Upper Room 2025-2026

Please have a parent or legal guardian complete the below form on behalf of the child or student, as it would be accurate for the 2025-2026 school year.

Read the description information before beginning.

Personal Information

Full Name

Preferred Name (For Name Tags, Attendance, etc.)

Contact Type

Program Participant

Date of Birth MM/DD/YYYY

Headshot (Help us put faces to names!)

Upload (8MB)

Current Program

Registered For...

Youth Cell (Middle School Up Only)

Youth Email (Middle School Up Only)

City and State of Birth

Sex

Male Female

Any allergies or medical information we should know?

Learning Differences?

Physical Limitations?

School Information

Other School if Not Listed Above

Grade Level

Family Information

We ask the following information formatted in this particular matter for the sake of our parish sacramental records and registration database.

Father's Full Name

Faith Tradition of Father

Mother's Full Name

Mother's Maiden Name

Faith Tradition of Mother

Registered at CTK?

If registered at another parish than CTK, please note name and city of parish.

Primary Parent or Legal Guardian Contact Information

This is the individual that will receive information regarding the program. Please forgive us if the information is redundant for you; we need to provide for a variety of family situations!

Parent or Guardian Full Name

Phone

This address will receive a confirmation email

Address

Would you be open to volunteer opportunities?

Yes No

Additional Parent or Legal Guardian Full Name (If you would like them to receive information regarding the program)

Additional Parent or Legal Guardian Cell Phone

Additional Parent or Legal Guardian Email Address

Non-Parent or Legal Guardian Emergency Contact Name

Relation of Non-Parent or Legal Guardian Emergency Contact to Individual

Non-Parent or Legal Guardian Cell Phone

Non-Parent or Legal Guardian Email

Baptism

If you HAVE received the Sacrament of Baptism, select "yes" below. You do NOT need to attach your teen's baptismal certificate or list their baptismal date. Note which boxes are required and which are not.

If you have NOT received Baptism, select "no" below.

If you are a returning family and you are POSITIVE you have already uploaded or given the Faith Formation Team your Baptismal Certificate, select "yes" below. You may leave the fields blank, as we should have your information from last year. If you are UNSURE, please re-provide the information in order to save our administration time contacting you for your certificate.

Received the Sacrament of Baptism?

Yes No Received in a non-Catholic church Unsure

Date of Baptism MM/DD/YYYY

Child's FULL Name as Written on Baptismal Certificate (Include middle name(s) if applicable)

Father's FULL Name (Include middle name(s) if applicable)

Mother's FULL MAIDEN NAME (Should not include current married last name, if one has been taken)

Church of Baptism Name

Church of Baptism Address

Copy of Baptismal Certificate

Upload (8MB)

Reconciliation

Received 1st Reconciliation?

Yes No Unsure

Church of 1st Reconciliation

Date of 1st Reconciliation MM/DD/YYYY

1st Communion

Received 1st Communion?

Yes No Unsure

Church of 1st Communion Name

Church of 1st Communion Address

Date of 1st Communion MM/DD/YYYY

1st Communion Celebrant (Priest)

Age at 1st Communion

Confirmation

Received Confirmation?

Yes No Unsure

Church of Confirmation Name

Church of Confirmation Address

Date of Confirmation MM/DD/YYYY

Confirmation Celebrant (Priest or Bishop)

Age at Confirmation

Consent to Participate, Liability Release, Consent to Treat, and Media Release

Please read this document, found under the description section of the form. Know that we care about keeping all individuals at Christ the King safe. Any pictures that we intend to use for community building and advertising will not include children's names.

I have read and agree to the following on the Consent to Participate, Liability Release, Consent to Treat, and Media Release, 2024-2025

Consent to Participate Liability Release Consent to Treat Media Release Please follow up with me because I have concerns regarding this language.

Description

BEFORE BEGINNING YOUR REGISTRATION:

1. Thank you for joining our program! We are so glad to have you. If you have any questions along the way, please contact the Program Coordinator, Josh Berkvosky (jberkovsky@ctkdallas.org, 214-389-3426).
2. Please view our program's release and liability language at the below link before completing the registration.
3. You will need your child's Baptismal Certificate (if they have been baptized) to complete this form UNLESS you are POSITIVE you uploaded it last year during registration.

"Copy and Paste" the following link into your browser to view our Consent to Participate, Liability Release, Consent to Treat, and Media Release: https://drive.google.com/file/d/1CK6M6UoBqA3kfJV7NqRbOm1vEOQZNvpV/view?usp=sharing

Upper Room 2025-2026

Description

Please Fix the Following