Student Registration Form

Schedule of Classes

September 2021-May 2022

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 Eucharist Preparation - Sunday, 10:15 a.m. to 11:30 a.m. - Fee: $150.00
9th Grade - Confirmation Preparation - Sundays, 10:00 a.m. to 1:00 p.m. - Fee: $150.00

Maximum fee per family $300.00

Note: If your family is experiencing financial difficulty and you would like to defer payment, check that box at the end of the registration form. Please do not delay in registering due to finances. Thank you!

Primary Family Address

Please Choose One

Our child(ren) will participate in the hybrid program. Our child(ren) will participate in the home school program.

Family Option

New Family Information Update Existing Family Information

Are you currently registered parishioners of IHMC?

Yes No

All families are expected to be registered and supportive members of Immaculate Heart of Mary Parish. 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

Father's 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

Mother's Name

Maiden 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. If no custody agreement, please indicate N/A

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Child 1

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Child lives with

Father Mother Both other: ‎

Date of Baptism

Baptismal Certificate required for first time registration.

Church of Baptism

Church Name, City & State

Religious Education Grade

Grade in Fall 2021

School Grade

School Grade in Fall 2021

School

School City, State

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

If none, please indicate N/A

Individualized Education Program (IEP)

No Yes

Does Your Child Have An Epi-Pen?

No Yes

Parents of children whose allergies require them to carry Epi-pens must comply with Archdiocese of Newark Guidelines regarding their use. The required forms are available on the parish website, and must be completed and returned to the Religious Education Office in order for these children to be allowed to attend class. These forms must be renewed on a yearly basis.

Child 2

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Child lives with

Father Mother Both other: ‎

Date of Baptism

Baptismal Certificate required for first time registration.

Church of Baptism

Church Name, City & State

Religious Education Grade

Grade in Fall 2021

School Grade

School Grade in Fall 2021

School

School City, State

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

If none, please indicate N/A

Individualized Education Program (IEP)

No Yes

Does Your Child Have An Epi-Pen?

No Yes

Parents of children whose allergies require them to carry Epi-pens must comply with Archdiocese of Newark Guidelines regarding their use. The required forms are available on the parish website, and must be completed and returned to the Religious Education Office in order for these children to be allowed to attend class. These forms must be renewed on a yearly basis.

Child 3

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Child lives with

Father Mother Both other: ‎

Date of Baptism

Baptismal Certificate required for first time registration.

Church of Baptism

Church Name, City & State

Religious Education Grade

Grade in Fall 2021

School Grade

School Grade in Fall 2021

School

School City, State

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

If none, please indicate N/A

Individualized Education Program (IEP)

No Yes

Does Your Child Have An Epi-Pen?

No Yes

Parents of children whose allergies require them to carry Epi-pens must comply with Archdiocese of Newark Guidelines regarding their use. The required forms are available on the parish website, and must be completed and returned to the Religious Education Office in order for these children to be allowed to attend class. These forms must be renewed on a yearly basis.

Child 4

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Child lives with

Father Mother Both other: ‎

Date of Baptism

Baptismal Certificate required for first time registration.

Church of Baptism

Church Name, City & State

Religious Education Grade

Grade in Fall 2021

School Grade

School Grade in Fall 2021

School

School City, State

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

If none, please indicate N/A

Individualized Education Program (IEP)

No Yes

Does Your Child Have An Epi-Pen?

No Yes

Parents of children whose allergies require them to carry Epi-pens must comply with Archdiocese of Newark Guidelines regarding their use. The required forms are available on the parish website, and must be completed and returned to the Religious Education Office in order for these children to be allowed to attend class. These forms must be renewed on a yearly basis.

Child 5

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Child lives with

Father Mother Both other: ‎

Date of Baptism

Baptismal Certificate required for first time registration.

Church of Baptism

Church Name, City & State

Religious Education Grade

Grade in Fall 2021

School Grade

School Grade in Fall 2021

School

School City, State

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

If none, please indicate N/A

Individualized Education Program (IEP)

No Yes

Does Your Child Have An Epi-Pen?

No Yes

Parents of children whose allergies require them to carry Epi-pens must comply with Archdiocese of Newark Guidelines regarding their use. The required forms are available on the parish website, and must be completed and returned to the Religious Education Office in order for these children to be allowed to attend class. These forms must be renewed on a yearly basis.

Epi-pen forms can be found on the website at https://ihmcmahwah.org/religious-education

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Emergency Contact

Emergency Contact Name

Relationship

Emergency Contact 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

I have read the IHMC Religious Education Parent Handbook and agree to the requirements of the program, including the Code of Conduct and the Digital Communications Policy.

I have read and agree to the rules of the parent handbook.

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

Volunteer Phone

Current Date

Total Cap

Total Choices

Convenience Fee

Late Fee

Total Normal

Coupon Code

Coupon Code Discount

Sub Total

Please select a payment option, verify and click on “Submit Form and Pay.” You will be redirected to the Parish Giving website, where you may pay by credit card or electronic check.

If you have chosen to pay by cash or check, or to defer payment, once you are redirected to the Parish Giving website, be assured that your child(ren)’s information has been successfully submitted. You will be contacted shortly by the Parish Catechetical Leader to make arrangements. Please do not delay in registering due to finances. Thank you!

Payment Options

Pay in Full Now. Will Pay by Cash or Check (payable to IHMC Religious Education). Need to defer payment; would like to discuss.

Total Amount

Maximum Fee Per Family: $300.00

Verification