Contact Information

Student

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

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

Mother

First Name Please enter valid data.

Last Name Please enter valid data.

Father

First Name Please enter valid data.

Last Name Please enter valid data.

Legal Guardian (if different than parents)

First Name Please enter valid data.

Last Name Please enter valid data.

Relationship to student Please enter valid data.

Mailing Address

Street 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.

Is this address the primary residence of the student? REQUIRED Yes No Please fill out this field.

If not, please provide the student's primary address:

Street Please enter valid data.

City Please enter valid data.

State

Zip Please enter a zip code.

Primary Contact

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

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

Phone Number Please enter a phone number.

Cell Phone Number (Textable) Please enter a phone number.

Email Please enter an email address.

Secondary Contact

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

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

Phone Number Please enter a phone number.

Cell Phone Number (Textable) Please enter a phone number.

Email Please enter an email address.

Student Contact (Grades 9-11)

Phone Number Please enter a phone number.

Cell Phone Number (Textable) Please enter a phone number.

Email Please enter an email address.

Class registration

Child Date of Birth REQUIRED Please fill out this field. Please enter a date.

Grade for 2023-2024 School Year REQUIRED Please fill out this field.

School Attending REQUIRED Please fill out this field. Please enter valid data.

Been Baptized? REQUIRED Yes No Please fill out this field.

(If Baptized) Church Name Please enter valid data.

Received First Communion? REQUIRED Yes No Please fill out this field.

Been Confirmed? REQUIRED Yes No Please fill out this field.

(If Confirmed) Church Name Please enter valid data.

Any Food or Other Alergies? REQUIRED Please fill out this field. Please enter valid data.

Class Requested (K-5) REQUIRED

Morning or Evening options are only available for grades K-5. Edge (grades 6-8) and LifeTeen (grades 9-11) will attend Sunday evenings 6:15pm-7:30pm.

Sunday Morning 11:30am-12:30pm Sunday Evening 6:15pm-7:15pm Please fill out this field.

Is there any reason your child will not be able to attend classes regularly? REQUIRED Please fill out this field.

Payment information

What is your preferred payment method? REQUIRED

Registration fee is $35 per child. After the form has been submitted and accepted, the parish office will contact you by phone to arrange payment.

Cash Check Debit or Credit Card Please fill out this field.

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

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

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

St. Charles Borromeo
Catholic Church

Picayune, MS

2023-2024 Child Registration Form

Contact Information

Student

Mother

Father

Legal Guardian (if different than parents)

Mailing Address

Primary Contact

Secondary Contact

Student Contact (Grades 9-11)

Class registration

Payment information