Immaculate Conception Catholic Church

4453 Kapaia Road, Lihue, Kauai, HI 96766

Family Last Name

Registered Member Of Immaculate Conception Church:

YES
NO

Mailing Address:

City, State, Zip Code:

Home Phone / Cell Phone:

E-mail:

Father's Name (last, first):

Religion:

Occupation / Business Phone:

Mother's Name (last, first)

Religion:

Occupation / Businesss Phone:

Number Of Children Registering:

One (1)
Two (2)
Three (3)
Four (4)

#1 Child's Name / DOB (mm/dd/yyyy):

School Attending / Grade:

Sacraments Received (submit copies of certificates):

Baptism
Penance
First Communion
Confirmation

#2 Child's Name / DOB (mm/dd/yyyy):

School Attending / Grade:

Sacraments Received (submit copies of certificates):

Baptism
Penance
First Communion
Confirmation

#3 Child's Name / DOB (mm/dd/yyyy):

School Attending / Grade:

Sacraments Received (submit copies of certificates):

Baptism
Penance
First Communion
Confirmation

#4 Child's Name / DOB (mm/dd/yyyy):

School Attending / Grade:

Sacraments Received (submit copies of certificates):

Baptism
Penance
First Communion
Confirmation

Child Lives With:

Parent(s)
Grandparent(s)
Guardian
Other

The fee for pre-school through grade 9 is $20.00 for one(1) child, $30.00 for two(2) children, and $40.00 for three(3) or more children, (not to exceed $40.00 per family).

The confirmation fee is $70.00 per person for grades 9 and 10 (for textbook and retreat).