish. Please enter valid data.
- Emergency Contacts:
  
  Name & Phone Number: Please enter valid data.
  
  Name & Phone Number: Please enter valid data.
- Medical Treatment Authorization
  
  As a parent/guardian, I do hereby authorize the treatment of my minor child/children listed below by a qualified and licensed physician of any condition which, in the opinion of the physician, is deemed necessary and appropriate. This authority is granted only after a reasonable effort has been made to reach me.
  I further authorize the person who presents the minor to sign the Acknowledgment of Receipt of Notice of Privacy Rights that may be presented by the physician or health care facility.
  This authorization is completed and signed of my own free will with the sole purpose of authorizing medical treatment deemed necessary and appropriate by the treating physician due to injury or illness sustained during religious education classes, testing, and/or activities by St. Joseph Parish Religious Education Program.
- Child: Medical Info (If your child has a learning disability that requires an IEP in their public school setting, please indicate that here.)
  
  Name of Child Please enter valid data.
  
  List of Allergies, Medications, or Other Pertinent Information
- Health Insurance Information:
  
  Company: Please enter valid data.
  
  Group#: Please enter valid data.
  
  Policy#: Please enter valid data.
  
  ID#: Please enter valid data.
  
  Family Physician - Name: Please enter valid data.
  
  Family Physician - Phone: Please enter valid data.
  
  Family Physician - Address Please enter valid data.
  
  Date: Please enter valid data.
  
  Parent Signature: (typing in your name below will act as your signature) Please enter valid data.
- *If there are any custodial/legal rights of parents and/or guardians that we should be made aware of or if you wish your child to be picked up by an adult other than a legal parent, please notify us in writing.
- Photo Release:
  
  With my signature, I hereby grant permission to St. Joseph Parish to publish my child’s/children’s names, photos, or video images in connection with a display, feature story, or other publication as deemed appropriate by the Parish. This photo may be used in connection with parish bulletin boards, parish or youth ministry websites, publicity materials, and/or parish bulletins.
  
  Permission is granted by: (typing in your name below will act as your signature) Please enter valid data.
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St. Joseph Catholic ParisH

220 CHURCH ST. ST. JOSEPH, MI 49085

Confirmation Request Form