Return form to Dottie Hibbeler 100 Thompson Dr., Troy, MO 63379

Or drop in the collection basket marked “PSR”. Fees are $75 per student. $200 for 3 or more students in same family. Please return ASAP, you may pay your fees at your convenience.

PSR Registration Form 2011-12
Family Information PLEASE PRINT
Father’s name
Occupation
Religion
Mother’s name
Occupation
Religion
Home address
Home phone
Mobile or cellular phone
Home e-mail address
Name of Parish you attend
Student Information
Student Name:		Student Name:
Birthday (MM/DD/YYYY):		Birthday (MM/DD/YYYY):
Grade in School:		Grade in School:
Male Female		Male Female
Baptismal Date (MM/DD/YYYY):		Baptismal Date (MM/DD/YYYY):
Church where Baptized:		Church where Baptized:
Disabilities:		Disabilities:
Allergies:		Allergies:
Known Medical Conditions:		Known Medical Conditions:
Special Concerns:		Special Concerns:
Student Name:		Student Name:
Birthday (MM/DD/YYYY):		Birthday (MM/DD/YYYY):
Grade in School:		Grade in School:
Male Female		Male Female
Baptismal Date (MM/DD/YYYY):		Baptismal Date (MM/DD/YYYY):
Church where Baptized:		Church where Baptized:
Disabilities:		Disabilities:
Allergies:		Allergies:
Known Medical Conditions:		Known Medical Conditions:
Special Concerns:		Special Concerns:
Emergency Information
Please list two contacts if you cannot be reached.
Name:	Name:
Address:	Address:
Telephone:	Telephone:
Relationship:	Relationship:
Local Physician’s Name
Office Telephone:	Exchange Telephone:
Emergency Center/Hospital
Telephone
In case of accident or serious illness, I request the school to contact me. If the school is unable to reach me, I hereby authorize the school to call the physician indicated above and to follow his instructions. If it is impossible to contact this physician, the school may make whatever arrangements seem necessary. Signature of Parent or Guardian: Date: _____________________
Publication Release
I hereby grant permission for my children to be photographed or interviewed for publication. I understand photographs or quotations may be reprinted for public dissemination. I release and relieve Sacred Heart Catholic Church and the Archdiocese of St. Louis from any responsibility or liability for any claims arising from the publication or reproduction of any photographs or interviews. I also understand that the photography or interview is being conducted with the knowledge and approval of Sacred Heart Catholic Church. These publications could be used on the Sacred Heart parish website, St. Louis Review, Archdiocese of St. Louis website, or the Lincoln County Journal. Parent/Guardian Signature: Date: _________________
Volunteer Information
Thank you for sharing your time & talents!
I would like to volunteer for the following:
Classroom Teacher:		Classroom Helper:
Hall Monitor:		Parking Lot Monitor:
Help with Parties:		Musician:
Fundraising:		Office Help During Day:
Office Help During PSR: