Register for Grades K-8 <div> Religious Education </div>

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

Phone Number 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.

Father's Full Name REQUIRED Please fill out this field. Please enter valid data.

Father's Religion Please enter valid data.

Home Phone Please enter valid data.

Cell Phone Please enter valid data.

Email Please enter an email address.

Mother's Full Name (Include Maiden Name) REQUIRED Please fill out this field. Please enter valid data.

Mother's Religion Please enter valid data.

Home Phone Please enter valid data.

Cell Phone Please enter valid data.

Email Please enter an email address.

Marital Status Church Married Civil Marriage Separated Divorced Single

We Are Registered Members of: St. Augustine St. Mary We Would Like to Register at the Parish Checked Above

Number of Children to be Registered for Grades K-12 REQUIRED Please fill out this field.
Child 1
- Student's Full Name REQUIRED Please fill out this field. Please enter valid data.
- Student's Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- Student's Grade REQUIRED Please fill out this field.
- Mark All Sacraments Received by the Above Student REQUIRED Baptism First Communion Confirmation None Please fill out this field.
- If Baptized, Date and Church/Place of Baptism Please enter valid data.
- If this child has any special needs, medical conditions or food allergies, please explain:
Child 2
- Student's Full Name REQUIRED Please fill out this field. Please enter valid data.
- Student's Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- Student's Grade REQUIRED Please fill out this field.
- Mark All Sacraments Received by the Above Student REQUIRED Baptism First Communion Confirmation None Please fill out this field.
- If Baptized, Date and Church/Place of Baptism Please enter valid data.
- If this child has any special needs, medical conditions or food allergies, please explain:
Child 3
- Student's Full Name REQUIRED Please fill out this field. Please enter valid data.
- Student's Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- Student's Grade REQUIRED Please fill out this field.
- Mark All Sacraments Received by the Above Student REQUIRED Baptism First Communion Confirmation None Please fill out this field.
- If Baptized, Date and Church/Place of Baptism Please enter valid data.
- If this child has any special needs, medical conditions or food allergies, please explain:
Child 4
- Student's Full Name REQUIRED Please fill out this field. Please enter valid data.
- Student's Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- Student's Grade REQUIRED Please fill out this field.
- Mark All Sacraments Received by the Above Student REQUIRED Baptism First Communion Confirmation None Please fill out this field.
- If Baptized, Date and Church/Place of Baptism Please enter valid data.
- If this child has any special needs, medical conditions or food allergies, please explain:
Child 5
- Student's Full Name REQUIRED Please fill out this field. Please enter valid data.
- Student's Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- Student's Grade REQUIRED Please fill out this field.
- Mark All Sacraments Received by the Above Student REQUIRED Baptism First Communion Confirmation None Please fill out this field.
- If Baptized, Date and Church/Place of Baptism Please enter valid data.
- If this child has any special needs, medical conditions or food allergies, please explain:
Child 6
- Student's Full Name REQUIRED Please fill out this field. Please enter valid data.
- Student's Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- Student's Grade REQUIRED Please fill out this field.
- Mark All Sacraments Received by the Above Student REQUIRED Baptism First Communion Confirmation None Please fill out this field.
- If Baptized, Date and Church/Place of Baptism Please enter valid data.
- If this child has any special needs, medical conditions or food allergies, please explain:
Child 7
- Student's Full Name REQUIRED Please fill out this field. Please enter valid data.
- Student's Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- Student's Grade REQUIRED Please fill out this field.
- Mark All Sacraments Received by the Above Student REQUIRED Baptism First Communion Confirmation None Please fill out this field.
- If Baptized, Date and Church/Place of Baptism Please enter valid data.
- If this child has any special needs, medical conditions or food allergies, please explain:

Children Live With REQUIRED Both Parents Mother Only Father Only Other Please fill out this field.

If Parents Not Together, Please Explain How Sharing is Arranged:

Additional Pick-Up or Emergency Contacts: In the event that I am unable to pick up my child(ren) from Religious Education classes, the following people have my permission to do so. They also have my permission to be contacted if I cannot be reached if my child is sick or injured.

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

Phone Number REQUIRED Please fill out this field. Please enter valid data.

Name Please enter valid data.

Phone Number Please enter valid data.

Additionally, if I cannot be reached, I authorize the DRE or other Religious Education staff of St. Augustine / St. Mary to Dial 911, to notify the above emergency contacts, and to authorize medical treatment when a physician or EMS deems necessary for the well-being of my child(ren).

Name of Submitting Parent/Guardian REQUIRED Please fill out this field. Please enter valid data.

