LIGHT Registration 2022-2023 Home Page LIGHT Registration Form 2022-2023 Step 1 of 6 16% Family InformationPlease fill out the family information below.Family Last Name* Is your family registered as a member of Our Lady of Mercy parish?* Yes No If not, you may go to our online parish registration here: https://olmercy.com/join/Please add your Family Parish ID number (if known) Mother's Name* First Last Father's Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email - Primary where all correspondences will be sent.* Home PhoneCell Phone* Student InformationPlease list all students you will be registering for programs (EDGE Grades 6-8). Information and details on specific programs will be sent to you after registration.Student Name #1 First Last Student Birth Date MM slash DD slash YYYY School Attending in Fall 2022 GRADE entering school in the Fall 2022*9101112Sacraments the Student has Received Baptism Reconciliation Communion/Eucharist Confirmation Please check all sacraments that have already been received.Child was baptized at Our Lady of Mercy parish? Yes No Student Name #2 First Last Student Birth Date MM slash DD slash YYYY School Attending in Fall 2022 GRADE entering school in the Fall 20229101112Sacraments the Student has Received Baptism Reconciliation Communion/Eucharist Confirmation Please check all sacraments that have already been received.Child was baptized at Our Lady of Mercy parish? Yes No Student Name #3 First Last Student Birth Date MM slash DD slash YYYY School Attending in Fall 2022 Grade entering school in the Fall 20229101112Sacraments the Student has Received Baptism Reconciliation Communion/Eucharist Confirmation Please check all sacraments that have already been received.Child was baptized at Our Lady of Mercy parish? Yes No Information and PoliciesPlease fill out the information below. You may leave the Confidential information blank if there are no concerns.Confidential InformationTo best support you and your child(ren), please let us know of any allergies, physical limitations, learning challenges, special needs and/or family circumstances (recent separation, divorce, death or illness). Please contact Dave (331-707-5371) prior to the start of classes so we may learn how to support you in the care of your child(ren)’s needs and faith development. Thank you!Video & Photograph Consent* I agree to the video and photograph policy.I understand that video and still photographs may be taken and used for future promotional efforts, but NO CHILD WILL BE IDENTIFIED BY NAME. Medical Insurance InformationOur Diocese ask for the information below to assure for child safety when they are in the care of the parish program.Medical Insurance/Policy in the name of: Medical Insurance Company Policy/Identification Number Authorized Physician Physician Phone NumberConsent* Yes, I consent to the policy.As a parent and/or guardian, I authorize the treatment of my minor child(ren) by a qualified and licensed medical doctor in the event of a medical emergency, which, in the opinion of the attending physician, may endanger his or her life, cause physical disability or undue discomfort if I am delayed. I authorize the Parish authorities to send my child (properly accompanied) to an available hospital or physician. This consent is granted only after a reasonable effort has been made to reach me. Program SelectionPlease select LIGHT program below.LIGHT Program for 2022-2023* The LIGHT program is for High School Teens who want to learn more about our Catholic Faith and live it out in their everyday life with their peers. Volunteers Needed!We need many people to help with the various programs we offer. Please check the box below if you would like to help OR if you would like more information and we'll contact you.Yes, I'd like to volunteer to help with the following: I would like to help with LIGHT High School Youth Ministry programs. Your Name First Last Email Cell Phone LIGHT TuitionStudents in the LIGHT program will be charged $100 per student each year. After you hit SUBMIT, you will be redirected to the PAYMENT page to make payment by credit/debit card. You may indicate a FULL payment or 1/2 payment option. If you need tuition assistance or would like to submit a check or cash as payment, please contact us at the email provided. THANK YOU!Please Sign Name Electronically Below* First Last The parties agree that this document may be electronically signed and that the electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability and admissibility. Transmission via email is not encrypted, so if you are concerned about the security of your sensitive information, please print and fax this form, surface mail it or hand deliver it.EmailThis field is for validation purposes and should be left unchanged.
