Student Registration Form

NOTICE

Payment is required at the time of registration. 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. You may contact Jeanne at 845-496-4101 or email stmarysjversweyveld@gmail.com. Please do not delay in registering due to finances. There will be an additional $25 late fee after June 1.

Primary Family Address

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

Deceased

Yes No

E-mail

Marital Status

Religion

Cell Phone

Birthday

Occupation

Mother / Guardian

Maiden Name

Name

Deceased

Yes No

E-mail

Marital Status

Religion

Cell Phone

Birthday

Occupation

Church-Place, Address and Date of Marriage

Other Household Members not listed on this form

Include Name / Birthdate

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Child 1

Is your child a New or Returning Student to our program?

New Student Returning Student

Is your child going to use our Home Study program?

Yes No

Name

Baptismal Name

Gender

Male Female

Date of Birth

Place of Birth

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

*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

Baptismal certificate needed for new students unless baptized at St. Mary’s. Certificates may be faxed to 845-496-3159. Child will be placed on class list only after receipt of certificate. A letter of transfer or last report card is required for new students level 2 and up.

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

Please note:

Level 2 & 4 are now at capacity for our Monday Session.

Level 4 & 5 are now at capacity for our Tuesday Session.

Please pick another session.

Child 1 Session Choice

Sunday 10:00-11:00 am (Grades 1-5) Monday 4:15-5:30 pm (Grades 1, 3, 5) Tuesday 4:15-5:30 pm (Grades 1-3) Monday 7:00-8:15 pm (Grades 6,7,8) Sunday 6:45-8:15 pm (Grade 9)

Child 1 Home Study

I understand weekly Mass attendance is required to remain in the Home Study program as well as attendance at the designated parent workshops. Failure to attend weekly Mass/Workshops will result in child being moved to the Classroom session.

Child 2

Is your child a New or Returning Student to our program?

New Student Returning Student

Is your child going to use our Home Study program?

Yes No

Name

Baptismal Name

Gender

Male Female

Date of Birth

Place of Birth

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

*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

Baptismal certificate needed for new students unless baptized at St. Mary’s. Certificates may be faxed to 845-496-3159. Child will be placed on class list only after receipt of certificate. A letter of transfer or last report card is required for new students level 2 and up.

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

Please note:

Level 2 & 4 are now at capacity for our Monday Session.

Level 4 & 5 are now at capacity for our Tuesday Session.

Please pick another session.

Child 2 Session Choice

Sunday 10:00-11:00 am (Grades 1-5) Monday 4:15-5:30 pm (Grades 1, 3, 5) Tuesday 4:15-5:30 pm (Grades 1-3) Monday 7:00-8:15 pm (Grades 6,7,8) Sunday 6:45-8:15 pm (Grade 9)

Child 2 Home Study

I understand weekly Mass attendance is required to remain in the Home Study program as well as attendance at the designated parent workshops. Failure to attend weekly Mass/Workshops will result in child being moved to the Classroom session.

Child 3

Is your child a New or Returning Student to our program?

New Student Returning Student

Is your child going to use our Home Study program?

Yes No

Name

Baptismal Name

Gender

Male Female

Date of Birth

Place of Birth

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

*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

Baptismal certificate needed for new students unless baptized at St. Mary’s. Certificates may be faxed to 845-496-3159. Child will be placed on class list only after receipt of certificate. A letter of transfer or last report card is required for new students level 2 and up.

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

Please note:

Level 2 & 4 are now at capacity for our Monday Session.

Level 4 & 5 are now at capacity for our Tuesday Session.

Please pick another session.

Child 3 Session Choice

Sunday 10:00-11:00 am (Grades 1-5) Monday 4:15-5:30 pm (Grades 1, 3, 5) Tuesday 4:15-5:30 pm (Grades 1-3) Monday 7:00-8:15 pm (Grades 6,7,8) Sunday 6:45-8:15 pm (Grade 9)

Child 3 Home Study

I understand weekly Mass attendance is required to remain in the Home Study program as well as attendance at the designated parent workshops. Failure to attend weekly Mass/Workshops will result in child being moved to the Classroom session.

Child 4

Is your child a New or Returning Student to our program?

New Student Returning Student

Is your child going to use our Home Study program?

Yes No

Name

Gender

Male Female

Date of Birth

Place of Birth

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

*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

Baptismal certificate needed for new students unless baptized at St. Mary’s. Certificates may be faxed to 845-496-3159. Child will be placed on class list only after receipt of certificate. A letter of transfer or last report card is required for new students level 2 and up.

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

Please note:

Level 2 & 4 are now at capacity for our Monday Session.

Level 4 & 5 are now at capacity for our Tuesday Session.

Please pick another session.

Child 4 Session Choice

Sunday 10:00-11:00 am (Grades 1-5) Monday 4:15-5:30 pm (Grades 1, 3, 5) Tuesday 4:15-5:30 pm (Grades 1-3) Monday 7:00-8:15 pm (Grades 6,7,8) Sunday 6:45-8:15 pm (Grade 9)

Child 4 Home Study

I understand weekly Mass attendance is required to remain in the Home Study program as well as attendance at the designated parent workshops. Failure to attend weekly Mass/Workshops will result in child being moved to the Classroom session.

Child 5

Is your child a New or Returning Student to our program?

New Student Returning Student

Is your child going to use our Home Study program?

Yes No

Name

Baptismal Name

Gender

Male Female

Date of Birth

Place of Birth

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

*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

Baptismal certificate needed for new students unless baptized at St. Mary’s. Certificates may be faxed to 845-496-3159. Child will be placed on class list only after receipt of certificate. A letter of transfer or last report card is required for new students level 2 and up.

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

Please note:

Level 2 & 4 are now at capacity for our Monday Session.

Level 4 & 5 are now at capacity for our Tuesday Session.

Please pick another session.

Child 5 Session Choice

Sunday 10:00-11:00 am (Grades 1-5) Monday 4:15-5:30 pm (Grades 1, 3, 5) Tuesday 4:15-5:30 pm (Grades 1-3) Monday 7:00-8:15 pm (Grades 6,7,8) Sunday 6:45-8:15 pm (Grade 9)

Child 5 Home Study

I understand weekly Mass attendance is required to remain in the Home Study program as well as attendance at the designated parent workshops. Failure to attend weekly Mass/Workshops will result in child being moved to the Classroom session.

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Emergency Contact / Doctor

Emergency Contact Name

Relationship

Emergency Contact Phone

Doctor's Name

Doctor's Phone

Dentist's Name

Dentist's Phone

Volunteer Information

Will you be volunteering?

Yes No

Volunteer Name

Volunteer Phone

Volunteer Interested in

Teacher Assistant Teacher Hall Monitor

So we can apply your volunteer discount, how many children did you register today?

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Terms & Conditions

If I cannot be reached I give permission for my children to receive emergency medical attention at the nearest hospital.

I agree

Photo Release: The Religious Education program has my permission to release pictures of my child for use in the newspaper, in The parish bulletin or display within the building.

I agree

Total Cap

Total Choices

Late Fee

Current Date

A Late Fee of $25.00 will be added after August 31, 2018

Total Normal

NOTICE

Payment is required at the time of registration. 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. You may contact Jeanne at 845-496-4101 or email stmarysjversweyveld@gmail.com. Please do not delay in registering due to finances. There will be an additional $25 late fee after June 1.

Total Amount

Verification