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Pilgrim Cluster Religious Education Program Registration Form for 2018-2019
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- 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 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.
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