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* 1. Information about the child receiving Reconciliation/1st Eucharist:

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* 2. Parent Information:

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* 3. Registered at Church of St. Therese?(If not, please fill out and turn in a registration form to office or Dianne Bailey)

Please provide a copy of Baptismal Certificate with notations that include date and place of First Eucharist by 1 January 2019.

Participation in workshops constitutes your permission for your photograph or likeness to be used on our church website or for publicity purposes.

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* 4. FOR OFFICE USE ONLY:

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