Student Registration 2011-2012

Our Lady of Perpetual Help Mission

Religious Education
Online Registration 2011-2012

Student Name *

First

Last

Student's Age? *

Student's Current Grade Level *

What School does your child attend? *

Was the student enrolled with us last semester? *

Yes No Partial Year

Home Address (Mailing Line 2 if Different)) *

Line 1

Line 2

City

State

Zip Code

Country

Parent Email Address *

Home Phone Number *

Cell Phone Number (MOM) *

Can we send you text messages? *

Yes NO Only in an emergency

Cell Phone Number (DAD) *

Can we send you text messages? *

Yes NO Only in an emergency

Emergency Contact Name *

Relationship to student? *

Emergency Phone Number *

Family Information and Safety Data

Is there any custody order or agreement in place that we should be aware of? Please indicate anyone that should not have access to this child if any or other such safety criteria. *

Sacramental Data

Is this child baptized? *

Yes No Schedule/In Process

Date of Baptism: *

Parish of Baptism Name: *

Parish of baptism address if available *

Line 1

Line 2

City

State

Zip Code

Country

Certificate of Baptism will be required for all students registering for Religious Education courses. Please be prepared to present this certificate to the office of religious education on or before the first day of classes. You will have an opportunity to scan and upload that file at the end of this registration for your convenience if you would like, otherwise please take a copy or original to the office of Religious Education.

Are you enrolling this student for First Communion Preparation? *

Yes No Not Sure

If yes, has this student been enrolled in previous religious education courses? *

Yes No

Health and Medical Data & Liability Waiver

Family Physician *

Physician Phone Number *

Medical Insurance Provider *

Insurance Plan Group/Number *

Do you authorize the adult leader to authorize medical treatment for your child in an emergency, as considered necessary by the attending physician? *

Yes No

If No, State any reasons why you do not want medical care given to your child in an emergency: *

List all ALERGIES, and CONDITIONS *

List any physical restriction or restriction for any activity *

I agree to be responsible for all medical expenses relating to injury of my/our child as a result of his/her participation in this event, whether or not caused by the negligence of diocese/parish, youth ministry program employees, agents or volunteers or other participants. *

I Agree I Disagree

Type your first and last name as your electronic signature to the question above. *

I agree on behalf of myself/ourselves, my/our child named herein or our heirs, successors and assigns, to release and waive any and all claims for damages which I or our child may have, so as to release and discharge in advances those parties hereinafter named and further agree to indemnity, hold harmless and defend the Roman Catholic Bishop of Las Cruces, and his successors, the Diocese of Las Cruces, its officers, directors and agents, volunteers, chaperons, and/or representatives and the parish of Our Lady of Perpetual Help Mission in Mesquite, NM from any and all liability arising from or in connection with my/our child attending and participating in the Religious Education Program/Ministry or in connection with any illness or injury or cost of medical treatment in connection. *

I Agree I Disagree

Type your first and last name as your electronic signature to the question above. *

I understand that from time-to-time Our Lady of Perpetual Help Mission, or the Diocese of Las Cruces may wish to publish photographs of children in the Sunday Bulletin or in another church-related publication. I understand that Children’s photographs posted on the Internet may include only the last name’s initial and first name of the children. I acknowledge that the church website content is not private and can be reviewed, copied; downloaded and transmitted by anyone with access to the Internet and that the church has no control over this. I hereby waive, release, and forever discharge any and all claims, demands or causes of action against the church and its faculty, staff, employees, agents, contractors and any other person, organization or entity assisting them in connection with the posting of information on the website for damages or injuries in any way related to, connected to or arising from the publishing or posting of information on the church’s Internet website or the use of that information and expressly assume the risk of any injury or damage resulting from said posting of information on the website. I further understand and agree that this authorization remains in effect until such time as it is withdrawn in writing. I understand that if I change my mind relating to this authorization, that I will submit another authorization form to the church. *

Agree to Publish Photos Do Not Publish Any Photos

Type your first and last name as your electronic signature to the question above. *

Do you wish to provide any other comment, requests, or questions? *

Upload Baptism Certificate Image File *

Max file size: 20MB

That's it!!! Please press submit to send us your chid's registration. Remember that a class fee will apply and needs to be payed at the Religious Education Office no later than December 20th, 2011. If you need to setup a payment plan, please see our office staff. If you have not uploaded your child's certificate of baptism, please take a copy to the Religious Education office to be imaged. THANK YOU! God Bless!

For multiple children, please complete another online form. Family Discounts are offered. Please see our office staff for more information.

Religious EducationOnline Registration 2011-2012

Family Information and Safety Data

Sacramental Data

Health and Medical Data & Liability Waiver

Religious Education
Online Registration 2011-2012