Registration

Father's Information

First Name REQUIRED Please fill out this field. Please enter valid data.

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.

Mother's Information

First Name REQUIRED Please fill out this field. Please enter valid data.

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 Maiden Name REQUIRED Please fill out this field. Please enter valid data.

Marital Status REQUIRED Please fill out this field.

Street 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.

Cell Phone REQUIRED Please fill out this field. Please enter a phone number.

Email REQUIRED Please fill out this field. Please enter an email address.

If parent addresses are different; should communications be sent to both parents/guardians? Yes No

If you answered yes, enter address, cell phone and email address of parent/guardian not listed above. Please enter valid data.

If you answered NO, who should receive information: Mother Father Guardian

Family Doctor or Clinic REQUIRED Please fill out this field. Please enter valid data.

Family Health Plan Carrier REQUIRED Please fill out this field. Please enter valid data.

Policy Number REQUIRED Please fill out this field. Please enter valid data.

Child 1

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Gender REQUIRED Female Male Please fill out this field.
Date of Birth REQUIRED Please fill out this field. Please enter valid data.
Current Grade 24/25 REQUIRED Please fill out this field. Please enter valid data.
My child has received the following Sacraments REQUIRED Baptism Reconciliation First Communion Please fill out this field.

Child 2

First Name Please enter valid data.

Last Name Please enter valid data.
Gender Female Male
Date of Birth Please enter valid data.
Current Grade 24/25 Please enter valid data.
My child has received the following Sacraments Baptism Reconciliation First Communion

Child 3

First Name Please enter valid data.

Last Name Please enter valid data.
Gender Female Male
Date of Birth Please enter valid data.
Current Grade 24/25 Please enter valid data.
My child has received the following Sacraments Baptism Reconciliation First Communion

Child 4

First Name Please enter valid data.

Last Name Please enter valid data.
Gender Female Male
Date of Birth Please enter valid data.
Current Grade 24/25 Please enter valid data.
My child has received the following Sacraments Baptism Reconciliation First Communion

MEDIA RELEASE AND AUTHORIZATION

I understand that by responding "Yes" I hereby grant authority to my child/children's parish/cluster for use of any videos, photos, or similar items to be used in social media or an a parish/cluster web page.

Please answer Yes or No to the above Media Release Question REQUIRED Yes No Please fill out this field.

PARENT/GUARDIAN CONSENT FORMS AND 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/children to participate in religious education and youth ministry events on St. Patrick parish property or that require transportation to a location away from the parish site. Activities will take place under the guidance and direction of parish employees and/or volunteers from St. Patrick Church. I understand that I will be given a description of the activity beforehand. I agree on behalf o myself, my child/children named, my spouse and our heirs, succedssors and assigns, that for the benefit of St. Patrick Catholic Church, its officers, directors and agents, and the Diocese of Sioux City, chaperones, and representatives associated with the event, that: We release and foever discharge them from any and all claims and causes of actions that we may have against them, arising in connections with the activities of the participant child while attending an event or in connection with any illness or injury or cost of medical treatment therewisth, in so much as they have made reasonable efforts to maintain the ssafety of my child while in their care and my child has complied with all rules and instructions of the program.

I have read the Consent and Liability Waiver paragraph and grant my permission, answer yes or no REQUIRED Yes No Please fill out this field.

EMERGENCY MEDICAL TREATMENT
I hereby warrant that to the best of my knowledge the child/children I am registering is/are in good health and I assume all responsibility for the health of my child. In the case 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.

I have read the Emergency Medical Treatment paragraph and grant my permission, answer yes or no REQUIRED Yes No Please fill out this field.

ILLNESS NOTIFICATION
In the event it comes to the attention of the parish/cluster, its officers, directors and agents and the Diocese of Sioux City, chaperones, or representatives associated with any off-site activity or while at parish/cluster events, that my child becomes ill with symptoms such as vomiting, sore throat, fever diarrhea, I wish to be notified.

I have read the above paragraph and grant my permission, answer yes or no REQUIRED Yes No Please fill out this field.

NON-PRESCRIPTION MEDICATION
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.

I have read the above paragraph and grant my permission, answer yes or no REQUIRED Yes No Please fill out this field.

ALLERGY INFORMATION
Does this child/children have allergic reactions? (medications, foods, plants, insects etc.)

Answer Yes or No to the allergy paragraph above. REQUIRED Yes No Please fill out this field.

If yes, supply a list of allergies, reactions and directives

OTHER MEDICAL INFORMATION
Does this child/children have any other medical conditions about with the parish/cluster should be aware? (asthma, prescribed diet, physical limitations, learning disabilities, etc.)

Answer Yes or No to the Other Medical Information paragraph above. REQUIRED Yes No Please fill out this field.

If yes, describe any conditions or limitations

ELECTRONIC SIGNATURE
Please enter your First and Last Name: two fill-in boxes (FIrst and Last Name)
"Please check one of the following:"
Yes="I am the parent or guardian of the participant(s) named above and have legal authority to execute the above permissions(s). I consent to signing this document electronically as demonstrated by typing my name and checking "Yes" here."
No="I am unwilling to sign this form electronically. I understand that I must contact the parish office for a hardcopy of the liability waiver before my child/children can participate in the program."

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Answer Yes or No to the Electronic Signature question as described in the above paragraph. REQUIRED Yes No Please fill out this field.

TUITION
Fees for Religious Education are $45 per student.

If you are unable to pay the fee at registration, please contact the office at 712-324-3181 to make payment arrangements.

If you are teaching a Religious Educaiton class for the full year there are no registration fees for your child/children.

There are several options to make your payment below.

Payment REQUIRED Pay on-line. Click the link below for on-line payment Mail payment to 1020 4th Avenue, Sheldon, IA 51201 Drop off payment at the office at 1020 4th Avenue, Sheldon, IA Place payment in the collection in an envelope marked RE registration payment Please fill out this field.

Highway 60 Catholic Cluster

St. Andrew. Sibley. IA, St. Mary, Ashton, IA, St. Patrick, Sheldon, IA

Registration