Household Last Name:  
Given First Name(s) (John or John, Kathryn):

Mailing Name (i.e. John Doe or Mr. & Mrs. John Doe, or John and Kathy):

Address:   Address2:

City:    St:    Zip:  -

Area Code: Home Phone:   Emergency Phone:

Family Email:  

Parish Giving Envelope Number (if assigned) :

Click in box if you do not want your information published in the Annual Parish Directory
               Phone number:       Address:      Email:

Are there any members of your household who would like to be visited by a priest? No Yes   If so, who?

Individual Household Member/s Information

Adult Member # 1:

First Name:   Nickname: 

Family Role:  Husband Wife Head of Household      Parish Status: Active Inactive        Gender:  Male Female   Date of Birth (MM/DD/YY):

Personal Email:    Work Phone:    Cell Phone:

First Language: English Spanish Korean French German Italian Russian Chinese Other   Occupation:    Employer: 

Last School Name:    Education Level Attained: Grade School High School 13+ years Associate Degree Bachelors Degree Masters Degree Doctorate Undisclosed Unknown Other

Sacramental Info:  (Please check the boxes and fill in the dates of sacramental celebration)
     Was person Baptized? Was person Baptized Catholic? Baptismal Date (if known MM/DD/YY):
     Did person receive Reconciliation?   Date:   First Eucharist?   Date:   Confirmation?   Date:

Marital Status: Single Married Separated Divorced Widowed Annulled Unknown   Valid Catholic Marriage: Yes No Not Sure Wedding Date:

Maiden Last Name if female: 

Please remember to press the "Submit" button at the bottom of this page when you are finished entering information,
Go to next section for next person in Household.  Thank You for filling in this form.

Adult Member # 2:

First Name:   Nickname: 

Family Role:  Husband Wife Head of Household      Parish Status: Active Inactive        Gender:  Male Female   Date of Birth (MM/DD/YY):

Personal Email:    Work Phone:    Cell Phone:

First Language: English Spanish Korean French German Italian Russian Chinese Other   Occupation:    Employer: 

Last School Name:    Education Level Attained: Grade School High School 13+ years Associate Degree Bachelors Degree Masters Degree Doctorate Undisclosed Unknown Other

Sacramental Info:  (Please check the boxes and fill in the dates of sacramental celebration, if available)
     Was person Baptized? Was person Baptized Catholic? Baptismal Date (if known MM/DD/YY):
     Did person receive Reconciliation?   Date:   First Eucharist?   Date:   Confirmation?   Date:

Marital Status: Single Married Separated Divorced Widowed Annulled Unknown   Valid Catholic Marriage: Yes No Not Sure Wedding Date:

Maiden Last Name if female: 

Please remember to press the "Submit" button at the bottom of this page when you are finished entering information,
Go to next section for next person in Household.  Thank You for filling in this form.

Dependent Member Living in Household Information

Dependent Member #1

Relationship of Dependent to Head of Household Above: Son Daughter Mother Father Grandchild Foster Child Grandparent  

First Name:   Last Name: NickName:

Gender: Male Female Unknown   Birthdate:   Birthplace (City, St, or Country if not USA):

Present School Attending:   High School Graduation Year, Anticipated or Past (YYYY):

First Language: English Spanish Korean French German Italian Russian Chinese Other   Phone:   EMail:

Special Needs (Disabled, allergies, etc): 

Sacramental Info:  (Please check the boxes and fill in the dates of sacramental celebration)
     Baptized? Baptized Catholic? Baptismal Date (if known MM/DD/YY):
     Reconciliation?   Date:   First Eucharist?   Date:   Confirmation?   Date:

Please remember to press the "Submit" button at the bottom of this page when you are finished entering information,
Go to next section for next person in Household.  Thank You for filling in this form.

Dependent Member #2

Relationship of Dependent to Head of Household Above: Son Daughter Mother Father Grandchild Foster Child Grandparent  

First Name:   Last Name: NickName:

Gender: Male Female Unknown   Birthdate:   Birthplace (City, St, or Country if not USA):

Present School Attending:   High School Graduation Year, Anticipated or Past  (YYYY):

First Language: English Spanish Korean French German Italian Russian Chinese Other   Phone:   EMail:

Special Needs (Disabled, allergies, etc): 

Sacramental Info:  (Please check the boxes and fill in the dates of sacramental celebration)
     Baptized? Baptized Catholic? Baptismal Date (if known MM/DD/YY):
     Reconciliation?   Date:   First Eucharist?   Date:   Confirmation?   Date:

Please remember to press the "Submit" button at the bottom of this page when you are finished entering information,
Go to next section for next person in Household.  Thank You for filling in this form.

Dependent Member #3

Relationship of Dependent to Head of Household Above: Son Daughter Mother Father Grandchild Foster Child Grandparent  

First Name:   Last Name: NickName:

Gender: Male Female Unknown   Birthdate:   Birthplace (City, St, or Country if not USA):

Present School Attending:   High School Graduation Year, Anticipated or Past  (YYYY):

First Language: English Spanish Korean French German Italian Russian Chinese Other   Phone:   EMail:

Special Needs (Disabled, allergies, etc): 

Sacramental Info:  (Please check the boxes and fill in the dates of sacramental celebration)
     Baptized? Baptized Catholic? Baptismal Date (if known MM/DD/YY):
     Reconciliation?   Date:   First Eucharist?   Date:   Confirmation?   Date:

Please remember to press the "Submit" button at the bottom of this page when you are finished entering information,
Go to next section for next person in Household.  Thank You for filling in this form.

Dependent Member #4

Relationship of Dependent to Head of Household Above: Son Daughter Mother Father Grandchild Foster Child Grandparent  

First Name:   Last Name: NickName:

Gender: Male Female Unknown   Birthdate:   Birthplace (City, St, or Country if not USA):

Present School Attending:   High School Graduation Year, Anticipated or Past  (YYYY):

First Language: English Spanish Korean French German Italian Russian Chinese Other   Phone:   EMail:

Special Needs (Disabled, allergies, etc): 

Sacramental Info:  (Please check the boxes and fill in the dates of sacramental celebration)
     Baptized? Baptized Catholic? Baptismal Date (if known MM/DD/YY):
     Reconciliation?   Date:   First Eucharist?   Date:   Confirmation?   Date:

Please remember to press the "Submit" button at the bottom of this page when you are finished entering information,
Go to next section for next person in Household.  Thank You for filling in this form.

Dependent Member #5

Relationship of Dependent to Head of Household Above: Son Daughter Mother Father Grandchild Foster Child Grandparent  

First Name:   Last Name: NickName:

Gender: Male Female Unknown   Birthdate:   Birthplace (City, St, or Country if not USA):

Present School Attending:   High School Graduation Year, Anticipated or Past  (YYYY):

First Language: English Spanish Korean French German Italian Russian Chinese Other   Phone:   EMail:

Special Needs (Disabled, allergies, etc): 

Sacramental Info:  (Please check the boxes and fill in the dates of sacramental celebration)
     Baptized? Baptized Catholic? Baptismal Date (if known MM/DD/YY):
     Reconciliation?   Date:   First Eucharist?   Date:   Confirmation?   Date:

Please remember to press the "Submit" button below when you are finished entering information, Thank You for filling in this form.