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OCIA-C Registration for Children and Teens

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  Family Contact Information
  
  Is your family registered at St. Luke Catholic Church? REQUIRED Yes No Please fill out this field.
  
  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.
  
  Name of Primary Contact REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to child REQUIRED Please fill out this field.
  
  Other-Please explain below
  
  Best Phone Number to contact REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Best Email to contact REQUIRED Please fill out this field. Please enter an email address.
  
  Father's Full Legal Name
  
  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 REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Mother's Full Legal Name
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Maiden Name Please enter valid data.
  
  Phone REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Marital Status REQUIRED Please fill out this field.
  
  Child Custody REQUIRED Please fill out this field.
  
  Number of Children Registering for Classes REQUIRED Please fill out this field.
  
  Child 1
  
  Child's full name (as it appears on Birth Certificate) REQUIRED Please fill out this field. Please enter valid data.
  
  Child's date of birth REQUIRED Please fill out this field. Please enter a date.
  
  Child's Current Age Please enter an integer (number).
  
  City and State or Country of Child's Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Has this child been baptized? REQUIRED Please fill out this field.
  
  Date of Baptism Please enter a date.
  
  Place of Baptism (church name and city/state) Please enter valid data.
  
  Has this child received the Sacrament of First Communion? REQUIRED Please fill out this field.
  
  Current school attending REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field. Please enter an integer (number).
  
  Please list any special needs or allergies: REQUIRED Please fill out this field.
  
  Child 2
  
  Child's full name (as it appears on Birth Certificate) REQUIRED Please fill out this field. Please enter valid data.
  
  Child's date of birth REQUIRED Please fill out this field. Please enter a date.
  
  Child's Current Age Please enter an integer (number).
  
  City and State or Country of Child's Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Has this child been baptized? REQUIRED Please fill out this field.
  
  Date of Baptism Please enter a date.
  
  Place of Baptism (church name and city/state) Please enter valid data.
  
  Has this child received the Sacrament of First Communion? REQUIRED Please fill out this field.
  
  Current school attending REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field. Please enter an integer (number).
  
  Please list any special needs or allergies: REQUIRED Please fill out this field.
  
  Child 3
  
  Child's full name (as it appears on Birth Certificate) REQUIRED Please fill out this field. Please enter valid data.
  
  Child's date of birth REQUIRED Please fill out this field. Please enter a date.
  
  Child's Current Age Please enter an integer (number).
  
  City and State or Country of Child's Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Has this child been baptized? REQUIRED Please fill out this field.
  
  Date of Baptism Please enter a date.
  
  Place of Baptism (church name and city/state) Please enter valid data.
  
  Has this child received the Sacrament of First Communion? REQUIRED Please fill out this field.
  
  Current school attending REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field. Please enter an integer (number).
  
  Please list any special needs or allergies: REQUIRED Please fill out this field.
  
  Child 4
  
  Child's full name (as it appears on Birth Certificate) REQUIRED Please fill out this field. Please enter valid data.
  
  Child's date of birth REQUIRED Please fill out this field. Please enter a date.
  
  Child's Current Age Please enter an integer (number).
  
  City and State or Country of Child's Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Has this child been baptized? REQUIRED Please fill out this field.
  
  Date of Baptism Please enter a date.
  
  Place of Baptism (church name and city/state) Please enter valid data.
  
  Has this child received the Sacrament of First Communion? REQUIRED Please fill out this field.
  
  Current school attending REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field. Please enter an integer (number).
  
  Please list any special needs or allergies: REQUIRED Please fill out this field.
  
  Child 5
  
  Child's full name (as it appears on Birth Certificate) REQUIRED Please fill out this field. Please enter valid data.
  
  Child's date of birth REQUIRED Please fill out this field. Please enter a date.
  
  Child's Current Age Please enter an integer (number).
  
  City and State or Country of Child's Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Has this child been baptized? REQUIRED Please fill out this field.
  
  Date of Baptism Please enter a date.
  
  Place of Baptism (church name and city/state) Please enter valid data.
  
  Has this child received the Sacrament of First Communion? REQUIRED Please fill out this field.
  
