Church of Saint Patrick, Pottsvillepa

Church of Saint Patrick, PottsvillePA

Parish Religious Education Program

Registration Form

Please print clearly. For first time registrations, please bring an original and one copy of each child’s Baptismal Certificate.

Tuition: Parishioners: One Child- $60, Two Children- $110, Three or more children- $150

Non-Parishioners: One Child- $85, Two Children- $135, Three or more children- $175

Sacramental Fees is due along with the Registration Fee ($10 – First Penance; $25 - First Holy Communion)

($50 – Confirmation with $20 being returned after the Confirmation gown is returned in good condition)

Child’s Full Name
(First, Middle, Last) / Sex
(M/F) / Date of Birth / Grade Level / Name of School / Baptism date and Parish / 1st Penance Date (if Applicable) / 1st Communion Date (if Applicable)

Family Name: ______Home Phone: ______

Address: ______Email: ______

StreetCityZip Code

Father’s Name: ______Cell #______Religion______

Mother’s Maiden Name: ______Cell #______Religion______

CUSTODY: Are there any custody/ legal issues? □Yes □No (If Yes, please provide a complete copy of the latest court order.)

*Name of the person responsible for Religious Education if not Parent/ Guardian______

Relationship to child______

*Parent / guardian must provide a signed, dated letter to the Associate of Religious Education (ARE) which is to be kept on file and updated annually.

Please check the box below if you are in agreement with the statement that follows:

□ I have (will) read the Parent Handbook and agree to the requirement and expectations of the Church of Saint Patrick Parish Religious Education Program.

□ I give permission for my child’s picture to appear on the parish website and Facebook page, bulletin boards & newspaper articles in relation to events that happen in the parish.

□ For First Penance, Holy Communion and Confirmation candidates only: I give permission for my child’s name to be printed in the Sacramental booklet and parish bulletin. Please note that the parish bulletin is also posted on the parish website.

□ I understand that my child(ren) will participate in the Safe Environment Lessons as outlined by the Diocese of Allentown.

Signature: ______Date______Relationship to Child______

EMERGENCY CONTACT INFORMATION:

If we are unable to reach you, whom should we contact?

Name______Relationship ______Phone#______

CONSENT FOR MEDICAL CARE

I give permission that, in my absence, my children whose names appear on Page 1 of this registration form, may receive emergency medical care for injuries and all situations that should occur while participating in the Parish Religious Education Programs and activities at Church of Saint Patrick parish.

Signed (Parent/ Legal Guardian) ______Date______

MEDICAL/ LEARNING DATE

If any of the following apply to your child, please list his/ her name and give details in the appropriate spaces.

Child’s Name / Medical Conditions/ Allergies / Prescribed Medications if needed to be taken during PREP / Learning Support Services (if needed) / Individualized Education Plan (IEP)
□Yes
□No
□Yes
□No
□Yes
□No
□Yes
□No

Is there any other information about your child that should be communicated? ______

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