Faith Formation Registration - for those attending at st. cecelia - Divine Mercy

Family Name REQUIRED Please fill out this field. Please enter valid data.

Parent(s) First Name(s) REQUIRED Please fill out this field. Please enter valid data.

Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Email REQUIRED Please fill out this field. Please enter an email address.

Phone Number REQUIRED Please fill out this field. Please enter valid data.

School Attending REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact Information

Name (Other than parent or guardian) REQUIRED Please fill out this field. Please enter valid data.
Relationship REQUIRED Please fill out this field. Please enter valid data.
Phone Number REQUIRED Please fill out this field. Please enter valid data.
Family Doctor Name Please enter valid data.
Phone number for Family Doctor Please enter valid data.

Consent and Liability Waiver

Please Read Carefully and choose "I agree" when finished : I/We, the parent(s) or guardian(s) agree to the following: I grant permission for my child(ren) to participate in parish youth ministry events that require transportation to a location away from the parish site. Activities will take place under the guidance and direction of parish employees and/or volunteers. This will serve as the permission slip for any such activites that occur during the 2022-2023 school year. As parent/legal guardian, I/we remain legally responsible for any personal actions taken by the above named minor "participants." I agree on behalf of myself, my child(ren), my spouse, and the Diocese of Sioux City, chaperones and respresentatives associated with the event, (referred collectively as "them") that: We release and forever discharge them from any and all claims and causes of action that we may have against them, arising in connections with the activities of the participating child(ren) while attending an event or in connection with any illness or injury of cost of medical treatment therewith, in so much as they have made reasonable efforts to maintain the safety of my child(ren) while in their care and my child(ren) has/have complied with all rules and instructions of the program.
Select "I agree" after reading REQUIRED I agree Please fill out this field.

Medical Matters (initial the statements that apply)

Emergency Medical Treatment: in the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor Please enter valid data.
Other medical treatment: I hereby grant permission for non-prescription medication (such as tylenol, throat lozenges, cough syrup) be given to my child(ren) if deemed appropriate Please enter valid data.
No medication of any type, whether prescription or non-prescription, may be administered to my child(ren) unless the situation is life-threatening and emergency treatment is required. Please enter valid data.
Please list any allergies, special diet, or other special restrictions and write child's name next to it: Please enter valid data.

Please read through and acknowledge by giving an electronic signature below for both sentences:

If your child must take medication during an event endorsed by Divine Mercy Parish, and you are not here, please send it with your child in a baggie with the child's name, and clear and concise instructions on how to administer the medicine. REQUIRED Please fill out this field. Please enter valid data.
I hereby warrant, that to the best of my knowledge, my child(ren) is/are in good health. This medical information is complete and correct, and it will be assumed that if my child becomes ill or injured, I will be called. REQUIRED Please fill out this field. Please enter valid data.

Fees- Family Formation K-6

If you have a child in grades K - 6, the initial fee is $50 for materials. Each additional child in this age group is $10. Please fill in the amount even if you are paying by cash or check later.
Number of K-6 Children

By checking this box, I agree to pay the total amount shown below for the faith formation of my children this coming year.

I Agree Please select this field.

Fees- Faith Formation 7-12th grade

The fee for each child in grades 7-8 is $35. The fee for each child in grade 9 (Which is Confirmation Prep) is $50. Please fill in the amount even if you are paying by cash or check later.
Number of 7-8 and/or 10-12 Grade Children
Number of 9th Grade- Confirmation Prep children
By checking this box, I agree to pay the total amount shown below for the faith formation of my children this coming year. If I choose to pay later, the total amount is due by the first class on September 7, 2022.
I Agree Please select this field.

Divine Mercy Catholic Parish