Online Registration 2020-2021

Father/Guardian Information:

Name Please enter valid data.
Primary/Home Phone Number Please enter a phone number.
Cell Phone Number Please enter a phone number.

Mother/Guardian Information:

Name Please enter valid data.
Maiden Name Please enter valid data.
Primary/Home Phone Number Please enter a phone number.
Cell Phone Number Please enter a phone number.

Primary Email (for teacher or office to use as a contact): Please enter an email address.

Mailing Address 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.

Call first REQUIRED Mother Father Please fill out this field.

I agree that the to the best of my knowledge the information on this form is accurate and true. I also agree that I have received and read a copy of the policies and procedures for faith formation classes, events & activities.

I Agree Please select this field.

Emergency Contact Information

If we are unable to reach you in an emergency, who should we contact instead:
First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Emergency Contact Phone Number REQUIRED Please fill out this field. Please enter a phone number.
Relationship Please enter valid data.

AUTHORIZED PICKUP: If registering a student grades 1-5 for a classroom program, please list 2 individuals other than parents that are authorized to pick up your child.
Name of Authorized Person Please enter valid data.
Phone Number Please enter a phone number.
Name of Authorized Person Please enter valid data.
Phone Number Please enter a phone number.

PHOTOGRAPH PERMISSION: Photographs are sometimes taken during faith formation sessions and events. They are displayed publically; i.e. on the parish website, parish facebook page, newspaper, brochure, bulletin boards, etc. and used to keep the community aware and informed of parish events and activities. If you do not want images taken and used as described, please send written notice to that effect to Michael Coughlin at the Parish Office, 16 Baboosic Lake Road, Merrimack NH 03054.
Please list below any circumstances that the teacher should be made aware of that might affect your child's abilities or behavior in the classroom - i.e. learning disabilities, hyperactivity, speech problems, medical issues, etc. Please be sure to identify the family member(s) to which the circumstances apply. (This information is kept confidential and is given only to the teacher and aide.)
Does your child receive professional support at school for developmental needs? If YES, a parent may be required to attend classes if needed. REQUIRED YES NO Please fill out this field.
MEDICAL FORMS: If your child carries an epi-pen, inhaler or other medical equipment with them during a session or event, please call Michael Coughlin, the Director of Parish Faith Formation Programs at 424-4477.

Student #1:

Name REQUIRED Please fill out this field. Please enter valid data.
Grade as of September REQUIRED Please fill out this field. Please enter an integer (number).
Date of Birth REQUIRED Please fill out this field. Please enter a date.
Class Selection REQUIRED Please fill out this field.
Received Baptism? REQUIRED YES NO Please fill out this field.
First Eucharist Received? REQUIRED YES NO Please fill out this field.
Confirmation Received? REQUIRED YES NO Please fill out this field.
Name of School Currently Attending Please enter valid data.

Student #2:

Name Please enter valid data.
Grade as of September Please enter an integer (number).
Date of Birth Please enter a date.
Class Selection
Baptism Received? YES NO
First Eucharist Received? YES NO
Confirmation Received? YES NO
Name of School Currently Attending: Please enter valid data.

Student #3:

Name Please enter valid data.
Grade as of September Please enter an integer (number).
Date of Birth Please enter a date.
Class Selection
Baptism Received? YES NO
First Eucharist Received? YES NO
Confirmation Received? YES NO
Name of School Currently Attending: Please enter valid data.

Student #4:

Name Please enter valid data.
Grade as of September Please enter an integer (number).
Date of Birth Please enter a date.
Class Selection
Baptism Received? YES NO
First Eucharist Received? YES NO
Confirmation Received? YES NO
Name of School Currently Attending: Please enter valid data.

Our Lady of Mercy Church

16 Baboosic Lake Road, Merrimack NH - (603) 424-3757

Online Registration 2020-2021