Our Lady of Perpetual Help Parish

Religious Education Enrollment Form, 2010 - 2011

Please complete this form and return with tuition payment of $45 for one child and $65 for two or more children.   Please complete one form for EACH child.

Today’s Date _________________________

Last Name:___________________________First Name:_____________________Middle Initial:_______

Grade ______ Family Name (if different) ______________________________Home Phone __________

Mailing Address: _________________________________________________Zip: _________________

Residence :__________________________________________________________________________

City:___________________________________ State: __________________ Zip: _________________

Date of Birth: _____________________ City: ________________________________ State:__________

Date of Baptism: __________________  City: ________________________________ State:__________              

                                                                              Church:____________________________________________

First Communion: ____________ ______ City: ________________________________ State _________

                                                                                 Church:___________________________________________

First Penance :_____________________ City: ________________________________ State _________

                                                                                  Church:__________________________________________

To be eligible for 1^st Communion your child must be enrolled in our program for 2yrs.

Mother’s First Name and Maiden Name: ___________________________________________________

Mother’s Employer: _________________________________________Work Phone: ________________

Father’s Name _______________________________________________________________________

Father’s Employer: _________________________________________ Work Phone ________________

Other Emergency Contact (Name and Phone) _______________________________________________

Has your child been enrolled in the CCD program or a Catechism program before? _________________

What grade was achieved? __________________

Does your child have any special medical needs? ____________________________________________

Office Use Only:

Early Enrollment ____________ Late Enrollment _______________

Tuition Received____________ Date: ____________

Notice Sent: _______________ Date: ____________

Paid in Full ________________ Date: ____________ Balance: _________________________________

 DIOCESE OF FRESNO ANNUAL PARISH CONSENT FOR

EMERGENCY MEDICAL TREATMENT, PARISH ACTIVITIES

PERMISSION, AND RELEASE OF LIABILITY FORM

TO THE PARENT/LEGAL GUARDIAN: You must give permission on this annual form for your child to attend and participate in parish-sponsored events and activities during this calendar year. You will also be required to sign permission forms for your child to participate in specific parish-sponsored activities, and sports conducted off parish grounds.

Name of Child	Year
Name of Parents/Guardian(s)	Parish Name

I, the undersigned parent or guardian, voluntarily wish to give permission for and request that my child be allowed to attend and participate in parish-sponsored events and activities during this calendar year including those conducted off parish grounds. My child is physically fit and capable of participation in parish events and activities, I agree to direct my child to cooperate and conform with directions, instructions, and rules given by parish personnal or agents, chaperones, or diocesan personnal responsible for all parish events and activities. If requested, I will sign a permission and release form for each specific event or activity conducted off parish grounds. I reserve the right not to have my child participate in parish-sponsored events.

1 understand that participation in parish-sponsored events and activities, including those off parish grounds, involve some risk (including any travel to and from these events or activities) and that unforseen events can occur. I am informed and agree that transportation, if involved, may be provided by parents, other private individuals, or commercial operators who are believed to be reliable and insured, but are not under the supervision or control of the parish.

In exchange for permitting my child to participate in the parish's activities, I waive and give up all claims (and the right to file a lawsuit) which I or my child (and our successors, heirs and assigns) may have against the parish and Diocese of Fresno. I release and discharge the parish and Diocese of Fresno from all liability or responsibility from death, illness, personal injury, or property damage arising out of the parish activity and any transportation involved with the parish activity.

1 the event of an emergency and if he parish is unable to contact me, I authorize parish personnal or other adult leadership of a parish-sponsored event or activity, at my expense, to secure and consent to x-ray examination, medical, dental, or surgical diagnosis, treatment, and hospital care advised and supervised by a duly licensed physician, surgeon, or dentist. I expect to be contacted as soon as possible. I agree that if emergency medical or dental services are required for my child, the Diocese of Fresno will not be responsible to pay for any medical or dental expenses.

This permission, waiver, release and consent applies to the parish named, and to The Roman Catholic Bishop of Fresno (a corporate sole), the Diocese of Fresno, Diocese of Fresno Education Corporation, all Diocese of Fresno schools, all parishes, affiliated organizations, and their offices, clergy, agents, and employees.

This waiver and release form is signed in order for my child to participate in the parish's events and activities for my child's own personal enjoyment and benefit and is done so freely with full knowledge of the risk and dangers that are or may be involved.

I authorize any hospital which has provided treatment to the above named minor pursuant to the provisions of Family Code section 6910 to surrender physical custody of such minor to the diocesan or parish representative upon the completion of treatment. This authorization is given pursuant to Health and Safety Code section 1283.

The following information is provided for the benefit of the parish:

Daytime phone numbers of Parent/Guardians	Nighttime phone numbers of Parent/Guardian
Pager/Call Phone Numbers	Child’s date of birth
Emergency Contact other than Parent/Guardian	Phone Number (s)
Allergies: (food, drugs, insects, etc.)
Medications: (name, dosage, reason)
Other information or Special Health/Physical Considerations (attach extra sheet if necessary)
Insurance Carrier	Insurance Group or ID Number
Name of Child’s Doctor	Phone Number
Name of Child’s Dentist	Phone Number
Name of Child’s Orthodontist	Phone Number

I, the undersigned, have read and understand all of its terms. I request that my child be allowed to participate in the parish’s events and activities. I execute this form voluntarily and with full knowledge of its significance. I have discussed the above with my child, and my child’s aware of and understands the importance of following all rules set out for the parish’s events, activities or sports. A copy of this form shall be as valid as the original authorization and may be given to the adult leader of the events, activities or sports.

Signature of Parent/Guardian: __________________________________ Date: _________________

Signature of Parent/Guardian: __________________________________ Date: _________________

Date Release Receive ________________________________ Received By: __________________

Please Note:

Parents /Guardians signature on this form also confirms receipt and acceptance of current C.C.D. policies concerning Family Mass Attendance and Attendance policies at class.

Thank You