Faith Formation Registration

Registration is open for the 2017-2018 Faith Formation Class Year for grades K-8 for all parishioners. Please fill in and submit the form below.  All requirements are for the protection of your child/children and must be met before the student is permitted to attend class.  

  1. Read Faith Formation Orientation here (includes everything you need to know)
  2. Pay the registration fee. (Scholarships available)

Registration is not complete until all the above requirements are met.

Any questions please call (386) 668-8270, email or see Lenny Jufko, Faith Formation Director. 

Parent/Guardian Information
Parent/Guardian Name
  •  
Relationship
  •  
Registered Date //
  •  
Phone -Best Number to call -- ext
  •  
Phone -Other -- ext
  •  
Address
  •  
Email
  •  
Send Mail to Email When Possible?
  •  
Mailing Address-If different from above
  •  
Marital Status
  •  
Religion
  •  
Occupation
  •  
Spouse Information
Spouse Name
  •  
Religion
  •  
Occupation
  •  
Student Information
Student Name
  •  
Grade
  •  
Gender
  •  
Language
  •  
Birth Date //
  •  
Parental/Guardian Medical Information & Consent
Message I hereby warrant to the best of my knowledge, all the information provided is true and correct and I assume all responsibility for the health of my child. I understand it is my responsibility to update the Medical Information & Consent Form if there are any changes to my child’s health.
Name
  •  
Agreement: I agree that typing my First and Last name is the legally binding equivalent to my handwritten signature.
Relationship
  •  
Phone -- ext
  •  
Date //
  •  
Emergency Medical Treatment:
Message In the event of an emergency, I hereby give permission to transport my child to a hospital/clinic for emergency medical or surgical treatment.
Yes
  •  
Medications
Message I hereby Grant Permission for my child to be given the following provided medications. All medications must be well labeled. [NOTE: Any/all prescription medications must be in original pharmacy container with young person’s name on the prescription label. Non-prescription/over-the-counter medications must be in original container with young person’s name on the container.] I release and hold harmless St. Ann's Church, the Diocese of Orlando and any other religious, employees, volunteers, agents and representatives from any injury or harm resulting from administering the medication.
Medication
  •  
List Medication, Dosage and Administer
Medical Conditions Information
(Reasonable steps will be taken to keep this information confidential, but it will be shared with Diocesan personnel and others, as warranted.)
My son/daughter: Is allergic to the following medications
  •  
My son/daughter has had allergic reactions to the following (foods, dyes, latex, etc.)
  •  
My son/daughter has had an episode or has been diagnosed with Seizures
  •  
My son/daughter has had an episode or has been diagnosed with Asthma
  •  
My son/daughter has had an episode or has been diagnosed a Diabetic
  •  
My son/daughter has had a medical surgery within the last six months?
  •  
My son/daughter is still under doctor’s care?
  •  
My son/daughter has a medically prescribed diet (please explain)
  •  
My son/daughter has the following physical limitations
  •  
My son/daughter immunizations are current and up to date?
  •  
My son/daughter date of last tetanus/diphtheria immunization is  
  •  
You should also be aware of these special medical conditions of my child:
  •  
Insurance Information
Do you carry medical insurance at this time?
  •  
Name of Insured:
  •  
Insurance Carrier:
  •  
Insurance Policy Number:
  •  
Name
  •  
In the event the participant does not have insurance, payment in full for medical care becomes the responsibility of the participant’s parent/guardian.
