St. Jude Parish School of Religion Registration Form
for the ______________ School Year (Complete both sides of the Form)
Student Information (Complete all information)
Student's Baptismal Name: ________________________________________________________________
Last First Middle
Nickname: ___________________________ Birth Date ____/____/____ Circle one: Male Female
Student's Address: _________________________________________________________________________
Street Address
________________________________________________________________________________________________________________
City State Zip Code
Student lives with (Circle one): Both Parents Mother Father Other Guardian
Parish where family is registered: _____________________________________________________________________
Name of Church
Name of Public School now attending: ________________________________________________ Grade Level: _____ Registering for PSR Grade: _____ Circle all PSR Grades your child has completed: 1 2 3 4 5 6 7 8
Please list any information regarding your child that a teacher should know (e.g. medical alert, special needs, etc.)
__________________________________________________________________________________________________________________________________________________________________________________________
New students to the PSR program
A copy of the Baptismal Certificate is required for all NEW students registering for the PSR program.
Please list the dates and churches where the student celebrated the following sacraments (complete all that apply).
Baptism: _______________________________________________________________________ Date ____/____/____
Name of Church
_________________________________________________________________________________________
City State Zip code
First Communion: ________________________________________________________________ Date____/____/____
Name of Church
Confirmation: ____________________________________________________________________Date____/____/____
Name of Church
Contact Information (Complete all that apply.)
Mother’s contact information _________________________________________________________________________
Mother’s Name Home Phone
_______________________________________________________________________________________________________________________________________
Work Phone Cell Phone E-mail address
Address (if different than student’s): _________________________________________ Stepfather _________________
Father’s contact information __________________________________________________________________________
Father’s Name Home Phone
______________________________________________________________________________________________________________________________________ Work Phone Cell Phone E-mail address
Address (if different than student’s): __________________________________________ Stepmother _______________
Guardian’s contact information (if applicable): ___________________________________________________________
Guardian’s Name Home Phone
______________________________________________________________________________________________________________________________________ Work Phone Cell Phone E-mail address
Parents Pledge
As parents/guardians, we recognize and accept our role as the primary religious educators of our children. We pledge to support the PSR program and its catechists regarding attendance, participation, discipline, and homework assignments. We will do our part to encourage our child’s spiritual growth by regularly attending mass and receiving the sacraments.
Signature: (Required) _______________________________________________________
Fees: $70 for each child before May 31st and $90 for each child after May 31st. Make checks payable to St. Jude Parish. Return all forms and payment to the Parish office by August 15th.
No child will be denied a religious education due to a lack of payment.
If you need tuition assistance, please contact the parish office.
Fee Discounts and waivers are available for parents who volunteer in the PSR program.
____I am interested in volunteering as a Catechist, a Classroom Assistant, or Hall Monitor during PSR class times. Name: ____________________________________ Phone # ______________________________
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The following release form will enable my child to participate in all scheduled PSR and sacramental preparation activities as identified in the PSR Handbook and as amended in the PSR newsletter.
ARCHDIOCESE OF CINCINNATI PERMISSION, RELEASE AND MEDICAL POWER OF ATTORNEY
1. I, the lawful parent or guardian of (name of student) (the "child"), give permission for my child to participate in the activity described above and release from all liability and indemnify the Archbishop of Cincinnati ("the Archbishop"), both individually and as trustee for the Archdiocese of Cincinnati and all parishes within the Archdiocese, and their officers, agents, representatives, volunteers, and employees from any and all liability, claims, judgments, cost or expenses, including attorney fees, arising out of any injury or illness incurred by my child while participating in or traveling to or from the activity.
2. I agree to instruct my child to cooperate with the Archbishop or his agents in charge of the activity.
3a. I appoint the Archbishop or his agents who are acting as leaders of the activity as my attorney in fact to act for me in my name and my behalf, in any way that I would act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity or related travel:
(i) To give any and all consents and authorizations to any physicians, dentist, hospital or other persons or institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other emergency actions as our attorney shall deem necessary or appropriate for the best interest of the child.
(ii) I understand that the agents of the Archbishop will make a reasonable attempt to contact me as soon as possible in the event of a medical emergency involving my child.
3b. This power of attorney shall lapse automatically upon completion of the activity and related travel.
4. I agree that the Archbishop or his agents may use my child's portrait or photograph for promotional purposes, website and office functions.
I have carefully read this statement, and my signature acknowledges that I fully understand the content and meaning.
**Parent Signature: ___________________________________________________ Date____/____/____
**Printed Name: _____________________________________________________
Emergency Medical Preferences (**Required information)
**Doctor's Name: ______________________________________________________ Phone: _______________________
**Dentist's Name: ______________________________________________________ Phone: ________________________
**Medical Specialist: _____________________________________________________ Phone: _______________________
**Local Hospital: _______________________________________________________ Phone: _______________________
Children's Hospital Emergency Room # is 636-4293
**Facts concerning the child's medical history including chronic conditions, allergies, medications being taken and any physical impairments to which a physician should be alerted: _________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________
**Emergency Contact if mother, father, or guardian cannot be reached: ______________________________________________________
Last Name First Name __________________________________________________________________________________________________
Relationship to student Evening phone number
**All required information must be completed on the Registration Form !