Student Registration Form

Primary Family Address

REGISTRATION FEE: $185.00 for one child / $205.00 for two children/ $235.00 for three or more

1. You must be a registered member of the parish in order to enroll in the program.
2. Complete this form in it's entirety.
3. Please notify us of any changes in your child's information throughout the year.

Deadline for registration is September 22nd. All classes will close at 20 students

Please be advised that if your child does not return to our Religious Education program it will be considered a termination. In order to re-enter the program, we will require proof of attendance in another CCD program, otherwise your child will have to enter at the grade level at which they left.

Family Name

Address

Primary E-mail

All CCD information will be distributed through 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

Deceased

Yes No

E-mail

Religion

Cell Phone

Mother / Guardian

Maiden Name

Name

Deceased

Yes No

E-mail

Religion

Cell Phone

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Child 1

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Religious Education Grade

Grade this upcoming Fall

School Grade

School Grade this upcoming Fall

School

School District

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

Does your child have medication that needs to be carried/administered during PREP? If your child carries an Epipen, they must be able to self administer.

Individualized Education Program (IEP)

No Yes

*As defined by Individuals with Disabilities Education Act (IDEA), the term "child with a disability" means a child: "with mental retardation, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities and who, by reason thereof, needs special education and related services."

Child 1 Sacraments

First Grade and New Students Only. We must have a copy of the Baptismal certificate on file as it must be recorded in the Sacramental Registries.

Was your child baptized at St. Cassian?

Yes No

If no, a copy of the baptismal certificate must be provided to secure registration.

Date of Baptism

Church of Baptism

Church Name, City & State

Date of Reconciliation

Church of Reconciliation

Church Name, City & State

Date of First Communion

Church of First Communion

Church Name, City & State

Child 1 Session Choice

Child 1 Session Choice (Grades 1-8)x

Sunday 10:15-11:15 AM Tuesday 5:30-6:30 PM Thursday 4:00-5:00 PM

All CCD Classes meet in St. Cassian School, 190 Lorraine Ave

Child 1 Session Choice (Grades 6-8)x

Tuesday 7:00-8:00 PM

All CCD Classes meet in St. Cassian School, 190 Lorraine Ave

Child 2

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Religious Education Grade

Grade this upcoming Fall

School Grade

School Grade this upcoming Fall

School

School District

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

Does your child have medication that needs to be carried/administered during PREP? If your child carries an Epipen, they must be able to self administer.

Individualized Education Program (IEP)

No Yes

*As defined by Individuals with Disabilities Education Act (IDEA), the term "child with a disability" means a child: "with mental retardation, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities and who, by reason thereof, needs special education and related services."

Child 2 Sacraments

First Grade and New Students Only. We must have a copy of the Baptismal certificate on file as it must be recorded in the Sacramental Registries.

Was your child baptized at St. Cassian?

Yes No

If no, a copy of the baptismal certificate must be provided to secure registration.

Date of Baptism

Church of Baptism

Church Name, City & State

Date of Reconciliation

Church of Reconciliation

Church Name, City & State

Date of First Communion

Church of First Communion

Church Name, City & State

Child 2 Session Choice

Child 2 Session Choice (Grades 1-8)x

Sunday 10:15-11:15 AM Tuesday 5:30-6:30 PM Thursday 4:00-5:00 PM

All CCD Classes meet in St. Cassian School, 190 Lorraine Ave

Child 2 Session Choice (Grades 6-8)x

Tuesday 7:00-8:00 PM

All CCD Classes meet in St. Cassian School, 190 Lorraine Ave

Child 3

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Religious Education Grade

Grade this upcoming Fall

School Grade

School Grade this upcoming Fall

School

School District

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

Does your child have medication that needs to be carried/administered during PREP? If your child carries an Epipen, they must be able to self administer.

Individualized Education Program (IEP)

No Yes

*As defined by Individuals with Disabilities Education Act (IDEA), the term "child with a disability" means a child: "with mental retardation, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities and who, by reason thereof, needs special education and related services."

Child 3 Sacraments

First Grade and New Students Only. We must have a copy of the Baptismal certificate on file as it must be recorded in the Sacramental Registries.

Was your child baptized at St. Cassian?

Yes No

If no, a copy of the baptismal certificate must be provided to secure registration.

