RE Registration Form 2026-2027

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:
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.
Signature of Parent or Guardian
Date

MonthDayYear
Date
Should be Empty:

Parent Info

Student 1

Student 2

Student 3

Student 4

Emergency Contact

Medical Information