RE Registration Form 2025-2026

Saint Joseph Parish Religious Education Registration
Parent Info
Parent 1 Name*
Address*
City State Zip*
Phone*
Format: (000) 000-0000.
Email*
example@example.com
Parent 2 Name
Address (if different)
City State Zip
Phone
Format: (000) 000-0000.
Email
example@example.com
Student 1
Student Name*
Grade*
Baptism*
Parish, City, State
First Communion*
Parish, City, State
Allergies, Medications, Medical Conditions, Food Restrictions*
Student 2
Student Name
Grade
Baptism
Parish, City, State
First Communion
Parish, City, State
Allergies, Medications, Medical Conditions, Food Restrictions
Student 3
Student Name
Grade
Baptism
Parish, City, State
First Communion
Parish, City, State
Allergies, Medications, Medical Conditions, Food Restrictions
Student 4
Student Name
Grade
Baptism
Parish, City, State
First Communion
Parish, City, State
Emergency Contact
Allergies, Medications, Medical Conditions, Food Restrictions
ADDITIONAL EMERGENCY CONTACT INFORMATION: Name and phone number of an adult to reach in case of emergency in the event that you cannot be reached at the numbers above.
Name*
Medical Information
Phone Number*
Format: (000) 000-0000.
Name of Family Physician
Phone Number
Format: (000) 000-0000.
Insurance Company*
My child may be given if needed:

ASPIRINTYLENOLIBUPROFEN
Policy*
Acknowledgement Statement*

I submit that this health history is accurate and correct as far as I know, and the students listed above have permission to engage in all planned activities, except as noted by me, or an examining physician, In the event of an emergency, I hereby give permission to the physician selected by the youth director to secure proper and adequate treatment including hospitalization, injection, anesthesia or surgery, for myself, if majority age, or the child listed, if a minor. I accept responsibility for all medical/surgical treatment charges, which may be incurred. I hereby release Saint Joseph Parish, DeWitt, Iowa, Diocese of Davenport, Davenport, Iowa, and all adult supervision from any and all claims arising out of or from any accident or other occurrence causing injury to any person or property during this activity.
I hereby authorize Saint Joseph Parish, DeWitt, Iowa, Diocese of Davenport, Davenport, Iowa to utilize photographic images of the above listed students for promotional purposes.
Signature of Parent or Guardian*
We are in need of multiple catechists this year. To help me in planning, please mark one of the responses below.*

I am willing to teach a classI am willing to assist in a classroom as a secondary adultI am unable to this year. Please explain.
Date*

MonthDayYear
Date
Should be Empty:

Parent Info

Student 1

Student 2

Student 3

Student 4

Emergency Contact

Medical Information