Image Release Form
Message (Photography and Image Assignment Waiver, and Release) By typing my First and Last Name below, I for valuable consideration received, and for being allowed access to Diocesan property, activities, or events, expressly assign to Saint Ann Catholic Church and the Diocese of Orlando, and to all of their current, former, and future agents and related entities (collectively, “the Diocese”), all rights, title and interest in, and to, the use of my and my child/ward’s image or likeness, including, but not limited to all videotape recordings, photographs, or audio recordings of, or made by, me and/or my child/ward on Diocesan property, during a Diocesan-sponsored event, or for any other Diocesan purpose (“the Property”). The Diocese shall have, without my consent, the right to assign its rights in the Property, in whole or in part, to any entity, parish, or school within the Diocese of Orlando. I hereby irrevocably grant the Diocese perpetually and exclusively, the right to use and incorporate (alone or together with other materials), in whole or in part, the Property, in any Diocesan publication, news release, or for any other purpose. Further, I hereby authorize the reproduction, sale, lease, copyright, exhibition, broadcast and/or distribution of the Property without limitation for any purpose whatsoever, and I further waive all rights to any compensation for my and/or my child/ward’s appearance or participation in the Property. I understand and have been advised that photographs or videotape of participants may be used in publications, websites or other materials produced from time to time by the Diocese. Participants’ names would not be identified, however, without specific written consent. I further understand that the Diocese has no control over the use of photographs or film taken by media that may be covering the event in which my child(ren)/ward(s) participate(s). I hereby waive any claims against and release the Diocese, its current, former, and future religious, employees, volunteers, agents, and successors and assigns from and against any and all claims, demands, actions, causes of actions, suits, costs, expenses, liabilities, and damages whatsoever that I and/or my child/ward may have against the Diocese in connection with the Property or the use of the Property. This release shall not obligate the Diocese to use the Property or to use any of the rights granted hereunder, or to exhibit, distribute, or exploit the Property. I acknowledge that the Diocese cannot control all photographic access to its properties, and that my child/ward’s name may be printed with photos/images in various publications, including non-Diocesan publications. I represent that I am eighteen years of age or older, and that I have read and understand the terms of this Assignment, Waiver, and Release.
First and Last Name
  •  
Agreement: I agree that typing my First and Last name is the legally binding equivalent to my handwritten signature.
Safe Environment Program- L.I.F.E. Plus
Message The Diocese of Orlando has implemented a child abuse awareness, prevention, and safety program in all parishes and Catholic schools as mandated by the United States Conference of Catholic Bishops (USCCB) in compliance with the Charter for the Protection of Children and Young People. Students enrolled in a Catholic School or parish-based catechesis are encouraged to participate in this programming. Our diocese is required, through an audit process, to verify to the USCCB that this training has been provided. We are also required to keep track of the number of students who are absent or whose parents do not allow them to participate in the training.
Opt-In or Opt Out
  •  
For the Parent/Guardian, By signing this form I (We) acknowledge the above and elect (NOT TO) have my (Our) child participate, or give my permsission for them (TO) participate in the aforementioned program. Please complete this form. A separate form is required for each child. Thank you for your assistance.
Parents First and Last Name
  •  
Agreement: I agree that typing my First and Last name is the legally binding equivalent to my handwritten signature.
Date //
  •  
Additional Persons allowed to pick up your child.
Name
  •  
If there's no other child/children to register:
I read the Faith Formation Orientation Document
  •  
It includes everything you need to know about the program. Link can be found at the top of this form.
Please scroll to the bottom and submit the form. Thank you for enrolling your child in St. Ann's Faith Formation Program. We are happy and grateful to be able to share our beautiful Catholic Faith with your child.
Give your Electronic Signature Go to the Electronic Signature box.
Student Information #2
Name
  •  
Grade
  •  
Gender
  •  
Language
  •  
Birth Date //
  •  
Parental/Guardian Medical Information & Consent-#2
Message I hereby warrant to the best of my knowledge, all the information provided is true and correct and I assume all responsibility for the health of my child. I understand it is my responsibility to update the Medical Information & Consent Form if there are any changes to my child’s health.
Parent/Guardian First and Last Name
  •  
Agreement: I agree that typing my First and Last name is the legally binding equivalent to my handwritten signature.
Relationship
  •  
Phone --
  •  
Date //
  •  
Emergency Medical Treatment-Student #2
Message In the event of an emergency, I hereby give permission to transport my child to a hospital/clinic for emergency medical or surgical treatment.
