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First Communion Request Form

- Parish Life
  - Ministries
    
    Parish Ministries
    Worship Ministries
    Music Ministries
    Youth Ministry
    Outreach Ministries
    Stephen Ministry
  - Faith Formation
    
    Religious Education
    
    First Communion Request Form
    
    RCIA
    Faithful In All Things: Women's Prayer and Reflection
    St. Andrew School of Evangelization
    Protecting God's Children
  - Sacraments
    
    Baptism
    Eucharist
    Reconciliation
    Confirmation
    Marriage
    Holy Orders
    Anointing of the Sick

SS. John & Bernard Parish 2022-2023
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- Child Name (Last, First, Middle) REQUIRED Please fill out this field. Please enter valid data.
- Mailing Address - Street (Apt. or Lot #) REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Home Phone Maximum 20 characters Please enter a phone number.
- Cell Phone - Mother Maximum 20 characters Please enter a phone number.
- Cell Phone - Father Maximum 20 characters Please enter a phone number.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- City & State of Birth Please enter valid data.
- Father's Full Name (Birth Father or Legally Adoptive Father) Please enter valid data.
- Mother's Full Name (Birth Mother or Legally Adoptive Mother) INCLUDE MAIDEN NAME Please enter valid data.
- Baptismal Information
  
  Date of Baptism / Year of Baptism Please enter valid data.
  
  Name of Baptismal Church Please enter valid data.
  
  Address of Baptismal Church - Street Please enter valid data.
  
  Address of Baptismal Church - City, State, Zip Please enter valid data.
- For any child NOT baptized at SS. John & Bernard Parish: Please submit a copy of your child’s baptismal certificate to the Parish Office. If you do not have a copy of the Baptismal Certifcate you must obtain proof of baptism in order to receive the sacrament. Please do so as soon as possible and have it sent to the SS. John & Bernard Parish Office.
- 2022-2023 Grade: Please enter valid data.
- Registered Member of SS. John & Bernard Parish? REQUIRED Please fill out this field.
- Registered Member of: (list parish if not SS. John & Bernard) *You must obtain a letter of permission in order to receive the sacrament of communion with us. Please gather this letter as soon as possible from your home parish. Please enter valid data.
- Emergency Contacts:
  
  Name & Phone Number Please enter valid data.
  
  Name & Phone Number Please enter valid data.
- Medical Treatment Authorization
  As a parent/guardian, I do hereby authorize the treatment of my minor child/children listed below by a qualified and licensed physician of any condition which, in the opinion of the physician, is deemed necessary and appropriate. This authority is granted only after a reasonable effort has been made to reach me.
  
  I further authorize the person who presents the minor to sign the Acknowledgment of Receipt of Notice of Privacy Rights that may be presented by the physician or health care facility.
  
  This authorization is completed and signed of my own free will with the sole purpose of authorizing medical treatment deemed necessary and appropriate by the treating physician due to injury or illness sustained during religious education classes, testing, and/or activities by SS. John & Bernard Parish Religious Education Program.
- Child: Medical Info (If your child has a learning disability that requires an IEP in their public school setting, please indicate that here.)
  
  Name of Child Please enter valid data.
  
  List of Allergies, Medications, or Other Pertinent Information Please enter valid data.
- Health Insurance Information:
  
  Company: Please enter valid data.
  
  Group #: Please enter valid data.
  
  Policy #: Please enter valid data.
  
  ID #: Please enter valid data.
  
  Family Physician - Name: Please enter valid data.
  
  Family Physician - Phone: Please enter valid data.
  
  Family Physician - Address: Please enter valid data.
  
  Date: Please enter valid data.
  
  Parent Signature: (typing in your name below will act as your signature) Please enter valid data.
- *If there are any custodial/legal rights of parents and/or guardians that we should be made aware of or if you wish your child to be picked up by an adult other than a legal parent, please notify us in writing.
- Photo Release:
  With my signature, I hereby grant permission to SS. John & Bernard Parish to publish my child’s/children’s names, photos, or video images in connection with a display, feature story, or other publication as deemed appropriate by the Parish. This photo may be used in connection with parish bulletin boards, parish or youth ministry websites, publicity materials, and/or parish bulletins.
- Permission is granted by: (typing in your name below will act as your signature) Please enter valid data.
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