Student Registration Form

Payment is required at the time of registration. Your child will not be assigned to a class without full payment. If your family is experiencing financial difficulty and you would like to create a payment plan, please call for an appointment to register in person. Please do not delay in registering due to finances.

Primary Family Address

Family Option

New Family Information Update Existing Family Information

Are you currently registered parishioners of IHMC?

Yes No

If you are not currently registered as parishioners, the information provided in this form will be forwarded to the Rectory and the Parish Office Manager will contact you to finalize your registration.

Family Name

Address

Primary E-mail

This will be the main e-mail address we will use to communicate with your family.

Primary Phone

This will be the main phone number we will use to communicate with your family.

Number of Children

Number of Children you will be registering today

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Father / Guardian

Name

Living Status

Living Deceased

E-mail

Marital Status

Religion

Cell Phone

We request that one or both parents include a cell phone number that we can use to contact you by phone, and/or to text information about closures, updates and important reminders.

Mother / Guardian

Maiden Name

Name

Living Status

Living Deceased

E-mail

Marital Status

Religion

Cell Phone

We request that one or both parents include a cell phone number that we can use to contact you by phone, and/or to text information about closures, updates and important reminders.

Custody Information

Are there any custody issues we should be made aware of? If there is a custody agreement please send a copy to the Religious Education Department.

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Schedule of Classes

Grades 1,3, 4 & 5 - Monday, 4:30 p.m. to 5:45 p.m. - Fee: $125.00
Grades 6, 7 & 8 - Monday, 7:00 p.m. to 8:15 p.m. - Fee: $125.00
2nd Grade - First Communion Preparation - Sunday, 10:15 a.m. to 11:45 a.m. - Fee: $150.00
9th Grade - Confirmation Preparation - 2 Sundays/month, 10:15 a.m. to 11:45 a.m. - Fee: $150.00

Fees payable for 1st and 2nd child in each family (3rd or more at no additional charge);
Maximum fee per family $300.00

Child 1

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Date of Baptism

Church of Baptism

Church Name, City & State

Religious Education Grade

Grade in Fall 2018

School Grade

School Grade in Fall 2018

School

School District

Medical/Learning Data: Medical Conditions/Allergies - Prescribed Medications - Disability/Learning Support Services

Individualized Education Program (IEP)

No Yes

Does Your Child Have An Epi-Pen?

No Yes

If your child carries an Epi-Pen, they must be able to self-administer

Child lives with

Father Mother Both other: ‎

Child 2

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Date of Baptism

Church of Baptism

Church Name, City & State

Religious Education Grade

Grade in Fall 2018

School Grade

School Grade in Fall 2018

School

School District

Medical/Learning Data: Medical Conditions/Allergies - Prescribed Medications - Disability/Learning Support Services

Individualized Education Program (IEP)

No Yes

Does Your Child Have An Epi-Pen?

No Yes

If your child carries an Epi-Pen, they must be able to self-administer

Child lives with

Father Mother Both other: ‎

Child 3

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Date of Baptism

Church of Baptism

Church Name, City & State

Religious Education Grade

Grade in Fall 2018

School Grade

School Grade in Fall 2018

School

School District

Medical/Learning Data: Medical Conditions/Allergies - Prescribed Medications - Disability/Learning Support Services

Individualized Education Program (IEP)

No Yes

Does Your Child Have An Epi-Pen?

No Yes

If your child carries an Epi-Pen, they must be able to self-administer

Child lives with

Father Mother Both other: ‎

Child 4

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Date of Baptism

Church of Baptism

Church Name, City & State

Religious Education Grade

Grade in Fall 2018

School Grade

School Grade in Fall 2018

School

School District

Medical/Learning Data: Medical Conditions/Allergies - Prescribed Medications - Disability/Learning Support Services

Individualized Education Program (IEP)

No Yes

Does Your Child Have An Epi-Pen?

No Yes

If your child carries an Epi-Pen, they must be able to self-administer

Child lives with

Father Mother Both other: ‎

Child 5

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Date of Baptism

Church of Baptism

Church Name, City & State

Religious Education Grade

Grade in Fall 2018

School Grade

School Grade in Fall 2018

School

School District

Medical/Learning Data: Medical Conditions/Allergies - Prescribed Medications - Disability/Learning Support Services

Individualized Education Program (IEP)

No Yes

Does Your Child Have An Epi-Pen?

No Yes

If your child carries an Epi-Pen, they must be able to self-administer

Child lives with

Father Mother Both other: ‎

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Emergency Contact / Doctor

Emergency Contact Name

Relationship

Emergency Contact Phone

Doctor's Name

Doctor's Phone

Child Pick up Information

Who will pick up the children?

Mother‎ Father‎ Other...‎

Other Name 1

Relationship

Step Father, Grandparent, Aunt, Uncle, Friend, etc.

Other Phone 1

Other Name 2

Relationship

Step Father, Grandparent, Aunt, Uncle, Friend, etc.

Other Phone 2

Terms & Conditions

I understand that in the case of injury or illness, every effort will be made to contact me in a medical emergency. In the event I cannot be reached, I give permission to parish staff to secure all proper and necessary treatment for my child(ren). I understand that no liability is assumed by the church or the Archdiocese for claims that may arise.

I agree

Parental Consent for Medical Care: In case of an emergency, I give permission for my child to receive emergency medical treatment and, if necessary, be transported to the nearest appropriate medical facility.

I agree

I understand that photos of my child(ren) may be taken and used in Parish publications including web and print media.

I agree I disagree

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Volunteer Information

Will you be volunteering?

Yes No

Volunteer Name

Volunteer Phone

Volunteer Interested in

Total Cap

Total Choices

Convenience Fee

Late Fee

Current Date

An additional fee of $25.00 will be added August 11, 2018.

Total Normal

Coupon Code

Coupon Code Discount

Sub Total

Payment is required at the time of registration. Your child will not be assigned to a class without full payment. If your family is experiencing financial difficulty and you would like to create a payment plan, please call for an appointment to register in person. Please do not delay in registering due to finances.

Total Amount

Maximum Fee Per Family: $300.00

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