Catechesis of the Good Shepherd Registration Form 2023/2024

Childs Name*

First NameMiddle NameLast NameSuffix

Gender*

MaleFemale

Birth Date*

MonthDayYear

Age*

I am registering my child for the following group:*

Level I Atrium, Ages 3-6+Level II Atrium, Ages 6-9+Level III Atrium, Ages 9-12+Confirmation Program (Ascension Press: Chosen)

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Family E-Mail*

example@example.com

School*

Entering Grade 2023/2024 School Year*

Sacrament Information

Church of Baptism (include city and state)*

If not baptized at the Church of the Transfiguration, Our Mother of Perpetual Help, Our Lady of La Salette or Divine Providence, the original baptismal certificate must be presented to office staff.

My child will prepare for these sacraments this year.

First Holy Communion (normally grade two)First Reconciliation/Confession (normally grade two)Confirmation (normally grade eight)

Parent/Guardian Information

Name (Father)*

First NameMiddle NameLast NameSuffix

Home Number (Father)

Area CodePhone Number

Cell Number (Father)

Area CodePhone Number

E-mail (Father)

example@example.com

Father's Religion

Father's Address if Different

Street Address

Street Address Line 2

CityState

Zip Code

Name (Mother)*

First NameMiddle NameLast NameSuffix

Home Number (Mother)

Area CodePhone Number

Cell Number (Mother)

Area CodePhone Number

E-mail (Mother)

example@example.com

Mother's Religion

Mother's Address if Different

Street Address

Street Address Line 2

CityState

Zip Code

If divorced or separated: Is there a court mandated custody/visitation order limiting access to this child.

YesNo

If YES, the parish must have a copy of that legal order.

Emergency Information

Please list the names of relatives/neighbors/friends in close proximity to the church to whom we may release your child or contact if you cannot be reached.

NO STUDENT WILL BE RELEASED TO ANYONE OTHER THAN THE PARENTS, GUARDIANS, OR ADULTS LISTED ON THIS FORM.

I/We hereby authorize the release of the child named above to the following persons in the event of illness, injury, evacuation, or emergency that may occur while at Religious Education/Youth Group.

Primary Emergency Contact Name*

First NameLast Name

Relationship*

Phone Number (must be available during the Sunday Experience and all religious education hours)*

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

Secondary Emergency Contact Name*

First NameLast Name

Relationship*

Phone Number (must be available during religious education hours)*

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

EMERGENCY AND MEDICAL INFORMATION

Name*

First NameMiddle NameLast NameSuffix

Does your child require medication during the Religious Education program? *

YesNo

All medication must be in the original prescription container with a current date and the child’s name. An “Authorization for Administration of Medication” form must be on file, including a signed physician’s order indicating dose, time and method of dispensing the medication.

Does your child have asthma?*

YesNo

Does your child need an Epi-pen?*

YesNo

Does your child use an inhaler?*

YesNo

Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.*

YesNo

If yes, please describe.

Please list any medical, physical, social or other condition which might require care or accommodation during class time.Examples: diabetes, ADHD, hearing impaired, etc.

Emergency Treatment Authorization:

I/we, the undersigned parent(s) or legal guardian(s) of the above named child, a minor, do hereby give authorization and consent to the Church of the Transfiguration and its associate parishes in South Oakland Family 5 to obtain emergency medical care and necessary transportation, including x-ray examination, anesthetic, medical or surgical diagnosis and emergency hospital which is deemed advisable by and is to be rendered under the general or specific supervision of medical and emergency room staff licensed under the provisions of the applicable laws of the State of Michigan.

It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the student, but that any of the above treatment will not be withheld if the undersigned or authorized adults cannot be reached.

Preferred Hospital*

Physician/Health Care Provider*

Insurance Information: Carrier, Contract Number, Group Number. etc.*

Emergency and Health Care Acknowledgement

BY ACKNOWLEDGING, ENTERING MY NAME AND SUBMITTING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Electronic Signature*

full name and relationship to child

Date*

Date

Electronic Signature

full name and relationship to child

Date

Media Consent Opt Out

The Family Sent on Mission / South Oakland Family 5 Religious Education Program engages in various correspondence and publicity with families, parishioners and other members of the community regarding various aspects of this program.

Parents may opt out of the use of their children’s photos for those purposes, if they so desire.

Please check the box below only if you are opting out.

My child may not be photographed or videotaped.

I OPT OUT.

The Tuition Fee is based on the number of children registering from this family*

One Child, $75Two Children, $100Three Children $150Four or More Children, $200

Safe Environment Training

I give my permission for my child to participate in the Safe Environment Training Program, as mandated by the Archdiocese of Detroit.*

YesNo

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by the Church of the Transfiguration and its associated parishes in South Oakland Family 5. In exchange for the acceptance of said child’s registration by the Church of the Transfiguration and its associated parishes in South Oakland Family 5, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless the Church of the Transfiguration and its associated parishes and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising during the religious education sessions and activities.

In case of injury to said child, I hereby waive all claims against the Church of the Transfiguration, including all leaders and affiliates, all participants, and the Roman Catholic Archdiocese of Detroit.

I give permission for the medical and other information on this form to be shared with the Coordinator, my child’s catechist and other volunteer staff as needed and necessary. I will notify the parish office immediately if there are any changes to the information provided on this form.

Confirmation

BY ACKNOWLEDGING, ENTERING MY NAME AND SUBMITTING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Electronic Signature*

full name and relationship to child

Date*

Date

Electronic Signature

full name and relationship to child

Date