First Communion Form ___________ PRINT ONLY FORM ______________

Saint Mary’s Parish Church

CCD Religious Education Office

Dear Parents of First Communicant, the following information is required (Please print):

Name of Child: First: _____________Middle:________Last:____________________

Date of Birth: Month: _____________Day:__________Year:___________

Place of Birth: Town - City: __________________State: ________________________

Baptismal Information: Name of church: _____________________________________

Street Address: __________________________________________

Town - City: _____________________State: ____________ Zip: _________

Date of Baptism: _________________

If your child was not BAPTISED in our parish, a certificate of Baptism is required. If your child received Baptism in our parish, please supply the exact date of Baptism. Validation of church Baptismal Register will be done by Parish Office staff given the date of Baptism and information below:

Name of Father: First: __________Middle: _________Last: _____________________

Mother’s Maiden Name: First: __________Middle: ______Last: __________________

Parent or Guardian: Name (If different from above): ___________________________

Street Address: __________________________________Apt. No.: ___________

Town - city: _______________________State: ______________ Zip: _________

Please return this form, with Baptismal Certificate if required, to CCD Office, Immaculate Conception of the Blessed Virgin Mary Church, 1730 Fowler Avenue, Berwick, PA 18603-1462, and telephone: (570) 759-9225