St. Mary & Sacred Heart Parishes
Parish School of Religion
2010 - 2011
Registration
(Please Print)
Name of Child:___________________________________________________________
Grade:_______________
Church of Baptism: Name of Church:___________________________________
City and State:_____________________________________
Year of Baptism:__________________________________________________________
Parents’ Names:__________________________________________________________
Address:_____________________________________________________________
___________________________________________________________
Telephone:___________________________________________________________
Registered Member of:
St. Mary _____ Sacred Heart _____
Other:______________________________________
Emergency Contact (other than parents):
Contact:_____________________________________________________________
Telephone:___________________________________________________________
Name of Family Physician:______________________________________________
Pertinent Medical Information: ___________________________________________
___________________________________________
Annual fee is $50.00 per child; not to exceed $100.00 per family.
Please enclose the fee and mail the registration to the Parish Office: 231
Washington Avenue, Urbana, OH 43078 or drop in the collection basket by
September 1. If you are unable to pay the fee, please contact Fr. Konerman:
653-1375. Make checks payable to St. Mary Church.