Student Registration Form

PSR registration is for 3-year-olds through Grade 12.

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.

St. Stanislaus Parish uses Flocknote to communicate with parishioners via text and email. This is how you will receive information about PSR. Do you prefer to receive texts or emails from Flocknote?

Texts Emails

PSR is for children 3 years old through high school

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

Name

Deceased

Yes No

Maiden Name

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 2019

School Grade

School Grade in Fall 2019

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 an intellectual disability, 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

Previous Religious Education Experience

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

Child 1 Sacraments

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

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

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 an intellectual disability, 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

Previous Religious Education Experience

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

Child 2 Sacraments

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

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

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 an intellectual disability, 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

Previous Religious Education Experience

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

Child 3 Sacraments

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

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

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 an intellectual disability, 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

Previous Religious Education Experience

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

Child 4 Sacraments

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

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

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 an intellectual disability, 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

Previous Religious Education Experience

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

Child 5 Sacraments

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

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

Emergency Contact Name 1

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

Relationship

Emergency Contact Phone 1

Emergency Contact Name 2

Relationship

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 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 Fees

Volunteer Discount

Additional Fee

Current Date

Total Normal

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