Religious Education Registration and Medical Release Form- 2023/2024

Child #1

First Name

Last Name

Date of Birth

Gender

Male Female

Choose schedule that best works for your family

*If you have signed your child up for a Sacramental Preparation Year, please indicate which school grade they are in:

Has your child been Baptized?

Yes, Roman Catholic Yes, Chaldean Catholic Yes, Eastern Catholic Rite Yes, in another faith denomination No

Has your child celebrated First Communion?

Yes No

List allergies, medication, special needs, or other pertinent comments.

Child #2

First Name

Last Name

Date of Birth

Gender Male Female

Choose schedule that best works for your family

*If you have signed your child up for a Sacramental Preparation Year, please indicate which school grade they are in:

Has your child been Baptized? Yes, Roman Catholic Yes, Chaldean Catholic Yes, Eastern Catholic Rite Yes, in another faith denomination No

Has your child celebrated First Communion? Yes No

List allergies, medication, special needs, or other pertinent comments.

Child #3

First Name

Last Name

Date of Birth

Gender Male Female

Choose schedule that best works for your family

*If you have signed your child up for a Sacramental Preparation Year, please indicate which school grade they are in:

Has your child been Baptized? Yes, Roman Catholic Yes, Chaldean Catholic Yes, Eastern Catholic Rite Yes, in another faith denomination No

Has your child celebrated First Communion Yes No

List allergies, medication, special needs, or other pertinent comments.

Child #4

First Name

Last Name

Date of Birth

Gender Male Female

Choose schedule that best works for your family

*If you have signed your child up for a Sacramental Preparation Year, please indicate which school grade they are in:

Has your child been Baptized? Yes, Roman Catholic Yes, Chaldean Catholic Yes, Eastern Catholic Rite Yes, in another faith denomination No

Has your child celebrated First Communion Yes No

List allergies, medication, special needs, or other pertinent comments.

Primary Adult Contact - For All Contact Information

Name

Relationship to child

Secondary Adult Contact

First Name

Last Name

Relationship to child

Family and Medical Information

School District

Primary Email

This address will receive a confirmation email

Secondary Email address (optional)

Primary Cell Phone (please use dashes ex: 248-555-1212)

Secondary Cell Phone (please use dashes ex: 248-555-1212)

Family Address

The following information will be used for a Medical Treatment Release Form

To Whom It May Concern:
As parent/guardian, I do hereby authorize the treatment of a qualified and licensed physician of any condition which, in the opinion of the physician, is deemed necessary and appropriate. This authority is granted only after reasonable effort has been made to reach me.
This form is intended for use only during Religious Education time.

Family Physician

Physician Phone (please use dashes ex: 248-555-1212)

Physician Address

Health Insurance Data

Company

Group #

Contract or Subscriber #

I further authorize the person who presents the minor to sign the Acknowledgement of Receipt of Notice Privacy Rights that may be presented by the physician or health care facility.

This authorization is completed and signed of my own free will with the sole purpose of authorizing medical treatment deemed necessary and appropriate by the treating physician. I acknowledge that it is my responsibility to submit a new form in any of the above information changes.

By checking this box, I am indicating that I agree with the above statement.

Electronic Signature*

*By entering my name in the box above, I am providing my digital signature on the Form.

I understand the registration fees are NON-REFUNDABLE

Agreed

Please contact the RE office if we should be aware of a particular family or parenting situation.

I consent to my child(ren) being photographed during religious education for publicity purposes, such as St. Joseph website and other promotional communications. I understand no compensation will be offered for such use.

Yes No

I consent to my child's work being published in the parish bulletin with only grade and/or first name used.

Yes No

Payment

Confirmation Year One Preparation requires an additional form and $40 fee. Please click here to fill out the Confirmation Year One Registration Form.

First Communion Preparation requires an additional form but no fee. Please click here to fill out the First Communion Registration Form.

There are several payment options available, including a pay later option. Please click the arrow to select your choice of payment. Approval is needed for or scholarship option, please call 248-693-9555.

Are you making this payment for a child in your household?

Yes No

Payment Options

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Religious Education Registration and Medical Release Form- 2023/2024

Description

Please Fix the Following