Registration

Child's Name REQUIRED Please fill out this field. Please enter valid data.

Date of Birth REQUIRED Please fill out this field. Please enter valid data.

Date of Baptism REQUIRED Please fill out this field. Please enter valid data.

School Attending REQUIRED Please fill out this field. Please enter valid data.

Grade Please enter valid data.

Home Address REQUIRED Please fill out this field. Please enter valid data.

Email REQUIRED Please fill out this field. Please enter an email address.

Home Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Father's Name REQUIRED Please fill out this field. Please enter valid data.

Cell Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Mother's Name REQUIRED Please fill out this field. Please enter valid data.

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

Mother's Maiden Name REQUIRED Please fill out this field. Please enter valid data.

Preferred Cell Number to receive test messages from Flocknote REQUIRED Please fill out this field. Please enter valid data.

Child Lives with: REQUIRED both parents Mother Father Step-parent Please fill out this field.

If applicable, please check option below Custody Papers Guardianship Papers Restraining Order

Does your child have a Learning Disability (remains confidential) REQUIRED Yes No Please fill out this field.

Does your child have a special medical condition/medications? REQUIRED Yes No Please fill out this field.

Does your child have allergies? REQUIRED Yes No Please fill out this field.

If yes, please list allergies below:

EMERGENCY CONTACT INFORMATION

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Relationship to Child: REQUIRED Please fill out this field. Please enter valid data.

Best Phone Number to contact REQUIRED Please fill out this field. Please enter a phone number.

In Case of Emergency, Child Pediatrician's Name REQUIRED Please fill out this field. Please enter valid data.

Pediatrician Phone Number REQUIRED Please fill out this field. Please enter a phone number.

In case of an emergency regarding my child, I request the representative of the parish catechetical program to call me the parent first and then the emergency contact listed above. If I am unable to be reached, I hereby authorize St. Mary-St. Columba parish representatives to call the physician indicated above and follow the physician’s instructions. In the event that the physician in unable to be reached, the representatives of St. Mary-St. Columba parish catechetical program may make whatever arrangements are necessary including but not limited to calling an ambulance and taking the child from the building to seek medical assistance. I agree to assume the financial responsibility fo diagnosis, treatment and or medication deemed necessary.
To the best of my knowledge, all information given here is accurate and complete. I hereby consent to, and authorize procedures that have been stated.

I Agree Please select this field.

I understand that attending Sunday Mass is an essential part of my child’s faith formation. I agree to bring my child/children to Mass on all Sundays and Holy Days of Obligation, barring illness or genuine emergencies, during the 2025-2026 year. Mass cards will be handed to the priest after the Mass weekly. I understand that failure to comply with the requirements may result in the inability to register for he following year as well as result in a delay in receiving sacraments.

I Agree Please select this field.

I hereby consent to the taking of photos or videos capable of reproduction of my child. I agree that images may be used for display, promotion, acknowledges and or advertising. Students name will not be published.

I Agree Please select this field.

***NOTICE: ALL TUITION AND FEES ARE NON-REFUNDABLE***

Please remember if your child is in Grade 2 or older, and has not attended religious education classes yet, or, if your child did not return after First Holy Communion, please call the office for placement.

St. Mary-St. Columba Parish

42 Goshen Ave. Washingtonville, NY
29 High Street, Chester NY

Registration

RELIGIOUS EDUCATION - ST. COLUMBA CAMPUS

REGISTRATION IS NOT COMPLETE UNTIL PAYMENT IS MADE

SEE ABOVE RIGHT OF PAGE!

registration payment