Sacred Heart of Jesus

Form: Confirmation Retreat Registration


2018-2019 Confirmation Retreat Registration 

January 27 at Sacred Heart of Jesus and St. Cecilia School campus in Broussard from 8:30am – 6:00pm.

Student Information
Date of Birth *
Date of Birth
Parent Information
Guardian Address 1 (required) *
Guardian Address 1 (required)
Guardian Address 2 (optional)
Guardian Address 2 (optional)
Cell Phone 1 (required) *
Cell Phone 1 (required)
Cell Phone 2 (optional)
Cell Phone 2 (optional)
Emergency Contact *
Emergency Contact
Please provide contact information of someone other than parent/guardian. This information will be used if parent/guardian cannot be reached.
Emergency Contact Cell Phone *
Emergency Contact Cell Phone
I have read and agree to the photograph/video/audio/media consent and release statement below. *
Date of consent and release of photograph/video/audio/media *
Date of consent and release of photograph/video/audio/media


 I, hereby consent to and authorize the Roman Catholic Diocese of Lafayette, Louisiana, (the Diocese) and all entities, representatives, employees, and agents operating under its authority to record, use, edit, reproduce, and/or publish photographs, video, audio, and/or other media that may portray and/or relate to the aforementioned minor child, his/her image, likeness and/or voice, without compensation. I understand that these materials may be used in various print and electronic media, including but not limited to the Diocesan website and the Diocesan publication, Acadiana Catholic, and/or for other endeavors related to Diocesan interests. I understand that the Diocese may use and/or publish materials relating to the aforementioned minor child and/or use his/her photograph, voice, video images, and other media relating to said minor child in any manner that the Diocese deems appropriate in order to promote and/or publicize its programs, or for any other lawful purpose. This authorization shall not expire and will remain effective indefinitely until rescinded in writing.

By signing electronically above I am verifying that I have read the above statements.