21-22 Religious Education Sign-up

Family Information

Parent Name, (Last, First) REQUIRED Please fill out this field. Please enter valid data.
Parents Relationship to Each Other REQUIRED Married Divorced Living separately Single Please fill out this field.
*[only if different from biological parents]* Parent/Guardian Name(s) that child lives with
Only fill out if the child doesn't live with their biological parents
Please enter valid data.
Home 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.
Email REQUIRED Please fill out this field. Please enter an email address.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.

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Emergency Contact Information

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

Last Name REQUIRED Please fill out this field. Please enter valid data.
Email REQUIRED Please fill out this field. Please enter an email address.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.

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General Release:

General Release

I give permission for my child to take part in the St. Bernard sponsored activities and programs for 2019-2020. In consideration of the opportunity for my child to participate and fully recognizing that such an undertaking involves an element of risk, we assume all risks and hazards incidental in such participation and do hereby release, absolve, indemnify, and agree to hold harmless the Diocese of Lafayette-in-Indiana/St. Bernard Parish its agents, employees and officers, the chaperones, leaders, organizers, sponsors, and persons transporting our child to and/or from these activities. Neither the Diocese of Lafayette-in-Indiana/St. Bernard Parish nor any of said persons shall be held financially responsible for any injury, illness, or death incurred as a direct or indirect result of the activity.

I, the undersigned, have read this release and understand all its terms and execute it voluntarily and with full knowledge of the significance. In the event of an emergency and I cannot be contacted, I hereby authorize emergency treatment to be administered.
We give our permission for our 6th-12th grade child(ren) to be contacted through social media or text-based communication REQUIRED Yes No Please fill out this field.
We give our permission for our child(ren)’s picture to be posted in photos with St. Bernard REQUIRED Yes No Please fill out this field.

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Children's Information

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

Last Name REQUIRED Please fill out this field. Please enter valid data.
Birthday REQUIRED Please fill out this field. Please enter a date.
What grade is your child in? REQUIRED Please fill out this field. Please enter valid data.
What Sacraments has your child already received? REQUIRED Baptism Eucharist Confirmation Please fill out this field.
Any allergies your child may have? Please enter valid data.
Registration Fees for the 2021-2022 year
$35 per child or up to $100 total for a family. Make checks payable to St. Bernard with a note to religious Education . Please contact Rick Bzdok at (765)362-6121, ext. 214 to make payment arrangements or if your family is in need of financial assistance.

Children's Information

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

Last Name REQUIRED Please fill out this field. Please enter valid data.
Birthday REQUIRED Please fill out this field. Please enter a date.
What grade is your child in? REQUIRED Please fill out this field. Please enter valid data.
What Sacraments has your child already received? REQUIRED Baptism Eucharist Confirmation Please fill out this field.
Any allergies your child may have? Please enter valid data.
Registration Fees for the 2021-2022 year
$35 per child or up to $100 total for a family. Make checks payable to St. Bernard with a note to religious Education . Please contact Rick Bzdok at (765)362-6121, ext. 214 to make payment arrangements or if your family is in need of financial assistance.

Children's Information

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

Last Name REQUIRED Please fill out this field. Please enter valid data.
Birthday REQUIRED Please fill out this field. Please enter a date.
What grade is your child in? REQUIRED Please fill out this field. Please enter valid data.
What Sacraments has your child already received? REQUIRED Baptism Eucharist Confirmation Please fill out this field.
Any allergies your child may have? Please enter valid data.
Registration Fees for the 2021-2022 year
$35 per child or up to $100 total for a family. Make checks payable to St. Bernard with a note to religious Education . Please contact Rick Bzdok at (765)362-6121, ext. 214 to make payment arrangements or if your family is in need of financial assistance.

Children's Information

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

Last Name REQUIRED Please fill out this field. Please enter valid data.
Birthday REQUIRED Please fill out this field. Please enter a date.
What grade is your child in? REQUIRED Please fill out this field. Please enter valid data.
What Sacraments has your child already received? REQUIRED Baptism Eucharist Confirmation Please fill out this field.
Any allergies your child may have? Please enter valid data.
Registration Fees for the 2021-2022 year
$35 per child or up to $100 total for a family. Make checks payable to St. Bernard with a note to religious Education . Please contact Rick Bzdok at (765)362-6121, ext. 214 to make payment arrangements or if your family is in need of financial assistance.

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St. Bernard Catholic Church