RE Registration 2018-2020

Divine Mercy Parish

Registraiton for Kindergarten through 8th Grade

If you have questions about this registration,

please contact our office at dm.shre@divinemercynorthshore.org or 847.446.6535.

*indicates required field

Registration Type

Is your family new or returning to Divine Mercy Children's Ministry? (You are considered a returning family if you were registered at either Sacred Heart or St. Philip the Apostle Religious Education program in 2018-2019) *

New Family

Returning Family

Primary Family Contact Information

Family Last Name *

Primary Home Address *

City *

State *

ZIP *

Primary Family Email Address *

Secondary Email Address (Optional)

Primary Family Phone Number *

Phone Type *

Secondary Family Phone Number *

Phone Type *

Are you registered in Divine Mercy Parish?
All Children's Ministry families must be registered. If you are not, we will contact you with information on how to register. *

Father's Information

Is address information same as the primary family information above? *

Yes

No

Father's First Name

Father's Last Name

Home Address

City

State

ZIP

Religion

Occupation

Mother's Information

Is address information same as the primary family information above? *

Yes

No

Mother's First Name

Mother's Last Name

Home Address

City

State

ZIP

Religion

Occupation

Other Family Details

Children live with: *

Both

Father

Mother

Other Other

If divorced, who has custody rights?

Father

Mother

Joint

Other Other

Child Information

How many children are you registering for Children's Ministry? *

Child One

Child's First Name *

Nickname

Child's Last Name *

Gender *

Date of Birth *

School *

Grade Registering For *

Session Registering For: *

Enrolled in Religious Education at either SH or SPA last year? *

Baptism Date

Church

City and State

Certificate on File at Divine Mercy?

First Reconcilation Date

First Communion Date

IT IS VITAL THAT WE KNOW ABOUT ANY SPECIAL NEEDS OR OTHER CIRCUMSTANCES THAT PERTAIN TO YOUR CHILD. THANK YOU FOR SHARING THIS CONFIDENTIAL INFORMATION.

Special Needs

My child has an IEP on record.

Yes

No

My child is allergic to:

My child has other special needs. Please explain.

What else would you like us to know about your child?

Child Two

Child's First Name

Nickname

Child's Last Name

Gender

Date of Birth

School

Grade Registering For

Enrolled in Religious Education at either SH or SPA last year?

Session Registering For:

Baptism Date

Church

City and State

Certificate on File at Divine Mercy?

First Reconcilation Date

First Communion Date

IT IS VITAL THAT WE KNOW ABOUT ANY SPECIAL NEEDS OR OTHER CIRCUMSTANCES THAT PERTAIN TO YOUR CHILD. THANK YOU FOR SHARING THIS CONFIDENTIAL INFORMATION.

Special Needs

My child has an IEP on record.

Yes

No

My child is allergic to:

My child has other special needs. Please explain.

What else would you like us to know about your child?

Child Three

Child's First Name

Nickname

Child's Last Name

Gender

Date of Birth

School

Grade Registering For

Enrolled in Religious Education at either SH or SPA last year?

Session Registering For:

Baptism Date

Church

City and State

Certificate on File at Divine Mercy?

First Reconcilation Date

First Communion Date

IT IS VITAL THAT WE KNOW ABOUT ANY SPECIAL NEEDS OR OTHER CIRCUMSTANCES THAT PERTAIN TO YOUR CHILD. THANK YOU FOR SHARING THIS CONFIDENTIAL INFORMATION.

Special Needs

My child has an IEP on record.

Yes

No

My child is allergic to:

My child has other special needs. Please explain.

What else would you like us to know about your child?

Child Four

Child's First Name

Nickname

Child's Last Name

Gender

Date of Birth

School

Grade Registering For

Enrolled in Religious Education at either SH or SPA last year?

Session Registering For:

Baptism Date

Church

City and State

Certificate on File at Divine Mercy?

First Reconcilation Date

First Communion Date

IT IS VITAL THAT WE KNOW ABOUT ANY SPECIAL NEEDS OR OTHER CIRCUMSTANCES THAT PERTAIN TO YOUR CHILD. THANK YOU FOR SHARING THIS CONFIDENTIAL INFORMATION.

Special Needs

My child has an IEP on record.

Yes

No

My child is allergic to:

My child has other special needs. Please explain.

What else would you like us to know about your child?

Tuition and Fees

Tuition and fees are expected to be paid in full at the time of registration.

If you chose to pay by check, please bring or send it to our office (1077 Tower Road, Winnetka, 60093) within 1 week of registration.

Payment plans and scholarships are available.

Please contact Sue Lehocky, our Director of Evangelization and Lifelong Formation,

for information on payment plans and scholarships.

Please select your payment option: *

Payment in full via credit card today. (Please select 'Pay by Credit Card' on the Checkout page that follows).

Payment in full by check within 1 week of registration. (Please select 'Pay by Check' on the following checkout page to view instructions on where to send your check).

Partial payment within 1 week of registration. Please contact me about a payment plan. (Please select 'Pay by Check' on the following checkout page. Your registration will process without a payment, then we will contact you to arrange payment details.)

Please contact me about a scholarship. (Please select 'Pay by Check' on the following checkout page. Your registration will process without a payment, then we will contact you to discuss your scholarship request.)

2018-2019 Tuition and Fees * Check all that apply. *

One Child ($585)

Two Children ($885)

Three Children ($1130)

Four Children ($1380)

Sacramental Offering
* Please enter the quantity (number of students)

	First Communion/Reconciliation - Grade 2 ($100 per student)
	Confirmation - Grade 8 ($150 per student)

Volunteer catechists may elect to receive a $300 discount off the total tuition. Please enter the coupon code below. (Call the Children's Ministry office for the coupon code if you haven't received one.)

Please consider making a donation to the Children's Ministry Scholarship Fund to help cover tuition for families needing assistance. Please enter your donation amount in the box below.

Current Total. Please click the "Calculate" button below for your total tuition due. You will see this amount again on the checkout pages.

$0.00

Emergency Information/Authorization for Medical Treatment/Special Needs

In the event that the undersigned, or my (our), physician cannot be reached, and in the judgment of the Coordinator of Children's Ministry or other authorized staff members, there is necessity for immediate examination and/or treatment of my (our) children(ren), I hereby authorize any of the aforesaid personnel to obtain for my (our) child(ren) such medical services.

Full Names of Children (Please enter in the box below. Use the "Enter" or "Return" keys to enter one child per line) *

0/255 characters

Physician Name *

Physician Phone *

Medical Insurance Company

Policy #

Emergency Contact - In case of emergency and parent(s) cannot be reached at the phone numbers provided to the Office of Religious Education, the following may be called.

Name *

Phone Numer *

Relationship *

Photo Release Affidavit: We sometimes publish photos of children participating in our program. Minors are not identified by name. Please grant permission to Divine Mercy Children's Ministry to use photos that may include your child(ren). *

Please sign to indicate your understanding and agreement with the above. *

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Volunteer Service

We ask each family to contribute their time and talent to our program. Please indicate below how you will help.

Name

Phone Number

Email Address

I would like to volunteer as (check all that apply)

Grade Preference(s)

Please submit your registration by clicking the "Submit" button below.

You will be re-directed to our checkout page.

If you have questions about this registration,

please contact our Children's Ministry Office at dm.shre@divinemercynorthshore.org,

or Sue Lehocky at slehocky@divinemercynorthshore.org or call 847.446.6535.

Thank you!