FAMILY INFORMATION:  When sending mail, address to?
Circle One:  Mr. & Mrs., Mr., Mrs.     Other __________
NAME: ___________________________________
ADDRESS: ___________________________________
P.O. BOX: ___________________________________
CITY:  _______________________________, NY
ZIP CODE: ___________________________________
HOME PHONE #: _____________________________
UNLISTED: Circle One: YES   /   NO
REGISTERED AT THIS CHURCH? Circle One:  YES   /   NO

BIRTH PARENT INFORMATION:_____________

FATHER'S NAME: _____________________________	MOTHER'S NAME: ________________________
BUSINESS: ___________________________________	MAIDEN NAME: ________________________
BUS. PHONE: _(____)___________________	BUSINESS: ______________________________
RELIGION: _________________________	BUS. PHONE: _(____)_____________
MARITAL STATUS:  ___________________	RELIGION: ___________________
Write "Same" if address in the Family Info mailing address above can be used.	MARITAL STATUS: _____________
ADDRESS: ___________________________________	ADDRESS: _______________________________
CITY:  _________________________  STATE: _______	CITY:  _____________________  STATE: _____
HOME PHONE: _(___)____	HOME PHONE:  __(____)_______________

GUARDIAN INFORMATION:
Write "Same" if address in the Family Info mailing address above can be used.
NAME:  _______________________________________ RELATIONSHIP:  __________________________
ADDRESS:  _______________________________________________________
CITY:  _________________________  STATE: _______ ZIP CODE:______________
HOME PHONE:  __(_____)________________  BUSINESS PHONE:  __(____)_______________

EMERGENCY INFORMATION:
In the event of an emergency, if you are unable to reach me, please contact the following:
NAME:  _______________________________________ RELATIONSHIP:  __________________________
ADDRESS:  _______________________________________________________________________________
HOME PHONE:  _(____)__________________  BUSINESS PHONE:  _(____)_____________
STUDENT'S DOCTOR:  ___________________________ DOCTOR'S PHONE:  __(____)____________
Authorization to act in the event of an emergency:  YES ___     NO ___
I understand that if any information on this registration should change, it is my responsibility to inform PSR.
Signature:  ___________________________  DATE:  _______________