Children's Religious Education Registration

Parent's Name
Name
  •  
Address
Address
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Phone Number
Phone --
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Email Address
E-mail
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Children's Names
Name
  •  
Date of Birth //
  •  
Grade
  •  
Allergies/Other
  •  
Name
  •  
Date of Birth //
  •  
Grade
  •  
Allergies/Other
  •  
Name
  •  
Date of Birth //
  •  
Grade
  •  
Allergies/Other
  •  
Name
  •  
Date of Birth //
  •  
Grade
  •  
Allergies/Other
  •  
Name
  •  
Date of Birth //
  •  
Grade
  •  
Allergies/Other
  •  
Are you registered at SS Peter & Paul Church?
List (Dropdown)
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Are you willing to help with special activities?
List (Dropdown)
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Financial Assistance
If financial assistance is needed to pay the religious education fee, please see Father Tony.
Questions or Concerns Please contact Drew Stuart, the Director of Religious Education with if you need assistance paying the religious education fee or if you have any other questions about payment. He can be reached at dstuart.sspp@gmail.com or by phone or text at 260-224-0522.
Office use only: Date_____________________ Fee amount paid___________________ Check___________________ Cash____________________
Emergency Information
I authorize the below named contact to authorize medical attention for my child(ren) and/or to pick up my child(ren) if I am not available.
Name
  •  
Relationship to Child
  •  
Home Phone --
  •  
Cell Phone --
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Health Insurance Provider
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Insurance Certificate Number
  •  
Hospital Preference
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Parent Providing Coverage
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Parent Date of Birth //
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Family Doctor
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Phone Number --
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In the event of an emergency In the event that I or the family physician indicated above cannot be reached and if, in the judgment of the Parish staff, immediate medical attention is indicated, I authorize the Parish staff to send my child(ren) to an available hospital or physician. I authorize the treatment of my minor child(ren) by qualified emergency medical personnel or licensed medical doctors in the event of an emergency which, in the opinion of the attending emergency medical personnel and/or doctors, may cause physical disability, undue discomfort and/or endangerment of life if delayed. This consent is granted only after a reasonable effort has been made to reach me.
Signature of Parent/Legal Guardian
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Date //
  •  
Other Contact Is there a grandparent, step-parent, or someone else who you would like us to have on file as a contact?
Name
  •  
Relationship to Child
  •  
Address
  •  
Home Phone Number --
  •  
E-mail
  •  
May this person pick up your child(ren) up after Religious Education classes?
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Photography Permission
Please grant or deny the parish permission to Use Pictures and videos of your child on the Parish's Social Media accounts (Facebook, YouTube, etc.) and the parish website.
Photography and Videography Permissions
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Do you grant the parish permission to use your photos and videos of Religious Education events and Sacraments that include your child(ren) on our parish Social Media accounts and website?
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