Date of Baptism

Church of Baptism

Church Name, City & State

Date of Reconciliation

Church of Reconciliation

Church Name, City & State

Date of First Communion

Church of First Communion

Church Name, City & State

Child 3 Session Choice

Child 3 Session Choice (Grades 1-8)x

Sunday 10:15-11:15 AM Tuesday 5:30-6:30 PM Thursday 4:00-5:00 PM

All CCD Classes meet in St. Cassian School, 190 Lorraine Ave

Child 3 Session Choice (Grades 6-8)x

Tuesday 7:00-8:00 PM

All CCD Classes meet in St. Cassian School, 190 Lorraine Ave

Child 4

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Religious Education Grade

Grade this upcoming Fall

School Grade

School Grade this upcoming Fall

School

School District

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

Does your child have medication that needs to be carried/administered during PREP? If your child carries an Epipen, they must be able to self administer.

Individualized Education Program (IEP)

No Yes

*As defined by Individuals with Disabilities Education Act (IDEA), the term "child with a disability" means a child: "with mental retardation, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities and who, by reason thereof, needs special education and related services."

Child 4 Sacraments

First Grade and New Students Only. We must have a copy of the Baptismal certificate on file as it must be recorded in the Sacramental Registries.

Was your child baptized at St. Cassian?

Yes No

If no, a copy of the baptismal certificate must be provided to secure registration.

Date of Baptism

Church of Baptism

Church Name, City & State

Date of Reconciliation

Church of Reconciliation

Church Name, City & State

Date of First Communion

Church of First Communion

Church Name, City & State

Child 4 Session Choice

Child 4 Session Choice (Grades 1-8)x

Sunday 10:15-11:15 AM Tuesday 5:30-6:30 PM Thursday 4:00-5:00 PM

All CCD Classes meet in St. Cassian School, 190 Lorraine Ave

Child 4 Session Choice (Grades 6-8)x

Tuesday 7:00-8:00 PM

All CCD Classes meet in St. Cassian School, 190 Lorraine Ave

Child 5

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Religious Education Grade

Grade this upcoming Fall

School Grade

School Grade this upcoming Fall

School

School District

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

Does your child have medication that needs to be carried/administered during PREP? If your child carries an Epipen, they must be able to self administer.

Individualized Education Program (IEP)

No Yes

*As defined by Individuals with Disabilities Education Act (IDEA), the term "child with a disability" means a child: "with mental retardation, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities and who, by reason thereof, needs special education and related services."

Child 5 Sacraments

First Grade and New Students Only. We must have a copy of the Baptismal certificate on file as it must be recorded in the Sacramental Registries.

Was your child baptized at St. Cassian?

Yes No

If no, a copy of the baptismal certificate must be provided to secure registration.

Date of Baptism

Church of Baptism

Church Name, City & State

Date of Reconciliation

Church of Reconciliation

Church Name, City & State

Date of First Communion

Church of First Communion

Church Name, City & State

Child 5 Session Choice

Child 5 Session Choice (Grades 1-8)x

Sunday 10:15-11:15 AM Tuesday 5:30-6:30 PM Thursday 4:00-5:00 PM

All CCD Classes meet in St. Cassian School, 190 Lorraine Ave

Child 5 Session Choice (Grades 6-8)x

Tuesday 7:00-8:00 PM

All CCD Classes meet in St. Cassian School, 190 Lorraine Ave

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Emergency Contact

Emergency Contact Name

Relationship

Emergency Contact Phone

Volunteer Information

The success of our program will be greater with your help. Could you volunteer your time in any of the following?

Yes No

Volunteer Name

Volunteer Phone

Volunteer Interested in

Classroom teacher Substitute teacher Class parent

If interested in teaching, what Day(s) & Grade(s)?

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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

DIGITAL COMMUNICATION CONSENT

I give permission for my children listed on this form to participate in the parish catechetical program through any and all digital networking and communication including, but not limited to, email, texting, Zoom, Facebook, other social networking site or digital educational platforms, etc. I understand that the use of digital media will be ministry related and NOT personal in nature. All communication will be restricted to matters concerning classes, youth ministry events, and parish events. Virtual sessions may be recorded for parish use. The person(s) being authorized to communicate with the minor child is in compliance with the Archdiocesan Child Protection policies and protocols. This form will be filed in a confidential folder for parish use only.

I agree

Parent / Legal Guardian Signature

Clear

Total Choices

Late Fee

Current Date

Total Normal

Total Amount

Verification