Catechesis of the Good Shepherd – Catholic Formation

Parishioners at:

St. Patrick Parish
Immaculate Conception Parish
Other

If other, please list parish:

Child's Name *

First

Last

Gender *

Birthdate *

Grade

Session FIRST Choice

Session SECOND Choice

Special Needs: (Medical, Learning Disabilities, Physical Disabilities, Allergies etc.)

Do You Need To Submit A Medication Consent Form?

Yes
No

File Upload Medication Form - Only if Needed

Click or drag a file to this area to upload.

Child's Name

First

Last

Gender

Birthdate

Grade

Session FIRST Choice

Session SECOND Choice

Special Needs: (Medical, Learning Disabilities, Physical Disabilities, Allergies etc.)

Do You Need To Submit A Medication Consent Form?

Yes
No

File Upload Medication Form - Only if Needed

Click or drag a file to this area to upload.

Child's Name

First

Last

Gender

Birthdate

Grade

Session FIRST Choice

Session SECOND Choice

Special Needs: (Medical, Learning Disabilities, Physical Disabilities, Allergies etc.)

Do You Need To Submit A Medication Consent Form?

Yes
No

File Upload Medication Form - Only if Needed

Click or drag a file to this area to upload.

Father's Name/Guardian

First

Last

Email

Phone

Mother's Name/Guardian

First

Last

Email

Phone

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact *

First

Last

Emergency Contact's Email *

Emergency Contact's Phone *

Please note: Your child must be toilet-trained to attend CGS. Please add any additional information below that you would like to communicate to us. Thank you!

Diocese of Superior Youth Image and Recording Release Form (Please carefully read the statements below. Indicate your permission or refusal of permission by signing and dating the appropriate statement.)

YES, I give permission to the Diocese of Superior and affiliated parishes and schools to use my child(ren)'s image and/or recording for above-said use for the child(ren) registered.
NO, I DO NOT give permission to the Diocese of Superior and affiliated parishes to use my child(ren)'s image and/or recording for above-said use for the child(ren) registered.

The Diocese of Superior and its affiliated parishes and schools may wish to use an image and/or recording of your child in print and electronic publicity and virtual education. It is the practice of the Diocese of Superior to protect all children at all times including the public use of their image and/or recording. This document has been developed to inform parents and guardians of their right to grant or refuse permission for their child's image and/or likeness to be used in Diocesan and affiliated parish and school media, promotional materials, and virtual education. Permission to use any video recording, photograph, slide, audio recording, or any other visual or audio reproduction in which your child may appear may include promotional and educational activities such as, but not limited to, websites, social media sites, newsprint, flyers or brochures, virtual classroom. We reserve the right to determine which image and/or recording is used and how long it will remain on the site or is used in media materials. The Diocesan Department, Parish or School Initiating this form is: Immaculate Conception Church. I understand that both print and electronic media have a large audience and that my child(ren)’s photographic image and/or recording may have wide distribution. The contact person is: Kristin Dittman. Phone 715-246-4652 ext 260. Email: k.dittman@ic-church.com. Fax: 715-246-2526.

Youth Image and Recording Release Signature *

Please type your name above to affirm your choice regarding the Youth Image and Recording Release permission.

The suggested donation for CGS is $60. I plan to pay for CGS by:

On-line Payment. Please use the link to the upper left (or below if on a mobile phone).
Drop off payment at Immaculate Conception Church Main office
Mail Check (payable to Immaculate Conception Church) to 151 S. Washington Ave, New Richmond, Wi, 54017

To register your child for a CGS session, please fill out the registration form below. If you have any questions, contact Kristin Dittman by phone at 715-246-4652 ext 260 or by email: k.dittman@ic-church.com.