Register for Religious Education

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.

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:

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.

Publications/Websites/Social Media Authorization Release

This authorization release form shall serve as parental/legal guardian permission for the use of the first name and last name’s first initial, likeness and/or photographic image of a child/youth where such permission is required. I hereby give permission for my child’s/youth’s name, photographic image (still or video) to appear in Diocesan, Parish, School, or Organization publications and/or websites/social media sites, marketing initiatives. No consideration, monetary or otherwise, shall be paid.

I understand that if, for whatever reason, at any point in time, I decide to revoke this agreement and I so notify the Parish, School or Organization in writing, all references to my child’s/youth’s name, likeness and/or photographic image will no longer be used. I understand that website/social media references and website/social media photographic images will be removed within thirty (30) days of written notification. I understand that the Diocese, Parish, School or Organization is not responsible for access to the information or downloads made by users using websites or social media sites prior to the removal of references (i.e., name, likeness and/or photographic image). I further understand that my child’s/youth’s name, likeness and/or photographic image may continue to be used in any publications already printed or published prior to my revocation of the consent provided herein.

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: [email protected].

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 Religious Education

Religious Education Dates & Times

Publications/Websites/Social Media Authorization Release

FAMILY INTERNET SAFETY PACT