Yes
  •  
Medications-Student #2
Medication I hereby Grant Permission for my child to be given the following provided medications. All medications must be well labeled. [NOTE: Any/all prescription medications must be in original pharmacy container with young person’s name on the prescription label. Non-prescription/over-the-counter medications must be in original container with young person’s name on the container.] I release and hold harmless St. Ann's Church, the Diocese of Orlando and any other religious, employees, volunteers, agents and representatives from any injury or harm resulting from administering the medication.
Medication
  •  
List Medication, Dosage and Administer
Medical Conditions Information For Student #2
(Reasonable steps will be taken to keep this information confidential, but it will be shared with Diocesan personnel and others, as warranted.)
My son/daughter is allergic to the following medications
  •  
My son/daughter has had an episode of the following or has been diagnosed with Seizures
  •  
My son/daughter has had an episode of the following or has been diagnosed with Asthma
  •  
My son/daughter has had an episode of the following or has been diagnosed a Diabetic
  •  
My son/daughter has had allergic reactions to the following (foods, dyes, latex, etc.)
  •  
My son/daughter has had a medical surgery within the last six months?
  •  
My son/daughter is still under doctor’s care?
  •  
My son/daughter has a medically prescribed diet (please explain)
  •  
My son/daughter has the following physical limitations
  •  
My son/daughter immunizations are current and up to date?
  •  
My son/daughter date of last tetanus/diphtheria immunization is  
  •  
You should also be aware of these special medical conditions of my child:
  •  
Insurance Information-Student #2
Do you carry medical insurance at this time?
  •  
Insurance Carrier:
  •  
Name of Insured:
  •  
Insurance Policy Number:
  •  
Parent/Guardian First and Last Name
  •  
In the event the participant does not have insurance, payment in full for medical care becomes the responsibility of the participant’s parent/guardian.
Image Release Form-Student #2
Image Release Form (Photography and Image Assignment Waiver, and Release) By typing my First and Last Name below, I for valuable consideration received, and for being allowed access to Diocesan property, activities, or events, expressly assign to Saint Ann Catholic Church and the Diocese of Orlando, and to all of their current, former, and future agents and related entities (collectively, “the Diocese”), all rights, title and interest in, and to, the use of my and my child/ward’s image or likeness, including, but not limited to all videotape recordings, photographs, or audio recordings of, or made by, me and/or my child/ward on Diocesan property, during a Diocesan-sponsored event, or for any other Diocesan purpose (“the Property”). The Diocese shall have, without my consent, the right to assign its rights in the Property, in whole or in part, to any entity, parish, or school within the Diocese of Orlando. I hereby irrevocably grant the Diocese perpetually and exclusively, the right to use and incorporate (alone or together with other materials), in whole or in part, the Property, in any Diocesan publication, news release, or for any other purpose. Further, I hereby authorize the reproduction, sale, lease, copyright, exhibition, broadcast and/or distribution of the Property without limitation for any purpose whatsoever, and I further waive all rights to any compensation for my and/or my child/ward’s appearance or participation in the Property. I understand and have been advised that photographs or videotape of participants may be used in publications, websites or other materials produced from time to time by the Diocese. Participants’ names would not be identified, however, without specific written consent. I further understand that the Diocese has no control over the use of photographs or film taken by media that may be covering the event in which my child(ren)/ward(s) participate(s). I hereby waive any claims against and release the Diocese, its current, former, and future religious, employees, volunteers, agents, and successors and assigns from and against any and all claims, demands, actions, causes of actions, suits, costs, expenses, liabilities, and damages whatsoever that I and/or my child/ward may have against the Diocese in connection with the Property or the use of the Property. This release shall not obligate the Diocese to use the Property or to use any of the rights granted hereunder, or to exhibit, distribute, or exploit the Property. I acknowledge that the Diocese cannot control all photographic access to its properties, and that my child/ward’s name may be printed with photos/images in various publications, including non-Diocesan publications. I represent that I am eighteen years of age or older, and that I have read and understand the terms of this Assignment, Waiver, and Release.
