In which Parish is your family registered?* Holy Rosary St. Stephen We are not registered at either
Parent/Guardian Information Parent/Guardian 1 Name*
First
Last
Parent/Guardian 2 Name
First
Last
Address*
I would be willing to volunteer for the PSR Program as the following:
Safe Environment Compliance
Parents and Volunteers are required to understand the Safe Environment policies and comply with them when serving in our parish. Please ensure you are compliant with Safe Environment requirements by visiting: diojeffcity.org/safe-environment
Emergency Contact Information
Student Section How many students are you registering?* 1 2 3 4 5 6
Student #1 Student #1 Name Please fill out student's full name.
First
Middle
Last
Student #1 Grade Level Please select Student's grade level
Kindergarten First Second Third Fourth Fifth Sixth Seventh Eighth Ninth Tenth Eleventh Twelfth
Student #1 Sacraments Received Please check all the Sacraments your child has received.
Chosen Youth Group If your child is in high school, would they be interested in the Chosen Youth Group on Wednesday evenings?
SEC Middle School Youth Group If your child is in 7th or 8th grade, would they be interested in the SEC Youth Group?
Does your child have any health concerns and/or food allergies that we should know? If Yes, please explain...
Student #2 Student #2 Name Please fill out student's full name.
First
Middle
Last
Student #2 Grade Please select Student's grade level
Kindergarten First Second Third Fourth Fifth Sixth Seventh Eighth Ninth Tenth Eleventh Twelfth
Student #2 Sacraments Received Please check all the Sacraments your child has received.
Chosen Youth Group If your child is in high school, would they be interested in the Chosen Youth Group on Wednesday evenings?
SEC Middle School Youth Group If your child is in 7th or 8th grade, would they be interested in the SEC Youth Group?
Does your child have any health concerns and/or food allergies that we should know? If Yes, please explain...
Student #3 Name Please fill out student's full name.
First
Middle
Last
Student #3 Sacraments Received Please check all the Sacraments your child has received.
Student #3 Grade Please select Student #1 grade level
Kindergarten First Second Third Fourth Fifth Sixth Seventh Eighth Ninth Tenth Eleventh Twelfth
Chosen Youth Group If your child is in high school, would they be interested in the Chosen Youth Group on Wednesday evenings?
SEC Middle School Youth Group If your child is in 7th or 8th grade, would they be interested in the SEC Youth Group?
Does your child have any health concerns and/or food allergies that we should know? If Yes, please explain...
Student #4 Student #4 Name Please fill out student's full name.
First
Middle
Last
Student #4 Sacraments Received Please check all the Sacraments your child has received.
Student #4 Grade Please select Student's grade level.
Kindergarten First Second Third Fourth Fifth Sixth Seventh Eighth Ninth Tenth Eleventh Twelfth
Chosen Youth Group If your child is in high school, would they be interested in the Chosen Youth Group on Wednesday evenings?
SEC Middle School Youth Group If your child is in 7th or 8th grade, would they be interested in the SEC Youth Group?
Does your child have any health concerns and/or food allergies that we should know? If Yes, please explain...
Student #5 Student #5 Name Please fill out student's full name.
First
Middle
Last
Student #5 Sacraments Received Please check all the Sacraments your child has received.
Student #5 Grade Please select Student's grade level
Kindergarten First Second Third Fourth Fifth Sixth Seventh Eighth Ninth Tenth Eleventh Twelfth
Chosen Youth Group If your child is in high school, would they be interested in the Chosen Youth Group on Wednesday evenings?
SEC Middle School Youth Group If your child is in 7th or 8th grade, would they be interested in the SEC Youth Group?
Does your child have any health concerns and/or food allergies that we should know? If Yes, please explain...
Student #6 Student #6 Name Please fill out student's full name.
First
Middle
Last
Student #6 Sacraments Received Please check all the Sacraments your child has received.
Student #6 Grade Please select Student's grade level
Kindergarten First Second Third Fourth Fifth Sixth Seventh Eighth Ninth Tenth Eleventh Twelfth
Chosen Youth Group If your child is in high school, would they be interested in the Chosen Youth Group on Wednesday evenings?
SEC Middle School Youth Group If your child is in 7th or 8th grade, would they be interested in the SEC Youth Group?
Does your child have any health concerns and/or food allergies that we should know? If Yes, please explain...
Consent for Direct Communication with Minors This section is for parents with students in grades 7-12 only.
Parents, please read the following:
Please select an option:* Contact with my child is permissible via the following methods: Please check the box for each communication method that is permissible.
Social Media used by Holy Rosary and St. Stephen PSR/Youth Ministry
Facebook:
@HolyRosaryMC
@HRSSYouthMinistry
@HRSSFaithFormation
Instagram:
hr_ssfaithformation
Websites:
www.holyrosary.diojeffcity.org
www.ststephenic.diojeffcity.org Consent for Direct Communication with Minors* Video and Photography Consent This section is for parents with students in grades 7-12 only. Parents, please read the following:
Please select an option:* I consent that photographs/video recordings/audio recordings of my child may be used in the following circumstances: Please check the box for each option that is permissible.
Video and Photography Consent*
PSR Fees Price Please select the number of students you are registering.
1 Student - $15.00;
2 Students - $25.00;
3 or more Students - $30.00
Payment Method* 
