Immaculate Conception Parish School of Religion (PSR)

Registration Form for 2009-2010

Please complete a form for EACH student.

Name of Student:__________________________________________________________________
Last First Middle Initial

Address:_________________________________________________________________________
Street City State Zip

Home Phone________________Date of Birth_____________Grade in School 2009-2010______

E-Mail (where you would like PSR info sent):__________________________________________
Marital Status of Parents: ______Married ______Separated ______Divorced ______Remarried
Student resides with : ____Mother ____Father ____Other (Name__________________________)
Father:
Full Name:_______________________________________________________________________
Last First Middle Initial

Address:_________________________________________________________________________
Street City State Zip

Home Phone#____________ Cell Phone#________________ Religion of Father_______________

Mother
Full Name:________________________________________________________________________
Last First Middle Initial

Address:__________________________________________________________________________
Street City State Zip

Home Phone#_____________ Cell Phone#________________ Religion of Mother______________

Step-Parent: (if resides with child)
Full Name:________________________________________________________________________
Last First Middle Initial

Home Phone#____________ Cell Phone#_______________Religion of Step-Parent_____________

Please Note: If a child repeats an academic grade, we recommend they do the same in the P.S.R. program,
although each case will be evaluated separately. Please notify the director as soon as possible if this
situation occurs. Thanks!
Registration Fees are: $125 for 1st child; $100 for 2nd child; $275 family max.

office use--
Date Paid:___________Amount Paid:___________Received by:________Check#/Cash__________
 Student Medical Information

Allergies:_________________________________________________________________________

Existing Medical Conditions:_________________________________________________________

Medications Currently being taken:___________________________________________________

Name of Physician:____________________________________ Phone#_____________________

Emergency Contacts:
1._______________________________________________________________________________
Name Relationship Home # Cell#

2._______________________________________________________________________________
Name Relationship Home# Cell#

3._______________________________________________________________________________
Name Relationship Home# Cell#

Person(s) who have permission to pick up my child at the end of the session:

1._______________________________________________________________________________
Name Relationship Home# Cell#

2._______________________________________________________________________________
Name Relationship Home# Cell#

3._______________________________________________________________________________
Name Relationship Home# Cell#

Signature of parent or guardian___________________________________ Date_______________

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