Registration 2022-2023

Please complete ONE below form per family!

Welcome to PSR 2022-2023.

PSR will be held for Grades K-4 on Sundays starting September 11, 2022 from 10am to 11:15am in the Parish Center.

Grades 5-8 will be on Wednesdays starting September 7, 2022 from 6:30pm to 7:45pm in the Parish Center.

Confirmation will be on scheduled Sundays 10:00am to 11:15am in the Parish Center. Mass at 11:30 am. See "Confirmation" page for schedule.

Information

Family Name

First Name*

Last Name*

Phone

Required* --

Address

Street 1*

Street 2

City*

State*

Zip*

Child Resides With
Required*

	Natural Mother
	Natural Father
	Step-Mother
	Step-Father
	Other

Additional Information

Please list other information: (new baby, adoption, separation, divorce, new marriage, serious illness, etc.)

Emergency Contact

First Name*

Last Name*

Emergency Contact Phone

Required* -- ext

Please select one
Required*

	Single
	Married
	Divorced
	Widowed
	Other

Additional Information

Phone

E-mail

Required*

To be used for emailing PSR schedule changes and updates.

Choose one or more

	Will your child(ren) return to PSR class?
	Enroll in Catholic School?
	Transfer to another PSR Program?
	Is the family moving out of Madison and not returning?

1. Child's Name

First Name*

Last Name*

Please complete an entry per child returning for their 2022-2023 PSR school year.

Date of Birth

Required* //

School & Grade 2022-23

Required*

PSR Grade 2022-23

Required*

2. Child's Name

First Name

Last Name

Date of Birth

School & Grade 2022-2023

PSR Grade 2022-2023

3. Child's Name

First Name

Last Name

Date of Birth

School & Grade 2022-2023

PSR Grade 2022-2023

4. Child's Name

First Name

Last Name

Date of Birth

School & Grade 2022-2023

PSR Grade 2022-2023

Medical Emergency Form

Allergies	Required*	If yes, please list what they are
Medications	Required*
Learning Disabilities	Required*
Fears	Required*

Rates

The rates for 2022-2023 PSR school year; $50 first child, $75 two children, $100 for three or more children. Please call the Parish Office (440-428-5164) if financial assistance is needed.

Photo Release

I (We) the parent(s) and/or guardian(s)hereby grant consent for Immaculate Conception Church (“Parish”), and/or its agents to record (in writing or otherwise), photograph, audiotape, or videotape my minor child’s name, image, likeness, spoken words, student work, and/or performance, in any form, and to display, release, exhibit, publish, or distribute the same, or any part thereof, for the purpose of and in connection with any material that may be created by or on behalf of the Parish including, without limitation, Parish bulletin boards; the Parish’s weekly bulletin; the Parish’s website; print and electronic media; Parish marketing, public relations and communications materials and/or presentations; and such other uses as may not be contemplated herein, without further notice or compensation as follows: I further understand that by entering into this informed consent and release, and by granting permission as stated herein, I hereby release Immaculate Conception, Madison, the Diocese of Cleveland, and their respective officers, directors, agents and/or employees from and against any and all liability, loss, damage, costs, claims, and/or causes of action arising out of or related to the above items to which I have consented. I further understand that the Parish and its respective officers, directors, agents and/or employees have no control over use of photographs, videotapes, audiotapes, or other records made by others and/or outside the scope of this consent and release. Finally, in signing below I acknowledge that all recordings, audiotape, videotape, photographic proofs, photographic negatives, positives, and prints shall constitute the property of the Parish.

Permission Options
Required*

	I grant permission
	I refuse permission

Parent's Signature

Parent or Guardian Signature

First Name*

Last Name*

Please enter your first and last name as your electronic signature.

Spam Capture

Registration 2022-2023

Welcome to PSR 2022-2023.

PSR will be held for Grades K-4 on Sundays starting September 11, 2022 from 10am to 11:15am in the Parish Center.

Grades 5-8 will be on Wednesdays starting September 7, 2022 from 6:30pm to 7:45pm in the Parish Center.

Confirmation will be on scheduled Sundays 10:00am to 11:15am in the Parish Center. Mass at 11:30 am. See "Confirmation" page for schedule.

Online Giving