PSR - 1st Reconciliation/1st Eucharist
Registration Form
Please list all names as appears on birth certificate as we need legal names.  
Please carefully fill in all information.

Registering for

​STUDENT 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 2020                          ​    

    School Registered

    List grade and elementary schools attended thus far



    List name of church parish & grade levels student attended Parish School of Religion




PARENT/GUARDIAN INFORMATION        

    Father's Name                FIRST       MIDDLE        LAST         Jr./Sr./III

​ 
            Father's Address

            Father's Home Phone

            Work Phone

            Cell Phone
         
            Father's Email Address

            Father's Religion

            Father's Church Parish

    Mother's Name              FIRST       MIDDLE        MAIDEN        LAST


            Mother's Address (if different from fathers)

            Mother's Home Phone

            Work Phone

            Cell Phone

            Mother's Email Address

​            Mother's Religion

            Mother's Church Parish

​   Guardian's Name             FIRST       MIDDLE        LAST


            Guardian's Address

            Guardian's Home Phone

             Guardian's Work Phone

             Guardian's Cell Phone

            Guardian's Email Address                             

            Guardian's Religion

            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:

    Name

    Relationship                                         

    Phone

    Doctor                                                               

    Phone

    Health Plan Carrier                                                                       

    Policy Number

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.