St Bernard FIRE Family Involved Religious Education Registration 2021-2022

St Bernard FIRE Family Involved Religious Education Registration 2021-2022

All K-5th graders welcome!
Suzie Malloy

Children's Catechesis Coordinator

480.661.9843 x315

smalloy@stboc.org
Student 1 Full Name *
Date of Birth *

Month Day Year
Date
School *
Grade for school year 2021-2022 *
T-Shirt Size (4th & 5th Grade Only)
Does student 1 need to receive any Sacraments? *

Yes No
If Yes, which sacraments?
If you have more than one student in the program, please fill out the information below for your second child. If not, please skip down to general family information.
Student 2 Full Name
Date of Birth

Month Day Year
Date
School
Grade for school year 2021-2022
Does student 2 need to receive any Sacraments?

Yes No
If Yes, which sacraments?
Student 3 Full Name
Date of Birth

Month Day Year
Date
School
Grade for school year 2021-2022
Does student 3 need to receive any Sacraments?

Yes No
If Yes, which sacraments?
Family Information
Street Address *
State *
Zip *
Parent/Guardian 1 Full Name *
Relationship to student(s) *
Parent/ Guardian 2 Full Name
Relationship to student
Who is the best contact for everyday information about events? *

Parent/Guardian 1 Parent/Guardian 2
Primary Parent/Guardian Phone (Please provide a cell phone for group texting purposes) *

Area Code Phone Number
Primary Parent/Guardian Email *
example@example.com
Secondary Parent/Guardian phone

Area Code Phone Number
MEDICAL AND EMERGENCY INFORMATION

This information will only be used in case of an emergency situation, and will not be shared.
Insurance Carrier *
Insurance ID# *
Does your student take any medication we need to be aware of? *

Yes No
If so, please list the medications below:
Describe any allergy, chronic illnesses or other conditions your teen(s) have that we need to be aware of. (Ex. Gluten intolerant, peanut allergy, etc.)
If your student(s) has any special needs due to a learning disability, physical disability, reading difficulty, hearing impairment, or any other medical or emotional need that you would like us to be aware of, please them describe below:
EMERGENCY CONTACT

Only contacted if parents/Guardian above cannot be reached
Name *
Relationship to student *
Phone *

Area Code Phone Number
Parent Involvement
OPTIONAL PARENT OPPORTUNITIES FOR SERVING (Check all that interest you)

I am interested in being an aide or leading a classroom. I would like to help with food planning and set ups for sessions I would like to help in the office or behind the scenes from home
Fees

$75 per child for the year of 2021-2022
I would like to make my FIRE fee payment to the St. Bernard FIRE Program by: *

By Credit/Debit Card (See below) In person with a check In person with cash
To pay with a credit card, please click here.
Parent Agreement
Parent/Teen Agreements

Almost done!
I/We, the parent(s)/guardian(s) of the above student(s), do hereby give my/our permission and approval for my/our son/daughter/guardianship to participate on St. Bernard of Clairvaux Roman Catholic Church’s FIRE Program during the present school year. I/ We do hereby, for myself, my heirs, executors, and administrators, waive, release, absolve, indemnify and agree to hold harmless any and all staff, chaperones, other participants, the parish of St. Bernard of Clairvaux, the Catholic Diocese of Phoenix, Edge, and any of the above named parties’ representatives, successors, supervisors, sponsors, and/or organizers, for any injuries in connection with the outing /event(s) named above provided that said injuries are not the result of negligence.

I/We give permission to seek any emergency care should my child be involved in any accident or be injured in any way during such events named above. I/We understand that in any such instance, all attempts will be made to contact the parent/guardian. In the event that I/we cannot be contacted, I/we hereby give permission to the attending physician to hospitalize, secure treatment for, and to order injection, anesthesia, and/or surgery for my child, as named herein. I also agree that I am legally responsible for all/any personal actions taken by my child/guardianship during this event, and agree to be financially responsible for any/all damages, legal fees, and other costs incurred as a result of the actions/behavior of my child/guardianship.

Furthermore, I/we agree that if the above named student's behavior is inappropriate, unsafe and/or detrimental to the group, I will be contacted immediately to secure means of removing my child/guardianship from the event premises. I understand that any financial costs incurred as a result of my child/guardianship being sent home are my responsibility.
Parent Signature *

Clear
Date *

Month Day Year
Date
Media Release
As parent or guardian, I hereby grant my consent to use and release to the Roman Catholic Diocese of Phoenix and St. Bernard of Clairvaux Catholic Church, the use of my name and/or my likeness, or my child’s/children’s name or likeness, whether in still, motion pictures, audio or video tape, photograph and/or other reproduction of me or my child/children including voice and features, with or without names, of any promotional purposes involving the Diocese or Parish or program, or other media or other purpose whatsoever, except for the endorsement of any commercial products, without further compensation or permission. I understand that the Diocese of Phoenix and St. Bernard of Clairvaux Catholic Church exclusively owns all rights to such recordings irrespective of the form in which they are produced or used.
Parent Signature

Clear
Date

Month Day Year
Date
Should be Empty:

St Bernard FIRE Family Involved Religious Education Registration 2021-2022

Family Information

MEDICAL AND EMERGENCY INFORMATION

EMERGENCY CONTACT

Parent Involvement

Fees

To pay with a credit card, please click here.

Parent Agreement

Parent/Teen Agreements

Media Release