Religious Education Registration Form Please fill out the following information to enroll for Religious Education Classes for 2020-21 school year. Classes are Wednesday evenings from 6:30pm-7:45pm for K-6th grade and 6:30pm-8:00pm for 7th-High School. Please contact the Faith Formation Office with any questions at 563-582-0377.
The fee for students in Religious Education is $195 for one child, $365 for two, $515 for three, and $645 for four or more children.
2nd Grade and 10th Grade RE/Confirmation will also have a $40 Sacramental Preparation Fee added to their tuition.
*Confirmation takes place in 10th grade*
Sacramental Preparation Fee for Holy Family Students in Grades 2 and Confirmation is $40
If you register and pay in full by June 15th, 2020 there is a $25 per family discount. Catechists and Aides also receive $25 off!
Family Information Family Last Name
Family Home Address (Street, City, State, Zip Code)
Parish Where Family is Registered
Family Email Address - Email is our main form of communication, please let us know if you do not use email.
Family Main Phone Number
Family Alternate Phone Number
Can your child receive text messages regarding RE/Confirmation Events
Yes, my child can receive text messages and I understand my provider may charge a fee. No Name of Student to whom texts will be sent
Student Cell Phone Provider
Parent/Guardian Information Marital Status
Married
Separated
Divorced
Single
Guardian 1 Name (Last, First)
Guardian 1 Email Address
Guardian 1 Cell Phone
xxx-xxx-xxx
Guardian 1 Relationship to Child
Mother
Step-Mother
Guardian
Father
Step-Father
Guardian 1 Religion
Guardian 2 Name (Last, First)
Guardian 2 Email Address
Guardian 2 Cell Phone #
xxx-xxx-xxx
Guardian 2 Relationship to Child
Mother
Step-Mother
Guardian
Father
Step-Father
Guardian 2 Religion
Non-Custodial Parent Information (If applicable) Dual Parent Reporting
Archdiocesan Policy #5124 states, “Unless otherwise decreed in the Order of Dissolution, information commonly made available to parents of any student in attendance (i.e., notices of school/catechetical program functions, report cards, appointments for parent-teacher conferences) should be provided to both parents.”
In a situation where parents are separated the following information must be filled out AND an additional form needs to be turned into the RE Office. The Form can be downloaded from the website -Dual Consent Reporting - Policy 5124
Non-Custodial Parent Name (Last, First)
Non-Custodial Parent Address (Street, City, State, Zip Code)
Non-Custodial Parent Email Address
Non-Custodial Parent Cell/Home Phone #
Emergency Contact Information Emergency Contact Name (Last, First)
Emergency Contact Relationship to Child
Emergency Contact Cell Phone #
Family Medical Information Family Doctor
Family Doctor Phone #
xxx-xxx-xxx
Family Health Plan Carrier
Family Health Plan Policy Number
Parent Volunteer Opportunities Your contribution of time and talent is crucial to the success of our program. Opportunities for your involvement are listed below. All volunteers make a difference for our kids. Help make a difference in your child's religious education!
Please check which options you are interested in!
RE Catechist RE Catechist Aide RE Entrance Monitor RE Crossing Guard High School Small Group Leader Donate Food/Beverage Office Help Youth Ministry Events Special Event Help Sing or Play Music for Special Events Required Permissions The following require a "Yes" or "No" response for each of the required permissions.
Consent and Liability Waiver This Consent and Liability waiver is required for and serves both on-site programs and off-site/field trip events/activities for the stated program year. I grant permission for my child to participate in parish/cluster events this year that may require transportation to a location away from the parish/cluster site. The activities will take place under the guidance and direction of parish/cluster employees and/or volunteers. As a parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“Participant”). I agree on behalf of myself, my child9ren) named herein, or our heirs, successors, and assigns, to hold harmless and defend, its officers, directors of the parish/cluster and agents, and the Archdiocese of Dubuque, chaperons, or representatives associated with the events, arising from or in connection with my child(ren) attending the events or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate the parish/cluster, its officers, directors and agents, and the Archdiocese of Dubuque, chaperons, or representatives associated with the events for reasonable attorney’s fees and expenses which they may incur in any action I/we may bring against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/cluster or the Archdiocese of Dubuque.
Yes-I agree to the liability statement
No- I do not give permission or agree with the liability statement
EMERGENCY MEDICAL TREATMENT PERMISSION I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me contact the emergency contacts/locations as listed in this online registration process.
Yes-I agree to emergency medical care
No-I do not agree to emergency medical care
ILLNESS NOTIFICATION In the event it comes to the attention of the parish/cluster, its officers, directors and agents and the Archdiocese of Dubuque, chaperons, or representatives associated with any off-site activity or while at parish/cluster that my child becomes ill with symptoms such as vomiting, sore throat, fever, diarrhea, I wish to be notified.
Yes-Please notify me about illness
No- It is not necessary to contact me unless there is a serious concern
NONPRESCRIPTION MEDICATION PERMISSION I hereby grant permission for nonprescription medication (such as ibuprofen, Tylenol, throat lozenges, etc.) to be given to my child in the event a condition arises after my child is already in attendance at a parish/cluster program/activity.
Yes-you may give child may have non-prescription medication
No-you may not give my child non-prescription medication
ALLERGY INFORMATION Do you have children that have allergic reactions? (medications, foods, plants, insects etc.)
Yes No If yes, please identify child and provide the parish/cluster with a written listing of known allergies, reactions and directives.
ASTHMA INFORMATION Do you have any children that utilize asthma or airway constricting prescription medication?
Yes No If yes, please identify child and provide the parish/cluster with written information on the child’s asthma condition.
PRESCRIBED DIET INFORMATION Do you have any children that have a medically prescribed diet?
Yes No If yes, please identify child and provide the parish/cluster with additional written information on the diet.
PHYSICAL LIMITATIONS INFORMATION Do any children have any physical limitations that require accommodations by the parish/cluster?
Yes No If yes, please identify and provide the parish/cluster with additional written information on the limitations.
OTHER MEDICAL INFORMATION Do any children have any other medical conditions about which the parish/cluster should be aware?
Yes No If yes, please identify child and provide the parish/cluster with additional written information on the medical conditions.
Learning Difficulty Information Do any children have any type of learning difficulty?
Yes, my child has a learning disability No, my child does not have a learning disability If yes, please identify child and provide more information
Special Education Information Do any children attend special education classes during public school?
Yes, my child is in special education No, my child is not in special education If yes, please identify and provide more information on what special education services they receive.
Administration of Medicine-- Archdiocesan Board of Education Policy 5141, items 9-10. Administration of Medication
9. Dispensing of prescription medication
1. For Catholic schools - Dispensing of prescription medication will be administered by a nurse or designated party with training and with the written consent of parent(s)/guardian(s). Prescription medication must be provided to the school in the original labeled container containing the physician’s name, name of the medication, and dosage/frequency to be given. A record of each dose of medication administered will be documented in the pupil’s health record.
2. For all other youth programs - Dispensing of prescription medication will be self-administered by the child if a written consent of parent(s)/guardian(s) accompanies the prescription medication and the following terms are followed. The prescription medication is provided in the original labeled container containing the physician’s name, name of the medication, and dosage/frequency to be given; the prescription medication is turned into the event supervisor who will hold all medication until the child/youth requests the medication for self-administration, the prescription medication is self-administered in the presence of the adult supervisor and for only the dosage stated on the prescription label.
3. Students utilizing asthma or airway constricting prescription medication are allowed to administer their own dosage provided a completed consent form is on file in the school/program office. Such forms must be filed annually.
4. Contraceptives will not be dispensed. Iowa Code §280.16
10. Dispensing of nonprescription medication may occur, provided the parent/guardian have signed and dated an authorization identifying medication, dosage, and time interval to be administered. Nonprescription medications can be provided on off-site field trips if the parent/guardian signs a nonprescription medication authorization for each off-site field trip.
To better help our students please state any other pertinent information that a catechists should know. (Example-if your child is on medication during the day, but is not on it during the evening class time.)
Helpful information you should know about my child
MEDIA RELEASE AND AUTHORIZATION I understand that by responding yes I hereby grant authority to my child’s parish/cluster for the use of any videotapes, photographs, or similar items to used by the media or on a parish/cluster web page. I also grant authority to my child’s parish/cluster to use any videotapes, photographs, or similar items in which my child might appear, or statements made by my child, in the production display or sale of public service announcements.
Yes, I agree to the media release No, I do not agree to the media release PARTICIPANT INFORMATION RELEASE I understand that by responding yes I hereby grant authority to my child’s parish/cluster for the publication of participant information in the parish/cluster directory and other parish/cluster publications.
Yes, I grant information release for my child for parish use No, I do not grant information release for my child Parent Obligations Parents are the first and primary teachers of their children. Children learn best by example. Mass is the most important part of our faith formation and attending weekly Mass is required for all Catholics. I understand my spiritual and financial obligations to the parish. I understand my responsibility to insure my student(s) adheres to the discipline that guarantees a respectful learning environment.
Yes, I understand the spirtual and financial obligations to the program No, I do not understand the spirtual and financial obligations to the program Electronic Signature I/We authorize St. Anthony's to verify our parish affiliation and if applicable adjust tuition accordingly. I am the parent or guardian of the participant(s) named herein and have legal authority to execute the above permissions.
Yes, I am the parent/guardian First and Last Name of Parent
This is a binding electronic signature