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Religious Education Program

Registration Form for 2011 - 2012 School Year

Student's Information

Child's Full Name: *

First Name

Middle Initial

Last Name

Date of Birth: * MM/DD/YYYY

Place of Birth:

Ethnic Background:

Grade in School:

Grade for Religious Ed.:

Registration fee:

Kindergarten to Pre-confirmation - $40
First Communion and Confirmation - $60

You may pay for the fees online after submitting all the information.

Sacraments Received: BaptismHoly Communion

Baptism Date:

Church and Place of Baptism:

*** A copy of Baptismal Certificate is required for new students who have been baptized already. ***

First Communion Date:

Church and Place of First Communion:

Family Information

Father's Full Name: *

First Name

Middle Initial

Last Name

Address

Street Address

Address continued

City

State

Zip

Mother's Maiden Name: *

First Name

Middle Initial

Last Name

Address

Street Address

Address continued

City

State

Zip

Phone Numbers:

Main: *

Cell:

Work:

Legal Guardian: *

First Name

Last Name

Legal Guardian's Phone Number:

Registered Member of St. Patrick?

If Yes, since when:

Medical and Emergency Information

Is your child currently taking medications for a chronic condition?

Please identify the medication and course of action should your child become ill during class:

Physician's Name:

Physician's Phone Number:

Physician's Address:

Medical Insurance Company:

Insurance Number:

Alternate contact in case of emergency

Name:

Phone Number:

Relationship:

Medical Release
In the event that the undersigned, or my (our) authorized physician, cannot be reached and in the judgment of the Director of Religious Education, or other appropriate staff member, there is a necessity for immediate examination and/or treatment of my (our) child, I (we) hereby request and authorize any of the aforesaid personnel to obtain for my (our) child any diagnosis/treatment and for medication deemed necessary.

Dates for which this release is intended: September 2011 through May 2012

Notice of Release of Liability
I (we) understand that my (our) child’s Religious Education session will end at 11:30 a.m. and that it is my (our) responsibility to pick up my (our) child at that time. The Religious Education teachers will NOT be responsible for my (our) child after that time and I (we) release St. Patrick Church from any and all liability.

By clicking the Agree button and submitting the information, I hereby agree to the conditions set above. * Yes, I/We Agree.No, I/We Do Not Agree.

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