Student Registration Form

Early Registration Discount (Before May 1):
$175/first child; $305/2 children; $435/3 children; $130/additional child after third child.

Tuition after May 1:
$200/first child; $330/2 children; $460/3 children; $130/additional child after third child.

Sacrament Fees:
$70/First Communion; $70/Confirmation

Primary Family Address

Are you registered members of Epiphany of Our Lord Church, Plymouth Meeting?

Yes No

If NO, in which parish are you registered?

Attach letter of permission from your pastor for your child(ren) to attend Epiphany of Our Lord’s REP. Upload form on page 3

Family Last Name

Address

Primary E-mail

This email will be used to provide program updates and information and, occasionally information from the parish. It is necessary as it will serve as the primary method of communication between the program and your family.

Primary Phone

This will be the main phone number we will use to communicate with your family.

Number of Children (Early Registration Discount)

Number of Children you will be registering today

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

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. If applicable, full name of Step-parent(s) or Guardian(s).

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Child 1

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Religious Education Grade

Grade in Fall 2019

School Grade

School Grade in Fall 2019

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

Child 1 Session Choice

Regular Classes Home School

Child 2

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Religious Education Grade

Grade in Fall 2019

School Grade

School Grade in Fall 2019

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

Child 2 Session Choice

Regular Classes Home School

Child 3

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Religious Education Grade

Grade in Fall 2019

School Grade

School Grade in Fall 2019

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

Child 3 Session Choice

Regular Classes Home School

Child 4

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Religious Education Grade

Grade in Fall 2019

School Grade

School Grade in Fall 2019

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

Child 4 Session Choice

Regular Classes Home School

Child 5

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Religious Education Grade

Grade in Fall 2019

School Grade

School Grade in Fall 2019

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

Child 5 Session Choice

Regular Classes Home School

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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Dismissal Information

My child(ren) should only be released to/picked-up by/signed out by the above people

Emergency Contact

Emergency Contact Name

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

Relationship

Emergency Contact Phone

Address, City, State, Zip

Emergency Contact Phone 2

Volunteer Information

Will you be volunteering?

Yes No

Volunteer Name

Volunteer Phone

Volunteer Interested in

Teacher Assistant Teacher Hall Monitor

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Terms & Conditions

I have read the Parent Handbook and agree to the requirements and expectations of the Epiphany of Our Lord Church Religious Education Program.

YES

Medical: Do you grant permission that, in your absence, your child(ren) whose names appear on this form, may receive emergency medical care for injuries and all situations that should occur while participating in the REP program at Epiphany of Our Lord Church, Plymouth Meeting?

I agree I disagree

Photo: Do you grant permission for photos (no names) of your child(ren) to appear on parish media including but not limited to website, bulletin or social media in relation to events that occur during REP?

I agree I disagree

Sacraments Fees

Additional Fees

Current Date

Registration Total

Payment is required at the time of registration. Your 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. Please do not delay in registering due to finances.

Total Amount

Verification