St. Mary of the Assumption Church, Brookline, MA

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Religious Education Registration Grades 9-10

Students Name:

Address:

City:

State: Zip code:

Email:

Phone:

Date of Birth

Did the student receive Baptism at St. Mary's? Yes No

If no, please provides Baptism info:

Name of Church:

Church Address:

City:

State: Zip code:

Date of Baptism:

Did the student receive First Communion at St. Mary's? Yes No

Did the student attend a Catholic grammar school? Yes No

Did the student attend CCD? Yes No | Grades attended:

CCD at St Mary's? Yes No | Grades attended:

Parent(s)/Guardian(s)
Full Name(s)	Phone(s)	Email(s)


Person to contact in case of an emergency:
Full Name(s)	Phone(s)	Relationship to student

School:

Name of high school the student attends:

Please indicate any activities or sports that the student
participates in:

Will these activities conflict with Confirmation
class attendance? (Sundays 10:30-11:30am) Yes No

Medical:

Does the student have any special medical needs?

Is the student taking any medications? Yes No

If so, please provide name of medication and dosage:

Do you have any additional concerns regarding the student
you are registering for Confirmation preparation?