**NOTE** If you are already registered for PREP Classes,
and just need to make your tuition deposit, please click here.

Please complete the form below or click here for a printable version you can complete and mail or fax to:
Saint Miriam Parish · 654 Bethlehem Pike · Flourtown, Pennsylvania · 19031 · Fax 215-701-4781

Registration for Religious Education (PREP)

Name *

Middle Name

Preferred Name

Please note: If the name given above is not the child’s legal name, for whatever reason, such as pending adoption, change in custody, etc., please provide the actual legal name for this child to ensure we are in full compliance with the security and insurance needs of the parish and our educational program. This name will not be used if you so desire. Please check the box below.

Legal Name

Legal Middle Name

I do not wish this name to be used

I do wish this name to be used

Age *

Birthdate *

Grade in Fall of Current Year *

Address *

Country

City

State

Zip code

Sacraments of Initiation Received

Baptism

Yes

Date

Church

God Mother

God Father

Confirmation

Yes

Date

Church

Eucharist

Yes

Date

Church

Parent/Guardian Information

Parent/Guardian #1

Address

Fill out only if this is different from the child's main address.

Country

City

State

Zip code

Email *

Home Phone *

Cell Phone

Parent/Guardian #2

Is this address the same as Parent/Guardian #1?

Yes

Address (Parent/Guardian #2)

Country

City

State

Zip code

Home Phone (Parent/Guardian #2)

Cell Phone (Parent/Guardian #2)

Special Needs, Medical Conditions (If Applicable)

Please enter any special needs that your child may have and/or your comments:

Captcha *

reCAPTCHA is required.

Parish Religious Education Program = *

To confirm your registration, please input the acronym that is used at Saint Miriam for the Parish Religious Education Program.