Parish Registration Form

Registration/Parish Census Renewal –2013

 

Head of Household

Name: (First, Middle, Last)                                                                                       

Nickname: (if any)                                                                                                     

Gender: (circle)           Male                Female            

Religion                                                 Birthday: (Month/Day/Year)                                   

Marital Status: (circle one)      Single  Married           Separated        Divorced         Widowed

Special needs: (circle those that apply)           Disabled          Wheelchair-bound       Home-bound       Hearing Impaired        Other                                      

Home Address (include street address and PO Box, City and Zip):                                                                                                                                            

Home phone number:                                                  Cell Phone:                                                     

Occupation:                                         Work Phone (if able to receive calls):                                    

Email Address                                                                                                                     

If Married…

Date and Year of Marriage                                                                

Name of Spouse                                                                                                         

Nickname of Spouse (if any)                                                                                     

Spouse’s Religion                                           Spouse’s Birthday (Month/day/year)                         

Special needs: (circle those that apply)    Disabled     Wheelchair-bound       Home-bound      Hearing Impaired        Other                                                  

Cell Phone:                                                     

Occupation:                                         Work Phone (if able to receive calls):                                    

Email Address                                                                                                                       

If Children (at home or at college)

Name                                       Birthday (Month/day/year)                             Grade              Age    

                                                                                                                                                                       

                                                                                                                                                                       

                                                                                                                                                                       

                                                                                                                                                                       

Ideas to make our parish or cluster better:                                                                                                     

                                                                                                                                                                       

Other comments/suggestions: