NAME OF PROPOSED SERVER (PLEASE PRINT):

______________________________________________________________________

ADDRESS: Street: __________________________________________________

Town: _________________________State/Zip: _______________

Telephone Number: _________________________________________________

E-Mail Address at which we can reach you or your family: (Please Print)

______________________________________________________________________

Grade in School: _____________ Date of Birth: ______________________

Are you in the St. Susanna Religious Education Program? Yes ____ No ____

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Each Altar Server must have a Responsible Parent, who agrees to help the server with putting assignments on the calendar, transportation to church, calling for a replacement if necessary, and related tasks.

Name of Responsible Parent (Please Print):

_____________________________________________________________________

E-mail address at which we can reach you:

_____________________________________________________________________

Telephone number(s) at which we can reach you:

Home: _________________________ Cell: _____________________________

Signature of Proposed Applicant: ___________________________________

Signature of Responsible Parent: ____________________________