New Student Registration form

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Child's Full Name as on Baptismal Certificate REQUIRED Please fill out this field. Please enter valid data.
Home Address REQUIRED
Please include both street address and if applicable, PO Box number
Please fill out this field. Please enter valid data.
City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.
Home Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Email REQUIRED Please fill out this field. Please enter an email address.
Gender REQUIRED Male Female Please fill out this field.
Was Child Baptized? REQUIRED Yes No Please fill out this field.
Provide the full name of the church where your child was baptized. REQUIRED Please fill out this field. Please enter valid data.
In what town or city is this church located? REQUIRED Please fill out this field. Please enter valid data.
In what state is this church located? REQUIRED Please fill out this field.
Please submit a copy of your child's Baptismal Certificate to the Religious Education Office or the Parish Office.
Child's Date of Birth REQUIRED Please fill out this field. Please enter a date.
Child's Grade in School REQUIRED Please fill out this field.
Has your child been registered in a Religious Education program in another parish? REQUIRED Yes No Please fill out this field.
If yes, please provide the name and location of that parish? Please enter valid data.
What level of instruction was your child registered in at this parish? Level 1 Level 2 Level 3 Level 4 Level 5 Level 6 Level 7 Level 8
What level of instruction are you requesting this year for your child? REQUIRED Please fill out this field.
Complete the contact information for the
CHILD'S MOTHER below:
Type mother's first name and maiden name below:
First name REQUIRED Please fill out this field. Please enter valid data.
Mother's maiden name REQUIRED Please fill out this field. Please enter valid data.
Religion REQUIRED Please fill out this field. Please enter valid data.
Email REQUIRED Please fill out this field. Please enter an email address.
Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Work Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Home Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Home Address REQUIRED Please fill out this field. Please enter valid data.
City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.
Complete the contact information for the
CHILD'S FATHER below:
First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Religion REQUIRED Please fill out this field. Please enter valid data.
Email REQUIRED Please fill out this field. Please enter an email address.
Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Work Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Home Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Home Address REQUIRED Please fill out this field. Please enter valid data.
City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.
Please complete the contact information for the child's step-parent / legal guardian (if applicable) below:
First Name Please enter valid data.

Last Name Please enter valid data.
Religion Please enter valid data.
Email Please enter an email address.
Cell Phone Number Maximum 20 characters Please enter a phone number.
Work Phone Number Maximum 20 characters Please enter a phone number.
Home Phone Number Maximum 20 characters Please enter a phone number.
Home Address Please enter valid data.
City Please enter valid data.

State

Zip Please enter a zip code.
Child resides with:
(e,g, Mother & Father, Mother, Father, Other (Please specify)
Please enter valid data.
Is there an order to limit access to the non-custodial parent? REQUIRED Yes No Please fill out this field.
Name & Cell phone number of person who will transport child/youth to and from Program. REQUIRED Please fill out this field.
Does child have special learning needs or learning problems? REQUIRED Please fill out this field.
Is there any additional information we should know about your child?
Emergency Contact Information
Person to contact if Parent/Legal Guardian cannot be reached. REQUIRED
Please give contact information specific to the time of the Religious Education session.)
Please fill out this field. Please enter valid data.
Relationship to child REQUIRED Please fill out this field. Please enter valid data.
Home Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Work Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Email REQUIRED Please fill out this field. Please enter an email address.
Address REQUIRED Please fill out this field. Please enter valid data.
City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.
Doctor's name for emergencies REQUIRED Please fill out this field. Please enter valid data.
Doctor's Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Special Medical Conditions REQUIRED Please fill out this field.
Procedure to be followed if this condition becomes an emergency
I understand that in case of an emergency, "911" will be called and an ambulance may be called by the Director of Religious Education or his/her designate.

In case of accident or illness, I request that the representative of the parish catechetical program contact me If I am unable to be reached, I hereby authorize this representative to call the physician indicated and to follow the physician's instructions. If it is impossible to contact this physician, the representative of the parish catechetical program may make whatever arrangements see necessary. I agree to assume the financial responsibility for any diagnosis, treatment and/or medication deemed necessary.

To the best of my knowledge all information given is accurate and complete. I hereby consent to, and authorize the necessary procedures that have been stated above.

I Agree Please select this field.
Agreement to be used in case of

a child with allergies
Does child have allergies? REQUIRED Yes No Please fill out this field.
Please list allergies REQUIRED
Please list all of the child's known allergies. If the child has no allergies, please enter "NONE."
Please fill out this field.
Course of action to be followed if allergy presents an emergency condition: REQUIRED
Please provide all follow up to an allergic emergency. If the child has no allergies, please enter "none."
Please fill out this field.
Parent and Director of Religious Education
agree on the following course of action:
What medication will be administered? REQUIRED
List all medications to be administered. If the child does not require medication, please enter "NONE."
Please fill out this field.
Who will administer medication? Please enter valid data.
Role of this person. Please enter valid data.
Where will this medication be kept so as to be readily available? Please enter valid data.
What other actions will be taken?
By whom? Please enter valid data.
Whenever emergency medication is
administered, "911" will be called without exception.
I Agree Please select this field.
We are always looking for volunteers to assist with our program. If you would like to help please check the position(s) you would be interested in. REQUIRED Catechist Assistant in classroom Office help Assist with special events No, thanks. I cannot help right now. Please fill out this field.

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St. John the Evangelist (Pawling, NY)
St. Charles Borromeo (Dover Plains, NY)

New Student Registration form

PREP registration is closed for the 2022 - 2023 Religious Education year.

Please submit a copy of your child's Baptismal Certificate to the Religious Education Office or the Parish Office.

Complete the contact information for the
CHILD'S MOTHER below:

Complete the contact information for the
CHILD'S FATHER below:

Please complete the contact information for the child's step-parent / legal guardian (if applicable) below:

New Student Registration form

PREP registration is closed for the 2022 - 2023 Religious Education year.

Please submit a copy of your child's Baptismal Certificate to the Religious Education Office or the Parish Office.

Complete the contact information for the CHILD'S MOTHER below:

Complete the contact information for the CHILD'S FATHER below:

Please complete the contact information for the child's step-parent / legal guardian (if applicable) below:

Complete the contact information for the
CHILD'S MOTHER below:

Complete the contact information for the
CHILD'S FATHER below: