Register for Grades 1-8

Please list the email(s) and phone number(s) you would like us to use for messages regarding class cancellations, schedule changes, and important reminders.

Email(s) REQUIRED Please fill out this field. Please enter an email address.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Alternate Phone Number Please enter a phone number.

Registering For REQUIRED Traditional Program - Wednesday Evenings Family Program - Sunday (1x month +homework) Please fill out this field.

Family Name REQUIRED Please fill out this field. Please enter valid data.

Family Street 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.

Mother's Name REQUIRED Please fill out this field. Please enter valid data.

Mother's Maiden Name REQUIRED Please fill out this field. Please enter valid data.

Mother's Religious Affiliation REQUIRED Please fill out this field. Please enter valid data.

Father's Name REQUIRED Please fill out this field. Please enter valid data.

Father's Religious Affiliation REQUIRED Please fill out this field. Please enter valid data.

Family Home Parish REQUIRED Saint Theresa Parish Other Please fill out this field.

If other, what is your home parish? Please enter valid data.

Please provide the name of a contact in the event we cannot reach you in an emergency: REQUIRED Please fill out this field. Please enter valid data.

Phone Number of the emergency contact REQUIRED Please fill out this field. Please enter a phone number.

Relationship of the emergency contact REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

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.

I authorize the staff of Saint Theresa to seek emergency medical care for my child as deemed appropriate

Physician's Name REQUIRED Please fill out this field. Please enter valid data.

Physician's Phone REQUIRED Please fill out this field. Please enter valid data.

Hospital Preference REQUIRED Please fill out this field. Please enter valid data.

Occasionally, we like to recognize the activities that take place in our Religious Education programs. Do you give permission for your child's picture to appear in parish media? REQUIRED Yes No Please fill out this field.

Volunteer Opportunities

Our program is volunteer based. Please consider helping in one of the following areas:

Catechist (Teacher) Substitute Catechist Classroom Aide Building Monitor (Wed evenings, about 1x month)

Comments/Concerns: Please enter valid data.

In registering my child for Saint Theresa Religious Formation, I acknowledge that I have a responsibility, as the primary faith educator of my child, to support the teaching of religion and to assist my student's education by our family practice of prayer and good works, observing the Law of God and attending Mass each Sunday and Holy Day.

Signature (Indicate parent name as electronic signature) REQUIRED Please fill out this field. Please enter valid data.

Date REQUIRED Please fill out this field. Please enter a date.

STUDENT INFORMATION. Information is shared only with the classroom teacher. IF YOUR CHILD IS NEW TO THE PROGRAM PLEASE INCLUDE A COPY OF HIS OR HER BAPTISMAL CERTIFICATE.

Saint Theresa of the Infant Jesus Parish

New Cumberland, PA
(717) 774-5918

Register for Grades 1-8

Please list the email(s) and phone number(s) you would like us to use for messages regarding class cancellations, schedule changes, and important reminders.

I authorize the staff of Saint Theresa to seek emergency medical care for my child as deemed appropriate