Student Registration

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

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

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

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

Student ID REQUIRED Please fill out this field. Please enter valid data.

Local Contact

Address - Local REQUIRED Please fill out this field. Please enter valid data.
City, State, Zip - Local REQUIRED Please fill out this field. Please enter valid data.

Permanent Contact

Address - Permanent REQUIRED Please fill out this field. Please enter valid data.
City, state, zip - permanent REQUIRED Please fill out this field. Please enter valid data.

Student Information

Graduation Year REQUIRED Please fill out this field. Please enter valid data.
Date of Birth (MM/DD/YYYY) REQUIRED Please fill out this field. Please enter valid data.
Religion REQUIRED Please fill out this field. Please enter valid data.
Choose Any I have been baptized. I have had my 1st communion. I have been confirmed.

Emergency contact Information: Father

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

Last Name REQUIRED Please fill out this field. Please enter valid data.
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.
Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Emergency contact Information: Mother

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

Last Name REQUIRED Please fill out this field. Please enter valid data.
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.
Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Are you interested in receiving information about any of the following opportunities?

By filling out this registration form, you will also be added as a member of the CSA (Catholic Student Association).