|||
Pilgrim Cluster
Catholic Parishes - Alton/Granville/Hospers, IA
Scroll down for Calendar Events, Catholic News, Daily Mass Readings and more...
Mass Times
Bulletin
Schools
Contact Us
Giving
Calendar
Search
Home
Parishes
About Us
St. Mary - Alton
St. Joseph - Granville
St. Anthony - Hospers
Bulletin
Calendar
Contact Us
Giving
Ministries
Schools
Sacraments
Mass Times
Faith Formation
Faith-Related Links
Religious Education Program
Religious Education Program
Faith Formation
Faith-Related Links
Religious Education Program
Diocese of Sioux City Field Trip Annual Parental Guardian Consent Form and Liability Waiver
Documents
2018-2019 Pilgrim Cluster REP Staff
Little Flowers and Hospitality Girls Clubs Information
REVISED REP 2018-2019 Calendar
Pilgrim Cluster Religious Education Program Registration Form for 2018-2019
The maximum number of form submissions has been reached. This form is currently not available.
Parish Affiliation:
REQUIRED
Please fill out this field.
Please enter valid data.
Student's First Name:
REQUIRED
Please fill out this field.
Please enter valid data.
Student's Middle Name or Initial:
REQUIRED
Please fill out this field.
Please enter valid data.
Student's Last Name:
REQUIRED
Please fill out this field.
Please enter valid data.
Student's Date of Birth:
REQUIRED
Please fill out this field.
Please enter valid data.
Home Phone Number:
REQUIRED
Please fill out this field.
Please enter a phone number.
Cell Phone Number(s)
REQUIRED
Please fill out this field.
Please enter a phone number.
Work Phone Number(s):
REQUIRED
Please fill out this field.
Please enter a phone number.
City
REQUIRED
Please fill out this field.
Please enter valid data.
State
REQUIRED
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Please fill out this field.
Zip
REQUIRED
Please fill out this field.
Please enter a zip code.
Baptism Date, Church, City/State
REQUIRED
Please fill out this field.
Please enter valid data.
Reconciliation Date, Church, City/State:
REQUIRED
Please fill out this field.
Please enter valid data.
Eucharist Date, Church, City/State:
REQUIRED
Please fill out this field.
Please enter valid data.
Confirmation Date, Church, City/State:
REQUIRED
Please fill out this field.
Please enter valid data.
Father (First & Last Name):
REQUIRED
Please fill out this field.
Please enter valid data.
Father's Religion:
REQUIRED
Please fill out this field.
Please enter valid data.
Father's Workplace, Workplace Address, and Phone:
REQUIRED
Please fill out this field.
Please enter valid data.
Mother (First, Maiden, Last Name):
REQUIRED
Please fill out this field.
Please enter valid data.
Mother's Religion:
REQUIRED
Please fill out this field.
Please enter valid data.
Mother's Workplace, Workplace Address, and Phone:
REQUIRED
Please fill out this field.
Please enter valid data.
Guardian/Stepparent Name (If applicable) Address/Phone:
Please enter valid data.
Parent not living w/child (If applicable), Address & Phone:
REQUIRED
Please fill out this field.
Please enter valid data.
Character of Home: 1st or 2nd Marriage, Single, DIvorced, Widow, Stepparent:
REQUIRED
Please fill out this field.
Please enter valid data.
Emergency Contact Name, Family Affiliation (Such as Grandparent/Friend), Address, Phone(s):
REQUIRED
Please fill out this field.
Please enter valid data.
Religious Education Program or Catholic School Previously attended:
REQUIRED
Please fill out this field.
Please enter valid data.
Any concerns that we should be aware of (physical, medical, or learning needs):
REQUIRED
Please fill out this field.
Please enter valid data.
Email Address and who the email is for:
REQUIRED
Please fill out this field.
Please enter valid data.
Grade Entering 2018-2019 REP Year:
REQUIRED
Please fill out this field.
Please enter valid data.
Pilgrim Cluster REP Photo Release Form: I agree to allow my student's photo(s) that are taken during REP activities to be used in REP Newsletters, REP Powerpoints, and Catholic Publications, such as the Globe.
Photo Release
Pilgrim Cluster REP Photo Release - I Agree
Photo Release
Pilgrim Cluster REP Photo Releast - I Disagree
REP MEDICAL INFORMATION
In te event of an emergency, if you are unable to reach me at the above number(s), contact the following person(s).
REQUIRED
Please fill out this field.
Please enter valid data.
Emergency Contact Relationship and Phone Number:
REQUIRED
Please fill out this field.
Please enter valid data.
Family Doctor and Family Doctor's Phone Number:
REQUIRED
Please fill out this field.
Please enter valid data.
Family Health Plan Carrier and Policy Number:
REQUIRED
Please fill out this field.
Please enter valid data.
OTHER MEDICAL TREATMENT; I want to be called collect (with phone charges reversed to me) in the event it comes to the attention of the parish, its officers, directors, and agents, and the Pilgrim Cluster Chaperones, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea.
OTHER MEDICAL TREATMENT
OTHER MEDICAL TREATMENT - I AGREE
Other Medical Treatment
Other Medical Treatment - I Disagree
MEDICATIONS: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosages and frequency of dosage are as follows:
Medications
Medications - I Agree
Medications
Medications - I Disagree
MEDICATION DOSAGE(S) IF APPLICABLE:
Please enter valid data.
No medication of any type, whether prescription or non-prescription may be administred to my child unless the situation is life threatening and emergency treatment is required.
Emergency Treatment of Prescription and Non-Prescription Medications
Emergency Treatment of Prescription and Non-Prescription Medications - I Agree
Emergency Treatment of Prescription or Non-Prescription Medication Permission
Emergency Treatment of Prescription or Non-Prescription Medication - I Disagree
I hereby grant permission for non-prescription medication (such as aspirin, throat lozenges, cough syrup) to be given to my child, if deemed appropriate.
Non-Prescription Medication Permission
Non-Prescription Medication Permission - I Agree
Non-Prescription Medications Permission
Non-Prescription Medications - I Disagree
SPECIFIC MEDICAL INFORMATION: The parish will take reasonable care to see that the following informatoin will be held in confidence:
1. Allergic Reactions (medications, foods, plants, insects, etc.)
REQUIRED
Please fill out this field.
Please enter valid data.
2. Immunizations: Date of last tetanus/diphtheria immunization.
REQUIRED
Please fill out this field.
Please enter valid data.
3. Does child have a medically prescribed diet?
REQUIRED
Please fill out this field.
Please enter valid data.
4. Any physical limitations?
REQUIRED
Please fill out this field.
Please enter valid data.
5. Does child have a medically prescribed diet?
REQUIRED
Please fill out this field.
Please enter valid data.
6. Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, bedwetting, fainting?
REQUIRED
Please fill out this field.
Please enter valid data.
7. Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc? If so, date and disease or condition.
REQUIRED
Please fill out this field.
Please enter valid data.
8. You should be aware of these special medical conditions of my child.
REQUIRED
Please fill out this field.
Please enter valid data.
Tuition for the 2018-2019 REP Year is the same as last year:
**$40 K-8
**$50 9th-10th
Please contact Tamara List prior to paying your tuition. 712-548-8375 or email at: Tamara.List.1958@outlook.com
Diocese of SIoux City
Office of Religious Education
Rev. 2001
Email
REQUIRED
Please fill out this field.
Please enter an email address.
Submit