CONSENT FOR RELEASE OF AUDIO, PHOTOGRAPH, VIDEO FOR MINOR

I, hereby consent to and authorize the use and reproduction by the parishes of St. Augustine’s and St. Mary’s ("Releasee"), its legal representatives, licensees, successors and assigns, those for whom the Releasee is acting, and those acting with its authority and permission (collectively, the "Authorized Parties"), of any and all photographs, digital images, videotapes or recordings made of my minor child, for use by the Releasee, its employees, officers and agents, and the right to copyright and/or use, reuse and/or publish, republish photographic pictures, digital images, videotapes or recordings in conjunction with my name.

I, on behalf of myself and on behalf of my minor child, also give permission for the photographs, digital images, videotapes, or recordings to be used in their entirety and/or edited versions as deemed necessary by the Releasee including the use of images on printed publications or materials, posters, brochures, greeting cards, calendars, electronic publications, or Web sites. I represent and warrant that any photographs, digital images, videotapes, or recordings submitted by me or on my behalf to the Releasee do not in any way infringe on the proprietary rights of any third party, including but not limited to copyright or trademark.

Furthermore, permission is also given for the photographs, digital images, videotapes, or recordings to be used by the Releasee at any time in the future without further clearance from me.

I, on behalf of myself and on behalf of my minor child, hereby release, discharge and agree to save harmless the Releasee and each of the Authorized Parties from any liability, costs or expenses arising by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form whether intentional or otherwise, that may occur or be produced in the taking of the Images or in any subsequent processing thereof, as well as any publication thereof, including without limitation any claims for libel, defamation, invasion of privacy, or breach of publicity or other property rights.

The Releasee will not sell these photographs, digital images, videotapes, or recordings to another company and will only use them for the mission of the church, school, or other entity seeking the permissions and releases granted herein.

The Releasee will not use the minor’s full name or otherwise identify the individual appearing in the photographs, digital images, videotapes, or recordings, unless explicitly permitted by checking the checkbox below.

I hereby affirm that I am over the age of majority and have the right to contract on behalf of myself and my minor child, 1 have read the above authorization, release and agreement, prior to its execution. I fully understand the contents thereof. This agreement shall be binding upon me, my minor child, and heirs, legal representatives and assigns thereof.

If at any point you wish to remove a picture or terminate your release consent form please contact the Releasee. Phone: 518-529-7433 or 518-483-6674 Web: staugustinesandstmarys.org Email: office@stmarysbrushton.org or staugustine6674@gmail.com

Choose one REQUIRED Please fill out this field.

Name of Submitting Parent/Guardian REQUIRED Please fill out this field. Please enter valid data.

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

FAMILY INTERNET SAFETY PACT

1.   I UNDERSTAND there is some danger online and on cell phones. Criminals roam the Internet just as they roam the streets.

2.   I UNDERSTAND that some people online and on cell phones pretend to be someone they are not. They can misrepresent their age, gender, interests, personality, job or anything else.

3.   I UNDERSTAND that some criminals try to befriend kids online and on cell phones, especially young people who are lonely or aren’t getting along with their parents.

4.   I UNDERSTAND that private and family matters should not be discussed online or on cell phones. Instead, I should talk about these matters with a parent or trusted adult.

5.   I UNDERSTAND that parents may spot-check my e-mail, my time online, and my cell phone usage because they love me and want to ensure my safety.

6.   I WILL NOT give out my full name, home address or phone number online or on my cell phone.

7.   I WILL NOT send inappropriate pictures of myself to anyone online or on my cell phone.

8.   I WILL NOT give out my internet or cell phone account passwords.

9.   I WILL NOT give out the name/location of the school I attend or my place of employment to anyone online or on my cell phone.

10. I WILL NOT respond to violent or X-rated e-mails, voice mails, or text messages. I WILL report it to my parents IMMEDIATELY and let them report it to www.cybertipline.com and my Internet Service Provider.

11. I WILL NOT go alone to meet in-person someone I know only from online or cell phone usage. If I really want to meet an online or cell phone acquaintance, I WILL ONLY go with my parent(s) or an adult designated by my parent(s).

Please read and discuss with your youth.

Confirm you have read this pact and discussed with your child(ren) REQUIRED By checking this box, I confirm I have read this policy with my child(ren) and discussed it with him/her/them. Please fill out this field.

St. Augustine's & St. Mary's

North Bangor & Brushton, NY

Register for Grades K-8
Religious Education

CONSENT FOR RELEASE OF AUDIO, PHOTOGRAPH, VIDEO FOR MINOR

FAMILY INTERNET SAFETY PACT

Register for Grades K-8 Religious Education

CONSENT FOR RELEASE OF AUDIO, PHOTOGRAPH, VIDEO FOR MINOR

FAMILY INTERNET SAFETY PACT

Register for Grades K-8
Religious Education