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Religious Education Form 2017-2018
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Family Address
Primary Family Address
REGISTRATION FEE: $170.00 for one child / $200.00 for two children/ $230.00 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 July 31st. There will be a $25 late registration. 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
1
2
3
4
5
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
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Grade in Fall 2017
School Grade
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
School Grade in Fall 2017
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
The following classes are filled: 5th Grade Thursday Nights
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
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Grade in Fall 2017
School Grade
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
School Grade in Fall 2017
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
The following classes are filled: 5th Grade Thursday Nights
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
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Grade in Fall 2017
School Grade
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
School Grade in Fall 2017
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
The following classes are filled: 5th Grade Thursday Nights
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
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Grade in Fall 2017
School Grade
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
School Grade in Fall 2017
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
The following classes are filled: 5th Grade Thursday Nights
Child 4 Session Choice (Grades 1-8)
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)
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
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Grade in Fall 2017
School Grade
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
School Grade in Fall 2017
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
The following classes are filled: 5th Grade Thursday Nights
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 / Doctor
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
Total Cap
Total Choices
Late Fee
Late Fee Date
A Late Fee of $25.00 will be added after August 1, 2017
Total Normal
Total Amount
Verification
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SUBMIT FORM AND PAY
