Holy Family Parish
5 Main Street
Russell, MA  01071
(413) 862-4418

Director:  Jo-Anne Auclair – 848-2029(home), 454-3878 (cell)
Assistant:  Kellye Dowd  - 862-0260 (home), 485-8889 (cell)

Academic year:  2012-2013
Registration fee:  $15 per student to assist with the expenses of the program.

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Both parents or guardians names
(if living with child(ren)):___________________________________________________

Full mailing address:_______________________________________________________

________________________________________________________________________

Home telephone:__________________________________________________________

Emergency contact and phone
(other than home/parent):___________________________________________________

Email address:____________________________________________________________

Would you be available to fill in as a substitute teacher on occasion?  ________________
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Student’s name:_________________________________  Grade to be enrolled in:______

Date of birth:__________________  Parish Baptized at:___________________________

Sacraments received (check all that apply): 
 Baptism:_____  Reconciliation:_____ First Holy Eucharist:_____ Confirmation:_______
 
Does this child have any special needs, dietary restrictions, or medical or physical limitations that we should be aware of?:
________________________________________________________________________
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(form continued on back to register additional child(ren))
Student’s name:_________________________________  Grade to be enrolled in:______

Date of birth:__________________  Parish Baptized at:___________________________

Sacraments received (check all that apply): 
 Baptism:_____  Reconciliation:_____ First Holy Eucharist:_____ Confirmation:_______
 
Does this child have any special needs, dietary restrictions, or medical or physical limitations that we should be aware of?: __________________________________________________________
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Student’s name:_________________________________  Grade to be enrolled in:______

Date of birth:__________________  Parish Baptized at:___________________________

Sacraments received (check all that apply): 
 Baptism:_____  Reconciliation:_____ First Holy Eucharist:_____ Confirmation:_______
 
Does this child have any special needs, dietary restrictions, or medical or physical limitations that we should be aware of?:________________________________________
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Student’s name:_________________________________  Grade to be enrolled in:______

Date of birth:__________________  Parish Baptized at:___________________________

Sacraments received (check all that apply): 
 Baptism:_____  Reconciliation:_____ First Holy Eucharist:_____ Confirmation:_______
 
Does this child have any special needs, dietary restrictions, or medical or physical limitations that we should be aware of?: _______________________________________
************************************************************************
Student’s name:_________________________________  Grade to be enrolled in:______

Date of birth:__________________  Parish Baptized at:___________________________

Sacraments received (check all that apply): 
 Baptism:_____  Reconciliation:_____ First Holy Eucharist:_____ Confirmation:_______
 
Does this child have any special needs, dietary restrictions, or medical or physical limitations that we should be aware of?: _______________________________________