Assumption of the BVM/Immaculate Conception Family Faith Formation Tuition Rates & Information 2017 2018 Family Name: IMPORTANT: Please provide your current e-mail address, as this is our method of communicating to parents. E-Mail address: Be sure to update this information if it changes throughout the Faith Formation Year. Family Information Please PRINT Registered at Assumption Catholic Church: ( ) Yes or ( ) No Today s Date: Registered at Immaculate Conception Catholic Church: ( ) Yes or ( ) No Street Address, City, Zip Father s Full Name: Fathers Cell: Text Msg? Mother s Full Name: Mother s Cell: Text Msg? Emergency Contact Information: Please provide your Cell Phone Provider for Text Messages: Family Status: ( ) Married ( ) Widow/er ( ) Single Parent ( ) Separated ( ) Divorced ( ) Remarried Do Children reside with both parents? ( ) Yes or ( ) No Children Information Child s First & Last Name: Birthdate: Gender: Special Needs: Medical, Learning Disability, Physical Disabilities: Any other information we should know about your Child? Child s First & Last Name: Birthdate: Gender: Special Needs: Medical, Learning Disability, Physical Disabilities: Any other information we should know about your Child? 1
Child s First & Last Name: Birthdate: Gender: Special Needs: Medical, Learning Disability, Physical Disabilities: Any other information we should know about your child? Child s First & Last Name: Birthdate: Gender: Special Needs: Medical, Learning Disability, Physical Disabilities Any other information we should know about your child? Family Faith Formation Tuition Rates & Information 2017 2018 1 Child 2 + Children Tuition: Registration 120.00 200.00 Confirmation Retreat (8 th Grade only): No Fees at this time Total Amount Due: Volunteer Credit (Catechists and Catechist Aides): 50% discount Net Amount Due Total Amount Received: (Cash / Check / E-Giving) Previous Balance Owed The Parish does not make a profit on RE tuition. Tuition is used to cover salary, supplies, speakers, Bibles, media, utilities etc. Choose a Family Faith Formation Session Note: Parents & Children Attend one (1) session per month We will attend the session held on: Sunday 9:00 a.m. until 10:30 a.m. Sunday 9a.m. Tuesday 6:15 p.m. until 7:45 p.m. Wednesday 6:15 p.m. until 7:45 p.m. Please Note: Monthly Family Faith Formation Sessions will be held in Berst Hall at Assumption of the Blessed Virgin Mary Catholic Church. 2
Assumption of the BVM / Immaculate Conception Family Faith Formation Tuition Rates & Information 2017 2018 Special Needs: Medical, Learning Disability, Physical Disabilities Any other information we should know about your child? Assumption Catholic Church is always looking for volunteers/talents. Are you interested in volunteering in any other areas? If yes, please describe. Payment schedule: I will pay in full upon registration. I would like to pay through Assumption of the BVM s E-Giving Program. (Attached) I would like to sign up for the payment plan. Your total account balance will be divided into 4 payments due on the following days. September 18, 2017 November 20, 2017 January 23, 2018 March 20, 2018 Please Note: A $5.00 administrative fee will added to each partial payment. Signature: Signature of person responsible for payment Date: No child will be turned away from Family Faith Formation because of inability to pay. If tuition creates a grave financial hardship for your family, please contact Deacon Bill Dunn, Director of Catechesis and Evangelization, to discuss tuition Assistance. Assistance is based on needs and availability of Funds. Call 815-634-4171. 3
FAMILY FAITH FORMATION E-GIVING PAYMENT CONFIDENTIAL I wish to pay through E-Giving (Please circle one) Visa MasterCard Discover Card # Expiration Date: / / Last three digits of Card Would you like to set up a reoccurring amount each month at a minimum of $25.00 Yes or No Printed Name Signature Address Home Phone Number Work Number Family Faith Formation Tuition Payments and other Stewardship giving if you choose to pay your RE tuition at one time or if you would like to pay through a credit card please consider participating in our Parish electronic (online) giving program. Visit our website www.stmaryassumptionparish.org and click on the E-Giving tab. E-Giving is a safe and secure system for your Sunday, monthly, or annual donations, as well as Family Faith Formation tuition, Our Lady of Mercy Fund and Assumption Building Campaign donations. Please help us each week financially if you do not regularly attend Sunday Mass. We rely on everyone to be good stewards of your gifts and financial giving as well as other ways of support for the Church is not only necessary but truly appreciated week after week. If any of you would like to help needy families in our parish that are not able to afford their tuition costs at this time, please consider giving them a financial gift at the time of your registration or through electronic giving as well. Please also remember Assumption of the Blessed Virgin Mary Parish in your estate planning. If you need assistance, please contact Sonia Hertogs, Parish Business Manager, at (815) 634-4171. We will be in contact with you to set up your payment soon. 4
Diocese of Joliet MEDICAL PERMISSION FORM I grant permission for the administration of First Aid to my child,, by the people in charge of the Family Faith Formation event, and those transporting my child to and from the event as their judgment deems advisable, and to make the necessary referrals to qualified physicians for treatment of illness or accidents of a more serious nature. I understand I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when delay in such communication would endanger life. In case of medical emergency, I understand that every effort will be made to contact the parent/guardian of the participant. In the event that I cannot be reached, I hereby give permission to the physicians selected by the adult staff to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery, if deemed necessary for my child. Print Name: (youth) Birth Date: (youth) Allergic to medication/other? NO YES If yes, please describe: Medication(s) presently taking: Insurance Information Policy in the name of: Insurance Company: Policy Number: Identification Number and/or Social Security Number: Authorized Physician: Phone: ( ) Signature of Parent/Guardian Date: Address: Street City State Zip Day Phone: ( ) Evening: ( ). In Case of Emergency, contact: Phone # s: 5
Assumption of the BVM / Immaculate Conception TEXT MESSAGE PERMISSION FORM Communication is important to receive text messages for emergencies and other updates, please fill out the information below. Please provide us with your cell phone provider. Name: Cell Phone Number: Name of Cell Phone Provider/Company: I agree to allow Assumption Catholic Church/Immaculate Conception Church to contact me by text message on my cell phone at the above number. Signature Date: 6