Religious Education / 2017 - 2018 Registration

Please enter the information for your child(ren) and then proceed to the bottom of the form to enter parent/guardian information, emergency contact details, and photo release information. - Thank you!

The fee for Religious Education classes is $20/student per year. This fee helps offset costs associated with the program such as educational materials and supplies.

Scholarships and payment plans are available. Prior approval is needed from the office prior to selecting either the $0 Scholarship or Payment Plan options at the bottom of this form. To obtain financial aid, please contact Michelle at 413-743-2110 or michelle@stmaryscheshire.com.

Child #1

Please complete the following fields.

First Name

Last Name

Child's Nickname

Date of Birth

Gender

Male Female

Grade Level as of September 2017

School

Sacraments Completed (check all that apply)

Baptism - Catholic Baptism - Non-Catholic First Reconcilliation First Communion N/A

Date of Baptism (if applicable)

Place of Baptism - Church, City/State, Other Denomination (if applicable)

Date of First Communion (if applicable)

Place of First Communion - Church, City/State, Other Denomination (if applicable)

Child #1 Medical Information

Does your child have any allergies and/or intolerance to food, medication, or any other substance? If so, what are the symptoms and actions to be taken if any reaction should occur?

Are there any other medical or non-medical issues we should be made aware of? If so, please list.

Does your child require medication that may need to be administered during class? If you answer yes, you will be required to complete a Medication Authorization Form.

Yes No

Child #2

Please complete the following fields for your child. The fields are marked optional for the families who are only enrolling one child in Religious Education.

First Name

Last Name

Child's Nickname (optional)

Date of Birth

Gender Male Female

Grade Level as of September 2017

School

Sacraments Completed (check all that apply) Baptism - Catholic Baptism - Non-Catholic First Reconcilliation First Communion N/A

Date of Baptism (if applicable)

Place of Baptism - Church, City/State, Other Denomination (if applicable)

Date of First Communion (if applicable)

Place of First Communion - Church, City/State, Other Denomination (if applicable)

Child #2 Medical Information

Does your child have any allergies and/or intolerance to food, medication, or any other substance? If so, what are the symptoms and actions to be taken if any reaction should occur?

Are there any other medical or non-medical issues we should be made aware of? If so, please list.

Does your child require medication that may need to be administered during class? If you answer yes, you will be required to complete a Medication Authorization Form.

ADDITIONAL CHILDREN MAY BE ENTERED AT THE BOTTOM OF THE FORM.

Parent/Guardian Information

Parent/Guardian Name

Address

Cell Phone

Home Phone

Work Phone

This address will receive a confirmation email

Are you a registered parishioner?

Yes No

If you are not a parishioner, to which parish do you belong?

If you are a parishioner, which location do you prefer to worship at?

North American Martyrs Chapel St. Mary of the Assumption Church

Secondary Parent/Guardian

Check if address is the same as above.

same address Option Option

Address

Cell Phone

Home Phone

Work Phone

Emergency Contact Information

Please provide the name, address, and phone number for TWO people to be called in the event that we cannot reach either parent/guardian.

Emergency Contact Name

Address

Phone

Emergency Contact Name

Address

Phone

Please list others who are authorized to pick-up your child in addition to the parents and/or guardians and emergency contacts.

Please let us know if there are any other special circumstances regarding your child being picked up or dropped off.

Authorization Information

Please complete the following fields. Upon registration, you will be provided a paper copy of this information and requested to sign a copy for parish records.

I give my permission to the staff and volunteers to seek medical attention for my child(ren) if necessary while participating in religious education classes or church activities. I understand that all necessary precautions will be taken for my child’s safety. I will not hold the St. Mary of the Assumption Parish, its staff or those volunteers liable. Please fill in your name below to signify you have read and understand this information.

I understand that St. Mary of the Assumption Parish may take photos and/or videos of my child(ren) during religious education programming. I hereby give St. Mary of the Assumption permission to use my child's photo for parish publications, website, and social media accounts. I understand this only applies to photographs taken in which my child is a main focus of the photo and that this authorization does not apply to large group shots in which my child may be visible but not the main focus of the photograph. Ex. a crowd photo at an event.

Yes No Please do not post on social media or on the website. Printing of the photographs for display within the church facilities is permissible.

PROCEED TO THE BOTTOM OF THE PAGE IF YOU ARE READY TO SUBMIT YOUR APPLICATION.

Child #3

Please complete the following fields for your child. The fields are marked optional for the families who are only enrolling one child in Religious Education.

First Name

Last Name

Child's Nickname (optional)

Date of Birth

Gender Male Female

Grade Level as of September 2017

School

Sacraments Completed (check all that apply) Baptism - Catholic Baptism - Non-Catholic First Reconcilliation First Communion N/A

Date of Baptism (if applicable)

Place of Baptism - Church, City/State, Other Denomination (if applicable)

Date of First Communion (if applicable)

Place of First Communion - Church, City/State, Other Denomination (if applicable)

Child #3 Medical Information

Does your child have any allergies and/or intolerance to food, medication, or any other substance? If so, what are the symptoms and actions to be taken if any reaction should occur?

Are there any other medical or non-medical issues we should be made aware of? If so, please list.

Does your child require medication that may need to be administered during class? If you answer yes, you will be required to complete a Medication Authorization Form.

Child #4

Please complete the following fields for your child. If you have more than four children, please contact the office to assist with registration. The fields are marked optional for the families who are only enrolling one child in Religious Education.

First Name

Last Name

Child's Nickname (optional)

Date of Birth

Gender Male Female

Grade Level as of September 2017

School

Sacraments Completed (check all that apply) Baptism - Catholic Baptism - Non-Catholic First Reconcilliation First Communion N/A

Date of Baptism (if applicable)

Place of Baptism - Church, City/State, Other Denomination (if applicable)

Date of First Communion (if applicable)

Place of First Communion - Church, City/State, Other Denomination (if applicable)

Child #4 Medical Information

Does your child have any allergies and/or intolerance to food, medication, or any other substance? If so, what are the symptoms and actions to be taken if any reaction should occur?

Are there any other medical or non-medical issues we should be made aware of? If so, please list.

Does your child require medication that may need to be administered during class? If you answer yes, you will be required to complete a Medication Authorization Form.

Payment

Registration Fee

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Religious Education / 2017 - 2018 Registration

Description

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