Office Use Only

R

Paid: _______  Balance: _______ Ck # ________  Cash: _________

Date  _______________________

Christ the King Parish

Religious Education Registration Form

Catechesis of the Good Shepherd

2017-2018

for children ages 3 - 6

Tuesday Afternoons -- 3:30 p.m. - 5:00 p.m.

beginning 9/19/17

PLEASE PRINT        

Parent Name(s): ______________________________________________________________________

Address: ______________________________________________________________________

City:_____________ State:____ Zip:_____  Phone #: ____________  

Email: _____________________

Please check here if you wish to have duplicate information sent to another address: ________  

Relation to child: ____________________________ Name: ____________________________________________  

Address: ___________________________________________ City: ______________________ State: _____  Zip: ________

Phone: ___________________   Cellphone: _____________________    Email: ______________________________

Registration fees if received by August 31, 2017  

$60/one student                $100/two students                $135/three or more students

There will be a $5 per student fee assessed for registrations received after August 31, 2017

$65/one student                    $115/two students             $150/three or more students 

Financial Assistance is available upon request

Name                                                                 Age        School                                        

1. _______________________________________      _______          __________________  

2.________________________________________     _______      __________________

3. _______________________________________      _______        __________________

Christ the King Religious Education Program

52473 Indiana State Road 933

South Bend, Indiana   46637

Note: Parents must sign either the Consent to Emergency Medical Care or the Refuse to Consent to Emergency Medical Care.

Consent to Emergency Medical Care

Name of Child_____________________________________________________________________________

In the event that reasonable attempts to contact me at (Phone #)_____________________________________

or (Name of Secondary Contact)_______________________________________________________________

at (Phone #)____________________ have been unsuccessful, I hereby give my consent for:

1. The administration of any treatment deemed necessary by

(Name of Preferred Physician) Dr._______________________________  phone #:_____________________ or

(Name of Preferred Dentist) Dr. _________________________________, phone #: ____________________ or

 in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and

2. The transfer of the child to (Preferred Hospital) _____________________________________ or any hospital reasonably accessible.  This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring the necessity for such surgery are obtained before surgery is performed.  

My health insurance carrier is __________________________  Policy/Group/Claim #_____________________

The following include allergies the child may have, any medication the child may be taking and any other

facts to which a physician or dentist should be alerted to:____________________________________________

_________________________________________________________________________________________

_____________                                ____________________________________________

                    Date                                                Parent / Guardian Signature

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Refuse to Consent to Emergency Medical Care

I do NOT give my consent for emergency medical treatment of my child.  In the event of illness or injury requiring emergency treatment, I wish the parish / diocesan authorities to take no action or to:

_________________________________________________________________________________________

_________________________________________________________________________

I fully understand what is involved in this program and the foregoing form and I understand that I have the opportunity to call the catechetical leader about any questions I may have.  

_____________                                ______________________________________

   Date                                                        Parent / Guardian Signature