Saint Pope John XXIII PSR Student Registration 2025-2026

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Please register each child individually.
If the question does not apply to you please type "None or N/A" in the box.

Student Last Name *

Student First Name *

Date of Birth *

Primary Email Address *

Main communication for all PSR information and updates.

Primary Phone Number *

Second Phone Number *

Student's Primary Home Address *

New or returning student? *

New

Returning

What class will this student participate in? *

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

7th Grade

8th Grade

School Attending *

What school does this student attend?

Student resides with *

Who does this student live with?

Both Parents

Mother Only

Father Only

Mother & Stepfather

Father & Stepmother

Guardian

Mother's Name *

Mother's Phone Number *

If different from primary phone number

Mother's Address *

If different from student's primary address.

Mother's Email Address *

If different from primary email address

Mother's Religion *

Mother's Occupation *

Father's Name *

Father's Phone Number *

If different from primary number

Father's Address *

If different than student's primary address.

Father's Email Address *

If different from primary email address

Father's Religion *

Father's Occupation *

Other Emergency Contact Name *

In the event of an emergency, whom should we contact other than yourself?

Other Emergency Contact Phone Number *

Please Type Phone Number

Sacraments *

Check each sacrament that this student has completed.

Baptism

Reconciliation

Eucharist/Communion

Confirmation

Other

Required

Sacramental Preparation

If applicable, check if this student is participating in a sacramental preparation class this year.

First Reconciliation and First Eucharist/Communion

Confirmation

If this student has any allergies, medical conditions or special needs of which we should be aware of, please list and explain. *

Affirmation of Parent/Guardian Responsibilities *

As the primary instructor of your child's Catholic education and formation, you are committed to full and active participation in your child's faith development and promise to promote Catholic Church teachings and Christian values. Please check each box showing your acknowledgement of the following:

Weekly attendance and participation at Saturday/Sunday and Holy Day Masses.

Making attendance at Sunday morning PSR sessions a priority in my child's life.

Participating in the parish's liturgical, service and social activities.

Praying daily for my child, family, friendships and parish community.

Consistently modeling a Christian lifestyle through my actions and deeds.

Required

Name of person completing this form. *

Include full name.

Date Completed *

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