Religious Education Program Registration 2022-2023

- Please complete the form here for each child you would like to enroll in the REP. Previous years' forms will not count toward this year's enrollment.
  
  Early Bird registration is available to families who enroll and pay full tuition and fees by July 31, 2022. Families with balances due from previous years are ineligible for Early Bird Registration.
  
  Please note that submission of this form does not constitute automatic enrollment into the REP. Registration is complete upon receipt of tuition and fees, review of Sacramental documentation, and assessment of prior religious formation.
  
  Students in Sacramental years, 2nd and 8th grade, must have attended and completed 1st and 7th grade Catechism classes. Please contact Mrs. Lauer at (914) 591-7480 if you have any questions about this.
  
  Once you have completed the registration, please visit https://iccirvington.churchgiving.com/ws/opportunities to pay your tuition.
- Registration Form - 2022-2023
  
  The maximum number of form submissions has been reached. This form is currently not available.
  
  Is your family registered in the Parish? REQUIRED
  Tuition fees are higher for non-registered families. Responses will be verified.
  Please fill out this field.
  
  Home Address REQUIRED
  Primary Residence of Children to which mail should be sent.
  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.
  
  Home Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Father's First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Father's Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Father's Religion REQUIRED Please fill out this field. Please enter valid data.
  
  Father's Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Father's Email Address REQUIRED Please fill out this field. Please enter an email address.
  
  Father's Work Phone Number (Secondary number for emergency calls) Maximum 20 characters Please enter a phone number.
  
  Mother's First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Mother's Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Mother's Maiden Name REQUIRED Please fill out this field. Please enter valid data.
  
  Mother's Religion REQUIRED Please fill out this field. Please enter valid data.
  
  Mother's Mobile Phone Number REQUIRED Maximum 20 characters
  In case of no response to first one.
  Please fill out this field. Please enter a phone number.
  
  Mother's Email Address REQUIRED
  In case primary email address does not work.
  Please fill out this field. Please enter an email address.
  
  Mother's Work Phone Number (Secondary number for emergency calls) REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  How many children are you enrolling in the REP? REQUIRED Please fill out this field.
  
  Child 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Does child live with both parents? REQUIRED Yes No Please fill out this field.
  
  Does child have permission to go home with or be released to either parent? REQUIRED Yes No Please fill out this field.
  
  Did your child attend the ICC REP during the 2018-2019 Academic Year? REQUIRED Please fill out this field.
  
  What primary school does your child attend? REQUIRED Please fill out this field.
  
  What grade of religious education formation do you believe your child is entering?
  
  Please list any learning or other special need for which your child may require accomodation. REQUIRED Please fill out this field.
  
  Please list any allergies your child has. If none, please right "no allergies" REQUIRED Please fill out this field.
  
  Is there any information concerning pick up or dismissal, or any other safety concern, which you believe would be important
  
  Do you grant the ICC REP permission to use a photograph of your child in the bulletin or newsletter? REQUIRED Yes No Please fill out this field.
  
  Child 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Does child live with both parents? REQUIRED Yes No Please fill out this field.
  
  Does child have permission to go home with or be released to either parent? REQUIRED Yes No Please fill out this field.
  
  Did your child attend the ICC REP during the 2018-2019 Academic Year? REQUIRED Please fill out this field.
  
  What primary school does your child attend? REQUIRED Please fill out this field.
  
  What grade of religious education formation do you believe your child is entering?
  
  Please list any learning or other special need for which your child may require accomodation. REQUIRED Please fill out this field.
  
  Please list any allergies your child has. If none, please right "no allergies" REQUIRED Please fill out this field.
  
  Is there any information concerning pick up or dismissal, or any other safety concern, which you believe would be important
  
  Do you grant the ICC REP permission to use a photograph of your child in the bulletin or newsletter? REQUIRED Yes No Please fill out this field.
  
  Child 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Does child live with both parents? REQUIRED Yes No Please fill out this field.
  
  Does child have permission to go home with or be released to either parent? REQUIRED Yes No Please fill out this field.
  
  Did your child attend the ICC REP during the 2018-2019 Academic Year? REQUIRED Please fill out this field.
  
  What primary school does your child attend? REQUIRED Please fill out this field.
  
  What grade of religious education formation do you believe your child is entering?
  
  Please list any learning or other special need for which your child may require accomodation. REQUIRED Please fill out this field.
  
