Parish Registration Today's Date* MM slash DD slash YYYY Name* First Last Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Contribution Envelopes Yes No Electronic Debit Yes No "Catholic Review" magazine Home delivery Pick up in lobby Household InformationMarital Status* Married Single Widowed Divorced Married by priest/deacon? Yes No Wedding Date MM slash DD slash YYYY Wedding Church/City, State Male Head of Household / HusbandName First Last Date of Birth MM slash DD slash YYYY Check if Sacrament received: Baptism Reconciliation First Eucharist Confirmation Catholic? Yes No Occupation Cell PhoneEmail Ministry I would like to be involved in: (Please call me) Female Head of Household / WifeName (Include Maiden Last Name) First Last Date of Birth MM slash DD slash YYYY Check if Sacrament received: Baptism Reconciliation First Eucharist Confirmation Catholic? Yes No Occupation Cell PhoneEmail Ministry I would like to be involved in: (Please call me) Children in HouseholdPlease complete for each individual child and send an email to Cynthia.Herrera@sjerc.org if more than four children need to be enrolled.Name Child #1 First Last Date of Birth MM slash DD slash YYYY Sex Male Female Special Needs Check if Sacrament received: Baptism Reconciliation First Eucharist Confirmation Date of Baptism Date of Reconciliation Date of First Eucharist Date of Confirmation Catholic? Yes No Name of Child #2 First Last Date of Birth MM slash DD slash YYYY Sex Male Female Check if Sacrament received: Baptism Reconciliation First Eucharist Confirmation Date of Baptism Date of Reconciliation Date of First Eucharist Date of Confirmation Catholic? Yes No Name of Child #3 First Last Date of Birth MM slash DD slash YYYY Sex Male Female Special Needs Check if Sacrament received: Baptism Reconciliation First Eucharist Confirmation Date of Baptism Date of Reconciliation Date of First Eucharist Date of Confirmation Catholic? Yes No Name of Child #4 First Last Date of Birth MM slash DD slash YYYY Sex Male Female Special Needs Check if Sacrament received: Baptism Reconciliation First Eucharist Confirmation Date of Baptism Date of Reconciliation Date of First Eucharist Date of Confirmation Catholic? Yes No
