C.C.D. - First REconciliationInformation & Registration - St. Timothy Parish

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

Student's First and Middle Name (if any) REQUIRED Please fill out this field. Please enter valid data.

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

Birth Place (City, State) REQUIRED Please fill out this field. Please enter valid data.

Age REQUIRED Please fill out this field.

Gender REQUIRED Please fill out this field.

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

Place of Baptism (Name of Church) REQUIRED Please fill out this field. Please enter valid data.

Location of Church (City & State) REQUIRED Please fill out this field. Please enter valid data.

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

Current Grade REQUIRED Please fill out this field.

Residence (Home 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.

Father's First Name, Middle Name (if any) REQUIRED Please fill out this field. Please enter valid data.

Father's 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.

Mother's First Name, Middle Name (if any) REQUIRED Please fill out this field. Please enter valid data.

Mother's Maiden 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.

Parishioner Information

Is the family registered at St. Timothy Church? REQUIRED Yes No Please register our family. Please fill out this field.

Emergency Contact (other than parents) REQUIRED Please fill out this field. Please enter valid data.

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

If your child has any allergies, please list here Please enter valid data.

In my absence, I hereby give consent to any St. Timothy staff member to provide all emergency care prescribed by a duly licensed physician for my child. This care may be given under whatever conditions are necessary to preserve the life or wellbeing of my dependent.

I Agree Please select this field.

Photo Release: Please check the box below as your authorization for St. Timothy Church to use your child's image for the church bulletin or website, as it pertains to Religious Education. REQUIRED I give permission I do not give permission Please fill out this field.

St. Timothy's Religious Education Ministry presents "Empowering God's Children and Young People Safety Program", developed by the Office of Safeguard the Children. It is taught by a trained instructor and is age appropriate. For more information visit the VIRTUS online website at www.virtus.org.

I allow my child to participate in "Empowering God’s Children and Young People Safety Program on the topic of "The Five Body Safety Rule". I specifically request that St. Timothy CCD/Confirmation present the program to my child. REQUIRED Yes No Please fill out this field.

Additional Information Please enter valid data.

Please choose the appropriate payment below. Registration fee will increase $50 after 9/10/23. 250.0 – 1st Child 200.0 – 2nd Child 150.0 – 3rd Child 150.0 – St. Timothy School Student (Sacramental Fee)

Other Amount $ Please enter a positive decimal.

Would you like to cover the 3% processing fee? REQUIRED Yes No Please fill out this field.

St. Timothy Catholic Church

10425 W. Pico Blvd, Los Angeles, CA 90064
310-474-1216

C.C.D. - First REconciliation
Information & Registration

2023-2024 First Reconciliation
Classes begin September 10