Youth Religious Education&lt;div&gt;Online Registration Form &lt;/div&gt;

Please provide complete information for each child at the bottom of this page.
Este formulario estará disponible en español en el futuro.

Father's Name REQUIRED Please fill out this field. Please enter valid data.

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

Mother's Maiden Name Please enter valid data.

Address: Street/PO Box, City and Zip Code

Mother's Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Father's Phone Number REQUIRED Please fill out this field. Please enter a phone number.

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

Liability Waiver: I, as parents/guardians of the minor(s) registered, hereby consent, and agree to hold harmless, Pastorate of St. Mary and St. Joseph Roman Catholic Churches and/or the Roman Catholic Diocese of Lafayette-in-Indiana, Inc., and any and all employees or volunteers thereof, for any accident, injury or occurrence arising out of, or in connection with our child's/children's regular for mation activity at the parish. I give my permission for my son/daughter, in case of an emergency, to be taken to a physician or hospi tal by either a parent in charge or by parish personnel. I understand that every effort will be made to contact me. If I cannot be reached, I hereby give permission to the physician selected by the parish member in charge or adult chaperon(s) to secure proper treatment for my son/daughter

Liability Waiver Confirmation I AGREE with the above Statement/ACEPTO la declaración de Exoneracion de Responsabilidad. I DO NOT AGREE with the above statement/NO ESTOY DE ACUERDO con la declaración de Exoneracion de Responsabilidad.

Media Waiver: At various times during the year, school, pastorate representatives, the Diocese of Lafayette-in-Indiana, part ners/vendors of the diocese and a variety of media outlets request permission to film, video tape and photograph activities and events at pastorate events. They subsequently publish, broadcast or use these materials, which often include images and de pictions of students/minors, as well as their work products. I CONSENT and allow my child to be filmed, videotaped and/or pho tographed for use by my school/pastorate/Diocese of Lafayette-in-Indiana and its partners and the media. I also allow my child's work product to be featured by the diocese.

Media Waiver Confirmation I AGREE with the above Statement/ACEPTO la declaración de Exoneracion de Responsabilidad. I DO NOT AGREE with the above statement/NO ESTOY DE ACUERDO con la declaración de Exoneracion de Responsabilidad.

Communication Waiver: I understand that Flocknotes are used to communicate with family and/or high school students and agree to be added to the appropriate list(s) for my child(ren). Furthermore, I understand that in high school youth ministry, the use of social networking websites and tools, especially Flocknotes, Facebook, and lnstagram may be used to effectively com municate with teens. I understand that I will be contacted when my teen(s) has registered for direct reception of communication. Ultimately, I am responsible for my children's communications, but I understand that these tools are used for the means of effective communication.

Communication Waiver Confirmation I AGREE with the above Statement/ACEPTO la declaración de Exoneracion de Responsabilidad. I DO NOT AGREE with the above statement/NO ESTOY DE ACUERDO con la declaración de Exoneracion de Responsabilidad.

As a responsible parent, I promise before God that I will participate in Mass every Sunday & Holy Day of Obligation. promise that my child (children) will attend with me. I understand that this is one of the requirements for my child (children) to participate in the religious education program at St. Mary Roman Catholic Church.

Parent of Guardian filling this form. By entering your name you verify all is true and correct. REQUIRED Please fill out this field. Please enter valid data.

Today's Date REQUIRED Please fill out this field. Please enter a date.

FIRST CHILD'S INFORMATION (Child A)

Child A: Full Name REQUIRED Please fill out this field. Please enter valid data.

Child A: Grade in Public School REQUIRED Please fill out this field. Please enter valid data.

Child A: Child's Date of Birth REQUIRED Please fill out this field. Please enter a date.

Child A: Place of Birth: City, State, Country REQUIRED Please fill out this field. Please enter valid data.

Child's Date of Baptism Child A REQUIRED Please fill out this field. Please enter a date.

Place of Baptism: Parish, City, State, Country Child A REQUIRED Please fill out this field. Please enter valid data.

Received First Communion: Child A Yes No

Child A: Location of First Communion: Parish, City, State, Country REQUIRED Please fill out this field. Please enter valid data.

Child A: Received Confirmation REQUIRED Yes No Please fill out this field.

Child A: Location of Confirmation: Parish, City, State, Country REQUIRED Please fill out this field. Please enter valid data.

SECOND CHILD'S INFORMATION (Child B)

Child B Full Name REQUIRED Please fill out this field. Please enter valid data.

Child B: Grade in Public School Please enter valid data.

Child B: Child's Date of Birth Please enter a date.

Child B: Child's Date of Baptism Please enter a date.

Child B: Place of Birth: City, State, Country Please enter valid data.

Child B: Place of Baptism: Parish, City, State, Country Please enter valid data.

Child B: Received First Communion Yes No

Child B: Location of First Communion: Parish, City, State, Country Please enter valid data.

Child B: Received Confirmation Yes No

Child B: Location of Confirmation: Parish, City, State, Country Please enter valid data.

THIRD CHILD'S INFORMATION (Child C)

Child C Full Name REQUIRED Please fill out this field. Please enter valid data.

Child C: Grade in Public School Please enter valid data.

Child C: Child's Date of Birth Please enter a date.

Child C: Place of Birth: City, State, Country Please enter valid data.

Child C: Child's Date of Baptism Please enter a date.

Child C: Place of Baptism: Parish, City, State, Country Please enter valid data.

Child C: Received First Communion: Yes No

Child C: Location of First Communion: Parish, City, State, Country Please enter valid data.

Child C: Received Confirmation Yes No

Child C: Location of Confirmation: Parish, City, State, Country Please enter valid data.

Additional Children/Grade/Date of Birth/Sacraments Please enter valid data.

St. Mary Catholic Church

A Pastorate of the Diocese of Lafayette-in-indiana

600 St. Mary's Ave, frakfort, In 46041

Youth Religious Education
Online Registration Form

Youth Religious EducationOnline Registration Form

Youth Religious Education
Online Registration Form