  Current school attending REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field. Please enter an integer (number).
  
  Please list any special needs or allergies: REQUIRED Please fill out this field.
  
  Child 6
  
  Child's full name (as it appears on Birth Certificate) REQUIRED Please fill out this field. Please enter valid data.
  
  Child's date of birth REQUIRED Please fill out this field. Please enter a date.
  
  Child's Current Age Please enter an integer (number).
  
  City and State or Country of Child's Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Has this child been baptized? REQUIRED Please fill out this field.
  
  Date of Baptism Please enter a date.
  
  Place of Baptism (church name and city/state) Please enter valid data.
  
  Has this child received the Sacrament of First Communion? REQUIRED Please fill out this field.
  
  Current school attending REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field. Please enter an integer (number).
  
  Please list any special needs or allergies: REQUIRED Please fill out this field.
  
  Child 7
  
  Child's full name (as it appears on Birth Certificate) REQUIRED Please fill out this field. Please enter valid data.
  
  Child's date of birth REQUIRED Please fill out this field. Please enter a date.
  
  Child's Current Age Please enter an integer (number).
  
  City and State or Country of Child's Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Has this child been baptized? REQUIRED Please fill out this field.
  
  Date of Baptism Please enter a date.
  
  Place of Baptism (church name and city/state) Please enter valid data.
  
  Has this child received the Sacrament of First Communion? REQUIRED Please fill out this field.
  
  Current school attending REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field. Please enter an integer (number).
  
  Please list any special needs or allergies: REQUIRED Please fill out this field.
  
  Child 8
  
  Child's full name (as it appears on Birth Certificate) REQUIRED Please fill out this field. Please enter valid data.
  
  Child's date of birth REQUIRED Please fill out this field. Please enter a date.
  
  Child's Current Age Please enter an integer (number).
  
  City and State or Country of Child's Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Has this child been baptized? REQUIRED Please fill out this field.
  
  Date of Baptism Please enter a date.
  
  Place of Baptism (church name and city/state) Please enter valid data.
  
  Has this child received the Sacrament of First Communion? REQUIRED Please fill out this field.
  
  Current school attending REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field. Please enter an integer (number).
  
  Please list any special needs or allergies: REQUIRED Please fill out this field.
  
  Child 9
  
  Child's full name (as it appears on Birth Certificate) REQUIRED Please fill out this field. Please enter valid data.
  
  Child's date of birth REQUIRED Please fill out this field. Please enter a date.
  
  Child's Current Age Please enter an integer (number).
  
  City and State or Country of Child's Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Has this child been baptized? REQUIRED Please fill out this field.
  
  Date of Baptism Please enter a date.
  
  Place of Baptism (church name and city/state) Please enter valid data.
  
  Has this child received the Sacrament of First Communion? REQUIRED Please fill out this field.
  
  Current school attending REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field. Please enter an integer (number).
  
  Please list any special needs or allergies: REQUIRED Please fill out this field.
  
  Child 10
  
  Child's full name (as it appears on Birth Certificate) REQUIRED Please fill out this field. Please enter valid data.
  
  Child's date of birth REQUIRED Please fill out this field. Please enter a date.
  
  Child's Current Age Please enter an integer (number).
  
  City and State or Country of Child's Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Has this child been baptized? REQUIRED Please fill out this field.
  
  Date of Baptism Please enter a date.
  
  Place of Baptism (church name and city/state) Please enter valid data.
  
  Has this child received the Sacrament of First Communion? REQUIRED Please fill out this field.
  
  Current school attending REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field. Please enter an integer (number).
  
  Please list any special needs or allergies: REQUIRED Please fill out this field.
  
  Of the following statements pertaining to medical matters, sign only in accordance with your wishes. Please type NA for irrelevant fields.
  
  Medical Matters
  
  Medical Matters
  Diocese of St. Augustine
  Catholic Center
  11625 Old St. Augustine Rd.
  Jacksonville, Fl 32258
  
  To my knowledge, my child is in good health, and I assume all responsibility for the health of my child.
  In the event of an emergency, I hereby give permission to Diocese of St. Augustine's employees, volunteers, or representatives to seek medical treatment for my child above named. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the Diocesan representatives or volunteers to hospitalize, secure proper treatment for, and order injection and/or anesthesia and/or surgery for my child above named.
  
