St. Amelia Religious Education Summer Session Registration Form- 2021
Online for Credit Only... Each transaction will be charged 3%
Family Last Name
*
Current Parish
Father's name:
Mother's name:
Phone Number
-
Area Code
Phone Number
E-mail
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child # 1 Info:
First Name:
Date of birth
/
Month
/
Day
Year
Date
Last Name (if Different):
Grade in Sept. '21
choose one
4th
5th
6th
7th
8th
9th
Male/Female
choose one
M
F
Allergies/Medical conditions:
Last attended religious ed where?
Tuition $70 parishoner/$120 non-parishoner
choose one
70
120
Please select
Child # 2 Info:
First Name:
Date of birth
/
Month
/
Day
Year
Date
Grade in Sept. '21
*
choose one
4
5
6
7
8
9
Male/Female
choose
M
F
Allergies/Medical conditions:
Last attended religious ed where?
Tuition $70 parishoner/$120 non-parishoner
70
120
0
Total Amount Due
Cost for charges:
$70 + $2.10 = 72.10
$120. + $3.60 = 123.60
Registration due
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USD
Description
Credit Card Info
First Name
Last Name
Credit Card Number
Security Code
Expiration Date
Postal Code
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