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Mailing Name (ie Mr. & Mrs. John Doe)

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone Number*

Emergency Phone

Individual Member Information

First Name*

Last Name*

Maiden Name (if applicable)

Role (Head of House, Husband, Wife etc.)

Parish Status

Active

Inactive

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Date of Birth*

MM slash DD slash YYYY

Gender*

Male

Female

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Email

Cell Phone

First Language

Birth Place

Occupation/Employer

Sacramental Info

Catholic

Please select all that apply

Baptism? Yes or No. If yes, please provide date (mm/dd/yyyy)

First Eucharist? Yes or No. If yes, please provide date (mm/dd/yyyy)

Reconciliation? Yes or No. If yes, please provide date (mm/dd/yyyy)

Confirmed? Yes or No. If yes, please provide date (mm/dd/yyyy)

Marital Status

Single

Married

Separated

Divorced

Annulled

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Valid Catholic Marriage

Yes

No

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Are there any members of your household who would like to be visited by a priest?

Individual Member #2

Member #2 Name*

First Last

Maiden Name (if applicable)

Role (Head of House, Husband, Wife, etc)

Parish Status

Active

Inactive

Select one

Date of Birth*

MM slash DD slash YYYY

Gender*

Male

Female

Select One

Email

Cell Phone*

First Language

Birth Place

Occupation/Employer

Sacramental Info

Catholic

Please select all that apply

Baptism? Yes or No. If yes, please provide date (mm/dd/yyyy)

First Eucharist? Yes or No. If yes, please provide date (mm/dd/yyyy)

Reconciliation? Yes or No. If yes, please provide date (mm/dd/yyyy)

Confirmed? Yes or No. If yes, please provide date (mm/dd/yyyy)

Marital Status

Single

Married

Separated

Divorced

Annulled

Select all that apply

Valid Catholic Marriage

Yes

No

Select one

Dependent Children/ Other Household Members

Dependent #1

First Last

Relationship to Head of Household (Son, Daughter, Mother, Father, etc)

Gender

Male

Female

Select one

Birthplace/ Date of Birth (mm/dd/yyyy)

High School Name/ Graduation Year

First Language

Check if Sacrament Received

Catholic

Reconciliation

Baptism

First Eucharist

Confirmation

Select all that apply

Baptism Date (if known mm/dd/yyyy)

First Eucharist Date (if known mm/dd/yyyy)

Reconciliation Date (if known mm/dd/yyyy)

Confirmation Date (if known mm/dd/yyyy)

Dependent #2

First Last

Relationship to Head of Household (Son, Daughter, Mother, Father, etc)

Gender

Male

Female

Select one

Birthplace/ Date of Birth (mm/dd/yyyy)

High School Name/ Graduation Year

First Language

Check if Sacrament Received

Catholic

Reconciliation

Baptism

First Eucharist

Confirmation

Select all that apply

Baptism Date (if known mm/dd/yyyy)

Reconciliation Date (if known mm/dd/yyyy)

First Eucharist Date (if known mm/dd/yyyy)

Confirmation Date (if known mm/dd/yyyy)

Dependent #3

First Last

Relationship to Head of Household (Son, Daughter, Mother, Father, etc)

Gender

Male

Female

Select one

Birthplace/ Date of Birth (mm/dd/yyyy)

High School Name/ Graduation Year

First Language

Check if Sacrament Received

Catholic

Reconciliation

Baptism

First Eucharist

Confirmation

Select all that apply

Baptism Date (if known mm/dd/yyyy)

Reconciliation Date (if known mm/dd/yyyy)

First Eucharist Date (if known mm/dd/yyyy)

Confirmation Date (if known mm/dd/yyyy)

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