Dirt – St. Patrick Parish

Reason for completing this formNew RegistrationUpdate my information

Street Address *

Apartment, suite, etc

City *

State *

ZIP *

Preferred SalutationMr & Mrs; Mr; Mrs; Ms; Dr & Mrs; John & Judy; etc

First Name (Head of Household )

Middle Initial

Last Name

Cell Phone (HOH) *

Email (HOH) *

Confirm Email Address *

Family Status

Family Status (Other)

On what day were you born (HOH)? *

HOH BD

What is your religious affiliation (HOH)Catholic, Episcopalian, Lutheran, Jewish, etc

Occupation (HOH)If student, list institution & anticipated graduation date

Work Phone (HOH)

Employer (HOH)For whom (or for what company) do you work?

Please tell us about your Sacramental Experiences

Are you married or living with a 'significant other'? (HOH) *YesNo

First or Second Marriage? (HOH)First MarriageSecond MarriageThree-or-more MarriagesLiving with my ‘Significant Other’ but not married

On what date did you get married?

(If married more than once, please indicate most recent marriage date)

Were you married before a Catholic priest or deacon?YesNo

Name of Church or place of marriage *

City

State/Province

ZIP

Country

Do you have children? *YesNo

How many children do you have?

Spouse

Please tell us a bit about your spouse

First Name (Spouse)

Middle Initial

Last Name

What is your maiden name?

On what day were you born? (Spouse)

What is your religious affiliation (Spouse)Catholic, Episcopalian, Lutheran, Jewish, etc

Cell Phone (Spouse)

Email (Spouse)

Occupation (Spouse)What do you do for a living?

Employer (Spouse)For whom (or for what company) do you work?

Please tell us about your Sacramental Experiences

First or Second Marriage? (Spouse)First MarriageSecond MarriageThree-or-more MarriagesLiving with my ‘Significant Other’ but not married.

Child #1

Please tell us a bit about your first child

First Name (Child #1)

Middle Initial

Last Name

On what day was Child #1 born?

Gender assigned at birth (Child #1)MaleFemale

In what faith are you raising your child? (Child #1)Catholic, Episcopalian, Lutheran, Jewish, etc

Religious Education? (Child #1)PSRCatholic SchoolNone

Present School (Child #1)

Child #2

Please tell us a bit about your second child

First Name (Child #2)

Middle Initial

Last Name

On what day was Child #2 born?

Gender assigned at birth (Child #2)MaleFemale

In what faith are you raising your child? (Child #2)Catholic, Episcopalian, Lutheran, Jewish, etc

Religious Education? (Child #2)PSRCatholic SchoolNone

Present School (Child #2)

Child #3

Please tell us a bit about your third child

First Name (Child #3)

Middle Initial

Last Name

On what day was Child #3 born?

Gender assigned at birth (Child #3)MaleFemale

In what faith are you raising your child? (Child #3)Catholic, Episcopalian, Lutheran, Jewish, etc

Religious Education? (Child #3)PSRCatholic SchoolNone

Present School (Child #3)

Child #4

Please tell us a bit about your fourth child

First Name (Child #4)

Middle Initial

Last Name

On what day was Child #4 born?

Gender assigned at birth (Child #4)MaleFemale

In what faith are you raising your child? (Child #4)Catholic, Episcopalian, Lutheran, Jewish, etc

Religious Education? (Child #4)PSRCatholic SchoolNone

Present School (Child #4)

Child #5

Please tell us a bit about your fifth child

First Name (Child #5)

Middle Initial

Last Name

On what day was Child #5 born?

Gender assigned at birth (Child #5)MaleFemale

In what faith are you raising your child? (Child #5)Catholic, Episcopalian, Lutheran, Jewish, etc

Religious Education? (Child #5)PSRCatholic SchoolNone

Present School (Child #5)

Child #6

Please tell us a bit about your sixth child

First Name (Child #6)

Middle Initial

Last Name

On what day was Child #6 born?

Gender assigned at birth (Child #6)MaleFemale

In what faith are you raising your child? (Child #6)Catholic, Episcopalian, Lutheran, Jewish, etc

Religious Education? (Child #6)PSRCatholic SchoolNone

Present School (Child #6)

Two Final questions before you finish

May we identify you in the bulletin as a new parishioner?YesNo

Does anyone at this address require Sacramental Services at home?Is someone homebound (eg. elderly parent, etc). If so, please elaborate…