  Please list any allergies your child has. If none, please right "no allergies" REQUIRED Please fill out this field.
  
  Is there any information concerning pick up or dismissal, or any other safety concern, which you believe would be important
  
  Do you grant the ICC REP permission to use a photograph of your child in the bulletin or newsletter? REQUIRED Yes No Please fill out this field.
  
  Child 4
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Does child live with both parents? REQUIRED Yes No Please fill out this field.
  
  Does child have permission to go home with or be released to either parent? REQUIRED Yes No Please fill out this field.
  
  Did your child attend the ICC REP during the 2018-2019 Academic Year? REQUIRED Please fill out this field.
  
  What primary school does your child attend? REQUIRED Please fill out this field.
  
  What grade of religious education formation do you believe your child is entering?
  
  Please list any learning or other special need for which your child may require accomodation. REQUIRED Please fill out this field.
  
  Please list any allergies your child has. If none, please right "no allergies" REQUIRED Please fill out this field.
  
  Is there any information concerning pick up or dismissal, or any other safety concern, which you believe would be important
  
  Do you grant the ICC REP permission to use a photograph of your child in the bulletin or newsletter? REQUIRED Yes No Please fill out this field.
  
  Child 5
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Does child live with both parents? REQUIRED Yes No Please fill out this field.
  
  Does child have permission to go home with or be released to either parent? REQUIRED Yes No Please fill out this field.
  
  Did your child attend the ICC REP during the 2018-2019 Academic Year? REQUIRED Please fill out this field.
  
  What primary school does your child attend? REQUIRED Please fill out this field.
  
  What grade of religious education formation do you believe your child is entering?
  
  Please list any learning or other special need for which your child may require accomodation. REQUIRED Please fill out this field.
  
  Please list any allergies your child has. If none, please right "no allergies" REQUIRED Please fill out this field.
  
  Is there any information concerning pick up or dismissal, or any other safety concern, which you believe would be important
  
  Do you grant the ICC REP permission to use a photograph of your child in the bulletin or newsletter? REQUIRED Yes No Please fill out this field.
  
  Child 6
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Does child live with both parents? REQUIRED Yes No Please fill out this field.
  
  Does child have permission to go home with or be released to either parent? REQUIRED Yes No Please fill out this field.
  
  Did your child attend the ICC REP during the 2018-2019 Academic Year? REQUIRED Please fill out this field.
  
  What primary school does your child attend? REQUIRED Please fill out this field.
  
  What grade of religious education formation do you believe your child is entering?
  
  Please list any learning or other special need for which your child may require accomodation. REQUIRED Please fill out this field.
  
  Please list any allergies your child has. If none, please right "no allergies" REQUIRED Please fill out this field.
  
  Is there any information concerning pick up or dismissal, or any other safety concern, which you believe would be important
  
  Do you grant the ICC REP permission to use a photograph of your child in the bulletin or newsletter? REQUIRED Yes No Please fill out this field.
  
  EMERGENCY CONTACT SECTION: Please indicate how many emergency contacts you have (min. of 2) REQUIRED Please fill out this field.
  
  Emergency Contact 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number 1 REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Phone Number 2 Maximum 20 characters Please enter a phone number.
  
  Emergency Contact 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number 1 REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Phone Number 2 Maximum 20 characters Please enter a phone number.
  
  Emergency Contact 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number 1 REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Phone Number 2 Maximum 20 characters Please enter a phone number.
  
  Emergency Contact 4
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number 1 REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Phone Number 2 Maximum 20 characters Please enter a phone number.
  
  Primary Care Physician in Case of Emergency
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Address 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.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Main Email For All REP Communications REQUIRED Please fill out this field. Please enter an email address.
  
  In case of accident or illness, I request that the representative of the Parish Religious Education Program contact me. If I am unable to be reached, I hereby authorize this representative to call the physician indicated and to follow the physician's instructions. If it is not possible to contact this physician, the Director of Religious Education may make whatever arrangements seem necessary. I agree to assume the financial responsibility for any diagnosis, treatment and/or medication deemed necessary.
  
  To the best of my knowledge, all information given is accurate and complete. I hereby consent to, and authorize, the necessary procedures that have been stated on this form.
  I Agree Please select this field.
  
  Submit
  
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Immaculate Conception

Irvington, NY

Religious Education Program Registration 2022-2023

Registration Form - 2022-2023