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Blaze - Registration

- Faith Formation
  - Study Programs
    
    Walking With Purpose
    Blaze - WWP ministry for 7th & 8th Grade Girls
    
    Blaze - 2021 Registration
  - Religious Education
    
    Religious Education
    Good Shepherd Program
  - Becoming a Catholic
    
    RCIA (Rite of Christian Initiation of Adults)
  - Deepening Your Faith
Payment

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Course Cost: $75 (cash/check/credit)
- includes Book & materials

1. Pay via WeShare (Credit Card)

WeShare

or

2. Mail Check to

Church of St. Patrick in Armonk
P.O. Box 6
Armonk, NY 10504
Attn. Blaze

Payable to: Church of St. Patrick

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- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- 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.
- Daughter's Cell Phone Maximum 20 characters Please enter a phone number.
- Grade as of Sept. 2021 REQUIRED Please fill out this field.
- Mother's Name Please enter valid data.
- Mother's Cell Phone: REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Mother's Home Phone: Maximum 20 characters Please enter a phone number.
- Mother's Email REQUIRED Please fill out this field. Please enter an email address.
- Father's Name Please enter valid data.
- Father's Cell Phone: REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Father's Home Phone: Maximum 20 characters Please enter a phone number.
- Father's Email REQUIRED Please fill out this field. Please enter an email address.
- Medical Information
- Doctor's Name REQUIRED Please fill out this field. Please enter valid data.
- Doctor's Phone REQUIRED Please fill out this field. Please enter valid data.
- Hospital Preference REQUIRED Please fill out this field. Please enter valid data.
- Notes Please enter valid data.
- In case of accident or illness, I request that the representative of the parish catechetical program contact me. If I am unable to be reached. I hereby authorize this representatiive to call the physician indicated and to follow the physician's instructions. If it is impossible to contact this physician, the representative of the parish catechetical program may make whatever arrangements seem necessary. I agree to assume the financial responsibility for any diagnosis, treatment and or medication deemed necessary. To the best of my knowledge, all information given is accurate and complete. I hereby consent to and authorize procedures that have been stated above.
- Parent Signature . . . . . . . . . . . . . .. . . . . . . .. . . . . . . . .. . . By typing in my name, I recognize and agree that I am affixing my signature to this document and submitting this form to the Church of St. Patrick in Armonk REQUIRED Please fill out this field. Please enter valid data.
- Email Please enter an email address.
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