Reconciliation and First Communion Sacrament Request Form

Thank you for requesting the sacraments of Reconciliation and First Eucharist for your child/children!  Below you will find the registration and payment form. The fee covers both the Reconciliation and First Eucharist programs.  **No child will ever be denied a Sacrament due to financial difficulty.** If you require financial assistance please do not fill out this form and contact Terri Telepak in the parish office.

Child 1 Sacramental Information
Child's Name
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Please fill in your child's name as it is listed on their Baptismal Certificate.
Date of Birth //
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City
State
Saint Raphael School/or PSR Teacher and Room Number Please select your child's Saint Raphael School or PSR teachers name and room number.
Additional Information for Non-PSR and Non-SRS Students **If your child does NOT attend St. Raphael School or PSR, list school/grade.**
Is your child Roman Catholic?
Church of Baptism **If your child was NOT baptized at Saint Raphael Parish or attends a school other than Saint Raphael School we need a copy of your child's baptismal certificate.**
City of Church
State of Church
Denomination
Date of Baptism //
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Child 2 Sacramental Information
Please make sure to fill in all fields for your application to be complete. You may skip this section if you only have one child to register.
Child's Name
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Please fill in your child's name as it is listed on their Baptismal Certificate.
Date of Birth //
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City
State
Saint Raphael School/or PSR Teacher and Room Number Please select your child's Saint Raphael School or PSR teachers name and room number.
Additional Information for Non-PSR and Non-SRS Students **If your child does NOT attend St. Raphael School or PSR, list school/grade.**
Is your child Roman Catholic?
Church of Baptism **If your child was NOT baptized at Saint Raphael Parish or attends a school other than Saint Raphael School we need a copy of your child's baptismal certificate.**
City of Church
State of Church
Denomination
Date of Baptism //
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Family Information
Please provide information as provided on the Baptismal Certificate.
Father's Name
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Mother's Maiden Name
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Is your family a member of Saint Raphael Parish?
Address
Parent's E-mail
Child lives with (if different from above)
Sacrament Preparation Statement
Sacraement Preparation Statement Our Family will spend time together attending Mass and learning more about the Sacraments of Reconciliation and First Eucharist this year. We understand that the meetings, retreats and celebrations for parents and children are part of the required preparation for these sacraments.
Parent/Guardian Signature
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Parent Consent Statement “By typing my name below, which shall constitute my electronic signature, I acknowledge that I am the parent or legal guardian of the above named Child(ren) and have the authority to sign this document and act on his/her or their behalf. I agree that my electronic signature is intended to authenticate this writing and to have the same force and effect as my manual signature. As the parent or legal guardian of the student(s) listed above, my signature constitutes my acknowledgement and agreement to all of the foregoing terms.” :
Name
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Sacrament Materials Fee
This fee covers both the First Reconciliation and First Eucharist programs and their materials.
Sacrament Materials Fee-First Reconciliation and First Eucharist **If this is a financial hardship, please contact Terri Telepak in the parish office for special consideration.**  
Selection Extended

Sacrament Materials Fee Single Child | $50.00

Sacrament Materials Fee Twin Fee | $75.00

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Discount Code Discount code provided by the parish office to families in need of financial assistance.

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