WE ARE UNABLE TO ACCEPT ON-LINE REGISTRATIONS. PLEASE FOLLOW DIRECTIONS BELOW.

• Return this form and a check for $60 to: Family Life Office, 222 N. 17th Street, Philadelphia, PA 19096-3069 (215-587-5639).
• Financial Assistance is available. Please call for information.

1st Choice Group #		2nd Choice Group #
Female Name:		Male name :
Address:		Address:
City/State/Zip:		City/State/Zip:
Phone (day) :		Phone (day) :
Phone (evening) :		Phone (evening):
Parish:		Parish:
Office use
Date Application Received: Payment # Amount Confirmed