2018-19 Religious Education Registration Available! March 8, 2018 Schedule There are three ways to register: online (see below), or in a PDF Fillable form coming soon and a printed out form by clicking here. If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Saint Raymond of Peñafort Religious Education K-12 Registration 8750 Pohick Road Springfield, VA 22153 703-440-0537 or fax 703-440-0538 ReligiousEducation@straymonds.org www.straymonds.org Registration Requirements: Parish registration is a prerequisite for enrollment. Complete entire form including the student background, carpool information, permission/opt-out etc. Payment is due at time of registration and fee structure is as follows: High School Aged Students are free! ◾1 child $100 ◾2 children $115 ◾3 or more children $130 ◾First Communion Administration Fee $10 per child (2nd grade) ◾Confirmation Administration Fee $50 per child (8th grade) Financial assistance is available (please call our Religious Education Office at 703-440-0537) We accept checks and also offer the option to pay online. The option to pay online is available only for your convenience but is not required for completing this registration process. Please note, high school aged children have no cost to register for this program. Good Shepherd Class available to students with special needs (please contact the Religious Education Office at 703-440-0537). First Communion/Penance and Confirmation Programs: Both programs are two-year programs. Students must complete both years. Baptismal Certificate: Due upon initial registration. Please note: Changes to schedules only accepted through October 31st. Class schedule is dependent on volunteers and enrollment. Parent/Guardian Last Name * Mother's Name Father's Name Home Phone Number * Mother's Cell Phone Number Father's Cell Phone Number Address 1 * Address 2 City * State Zip / Post Code * In order for us to make sure this is not a spam version, please answer the following question. What is the sum of 2+3 equal? * Mother's Work Phone Number Father's Work Phone Number Primary Email * Emergency Contact Name * Emergency Contact Phone * Emergency Contact Relationship * Student <1> Full Name (Last, First MI) * Student <1> Sex * MaleFemale Class options include: Schedule Sunday 6:30- 8:00 PM (Grades 1 - 12); Monday 4:45 - 6:15 PM (Grades K - 8); Tuesday 6:00 - 7:30 PM (Grades 1 - 8) Student <1> Class Schedule First Choice * SunMonTueHome School Student <1> Class Schedule Second Choice * SunMonTue Student <1> Class Schedule Third Choice SunMonTue Student <1> Academic Grade in 2020-21 K123456789101112 Check the box if Student <1> has Special Needs If Student <1> requires special needs please provide as much information as possible. Student <1> Year of Birth (last two digits) * 010203040506070809101112131415 Student <1> Month of Birth (in two digit format) * 010203040506070809101112 Student <1> Day of Birth (double digit) * 01020304050607080910111213141516171819202122232425262728293031 Student <1> Sacraments Received (B=Baptism, FC=First Communion, C=Confirmation) BFCC Where did Student <1> receive their Religious Education in 2019-2020 (Name and location of Parish)? * Student <1> resides with whom? * Both ParentsMotherFatherOther (if "other" is selected, please provide name and relationship in next section If Student <1> does not live with parents please list with whom they live and what their relationship to them is. Student <2> Full Name (Last, First MI) Student <2> Sex MaleFemale Class options include: Sunday 6:30 - 8:00 PM (Grades 1 - 12); Monday 4:45 - 6:15 PM (Grades K - 8); Tuesday 6:00 - 7:30 PM (Grades 1 - 8) Student <2> Class Schedule First Choice SunMonTueHome School Student <2> Class Schedule Second Choice SunMonTue Student <2> Class Schedule Third Choice SunMonTue Student <2> Academic Grade in 2020-21? K123456789101112 Check the box if student <2> has Special Needs If Student <2> requires special needs please provide as much information as possible Student <2> Year of Birth (last two digits) 010203040506070809101112131415 Student <2> Month of Birth (in two digit format) 010203040506070809101112 Student <2> Day of Birth (in two digit format) 010203040506070809101112131415171819202122232425262728293031 Student <2> Sacraments Received BFCC Where did Student <2> receive their Religious Education in 2019-20 (name and location of Parish)? Student <2> resides with whom? Both ParentsMother FatherOther (if "other" is selected, please provide name and relationship in next section If Student <2> does not live with parents please list with whom they live and what their relationship to them is. Student <3> Full Name (Last, First MI) Student <3> Sex MaleFemale Class options include: Sunday 6:30 - 8:00 PM (Grades 1 - 12); Monday 4:45 - 6:15 PM (Grades K - 8); Tuesday 6:00 - 7:30 PM (Grades 1 - 8) Student <3> Class Schedule First Choice SunMonTueHome School Student <3> Class Schedule Second Choice SunMonTue Student <3> Class