English Online Registration

REGISTRATION FORM

St. Patrick's - St. Mary's
Parish Religious Education Program
Newburgh, NY

2023-2024

The program fee is $110.00
Sacramental Fee is $25.00

Please make checks payable to St. Patrick’s Religious Education Program

Saturday from 9:00am-10:300am, or Wednesday from 5:00pm to 6:15pm

PLEASE FILL IN ALL INFORMATION

Registration will not be accepted unless all information is provided.

Class Choice REQUIRED Tuesday English (5:00pm - 6:15pm) Wednesday English (5:00pm to 6:15pm) Wednesday Grade 1 Spanish (5:00pm to 6:15pm) Saturday English (9:30am to 11:00am) Saturday Spanish (11:30am to 1:00pm) Sunday Confirmation English (1:30pm to 6:00pm) Please fill out this field.

Registration for Grade REQUIRED 1st 2nd 3rd 4th 5th 6th 7th Confirmation Please fill out this field.

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

Date of Birth REQUIRED Please fill out this field. Please enter a date.

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.

Telephone# REQUIRED Please fill out this field. Please enter a phone number.

Mobile REQUIRED Yes No Please fill out this field.

Emergency# REQUIRED Please fill out this field. Please enter a phone number.

Mobile REQUIRED Yes No Please fill out this field.

Religous Education Grade Last Attended REQUIRED 1st 2nd 3rd 4th 5th 6th 7th None Please fill out this field.

Year REQUIRED Please fill out this field. Please enter an integer (number).

Where REQUIRED Saint Patrick's Saint Mary's Saint Mother Teresa of Calcutta Sacred Heart Saint Francis Other specify below Please fill out this field.

Other Church and Address Please enter valid data.

Father's Name (Or Legal Guardian) REQUIRED Please fill out this field. Please enter valid data.

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

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

Mother's Name (Or Legal Guardian) REQUIRED Please fill out this field. Please enter valid data.

Mother's Maiden Name REQUIRED Please fill out this field. Please enter valid data.

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

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

Child Lives With REQUIRED Both Parents Mother Father Other, specify below Please fill out this field.

Lives with Other Please enter valid data.

No child may receive Holy Eucharist or Confirmation
unless he/she has attended two consecutive years in the program
and has completed all required work. All transfer students must have a letter and permanent record card from the previous Religious Education Program.

All first-time registrations must be accompanied by a Baptismal Certificate.

Child Baptized REQUIRED Yes No Please fill out this field.

Name of Church REQUIRED Saint Patrick's Saint Mary's Saint Mother Teresa of Calcutta Sacred Heart Saint Francis Other specify below Please fill out this field.

Other Church and Address Please enter valid data.

Holy Eucharist REQUIRED Yes No Please fill out this field.

Name of Church REQUIRED Saint Patrick's Saint Mary's Saint Mother Teresa of Calcutta Sacred Heart Saint Francis Other specify below Please fill out this field.

Other Church and Address REQUIRED Please fill out this field. Please enter valid data.

Public School Attending in Fall 2022 REQUIRED Please fill out this field. Please enter valid data.

Grade REQUIRED 1st 2nd 3rd 4th 5th 6th 7th 8th Please fill out this field.

If you wish to mail in your registration, please include the registration form,
the payment and a copy of the baptismal record if you are registering for the first time.

Please mail to:

St. Patricks St. Marys Church,
55 Grand St.,
Newburgh, NY 12550
Attn: Religious Education Office

Student Information Record

Special Medical Conditions REQUIRED Please fill out this field.

Procedures to be followed if above conditiuon presents an emergency REQUIRED Please fill out this field.

In Case of Emergency:
Persons to Contact if Parents/ Legal Guardian Cannot Be Reached:

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

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

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

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Mobile REQUIRED Yes No Please fill out this field.

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

Doctor for Emergency REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

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

In case of accident or illness, I request that the representative of the parish catechetical program contact
me. If I am unable to be reached, I hereby authorize this representative to call the physician indicated and to follow the physician’s instructions. If it is impossible to contact the physician, the representative of the parish catechetical program may make whatever arrangements seem necessary. I agree to assume the financial responsibility for any diagnosis, treatment and/or medication deemed necessary.

To the best of my knowledge, all information given is accurate and complete. I hereby consent to and
authorize the necessary procedures that have been stated above.

I Agree Please select this field.

Parent / Guardian Signature REQUIRED Please fill out this field. Please enter valid data.

Date REQUIRED Please fill out this field. Please enter a date.

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

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