St. Mary of the Assumption Church, Brookline, MA



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Religious Education Registration Grades K - 8

Students Name:

Address:

City:

State: Zip code:

Email:

Phone:

Date of Birth

City of Birth:

School:

Grade:

Current Church?
St. Mary's St Lawrence's

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 Penance? Yes No

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

(If student received First Eucharist here, the record of Baptism should be on
file. If not, a currently dated record of Baptism must be provided by you!)

Parent(s)/Guardian(s)
Full Name(s)	Parents Religion	Phone(s)


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

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
religious education program?