2020 - 2021 St. Teresa Church Religious Education Registration
Event Timing: September 26, 2019 - May 31, 2021
Grades K-5: Saturdays 4:00pm-5:30PM or Thursdays 6:00pm-7:30pm
Grades 6-8: Tuesday 6:00pm-7:30pm
Address: 141 Henry Street, New York, NY 10002
Contact us at (212) 233-0233 or StTeresaYouthNY@gmail.com
Email address *
First Name of Student *
Last Name of Student *
Date of Birth *
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School Grade in September 2020 *
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
College
Grade
I would like to have class
Clear selection
I prefer class on
Clear selection
Name of School Child Attends *
Last Grade completed in Religious Education *
None
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Grade
Name of Parish Where Completed:
Name of Church where student was Baptized:
Baptism Year:
Name of Church where student received First Communion :
First Communion Year:
Is the student preparing for a communion if so what year of preparation are they in: *
Is the student preparing for a confirmation if so what year of preparation are they in: *
Is the student is interested in joining the following Youth Ministry Programs *
Required
Is your family registered at St. Teresa Church? *
Name of Parent / Guardian (Last Name, First Name) *
Home Address *
City *
State *
Zip Code *
Primary Phone Number *
Secondary Phone Number
Email *
Does student have any allergies or health issues: *
If so, please provide details below:
Does the Student carry an Epi Pen: *
Does the Student have an IEP (Individualized Education Plan) *
If so, please provide details below:
Any Special needs or relevant information that you would like us to know:
Dietary restrictions *
Emergency Contact ( Last Name, First Name) *
Relationship to Student: *
Emergency Contact Phone Number *
Who is allowed to pick up Student: (Please provide full name and contact phone numbers) *
Electronic Signature (Last Name, First Name) *
Date of Registration *
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Assumption of Risk and Waiver of Liability Relating to Coronavirus/COVID-19The novel coronavirus (“COVID-19”) has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.The [St. Teresa] (“St. Teresa” or the “Parish”) has put in place preventative measures to reduce the spread of COVID-19; however, we cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, participation in [Religious Education] could increase your child(ren)’s or your risk of contracting COVID-19.By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by participating in [Religious Education] at St. Teresa and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at St. Teresa may result from the actions, omissions, or negligence of myself and others, including, but not limited to, School employees, volunteers, and program participants and their families.I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s participation in [Religious Education]] at St. Teresa (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless St. Teresa and the Archdiocese of New York, and all of their current, former, and future agents, representatives, religious and employees and related entities (collectively, “the Diocese”) of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Diocese, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after or participation in [Religious Education]]. *
I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document. *
Required
Z. I understand that checking this box I attest that our family will donate $25.00 per semester toward the religious instruction of my child. *
Required
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