Parish School of Religion

Child’s Name *

Other Children’s Names

Address 1 *

Address 2

City *

Zip Code *

Date of Birth *

Other Date(s) of Birth

Primary Phone *

Grade *

Grade(s)

Choose one:

Hybrid (homeschool plus in-person gathering)

Homeschool only

Sacramental Information

Please indicate where your child/children received sacraments. We will require records from parishes other than St. Patrick, St. Malachi or St. Wendelin. Please bring the records to Catechetical Leader or UCS Faith Formation Director.

(Please use the “Additional Information” field at the end of the final page of this form if you have sacramental information about other children.)

Sacrament

Baptism

Received at What Parish?

Reconciliation

First Eucharist

Confirmation

Mother’s Name *

Mother’s Email *

Father’s Name *

Father’s Email *

Mother’s Religion *

Mother’s Phone

Father’s Religion *

Father’s Phone

Child/ren lives with *

Who does the child/ren live with?

Parish Of Registration *

Health and Medical Information

In the event your child requires emergency medical treatment while with us, we will first attempt to contact you for instructions. In the event we are unable to reach you, please, please specify your desires (select only one below)

Emergency Medical Instructions *

TO GRANT CONSENT: I consent to (1) administration of any treatment deemed necessary by the named doctors, or in the event they are not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the surgery.

TO DENY CONSENT: I refuse consent for emergency Medical Treatment.

If consent is granted, complete the following

Emergency Contact Name

Physician Name

Dentist Name

Relationship

Physician Phone

Dentist Phone

Emergency Contact Phone

Environmental Considerations

Please let us know about allergies or other environmental considerations we should be aware of. (Indicate child’s name.)

Learning and Behavioral Considerations

It is our policy to provide accommodations for special needs. Please list any special learning and/or behavioral considerations we should be aware of. (Indicate child’s name.)

Photo Release

Choose One *

I, the parent and/or guardian, consent and authorize the release and publication of any and all photographs taken of my child while enrolled in the St. Patrick & St Malachi PSR program. I understand that all photographs are the property of St. Patrick /St Malachi Church to be used at its discretion, including but not limited to promotional publications, newsletters, and website, without notice or compensation.

I, the parent and/or guardian, withhold consent regarding photographs of my child.

Called to Protect

Called to Protect lessons, mandated by the Diocese, teach children about healthy, safe boundaries as well as how to identify and report any form of abuse. These occur during the PSR program. Parents are notified by the Catechetical Leader via email when these are taught.

If you choose to opt your child out of this program, please indicate here.

I opt out of Called to Protect Lessons

Parent Volunteer

Please indicate your ability to help as a parent volunteer *

Catechist

Catechist Assistant

Substitute Catechist/Assistant

Assist with Reconciliation Preparation

Assist with First Eucharist Preparation

Assist with Confirmation Preparation

Assist with Special Programs

No ability to volunteer at this time