Saint Raphael's Parish, Poultney, Vermont

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Faith Formation

- Faith Formation

Religious Education Registration
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- Family Last Name REQUIRED Please fill out this field. Please enter valid data.
- Academic Year REQUIRED Please fill out this field. Please enter valid data.
- Mother's or Guardian's Information
  
  Full Name REQUIRED Please fill out this field. Please enter valid data.
  
  Home or Cell Phone REQUIRED Please fill out this field. Please enter valid data.
  
  Work Phone Please enter valid data.
  
  Mailing Address REQUIRED Please fill out this field.
  
  Email Address (Personal) REQUIRED Please fill out this field. Please enter valid data.
  
  Email Address (Work) Please enter valid data.
- Father's or Guardian's Information
  
  Full Name REQUIRED Please fill out this field. Please enter valid data.
  
  Full Name REQUIRED Please fill out this field. Please enter valid data.
  
  Home or Cell Phone REQUIRED Please fill out this field. Please enter valid data.
  
  Work Phone Please enter valid data.
  
  Mailing Address REQUIRED Please fill out this field.
  
  Email Address (Personal) REQUIRED Please fill out this field. Please enter valid data.
  
  Email Address (Work) Please enter valid data.
- Current Church you are attending or are registered in REQUIRED Our Lady of Seven Dolors St. John the Baptist St. Paul St. Raphael Please fill out this field.
- Student Information - Child 1
  
  Please list all children in your family that you are registering on this form
  
  Student Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field. Please enter valid data.
  
  Birth Date REQUIRED Please fill out this field. Please enter valid data.
  
  Baptism (Parish & Date) REQUIRED Please fill out this field.
  
  NOTE: If your child was baptized outside of our parishes, please provide a copy of the child's baptismal record for our files.
  
  First Communion (Parish & Date) REQUIRED Please fill out this field.
  
  Food Allergies, special needs, or any other concerns you would like to express regarding your child.
- Student Information - Child 2
  
  Please list all children in your family that you are registering on this form
  
  Student Name Please enter valid data.
  
  Grade Please enter valid data.
  
  Birth Date Please enter valid data.
  
  Work Phone Please enter valid data.
  
  Baptism (Parish & Date)
  
  NOTE: If your child was baptized outside of our parishes, please provide a copy of the child's baptismal record for our files.
  
  First Communion (Parish & Date)
  
  Food Allergies, special needs, or any other concerns you would like to express regarding your child.
- Student Information - Child 3
  
  Please list all children in your family that you are registering on this form
  
  Student Name Please enter valid data.
  
  Grade Please enter valid data.
  
  Birth Date Please enter valid data.
  
  Work Phone Please enter valid data.
  
  Baptism (Parish & Date)
  
  NOTE: If your child was baptized outside of our parishes, please provide a copy of the child's baptismal record for our files.
  
  Email Address (Personal) REQUIRED Please fill out this field. Please enter valid data.
  
  First Communion (Parish & Date)
  
  Food Allergies, special needs, or any other concerns you would like to express regarding your child.
- Student Information - Child 4
  
  Please list all children in your family that you are registering on this form
  
  Student Name Please enter valid data.
  
  Grade Please enter valid data.
  
  Birth Date Please enter valid data.
  
  Baptism (Parish & Date)
  
  NOTE: If your child was baptized outside of our parishes, please provide a copy of the child's baptismal record for our files.
  
  First Communion (Parish & Date)
  
  Food Allergies, special needs, or any other concerns you would like to express regarding your child.
- Authorized Pick-Up Person(s) REQUIRED Please fill out this field.
- EMERGENCY CONTACT INFORAMATION
- Name REQUIRED Please fill out this field. Please enter valid data.
- Relationship REQUIRED Please fill out this field. Please enter valid data.
- Phone REQUIRED Please fill out this field. Please enter valid data.
- Phone Please enter valid data.
- Email REQUIRED Please fill out this field. Please enter valid data.
- RELEASE & CONSENT
  
  By submitting this form, I give my child/children/ward permission to participate in all religious education activities. In the event of a medical emergency, I give permission for my child/children/ward to receive medical treatment for injury or illness, in accordance with standard medical practice by licensed medical personnel, when it is not practical to obtain the consent of the undersigned. Permission is also granted to treat minor injury on a first aid basis.
  
  LIABILITY RELEASE
  I hereby release and agree to hold harmless the Roman Catholic Diocese of Burlington and the parish named on the registration form, their officers, directors, employees, staff members, volunteers, and agents from any and all liability, claims and/or damages for personal injury, property loss or damage which may result to my child/children/ward. I further state that my child/children/ward is physically fit and able to participate in religious education activities and classes.
  
  I further state that my child/children/ward may ride in any vehicle used for the purpose of events related to religious education events. I release, hold harmless and agree to indemnify the Roman Catholic Diocese of Burlington, the parish named on the registration form, their officers, directors, employees, staff members, volunteers, and agents for personal injury, property loss or damage, whether foreseen or unforeseen, to my child/children/ward while traveling in authorized vehicles.
  
  ACKNOWLEDGEMENT OF NO INSURANCE COVERAGE- BENEFITS
  I hereby acknowledge that neither the Roman Catholic Diocese of Burlington nor the parish named on this registration form are providing insurance coverage of any kind for any of the participants, inculding, but not limited to, life, health, accident, disability, liabilitiy, or any other kind of insurance whatsoever. I agree to undertake responsibility for any and all losses, damages, liabilities or expenses associated with, or arising from, religiuos education events and classes. I understand that it is my sole responsibility to acquire insurance to provide the appropriate coverage(s) for the risks associated with participation in the events of religious education.
- Release & Consent Acknowledgement REQUIRED I Agree Please fill out this field.
- Parent/Guardian REQUIRED Please fill out this field. Please enter valid data.
- Date REQUIRED Please fill out this field. Please enter valid data.
- RELEASE & CONSENT MEDIA
  
  MEDIA RELEASE
  I hereby authorize the Roman Catholic Diocese of Burlington or the parish named on this registration form to use the name, voice and likeness of my child/children/ward in any manner, form or way relating to communication in any media, and I hereby release these entities from any and all claims associated therewith in connection with religious education activities and classes.
- Release & Consent Acknowledgement REQUIRED I Agree I Disagree Please fill out this field.
- Parent/Guardian REQUIRED Please fill out this field. Please enter valid data.
- Date REQUIRED Please fill out this field. Please enter valid data.
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