Religious Education Registration Form

Religious Education Registration Form

St. Joseph the Worker, Loma Linda | TK-12th
Family Information
Parent 1 Name

First NameLast Name
Parent 1 Email*
example@example.com
Parent 1 Cell Phone*
Please enter a valid phone number.
Parent 2 Name

First NameLast Name
Parent 2 Email
example@example.com
Parent 2 Cell Phone
Please enter a valid phone number.
Family Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your family registered and active at St. Joseph the Worker?

YesNo
Are you interested in volunteering with Religious Education Classes?

Yes, main catechistYes, assistantYes, subNo
Are you interested in hearing more about home school options?

YesNo
Are you interested in a payment plan for tuition fees?

YesNo
Emergency Contact Information

Please include 2 adults other than the parents for emergency contacts.
Emergency Contact 1 Name*

First NameLast Name
Emergency Contact 1 Phone Number*
Please enter a valid phone number.
Emergency Contact 2 Name

First NameLast Name
Emergency Contact 2 Phone Number
Please enter a valid phone number.
Student Information

If you have more than 3 students please contact the Office of Religious Education.
Student 1 Name*

First NameLast Name
Student 1 Birthday*

MonthDayYear
Date
Student 1 Grade in the 24-25 year*
Student 1 has the following Sacraments:*

BaptismFirst ConfessionFirst Holy CommunionConfirmation
Please upload a copy of all previous Sacraments and Birth Certificate for Student 1

No registrations are final until all certificates have been turned in.
Cancelof
Student 1 Allergies and/or Medication*
Please be as clear as possible with allergy action plans and medication administration.
Student 2 Name

First NameLast Name
Student 2 Birthday

MonthDayYear
Date
Student 2 Grade in the 24-25 year
Student 2 has the following Sacraments:

BaptismFirst ConfessionFirst Holy CommunionConfirmation
Please upload a copy of all previous Sacraments and Birth Certificate for Student 2

No registrations are final until all certificates have been turned in.
Cancelof
Student 2 Allergies and/or Medication
Please be as clear as possible with allergy action plans and medication administration.
Student 3 Name

First NameLast Name
Student 3 Birthday

MonthDayYear
Date
Student 3 Grade in the 24-25 year
Student 3 has the following Sacraments:

BaptismFirst ConfessionFirst Holy CommunionConfirmation
Please upload a copy of all previous Sacraments and Birth Certificate for Student 3

No registrations are final until all certificates have been turned in.
Cancelof
Student 3 Allergies and/or Medication
Please be as clear as possible with allergy action plans and medication administration.
Annual Medical Release Information *

Name of Preferred Hospital & Primary Physician

Insurance Carrier

Policy #Group #

Name of Policy Holder
I have fully answered this Medical Release Form to the best of my knowledge. I also understand that in the event medical intervention is necessary, every attempt will be made to contact immediately the persons listed on this form. If I cannot be reached in an emergency during Religious Education, I give my permission to the physician selected by the activity leader to hospitalize in order to secure medical treatment and/or an injection, anesthesia, or surgery for my child(ren) as deemed necessary.

By signing this form electronically, I accept the requirements stated in this Medical Release Form.
Media Release*

I give permission for St. Joseph the Worker Catholic Churchto include photos and videos of my child(ren) from church events in St. Josephthe Worker Catholic Church publications including media presentations,brochures, bulletin boards, our website and bulletin.I DO NOT give permission for St. Joseph the Worker Catholic Church toinclude photos and videos of my child(ren) from church events in St. Joseph theWorker Catholic Church publications including media presentations, brochures,bulletin boards, our website and bulletin.
Tuition Fees

1 Student = $85, 2 Students = $135, 3+ Students = $175

Outside of Parish Fee = $40 | Late Registration Fee (After Sept. 1st) = $25

1st Confession Retreat = $15 per student, 1st Communion Retreat = $15 per student, Confirmation Year 1 & 2 Retreat = $150 per student

Tuition Payment

You may make a cash or check payment in person during Office Hours or online at https://www.osvhub.com/stjosephlomalinda/giving/funds.
Signature*

Clear
Should be Empty:

Religious Education Registration Form

Family Information

Emergency Contact Information

Student Information