PSR Online Registration

Child's Information

Family Name and Parish Name(Required)

How many children will you register?(Required)

Which Catechetical Program are you interested in?

Child 1 Information

Please include full name, age, birthday, gender, school, and grade.

Child 2 Information

Please include full name, age, birthday, gender, school, and grade.

Child 3 Information

Please include full name, age, birthday, gender, school, and grade.

Child 4 Information

Please include full name, age, birthday, gender, school, and grade.

Child 5 Information

Please include full name, age, birthday, gender, school, and grade.

Sacramental Information

This section is for FIRST-time families or FIRST-time children only.
Skip this section if you are a returning family.

Your Child's Sacraments

For each child, type their full name and list each of their received sacraments (Baptism, 1st Confession, 1st Communion, Confirmation, etc). Sacramental information must include the date of sacrament received, Church name, and Church full address (only list the Church address once if it's the same).

Parent's Information

Father's Name

Father's Phone #

Father's Email Address

Father's Address

Mother's Name

Mother's Phone #

Mother's Email Address

Does Mother have the same address as Father?(Required)

Yes

No

Mother's Address

Emergency Info and Medical Authorization

PURPOSE: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under the Catholic Faith Formation program for the City of Steubenville supervision, and when parents or guardians cannot be reached.

Part I or Part II must be completed.

OPTION I:

(To grant consent)
In the event that reasonable attempts to contact me (the signer), at the PRIMARY phone number below or other parent or guardian at the SECONDARY phone number below, have been unsuccessful, I hereby give consent for:

1. The administration of any treatment deemed necessary by: ––a. Preferred physician: ––b. Preferred dentist: ––c. Or in the event the designated preferred practitioner is not available, by another licensed physician or dentist.

2. The transfer of the child to the preferred hospital: or any hospital reasonably accessible for the condition of emergency.

MEDICAL HISTORY: This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of the surgery. The following are facts concerning the child’s medical history including allergies, medications being taken, and any physical impairment to which a physician should be alerted:

List Medical History

Emergency Primary Phone

Emergency Secondary Phone

Today's Date

Emergency: Name of parent or guardian

OPTION II:

(Refusal of consent)
I do not give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the supervisors to take no action.

Date

Refusal of Consent: Name of parent or guardian

Diocese of Steubenville Child Protection Policy

Diocese of Steubenville Mandatory Child Protection Policy Registration and Permission Form for Parish Religious Education

NAME OF PARISHES:
Holy Family, Saint Peter, Triumph of the Cross, St. Agnes, Blessed Sacrament, Our Lady of Lourdes

PRIEST COORDINATOR and PHONE NUMBER:
Father Matthew Gossett – 740-264-6177

PROGRAM INFORMATION: Director of Religious Education:
- Catechetical Leader: Barbara Van Beveren
- Phone Number: 740-264-6177

- Location: Holy Family Church, St. Peter, Triumph of the Cross, Blessed Sacrament, Our Lady of Lourdes and Bishop John King Mussio School Properties

- Events include: Catechesis of the Good Shepherd and Faith and Life; Sacramental Preparation; Youth Days; Retreats; VBS

- Begins: Wednesday, September 21 - Ends: June 2023

I give the children listed on this form ( children listed on this form under my care) MY PERMISSION to attend Catholic Faith Formation Program for the period listed above. I understand that I can contact the catechist, the catechetical leader, or the priest coordinator if I have any concerns about religious education.

Date

Permission to Attend: Name of parent or guardian

Publicity Release

Posting Pictures on our Website, Diocesan Paper and Bulletin Board

I give permission for my child’s picture to be posted on the Catholic Faith Formation website and/or the diocesan newspaper, “The Register.” I understand that the pictures will not have my child’s name listed.

Date

Permission for Pictures: Name of parent or guardian

CAPTCHA

2022-2023 PSR Online Registration Form

Child's Information

Sacramental Information

Parent's Information

Emergency Info and Medical Authorization

OPTION I:

OPTION II:

Diocese of Steubenville Child Protection Policy

Publicity Release

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