First and Last Name of Parent/Legal Guardian
  •  
Agreement: I agree that typing my First and Last name is the legally binding equivalent to my handwritten signature.
Safe Environment Program- L.I.F.E. Plus-Student #2
Message The Diocese of Orlando has implemented a child abuse awareness, prevention, and safety program in all parishes and Catholic schools as mandated by the United States Conference of Catholic Bishops (USCCB) in compliance with the Charter for the Protection of Children and Young People. Students enrolled in a Catholic School or parish-based catechesis are encouraged to participate in this programming. Our diocese is required, through an audit process, to verify to the USCCB that this training has been provided. We are also required to keep track of the number of students who are absent or whose parents do not allow them to participate in the training.
Safe Environment Program- L.I.F.E. Plus
  •  
For the Parent/Guardian, By signing this form I (We) acknowledge the above and elect (NOT TO) have my (Our) child participate, or give my permsission for them (TO) participate in the aforementioned program. Please complete this form. A separate form is required for each child. Thank you for your assistance.
Parents First and Last Name
  •  
Agreement: I agree that typing my First and Last name is the legally binding equivalent to my handwritten signature.
Date //
  •  
If there's no other child/children to register:
I read the Faith Formation Orientation Document
  •  
Give your Electronic Signature Fill in the Electronic Signature box.
Please scroll to the bottom and submit the form. Thank you for enrolling your child in St. Ann's Faith Formation Program. We are happy and grateful to be able to share our beautiful Catholic Faith with your child.
Student Information #3
Name
  •  
Grade
  •  
Gender
  •  
Language
  •  
Birth Date //
  •  
Parental/Guardian Medical Information & Consent-#3
Message I hereby warrant to the best of my knowledge, all the information provided is true and correct and I assume all responsibility for the health of my child. I understand it is my responsibility to update the Medical Information & Consent Form if there are any changes to my child’s health.
Parent/Guardian First and Last Name
  •  
Agreement: I agree that typing my First and Last name is the legally binding equivalent to my handwritten signature.
Relationship
  •  
Phone --
  •  
Date //
  •  
Emergency Medical Treatment-Student #3
Message In the event of an emergency, I hereby give permission to transport my child to a hospital/clinic for emergency medical or surgical treatment.
Yes
  •  
Medications-Student #3
Message I hereby Grant Permission for my child to be given the following provided medications. All medications must be well labeled. [NOTE: Any/all prescription medications must be in original pharmacy container with young person’s name on the prescription label. Non-prescription/over-the-counter medications must be in original container with young person’s name on the container.] I release and hold harmless St. Ann's Church, the Diocese of Orlando and any other religious, employees, volunteers, agents and representatives from any injury or harm resulting from administering the medication.
Medication
  •  
List Medication, Dosage and Administer
Medical Conditions Information-#3
(Reasonable steps will be taken to keep this information confidential, but it will be shared with Diocesan personnel and others, as warranted.)
My son/daughter is allergic to the following medications
  •  
My son/daughter has had an episode of the following or has been diagnosed with Seizures
  •  
My son/daughter has had an episode of the following or has been diagnosed with Asthma
  •  
My son/daughter has had an episode of the following or has been diagnosed a Diabetic
  •  
My son/daughter Has had allergic reactions to the following (foods, dyes, latex, etch
  •  
My son/daughter has had a medical surgery within the last six months?
  •  
My son/daughter is still under doctor's care?
  •  
My son/daughter has a medically prescribed diet (please explain)
  •  
My son/daughter has the following physical limitations
  •  
My son/daughter immunizations are current and up to date?
  •  
My son/daughter date of last tetanus/diphtheria immunization is  
  •  
You should also be aware of these special medical conditions of my child:
  •  
Insurance Information-Student #3
Do you carry medical insurance at this time?
  •  
Name of Insured:
  •  
Insurance Carrier:
  •  
Insurance Policy Number:
  •  
Name
  •  
In the event the participant does not have insurance, payment in full for medical care becomes the responsibility of the participant’s parent/guardian.
Image Release Form-Student #3
Message (Photography and Image Assignment Waiver, and Release) By typing my First and Last Name below, I for valuable consideration received, and for being allowed access to Diocesan property, activities, or events, expressly assign to Saint Ann Catholic Church and the Diocese of Orlando, and to all of their current, former, and future agents and related entities (collectively, “the Diocese”), all rights, title and interest in, and to, the use of my and my child/ward’s image or likeness, including, but not limited to all videotape recordings, photographs, or audio recordings of, or made by, me and/or my child/ward on Diocesan property, during a Diocesan-sponsored event, or for any other Diocesan purpose (“the Property”). The Diocese shall have, without my consent, the right to assign its rights in the Property, in whole or in part, to any entity, parish, or school within the Diocese of Orlando. I hereby irrevocably grant the Diocese perpetually and exclusively, the right to use and incorporate (alone or together with other materials), in whole or in part, the Property, in any Diocesan publication, news release, or for any other purpose. Further, I hereby authorize the reproduction, sale, lease, copyright, exhibition, broadcast and/or distribution of the Property without limitation for any purpose whatsoever, and I further waive all rights to any compensation for my and/or my child/ward’s appearance or participation in the Property. I understand and have been advised that photographs or videotape of participants may be used in publications, websites or other materials produced from time to time by the Diocese. Participants’ names would not be identified, however, without specific written consent. I further understand that the Diocese has no control over the use of photographs or film taken by media that may be covering the event in which my child(ren)/ward(s) participate(s). I hereby waive any claims against and release the Diocese, its current, former, and future religious, employees, volunteers, agents, and successors and assigns from and against any and all claims, demands, actions, causes of actions, suits, costs, expenses, liabilities, and damages whatsoever that I and/or my child/ward may have against the Diocese in connection with the Property or the use of the Property. This release shall not obligate the Diocese to use the Property or to use any of the rights granted hereunder, or to exhibit, distribute, or exploit the Property. I acknowledge that the Diocese cannot control all photographic access to its properties, and that my child/ward’s name may be printed with photos/images in various publications, including non-Diocesan publications. I represent that I am eighteen years of age or older, and that I have read and understand the terms of this Assignment, Waiver, and Release.
First and Last Name of Parent/Legal Guardian
  •  
Agreement: I agree that typing my First and Last name is the legally binding equivalent to my handwritten signature.
Safe Environment Program- L.I.F.E. Plus-Student #3
Message The Diocese of Orlando has implemented a child abuse awareness, prevention, and safety program in all parishes and Catholic schools as mandated by the United States Conference of Catholic Bishops (USCCB) in compliance with the Charter for the Protection of Children and Young People. Students enrolled in a Catholic School or parish-based catechesis are encouraged to participate in this programming. Our diocese is required, through an audit process, to verify to the USCCB that this training has been provided. We are also required to keep track of the number of students who are absent or whose parents do not allow them to participate in the training.
Safe Environment Program- L.I.F.E. Plus
  •  
A seperate selection must be made for each child. Thank you for your assistance.
Parent/Guardian First and Last Name
  •  
Agreement: I agree that typing my First and Last name is the legally binding equivalent to my handwritten signature.
Date //
  •  
Electronic Signature
I agree
  •  
I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document.
First and Last Name of Parent/Legal Guardian
  •  
AGREEMENT: By signing this Electronic Signature Acknowledment Form, I agree that my electronic signature is the leagally binding equivalent to my hand written signature. Whenever I execute an electronic signature it has the same validity and meaning as my handwritten signature for all areas of this registration form. I will not, in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not leagally binding. I acknowledge and warrant the truthfulness of the information povided in this form.
Date //
  •  
Questions or Comments
Please include any additional information we should know about your child.
  •  
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  •  
 
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