PSR - 1st Reconciliation/1st Eucharist
Please list all names as appears on birth certificate as we need legal names.
Please carefully fill in all information.
Name of Student FIRST MIDDLE LAST Jr./Sr./III
Date of Birth
City & State of Birth
Date of Baptism
Church, City & State of Baptism
Grade Level Entering Fall of 2022
List grade and elementary schools attended thus far
List name of church parish & grade levels student attended Parish School of Religion
Father's Name FIRST MIDDLE LAST Jr./Sr./III
Father's Home Phone
Father's Email Address
Father's Church Parish
Mother's Name FIRST MIDDLE MAIDEN LAST
Mother's Address (if different from fathers)
Mother's Home Phone
Mother's Email Address
Mother's Church Parish
Guardian's Name FIRST MIDDLE LAST
Guardian's Home Phone
Guardian's Work Phone
Guardian's Cell Phone
Guardian's Email Address
Guardian's Church Parish
EMERGENCY MEDICAL TREATMENT
In an event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical
or surgical treatment. In the event of an emergency, if you are unable to reach me at the above number, contact:
Health Plan Carrier
Please indicate the date of the meeting that you plan to attend.
To complete your registration, your signature on the above information is required.
Your registration fee (check please) is due at the meeting.
You will receive your printed form at the Registration Meeting to review and sign.