Family Last Name  
Street Address  
Apt #  
City  
State  
Zip Code  
Home Telephone Number  
_______________________________________________________________

Mr.
First Name Middle Name Last Name (if different from Family Last Name)  
Nickname
Cell Phone Number Work Phone Number  
E-Mail Address  
Birth Date (mm/dd/yyyy) Sex MF   Marital Status Choose Married Single Widow/Widower Separated Divorced
Occupation
Religion Choose Catholic Baptist Episcopalian Lutheran Methodist Presbyterian Jewish Muslim None Other   Church Attendance Choose Weekly Occasionally Seldom Does Not Attend
Check Sacraments Received: Baptism Confirmation Communion
Special None Blind Deaf Physical Disability Mental Disability Developmental Disability
_______________________________________________________________

Title: Mrs. Ms. Miss
First Name Middle Name Last Name (if different from Family Last Name)  
Nickname
Maiden Name  
Cell Phone Number Work Phone Number  
E-Mail Address  
Birth Date (mm/dd/yyyy) Sex MF   Marital Status Choose Married Single Widow/Widower Separated Divorced
Occupation
Religion Choose Catholic Baptist Episcopalian Lutheran Methodist Presbyterian Jewish Muslim None Other   Church Attendance Choose Weekly Occasionally Seldom Does Not Attend
Check Sacraments Received: Baptism Confirmation Communion
Special None Blind Deaf Physical Disability Mental Disability Developmental Disability

If applicable: Date of Marriage (mm/dd/yyyy) Church of Marriage  
If non-catholic Church, did you have permission of the Roman Catholic Church? Yes No  
_______________________________________________________________

Other Members of Household 

1.
 First Name Middle Name Last Name (if different from Family Last Name)  
Nickname
Cell Phone Number Work Phone Number  
E-Mail Address  
Birth Date (mm/dd/yyyy) Sex MF   Marital Status Choose Married Single Widow/Widower Separated Divorced
Occupation or School & Grade
Religion Choose Catholic Baptist Episcopalian Lutheran Methodist Presbyterian Jewish Muslim None Other   Church Attendance Choose Weekly Occasionally Seldom Does Not Attend
Check Sacraments Received: Baptism Confirmation Communion
Special None Blind Deaf Physical Disability Mental Disability Developmental Disability
_______________________________________________________________
2. 
First Name Middle Name Last Name (if different from Family Last Name)  
Nickname
Cell Phone Number Work Phone Number  
E-Mail Address  
Birth Date (mm/dd/yyyy) Sex MF   Marital Status Choose Married Single Widow/Widower Separated Divorced
Occupation or School & Grade
Religion Choose Catholic Baptist Episcopalian Lutheran Methodist Presbyterian Jewish Muslim None Other   Church Attendance Choose Weekly Occasionally Seldom Does Not Attend
Check Sacraments Received: Baptism Confirmation Communion
Special None Blind Deaf Physical Disability Mental Disability Developmental Disability
_______________________________________________________________
3. 
First Name Middle Name Last Name (if different from Family Last Name)  
Nickname
Cell Phone Number Work Phone Number  
E-Mail Address  
Birth Date (mm/dd/yyyy) Sex MF   Marital Status Choose Married Single Widow/Widower Separated Divorced
Occupation or School & Grade
Religion Choose Catholic Baptist Episcopalian Lutheran Methodist Presbyterian Jewish Muslim None Other   Church Attendance Choose Weekly Occasionally Seldom Does Not Attend
Check Sacraments Received: Baptism Confirmation Communion
Special None Blind Deaf Physical Disability Mental Disability Developmental Disability
_______________________________________________________________
4. 
First Name Middle Name Last Name (if different from Family Last Name)  
Nickname
Cell Phone Number Work Phone Number  
E-Mail Address  
Birth Date (mm/dd/yyyy) Sex MF   Marital Status Choose Married Single Widow/Widower Separated Divorced
Occupation or School & Grade
Religion Choose Catholic Baptist Episcopalian Lutheran Methodist Presbyterian Jewish Muslim None Other   Church Attendance Choose Weekly Occasionally Seldom Does Not Attend
Check Sacraments Received: Baptism Confirmation Communion
Special None Blind Deaf Physical Disability Mental Disability Developmental Disability

If there are additional members of the household, enter them on the page after you submit this page.

Enter the Family Last Name then the additional members in the Other Members section.