PARISH REGISTRATION FORM If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required FAMILY REGISTRATION INFORMATION Last Name * First Name * Address 1 * Address 2 City * State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code * Phone * Emergency Phone * Family Email Choice of Tithing EnvelopesCollection BasketOn-Line Giving INDIVIDUAL MEMBER INFORMATION Adult 1 First Name/Nickname * Adult 1 Role (Head of House, Husband, Wife, etc.) Adult 1 Gender MaleFemale Adult 1 Maiden Name (if applicable) Adult 1 Date of Birth Adult 1 Email Adult 1 Work Phone/Cell Phone Adult 1 First Language Adult 1 Occupation/Employer Adult 1 Sacramental Information: Adult 1 Catholic? YesNo Adult 1 Marital Status (Single, Married, Separated, Divorced) Adult 1 Valid Catholic Marriage? YesNo If yes, list name of church, city, and state. If no, list name of place, city, and state. (Examples: name of Christian church, city hall, park, house address, etc.) Adult 1 Marriage Date Adult 1 Baptized? YesNo Adult 1 Baptism Date Adult 1 First Reconciliation? YesNo Adult 1 First Eucharist YesNo Adult 1 First Eucharist Date Adult 1 Confirmed? YesNo Adult 1 Confirmed Date Adult 2 First Name/Nickname Adult 2 Role (Husband, Wife, etc) Adult 2 Gender MaleFemale Adult 2 Maiden Name (if applicable) Adult 2 Date of Birth Adult 2 Email Adult 2 Work Phone/Cell Phone Adult 2 First Language Adult 2 Occupation/Employer Adult 2 Catholic? YesNo Adult 2 Marital Status (Single, Married, Separated, Divorced) Adult 2 Valid Catholic Marriage? YesNo If yes, list name of church, city, and state. If no, list name of place, city, and state. (Examples: name of Christian Church, city hall, park, home address, etc.) Adult 2 Baptized? YesNo Adult 2 Baptism Date Adult 2 First Reconciliation? YesNo Adult 2 First Eucharist? YesNo Adult 2 First Eucharist Date Adult 2 Confirmed? YesNo Adult 2 Confirmed Date Are there any members of your household who would like to be visited by a priest? YesNo DEPENDENT CHILDREN More Than 4 Children? (If you have more than four children; after checking the box below, go directly to the bottom of this form and click the submit button. To complete the registration process please call the Parish Office at 715-352-3011.) Child 1 First Name Child 1 Last Name Child 1 Gender MaleFemale Child 1 Birth Date Child 1 School Grade/Year Child 1 First Language Child 1 is Catholic? YesNo Check Sacraments Child 1 Received BaptismEucharistReconciliationConfirmation Child 1 Baptism Date Child 1 First Reconciliation Date Child 1 First Eucharist Date Child 1 Confirmation Date Child 2 First Name Child 2 Last Name Child 2 Gender MaleFemale Child 2 Birth Date Child 2 School Grade/Year Child 2 First Language Child 2 is Catholic? YesNo Check Sacraments Child 2 Received BaptismEucharistReconciliationConfirmation Child 2 Baptism Date Child 2 First Reconciliation Date Child 2 First Eucharist Date Child 2 Confirmation Date Child 3 First Name Child 3 Last Name Child 3 Gender MaleFemale Child 3 Birth Date Child 3 School Grade/Year Child 3 First Language Child 3 is Catholic? YesNo Check Sacraments Child 3 Received BaptismEucharistReconciliationConfirmation Child 3 Baptism Date Child 3 First Reconciliation Date Child 3 First Eucharist Date Child 3 Confirmation Date Child 4 First Name Child 4 Last Name Child 4 Gender MaleFemale Child 4 Birth Date Child 4 School Grade/Year Child 4 First Language Child 4 is Catholic? YesNo Check Sacraments Child 4 Received BaptismEucharistReconciliationConfirmation Child 4 Baptism Date Child 4 First Reconciliation Date Child 4 First Eucharist Date Child 4 Confirmation Date Confirm that you are not a bot *