  Medical Matters REQUIRED I Agree I Disagree Please fill out this field.
  
  Other Medical Treatment
  
  OTHER MEDICAL TREATMENT: In the event it comes to the attention of the Diocese of St. Augustine’s employees, volunteers, or representatives that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, or diarrhea, I hereby give permission for over-the-counter medication to be administered to my child according to directions.
  
  Medical Matters REQUIRED I Agree I Disagree Please fill out this field.
  
  Emergency Contact
  
  If I cannot be reached in an emergency, I hereby give permission to the physician selected by the Diocesan representatives or volunteers to hospitalize, secure proper treatment for, and to order injection and / or anesthesia and / or surgery for my child above named.
  
  Emergency Contact REQUIRED I Agree I Disagree Please fill out this field.
  
  In the event of an emergency, if you are unable to reach me at the above number, 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.
  
  Relationship REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Doctor & Medications
  
  If I cannot be reached in an emergency, I hereby give permission to the physician selected by the Diocesan representatives or volunteers to hospitalize, secure proper treatment for, and to order injection and / or anesthesia and / or surgery for my child above named.
  
  Family Doctor REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Family Health Plan Carrier REQUIRED Please fill out this field. Please enter valid data.
  
  Policy Number REQUIRED Please fill out this field. Please enter valid data.
  
  I make the following exception:
  
  I make the following exception:
  
  Emergency Contact REQUIRED I Agree I Disagree Please fill out this field.
  
  In the event of an emergency, if you are unable to reach me at the above number, 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.
  
  Media Release
  
  Diocese of St. Augustine |Photography and Media Release Form for Minor Children
  
  Without compensation, I hereby grant the Catholic Diocese of St. Augustine (the “Diocese of St. Augustine”), its ministries, parishes, schools and other affiliated entities, permission to record my child’s appearance, physical likeness and/or voice on videotape, on film, or digital video disk, or other means, and/or take photographs of my child. Notwithstanding any prohibition as may be contained in Section 540.08, Florida Statutes, I hereby freely and voluntarily
  consent to the use, reproduction, and distribution of photographs, video recordings or other media capturing my child’s image, physical likeness, or voice for an indefinite period of time or until such time I expressly revoke my consent in writing. These materials may include, but are not limited to news, editorial content, publications, promotional materials, electronic
  media (websites, social media channels, podcasts, videos), and/or printed brochures.
  In addition, I understand and agree that:
  * The Diocese of St. Augustine, its ministries, parishes, schools, and other affiliated entities may alter, edit or modify these materials as needed, without restriction.
  * The Diocese of St. Augustine retains the sole ownership and right to copyright any such materials.
  * My consent is voluntary, and I waive any rights to inspect or approve the finished products or the specific use of such
  materials.
  
  I agree to hold the Diocese of St. Augustine, the Bishop of the Diocese of St. Augustine, its employees and agents, and any media outlet or representatives involved in the creation of distribution of the materials harmless against claim, liability, loss, or damage caused by, or arising from any claims, demands or liability arising from or related the creation, use, production, or distribution of these materials. This Photography and Media Release Form for Minor Children is binding and applies to any claims of defamation, invasion of privacy, or rights of publicity. I have read this Photography and Media Release Form for Minor Children before signing and fully understand the contents, meaning, and impact of this release. I understand that I am free to address any specific questions and have done so prior to signing this release.
  
  Diocese of St. Augustine Catholic Center Last updated: 2/6/25
  Address: 11625 Old St. Augustine Road, Jacksonville, FL 32258
  Phone: (904) 262-3200
  
  Media Release REQUIRED I Agree I Disagree Please fill out this field.
  
  Signature
  
  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 REQUIRED Please fill out this field. Please enter a date.
  
  Submit

OCIA-C Registration for Children and Teens

Family Contact Information

Signature