Registration Form - 9th - St. Vincent Martyr, Madison

Welcome to SVM Youth Ministry 2023 - 2024 We are looking forward to this year with all of its possibilities!

Please register one child per form.

Thank you!

Any questions, contact Jody at 973-377-4000 ext 301

Student Information

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.

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

Mobile Phone Number Please enter a phone number.

Date of Birth REQUIRED Please fill out this field. Please enter valid data.

Family Email REQUIRED

Thank you for registerig your teen for our Youth Program. Please make sure that you are signed up for our Flocknote System.

Please fill out this field. Please enter an email address.

Student Email REQUIRED Please fill out this field. Please enter an email address.

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

Grade in Fall 2023 REQUIRED Please fill out this field. Please enter valid data.

Sacrament Information Below.

Please provide the Date, Parish, City and State for each Sacrament.

Baptism Information REQUIRED Please fill out this field. Please enter valid data.

First Eucharist Information REQUIRED Please fill out this field. Please enter valid data.

Are there any medical concerns or special needs of which Youth Ministry should be aware? Please specify below.

Special Needs or Concerns

Father's Information

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

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

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

Religion Please enter valid data.

Mother's Information

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

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

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

Religion Please enter valid data.

Mother's Maiden Name Please enter valid data.

Primary Household Email Please enter valid data.

Marital Status Parents are Married Parents are Divorced Parents are Separated Deceased Parent Other

Parent participation is required for an effective Youth Program. Please check those areas where you can help. REQUIRED Serve at Retreats Shop for Retreats Serve at Confirmation Reception Please fill out this field.

Permission for photos to be published without names. REQUIRED Yes No Please fill out this field.

Emergency Contact Name and Phone REQUIRED Please fill out this field. Please enter valid data.

Registration Fee125.0