PSR REGISTRATION FORM
Fees: $30.00 (1 child) $40.00 (2 children) $50.00 (3 or more children)—Max $50.00/family
There is an additional $25.00 fee for each child receiving sacraments –1
st
Communion & Confirmation
School Year
Father's Name
*
First Name
Last Name
Father's Primary Phone Number
Format: (000) 000-0000.
Father's Email address
example@example.com
Father's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is Father Catholic
Yes
No
If no, what religion is Father
Mother's Name
*
First Name
Last Name
Mother's Primary Phone Number
Format: (000) 000-0000.
Mother's Email Address
example@example.com
Does the Mother reside at the same address as the father
Yes
No
If not, please complete
Mother's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is Mother Catholic
Yes
No
If no, what religion is Mother
Person to contact regarding student(s) religious education
Father
Mother
Either
Other
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Name/Phone/Relationship
Please complete the following for each student enrolled in program
Student #1
Student's First and Last Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade
*
School
Baptized
*
Yes
No
If yes, name of the church
First Confession
Yes
No
First Communion
Yes
No
Confirmation
Yes
No
Student #2
Student's First and Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade
School
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Baptized
Yes
No
If yes, name of the church
First Confession
Yes
No
First Communion
Yes
No
Confirmation
Yes
No
Student #3
Student's First and Last Name
Date of Birth
Grade
School
Baptized
Yes
No
If yes, name of the church
First Confession
Yes
No
First Communion
Yes
No
Confirmation
Yes
No
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Student #4
Student's First and Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade
School
Baptized
Yes
No
If yes, name of the church
First Confession
Yes
No
First Communion
Yes
No
Confirmation
Yes
No
Student #5
Student's First and Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade
School
Baptized
Yes
No
If yes, name of the church
First Confession
Yes
No
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First Communion
Yes
No
Confirmation
Yes
No
Student's First and Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade
School
Baptized
Yes
No
If yes, name of the church
First Confession
Yes
No
First Communion
Yes
No
Confirmation
Yes
No
Do any children have any allergies or special needs
Yes
No
If yes, which child(ren)
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Explain
Is Father Virtus Trained
Yes
No
Is Mother Virtus Trained
Yes
No
Would parent be willing to provide transportation to/from activities if needed
Yes
No
Would parent be willing to help with activities
Yes
No
Would parent be interested in teaching or helping in religion classes
Yes
No
Comments/Questions
Medical Authorization
I/We understand that the Catholic Diocese of Wichita and the Office of Faith Formation assume no responsibility for accidents which may occur in association with diocesan events and activities. I/We agree to use my/our personal insurance to cover any such incidents.
I/We understand that, in the event medical intervention is needed, every attempt will be made to contact the parsons listed above. In the event those individuals cannot be reached, I/We hereby give permission to the physician or any other qualified medical staff selected by the event leader to hospitalize, secure medical treatment, and/or order injection, anesthesia or surgery for participant as deemed necessary.
*
Yes
No
Waiver
I/We understand all reasonable safety precautions will be taken at all times by the Catholic Diocese of Wichita and the Office of Faith Formation and its agents during events and activities. I/We understand the possibility of unforeseen hazards and know the inherent possibility of risk. I/We agree to indemnify
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and hold harmless the Catholic Diocese of Wichita and/or the Office if Faith Formation, its leaders, employees and volunteer staff from any claim arising from or in connection with attending this event.
*
Yes
No
Code of Behavior
I/We agree to abide by and/or instruct participant/(s) to abide by all rules and regulations as outlined by the aforementioned chaperones/representatives. I agree that if I/We/participant(s) fail(s) to abide in any way by the rules, that I/We/participant can be dismissed from the trip/event and sent home immediately at my/out/participant's expense with no right of reimbursement or refund for any amount in connection therewith from the Catholic Diocese of Wichita or its chaperones/representatives.
*
Yes
No
Signature of Parent/Guardian
*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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