Schedule Third Choice SunMonTue Student <3> Academic Grade in 2020-21? KindergartenFirstSecondThirdFourthFifthSixthSeventhEighthNinthTenthEleventhTwelfth Check the box if Student <3> has Special Needs If Student <3> requires special needs please provide as much information as possible. Student <3> Year of Birth 010203040506070809101112131415 Student <3> Month of Birth (two digit format) 010203040506070809101112 Student <3> Day of Birth 12345678910111213141516171819202122232425262728293031 Student <3> Sacraments Received BFCC Where did Student <3> receive their Religious Education in 2019-20 (Name and location of Parish)? Student <3> resides with whom? Both ParentsMother FatherOther If Student <3> does not live with parents please list with whom they live and what their relationship to them is. Student <4> Full Name (Last, First MI) Student <4> Sex MaleFemale Class options include: Sunday 6:30 - 8:00 PM (Grades 1 - 12); Monday 4:45 - 6:15 PM (Grades K - 8); Tuesday 6:00 - 7:30 PM (Grades 1 - 8) Student <4> Class Schedule First Choice SunMonTuesHome School Student <4> Class Schedule Second Choice SunMonTue Student <4> Class Schedule Third Choice SunMonTue Student <4> Academic Grade in 2020-21? K123456789101112 Check the box if Student <4> has Special Needs If Student <4> requires special needs please provide as much information as possible. Student <4> Year of Birth (two digit format) 0102030405060708091011121315 Student <4> Month of Birth (two digits) 010203040506070809101112 Student <4> Day of Birth 12345678910111213141516171819202122232425262728293031 Student <4> Sacraments Received BFCC Where did Student <4> receive their Religious Education in 2019-20 (Name and location of Parish)? Student <4> resides with whom? Both ParentsMotherFatherOther If Student <4> does not live with parents please list with whom they live and what their relationship to them is. Special Student Accommodations (this information will be kept confidential): Please note any allergies or other pertinent information, including special educational accommodations (IEP, 504, etc.), which will help us to provide a positive learning environment for your child. By leaving this blank, you are stating that your child has no need for special accommodations. DECLARATION I hereby authorize the Diocese of Arlington and St. Raymond of Penafort Catholic Church to use my child’s picture or video for educational and/or marketing purposes. * YesNo I acknowledge that I am aware of my role and responsibility of primary catechist of my children. I agree to comply with the policies and requirements of the St. Raymond Religious Education program. Please sign below by typing your full name. Include the relationship you are with the student(s) and date. * FORMATION IN CHRISTIAN CHASTITY PROGRAM The Office of Child Protection and Safety for the Diocese of Arlington provides programs to ensure a safe environment for children within the community of the Church. Depending on the age of the child, and with parental permission and involvement, the Diocese of Arlington offers several training programs designed for youth to permit them to be a last line of defense and to ensure every child has the tools necessary to combat abuse. For children in grades 1-8 Religious Education, St. Raymond Catholic Church uses the Diocesan training program Formation in Christian Chastity. For high school aged children in Religious Education or youth ministry the training program used is Called to Protect. Please INITIAL below whether or not you wish your child(ren) to participate in the program. If you choose not to have your child(ren) participate, you will receive an official Arlington Diocese Opt-Out Form (for each child) to be completed and returned to the Religious Education Office. Yes, my child(ren) may participate in the “Formation in Christian Chastity/Called to Protect” lesson. No, my child(ren) may NOT participate in the “Formation in Christian Chastity/Called to Protect” lesson INFORMATION ON THIS PROGRAM IS AVAILABLE ON THE DIOCESAN WEBSITE: http://www.arlingtondiocese.org/Child-Protection/Youth-Training-Programs/ Carpool Authorization- Name and Phone Number I am able to teach or assist for this school year. * YesNo If you responded to the above question as "Yes", what grade preference do you have? 121110987654321K The FCPS Family Life Education Program (FLE) contains elements which compromise Church teachings. Have you opted your child(ren) out of this program? YesNo Below is the "Submit" button. It only needs to be pushed one time. All required fields must be filled out in order to register. If you receive an error message that states you are missing information, please go back and finish completing your registration then push submit. If you receive a message that starts “Notice: bbp_setup_current_user was called incorrectly" this indicates that we did receive your registration. You should receive an email from us confirming your registration was received.