PSR Student Registation Welcome to Ss. Peter and Paul Parish School of Religion (PSR), we are happy that you have chosen to enroll your child in our program.
Family Information Family Name:
Are you new to the parish within the last year?
Family Email:
Address (Street, City, State, Zip Code):
Primary Phone Number:
Father's Information Name (Last, First):
Religion:
Cell Phone:
Email:
Mother's Information Name (Last, First):
Religion:
Cell Phone:
Email:
Emergency Contact(s) other than parents (2 contacts are required) Name:
Relationship (aunt, uncle, grandparent, friend, etc.):
Phone:
Name:
Relationship (aunt, uncle, grandparent, friend, etc.):
Phone:
Student Information Child's Name:
Birthdate (Month, Day, Year):
Place of Baptism:
Please note that if not baptized at Ss. Peter & Paul a copy of their Baptism Certificate is required.
Grade in School on 9/1
Choose 1
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Did this child attend PSR at Ss. Peter & Paul last year?
Medical Conditions (Asthama, allergies, food restrictions):
Emergency Medications (please include dosage if necessary):
Special Needs (disabilites, or special needs):
Child's Name:
Birthdate (Month, Day, Year):
Place of Baptism:
Please note that if not baptized at Ss. Peter & Paul a copy of their Baptism Certificate is required.
Grade in School on 9/1
Choose 1
1
2
3
4
5
6
7
8
Did this child attnd PSR at Ss. Peter & Paul Last year?
Medical Conditions (Ashtma, allergies, food restrictions):
Emergency Medications (please include dosage if necessary):
Special Needs (Disabilites, or special needs):
Child's Name:
Birthdate (Month, Day, Year):
Place of Baptism:
Please note that if not baptized at Ss. Peter & Paul a copy of their Baptism Certificate is required.
Grade in School on 9/1
Choose 1
1
2
3
4
5
6
7
8
Did your child attend PSR at Ss. Peter & Paul last year?
Medical Conditions (Asthma, allergies, food restrictions):
Emergency Medications (please provide dosges if necessary):
Special Needs (disabilities or special needs)
Child's Name:
Birthdate (Month, Date, Year)
Place of Baptism:
Please note that if not baptized at Ss. Peter & Paul a copy of the Baptismal Certificate is required.
Grade in school on 9/1
Choose 1
1
2
3
4
5
6
7
8
Did your child attend PSR at Ss. Peter & Paul last year?
Medical Conditions (Asthma, allergies, food restrictions):
Emergeny Prescriptions (please provide dosage if necessary):
Special Needs (disabilities or special needs):
Parishioner Declaration Ss. Peter and Paul, along with our feeder parishes, is dedicated to promoting Catholic Education to all students. The cost to provide Catholic Education is subsidized for the children of Active Parishioners. An Active Parishioner meets the following requirements:
We are active members of:
Parental Permission With Liability Release The undersigned, being the lawful parent and/or guardian of the above named child(ren) (hereinafter referred to as “Child(ren)”), hereby consents to the participation of said Child(ren) in the Ss. Peter and Paul Parish School of Religion Program (the “Program”) and to said Child(ren) participating in all events relating to the activities through the Program.
I authorize my consent:
Caritas Family Solutions Child Protection Video Caritas Family Solutions will present an age appropriate Child Protection Video to Ss. Peter and Paul PSR students. Students will be grouped by classes for the presentations.
Please check ONE box only:
Child Release For for Video/Photographs The undersigned, being the lawful parent and/or guardian of the child named below (hereinafter referred to as “Child”), hereby consents and grants permission to the use of any video, photographs, or any other visual or audio reproductions of my child(ren) without compensation. I understand that these visual or audio productions may be used by the parish or Diocese of Belleville for videos, web pages and/or organization Facebook page, class and school projects, exhibits, promotions or fundraising. Pictures may also be submitted to the local newspapers for publishing. I release the parish and the Diocese of Belleville from any liability connected with the use of any visual or audio formats for the purposes listed above. NAMES WILL NOT BE USED
I hereby give permission to Ss. Peter and Paul Parish to use any photographs or video footage taken of my child in print and on their website and social media sites for promotional purposes
Parent/Guardian Name:
