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.
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
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
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!
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.)
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?
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?
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?
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?
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?
If yes, please identify child and provide more information
Special Education Information Do any children attend special education classes during public school?
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
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.
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.
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.
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.
First and Last Name of Parent
This is a binding electronic signature
