Student Registration Form

Primary Family Address

Are you a member of our Parish?

Yes No

If NO, What is you current parish?

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

Number of Children (Alternate Pricing)

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

Mother / Guardian

Maiden Name

Name

Deceased

Yes No

E-mail

Marital Status

Religion

Cell Phone

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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Child 1

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Religious Education Grade

Grade in Fall 2021

School Grade

School Grade in Fall 2021

School

School District

Individualized Education Program (IEP)

No Yes

Please list all pertinent medical/learning data so we can best meet the needs of your child. (Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services)

Medical/Learning Data

*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."

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

New Student Returning Student

Child 1 Sacraments

Previous Religious Education Experience

Please provide student's last grade completed and Parish Name / Address

If registering for first time your Child's Baptismal Certificate must be submitted to the office.

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

Is your child going to use our Home Study program?

Yes No

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 1 Home Study

Child 1 Session Choice

Sundays 10:45-12:00 noon (Grades 1-6) Sunday 10:45-12:00 noon (Grades 7-12) Monday 7:00-8:30 pm (Grades 7-12)

Child 2

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Religious Education Grade

Grade in Fall 2021

School Grade

School Grade in Fall 2021

School

School District

Individualized Education Program (IEP)

No Yes

Please list all pertinent medical/learning data so we can best meet the needs of your child. (Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services)

Medical/Learning Data

*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."

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

New Student Returning Student

Child 2 Sacraments

Previous Religious Education Experience

Please provide student's last grade completed and Parish Name / Address

If registering for first time your Child's Baptismal Certificate must be submitted to the office.

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

Is your child going to use our Home Study program?

Yes No

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 Home Study

Child 2 Session Choice

Sundays 10:45-12:00 noon (Grades 1-6) Sunday 10:45-12:00 noon (Grades 7-12) Monday 7:00-8:30 pm (Grades 7-12)

Child 3

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Religious Education Grade

Grade in Fall 2021

School Grade

School Grade in Fall 2021

School

School District

Individualized Education Program (IEP)

No Yes

Please list all pertinent medical/learning data so we can best meet the needs of your child. (Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services)

Medical/Learning Data

*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."

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

New Student Returning Student

Child 3 Sacraments

Previous Religious Education Experience

Please provide student's last grade completed and Parish Name / Address

If registering for first time your Child's Baptismal Certificate must be submitted to the office.

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

Is your child going to use our Home Study program?

Yes No

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 Home Study

Child 3 Session Choice

Sundays 10:45-12:00 noon (Grades 1-6) Sunday 10:45-12:00 noon (Grades 7-12) Monday 7:00-8:30 pm (Grades 7-12)

Child 4

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Religious Education Grade

Grade in Fall 2021

School Grade

School Grade in Fall 2021

School

School District

Individualized Education Program (IEP)

No Yes

Please list all pertinent medical/learning data so we can best meet the needs of your child. (Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services)

Medical/Learning Data

*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."

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

New Student Returning Student

Child 4 Sacraments

Previous Religious Education Experience

Please provide student's last grade completed and Parish Name / Address

If registering for first time your Child's Baptismal Certificate must be submitted to the office.

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

Is your child going to use our Home Study program?

Yes No

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 Home Study

Child 4 Session Choice

Sundays 10:45-12:00 noon (Grades 1-6) Sunday 10:45-12:00 noon (Grades 7-12) Monday 7:00-8:30 pm (Grades 7-12)

Child 5

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Religious Education Grade

Grade in Fall 2021

School Grade

School Grade in Fall 2021

School

School District

Individualized Education Program (IEP)

No Yes

Please list all pertinent medical/learning data so we can best meet the needs of your child. (Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services)

Medical/Learning Data

*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."

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

New Student Returning Student

Child 5 Sacraments

Previous Religious Education Experience

Please provide student's last grade completed and Parish Name / Address

If registering for first time your Child's Baptismal Certificate must be submitted to the office.

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

Is your child going to use our Home Study program?

Yes No

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 Home Study

Child 5 Session Choice

Sundays 10:45-12:00 noon (Grades 1-6) Confirmation Program Sunday 10:45-12:00 noon (Grades 7-12) Monday 7:00-8:30 pm (Grades 7-12)

Document Uploads

File Uploads

Add files

Drop files anywhere to add

Please upload any documents required by the office with this form. (Baptism, Custody, etc.)

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Emergency Contact / Doctor

Emergency Contact Name

If we are unable to contact a parent in the event of an emergency, whom should we contact?

Relationship

Emergency Contact Home Phone

Emergency Contact Cell Phone

Doctor's Name

Doctor's Phone

Volunteer Information

Will you be volunteering?

Yes No

Volunteer Name

Volunteer Phone

Volunteer Interested in

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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

Sacramental Fee

Additional Fee

Current Date

An additional fee of $20.00 will be added after September 10, 2021

Registration Fee

If your family is experiencing financial difficulty and you would like to create a payment plan, please call the Parish Office at 963-4205. Please do not delay in registering due to finances.

Total Amount

Verification