PSR - Parish School of Religion - Epiphany of Our Lord Parish

Parish of registration REQUIRED Please fill out this field. Please enter valid data.

Parent 1 First and Last Name REQUIRED Please fill out this field. Please enter valid data.

Parent 1 Phone Number REQUIRED Please fill out this field. Please enter valid data.

Parent 1 Email REQUIRED Please fill out this field. Please enter valid data.

Parent 2 First and Last Name Please enter valid data.

Parent 2 Phone Number Please enter valid data.

Parent 2 Email Please enter valid data.

Student's Primary 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.

Emergency Contact First and Last Name REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact Phone Number REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact Relationship REQUIRED Please fill out this field. Please enter valid data.

Student 1 First and Last Name REQUIRED Please fill out this field. Please enter valid data.

Student 1 Date of Birth 00/00/0000 REQUIRED Please fill out this field. Please enter valid data.

Student 1 Grade Level REQUIRED Please fill out this field. Please enter valid data.

Please List Allergies or Special Educational Needs for Student 1

Please check all sacraments that student 1 has received. Baptism Reconciliation Eucharist Confirmation

Student 2 First and Last Name Please enter valid data.

Student 2 Date of Birth 00/00/0000 Please enter valid data.

Student 2 Grade Level Please enter valid data.

Please List Allergies or Special Educational Needs for Student 2

Please check all sacraments that student 2 has received. Baptism Reconciliation Eucharist Confirmation

Student 3 First and Last Name Please enter valid data.

Student 3 Date of Birth 00/00/0000 Please enter valid data.

Student 3 Grade Level Please enter valid data.

Please List Allergies or Special Educational Needs for Student 3

Please check all sacraments that student 3 has received. Baptism Reconciliation Eucharist Confirmation

PSR Agreements

I give permission for my child(ren) to attend PSR and that all information is correct. I understand that my children will be under the supervision of Epiphany of Our Lord staff and volunteers.
I recognize that there are risks inherent in participation in any activity and agree to hold the Archdiocese of St. Louis, its affiliates and their employees, volunteers, and agents, harmless from any injury to my child or damage to or loss of personal property of my child not caused by the negligence or misconduct of the Archdiocese of St. Louis, its affiliates and their employees, volunteers and agents.
In case of medical emergency, I understand that every effort will be made to contact me, but in the event that I cannot be reached, I hereby give permission for my child to be evaluated, diagnosed, and treated in accordance with standard medical practice by licensed medical personnel.
I hereby give permission to the Epiphany of Our Lord to use any photographs or video footage taken of my child in print and on their website for promotional purposes.
I understand that for PSR activities there is a zero tolerance policy for the use of any mood altering chemicals (including alcohol and illegal drugs), foul language, threats or any type of abuse, and inappropriate physical contact. I agree to follow this policy.

After reading the PSR Agreement, please select the appropriate box below. I agree. I agree to all terms, but do not want my children photographed.

Please select the each box that applies to your family. After boxes have been selected, please add each amount together to calculate the total amount due for the 2017-2018 year. 1 child for PSR is $65.00 2 children for PSR is $125.00 3 or more children for PSR is $175.00

Payment

Your registration is not complete until your payment is made. You will receive direction on how to make online payment after you click the submit button. Please know when paying online there is a $2.00 administration fee. Checks can be mailed to 6596 Smiley Avenue St. Louis, MO 63139. If you are in need of financial assistance, please contact the parish office at 314-781-1199. Any other questions can be directed to Michaelrennier@gmail.com. By clicking the submit button you agree that all of the above information has been read, is correct, and to the payment terms of PSR.