Reg Registration Church of St. Patrick Registration / Change Form * Family Name Name and Address Street Address Address Line 2 City 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 State ZIP Code * Home Phone * Registration Type New Registration Change of information * Head of Household First Last Preferred Salutation Mr. & Mrs.; Ms.; Miss; Dr. & Mrs.; John & Judy; etc. * Family Status Single (residing alone) Single (residing with parents) Married with Minor Children Married without Minor Children Single Parent with minor children Divorced (residing alone) Divorced with minor children Living with "significant other" Widow(er) (residing alone) Widow(er) with minor children Widow(er) (residing with adult children) Other (Identify below) Family Status Other (if "Other" from above) * Date of Birth Religion if not Catholic * Occupation If student, list institution & anticipated graduation date Employer Work Phone E-Mail Address Email Confirm Email Mobile Phone Sacramental History * Baptized? Yes No * First Eucharist? YEs No * Confirmed? Yes No * Are you married? Yes No * First or Second Marriage First Marriage Second Marriage * Do you have children Yes No Spouse Your spouse's information Spouse's Name First Last Date of Birth Religion if not Catholic Occupation if student, list institution & anticipated graduation date Work Phone E-Mail Email Confirm Email Mobile Phone Sacramental History Baptized? Yes No First Eucharist? Yes No Confirmed? Yes No Is this your ... First Marriage Second Marriage Maiden Name Were you married by a priest? Yes No Church or place of Marriage Address of Marriage Street Address Address Line 2 City 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 State ZIP Code Marriage Date First Child Please fill in all information for each child First Child's Name First Last Date of Birth Gender Male Female Baptized? Yes No First Communion? Yes No Confirmed? Yes No Religious Education PSR Xolic None Present School Second Child Please fill in all information for each child Second Child's Name First Last Date of Birth Gender Male Female Baptized? Yes No First Communion Yes No Confirmed? Yes No Religious Ed PSR Xolic None Present School Third Child Please fill in all information for each child Third Child's Name First Last Date of Birth Gender? Male Female Baptized? Yes No First Communion? Yes No Confirmed? Yes No Religious Educatoin PSR Xolic None Present School Fourth Child Please fill in all information for each child Fourth Child's Name First Last Date of Birth Gender? Male Female Baptized? Yes No First Communion? Yes No Confirmed? Yes No Religious Education PSR Xolic None Present School * May we identify you in the bulletin as a new parishioner? Yes No Does anyone at this address require Sacramental services at home? * Secure