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Immaculate Conception Parish Religious Education Registration

- The maximum number of form submissions has been reached. This form is currently not available.
  
  Family Information (Please add Middle name with First name)
  
  Family Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Dad's Name (First and Middle) REQUIRED Please fill out this field. Please enter valid data.
  
  Mom's Name (First and Middle) REQUIRED Please fill out this field. Please enter valid data.
  
  Maiden Name Please enter valid data.
  
  Guardian's Name (If Different Than Mom or Dad) Please enter valid data.
  
  Home Phone / Cell Phone REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Home Street 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.
  
  Dad's Cell / Work Phone Number Please enter valid data.
  
  Mom's Cell / Work Phone Number Please enter valid data.
  
  Email Address REQUIRED Please fill out this field. Please enter an email address.
  
  Emergency Contact Name REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Student Information - Please Select the Number of Children You Are Registering for Religious Education (Include First and Middle Name) REQUIRED
  Please use First & Middle name
  Please fill out this field.
  
  Child 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child Gender REQUIRED Please fill out this field.
  
  Child's Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  What Grade Will the Child Be Entering in the '23-'24 School Year? REQUIRED Please fill out this field.
  
  Is the Child Catholic? REQUIRED Yes No Please fill out this field.
  
  Which Sacrament(s) Has the Child Received? Please Select All That Apply Baptism Confirmation Reconciliation First Holy Communion
  
  Baptism: Date / Church / City (If Applicable) Please enter valid data.
  
  Reconciliation: Date / Church / City (If Applicable) Please enter valid data.
  
  First Holy Communion: Date / Church / City (If Applicable) Please enter valid data.
  
  Confirmation: Date / Church / City (If Applicable) Please enter valid data.
  
  Special Needs: (Medical, Learning Disabilities, Physical Disabilities, etc. and accommodations needed)
  
  Child 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child Gender REQUIRED Please fill out this field.
  
  Child's Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  What Grade Will the Child Be Entering in the '23-'24 School Year? REQUIRED Please fill out this field.
  
  Is the Child Catholic? REQUIRED Yes No Please fill out this field.
  
  Which Sacrament(s) Has the Child Received? Please Select All That Apply Baptism Confirmation Reconciliation First Holy Communion
  
  Baptism: Date / Church / City (If Applicable) Please enter valid data.
  
  Reconciliation: Date / Church / City (If Applicable) Please enter valid data.
  
  First Holy Communion: Date / Church / City (If Applicable) Please enter valid data.
  
  Confirmation: Date / Church / City (If Applicable) Please enter valid data.
  
  Special Needs: (Medical, Learning Disabilities, Physical Disabilities, etc. and accommodations needed)
  
  Child 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child Gender REQUIRED Please fill out this field.
  
  Child's Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  What Grade Will the Child Be Entering in the '23-'24 School Year? REQUIRED Please fill out this field.
  
  Is the Child Catholic? REQUIRED Yes No Please fill out this field.
  
  Which Sacrament(s) Has the Child Received? Please Select All That Apply Baptism Confirmation Reconciliation First Holy Communion
  
  Baptism: Date / Church / City (If Applicable) Please enter valid data.
  
  Reconciliation: Date / Church / City (If Applicable) Please enter valid data.
  
  First Holy Communion: Date / Church / City (If Applicable) Please enter valid data.
  
  Confirmation: Date / Church / City (If Applicable) Please enter valid data.
  
  Special Needs: (Medical, Learning Disabilities, Physical Disabilities, etc. and accommodations needed)
  
  Child 4
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child Gender REQUIRED Please fill out this field.
  
  Child's Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  What Grade Will the Child Be Entering in the '23-'24 School Year? REQUIRED Please fill out this field.
  
  Is the Child Catholic? REQUIRED Yes No Please fill out this field.
  
  Which Sacrament(s) Has the Child Received? Please Select All That Apply Baptism Confirmation Reconciliation First Holy Communion
  
  Baptism: Date / Church / City (If Applicable) Please enter valid data.
  
  Reconciliation: Date / Church / City (If Applicable) Please enter valid data.
  
  First Holy Communion: Date / Church / City (If Applicable) Please enter valid data.
  
  Confirmation: Date / Church / City (If Applicable) Please enter valid data.
  
  Special Needs: (Medical, Learning Disabilities, Physical Disabilities, etc. and accommodations needed)
  
  Child 5
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child Gender REQUIRED Please fill out this field.
  
  Child's Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  What Grade Will the Child Be Entering in the '23-'24 School Year? REQUIRED Please fill out this field.
  
  Is the Child Catholic? REQUIRED Yes No Please fill out this field.
  
  Which Sacrament(s) Has the Child Received? Please Select All That Apply Baptism Confirmation Reconciliation First Holy Communion
  
  Baptism: Date / Church / City (If Applicable) Please enter valid data.
  
  Reconciliation: Date / Church / City (If Applicable) Please enter valid data.
  
  First Holy Communion: Date / Church / City (If Applicable) Please enter valid data.
  
  Confirmation: Date / Church / City (If Applicable) Please enter valid data.
  
  Special Needs: (Medical, Learning Disabilities, Physical Disabilities, etc. and accommodations needed)
  
  Child 6
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child Gender REQUIRED Please fill out this field.
  
  Child's Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  What Grade Will the Child Be Entering in the '23-'24 School Year? REQUIRED Please fill out this field.
  
  Is the Child Catholic? REQUIRED Yes No Please fill out this field.
  
  Which Sacrament(s) Has the Child Received? Please Select All That Apply Baptism Confirmation Reconciliation First Holy Communion
  
  Baptism: Date / Church / City (If Applicable) Please enter valid data.
  
  Reconciliation: Date / Church / City (If Applicable) Please enter valid data.
  
  First Holy Communion: Date / Church / City (If Applicable) Please enter valid data.
  
  Confirmation: Date / Church / City (If Applicable) Please enter valid data.
  
  Special Needs: (Medical, Learning Disabilities, Physical Disabilities, etc. and accommodations needed)
  
  Child 7
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child Gender REQUIRED Please fill out this field.
  
  Child's Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  What Grade Will the Child Be Entering in the '23-'24 School Year? REQUIRED Please fill out this field.
  
  Is the Child Catholic? REQUIRED Yes No Please fill out this field.
  
  Which Sacrament(s) Has the Child Received? Please Select All That Apply Baptism Confirmation Reconciliation First Holy Communion
  
  Baptism: Date / Church / City (If Applicable) Please enter valid data.
  
  Reconciliation: Date / Church / City (If Applicable) Please enter valid data.
  
  First Holy Communion: Date / Church / City (If Applicable) Please enter valid data.
  
  Confirmation: Date / Church / City (If Applicable) Please enter valid data.
  
  Special Needs: (Medical, Learning Disabilities, Physical Disabilities, etc. and accommodations needed)
  
  Non-Residential Parent / Guardian Information (Include First and Middle name)
  
  First Name Please enter valid data.
  
  Last Name Please enter valid data.
  
  Address: Street Address, City, State, Zip Code Please enter valid data.
  
  Phone Number Maximum 20 characters Please enter a phone number.
  
  Email Address Please enter an email address.
  
  Do You Wish For This Person to Be Contacted with Religious Education Updates? Yes No
  
  Parent / Guardian Volunteering (Please Select At Least One) REQUIRED
  Please note: some opportunities may require short trainings, paperwork, and / or background checks.
  Transport During Field Trips, Service Programs, Youth Activities, Etc. Aid in Classrooms Monitor Students Before And/Or After Religious Education Substitute Teach in Elementary, Middle School, Confirmation, or Youth Group Rooms Chaperone Field Trips, Service Programs, Youth Activities, Etc. Lead A Discussion Group Teach in Elementary, Middle School, or High School Rooms Please fill out this field.
  
  General Field Trip Consent and Liability Waiver
  
  For most activities that require transportation to a location away from the parish site by vehicles, a separate permission form will be issued for each event.
  
  I grant permission for my child(ren) name in this Religious Education registration form to participate in Religious Education / youth ministry events that may take place away from the parish site. I understand that such events / activities may take place under the guidance and supervision of parish staff and / or parish volunteers. As parent and / or legal guardian, I remain legally responsible for any personal actions taken by my child(ren), my spouse and our heirs, successors, and assigns, that for the benefit of Immaculate Conception Parish, its officers, directors, agents and volunteers, and the Diocese of Sioux City, that we release and forever discharge them from any and all claims and causes of actions that we may have against them, arising in connections with the activities and actions of the participant child(ren) while attending said events, or in connection with any illness or injury or cost of medical treatment therewith, in so much as all reasonable efforts have been taken to maintain the safety of my child(ren) while in their care and my child(ren) has (have) complied with all rules and instructions of the program.
  
  Medical Matters
  
  I hereby warrant to the best of my knowledge the child(ren) I am registering for Religious Education is (are) in good health. I assume all responsibility for the health and medical expenses of my child(ren). In the event of an emergency, I hereby grant permission for my child(ren) to be transported to a hospital for emergency medical treatment. I will be notified prior to any treatment by the hospital or doctor.
  
  By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you, Immaculate Conception Church and the Diocese of Sioux City. You further agree that each use of your email address and printed name equates to your E-Signature and constitutes your agreement to be bound by the terms and conditions of these Disclosures and Agreement as they exist on the date of your E-Signature on this form.
  
  Agreement REQUIRED I Agree Please fill out this field.
  
  Parent / Guardian Full Name Signifying Electronic Signature REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Electronic Signature REQUIRED
  Day, Month, Year
  Please fill out this field. Please enter a date.
  
  Emergency Contact (Other Than Parent / Guardian Listed Above)
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Relationship to Your Child(ren) REQUIRED Please fill out this field. Please enter valid data.
  
  Family Doctor Name / Phone Number REQUIRED Please fill out this field. Please enter valid data.
  
  Pick Up Permission For Students Grades Kindergarten, 1st and 2nd Grades
  
  Children in kindergarten, 1st and 2nd grades must be picked up at their classrooms unless parent permission is given for them to walk. Please select one of the options below. If someone other than the listed persons(s) will be picking up your child(ren), or if they are normally picked up and will be walking on a specific day, please call the parish office.
  
  Please List the Name(s) and Phone Number(s) of Anyone Will Be Picking Up Your Child(ren)
  
  Please select if your child(ren) has/have permission to walk after Religious Education My Child(ren) May Walk
  
  Permission to Publish Photos / Videos
  
  When pictures and / or videos are taken at Immaculate Conception Church, or another Faith Formation setting / activity: REQUIRED I DO give permission for Immaculate Conception Church staff / volunteers to publish said photos / pictures of my child in parish / diocesan newsletters, bulletins, parish websites, or other parish communications. I DO NOT give permission for Immaculate Conception Church staff / volunteers to publish said photos / pictures of my child in parish / diocesan newsletters, bulletins, parish websites, or other parish communications. Please fill out this field.
  
  Parent / Guardian Full Name Signifying Electronic Signature REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Electronic Signature REQUIRED Please fill out this field. Please enter a date.
  
  Permission to Contact by Text Message
  
  Please Select Any That Apply Text The Child(ren)'s Mother Text The Child(ren)'s Father Text BOTH The Child(ren)'s Mother and Father
  
  For Students in Grades 9 - 12: I hereby grant permission for the Religious Education Director and / or my child(ren)'s catechist(s) to text message my child(ren) for the purpose of communicating about Religious Education or Youth Ministry activities. I will also be sent the same text message at the same time as my child(ren).
  
  Please Select One I am fine with my child(ren) being contacted by text or email message. I am NOT fine with my child(ren) being contacted by text or email message.
  
  If yes, please list student(s) name(s) and cell phone number(s)/email(s):
  
  Parent / Guardian Full Name Signifying Electronic Signature REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Electronic Signature REQUIRED
  Day, Month, Year
  Please fill out this field. Please enter a date.
  
  PAYMENT:
  
  Your Religious Education fees help to offset the costs of supplies, books, mailings, crafts, administration costs, copies, building maintence and utilities, and retreats. These fees help to provide a quality program for our children and youth. If financial hardship exists, please contact the parish office about sponsorship or payment plan.
  
  Any checks returned due to insufficient funds will retuls in a $35.00 fee in addition to the Faith Formation fees.
  
  2023-2024 Faith Formation Costs:
  
  Regular Registration Fee (July 2023- August 2023)
  Students Kindergarten - 9th Grade: $55.00 / each child
  Students 10th Grade - 12th Grade: $30.00 / each child
  There is a maximum fee of $160.00 per family.
  
  Late Student Registration Fees* (September 2023 or later)
  Kindergarten - 9th Grade: $60.00 / each child
  Students 10th Grade - 12th Grade: $35.00 / each child
  There is a maximum fee of $175.00 per family.
  *Does not apply to new families to the parish
  
  FOR ANYONE WHO WISHES TO PAY BY CHECK OR CASH, PLEASE MAKE THE CHECK PAYABLE TO 'IMMACULATE CONCEPTION CHURCH - RELIGIOUS EDUCATION REGISTRATION' AND PLACE IT IN THE COLLECTION BASKET AT MASS, MAIL IT TO THE PARISH OFFICE, OR DROP IT OFF IN THE PARISH OFFICE. PLEASE SELECT ' PAY LATER ' TO SUBMIT THIS REGISTRATION WITHOUT PAYING ONLINE.
  
  Number of Children Grades K-9 ($55.00 / Each Child)
  
  Number of Children Grades 10-12 ($30.00 / Each Child)
  
  Email Confirmation REQUIRED
  A copy of your registration will be emailed to the email address you provide.
  Please fill out this field. Please enter an email address.
  
  Total:
  
  Submit
  
  Pay Now
  
  Pay Later
  
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Immaculate Conception Parish Religious Education Registration