Religious Education Registration Form - St. Charles

St. Ann Parish, Phoenixville

2016-17Religious Education Registration Form

Registration open April 3 to July 31; a late fee of $50/family will be assessed beginningAug. 1

Family tuition rates: one child/$130, two children/$220, three or more children/$300

Please choose which day your child(ren) will be attending PREP during the 2016-17 PREP year.

____ Sundays 10:35 a.m. - 12:05 p.m. @ St. Ann’s (K-6)____ Tuesdays 6:20-7:50 p.m. @ St. Ann’s (K-6)

Please supply all requested information. Print clearly. For first time registrations, please provide one copy of each child’sBaptismal Certificateif not baptized at the home parish.

Child’s Full Name
(First, Middle, Last) / M/F / DOB / Last PREP
Level completed / Name ofday school and
grade level / Baptism
Date & Parish / 1st Penance
Date & Parish / 1st Communion
Date & Parish

Family Name:______Home Parish:______

Home Phone:______Family Email: ______

Address:______

Street City Zip Code

Father’s Full Name:______Living/Deceased?______Religion:______

Father’s Cell Phone:______Email:______

Mother’s Full Name (with maiden):______Living/Deceased?______Religion:______

Mother’s Cell Phone:______Email:______

Emergency Contact Information:

Name: ______Relationship:______Phone: Home______Cell______

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 religious education programs and activities.

Medical/Learning Data: 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 / Disability/Learning Support Services / G/IEP or 504
 YES
 NO
 YES
 NO
 YES
 NO
 YES
 NO

If you answered “Yes” to G/IEP or 504 then please also complete and attach a detailed Child Information Form, available through the D/CRE.

Is there any other information about your child that should be communicated? If yes, please attach to this form.

Custody: Are there any custody/legal issues?  yes  no (If yes, please attach a complete copy of the latest court order.)

*Name of person responsible for Religious Education if not a Parent/Guardian______Relationship______

Parent/guardian must provide a signed, dated letter of permission which is to be kept on file and updated annually.

I have read the Religious Education Program Handbook (on parish website) and agree to the program requirements and expectations.

I give permission for my child's name and picture to appear on parish websites, bulletins, sacramental programs, and related media in relation to events that happen in the program.

Parent/Guardian Signature ______Date ______

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