Religious Education Enrollment

"Religious Education Registration Form"

Grades Pre-K thru10 Registration Form for Faith Formation

Please complete one form per child. Please complete the entire Document. After you complete this Form and "Click Submit" to complete the registration process for your child. If you prefer to mail completed forms along with the registration fee

($25.00 per child or $45.00 per family) "Click" here for printer friendly form.

and mail to: Immaculate Conception Faith Formation Program, P. O. Box 379, Haines Falls, NY 12436

Adult responsible to pick up your child from church:

*Parent/Guardian1*
Street Address
Address (cont.)
City
Zip Code
Work Phone
Home Phone
Mobile Phone
Fax
E-mail

*Parent/Guardian2*
Street Address
Address (cont.)
City
Zip Code
Work Phone
Home Phone
Mobile Phone
Fax
E-mail

Student's First Name Middle Name Last Name

Grade Birth Date example: MM/DD/YY

Sacraments Received: Please check all that apply Baptism Reconciliation Eucharist

If Sacraments were received in another Parish, Please Send Certificate to the Rectory.

*Name*
Street Address
Address (cont.)
City
Zip/Postal Code
Work Phone
Home Phone
Mobile Phone

Emergency Information:

Emergency Contact Name

Emergency Contact's Phone Number

Physicians Name

Physicians Phone Number

Health Issues, Allergies, etc.

Check if there aren't any health issues

I hereby (please check to permit) authorize and give my consent for the taking of pictures of my child (Moving or still) and approve of their reproduction for: Teaching Purposes, News Release, Publication, and Community Awareness Programs.

This is to certify that on this datemm/dd/yy

I (type your name) legal parent/guardian of (type your child's name) Give my consent to a church representative to obtain medical care from a licensed Physician, Hospital or Clinic for the above mentioned student for any injury that could arise during any church activities

Electronic Signature: The form will not be "signed" in the sense of a traditional paper document. To verify the contents of this Registration Form, the signatory must enter his or her complete name here

then on the "Click Submit"

PO Box 379

67 North Lake Road

Haines Falls, NY 12436

518-589-5577