New Parishioner Registration Form
Which location are you most likely to attend?
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Please Select
St. Patrick Church (Bloomington, IL)
St. Mary Church (Downs, IL)
Name
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FIRST NAME
LAST NAME
Spouse's Name
Select One
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Miss
Ms
Mr
Mrs
Dr
Mr/Mrs
Dr/Mrs
Mr/Dr
Dr/Dr
Address
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ADDRESS
Street Address Line 2
CITY
State / Province
ZIP
Home Phone
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Work # Husband
Work # Wife
Cell # Husband
Cell # Wife
Martial Status
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Catholic Marriage
Married
Engaged
Single
Widowed
Separated
Divorced
What Date Did You Get Married?
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Month
/
Day
Year
What Church Did You Get Married In?
What City & State Did You Get Married In?
Have You Received a Parish Ministry Handbook?
*
Yes
No
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Head of Household Information
First Name
*
Preferred Name
Last Name / Maiden Name
*
Email Address
*
example@example.com
Disability
Religion
*
Language Spoken
*
Occupation / Place of Employment
*
Schooling
*
Sex
*
Male
Female
Date of Birth
*
/
Month
/
Day
Year
Have You Been Baptized?
*
Yes or No
Have You Received 1st Reconciliation?
*
Yes or No
Have You Received 1st Communion?
*
Yes or No
Have You Received Confirmation?
*
Yes or No
Do You Have a Spouse?
*
Yes
No
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Spouse Information
First Name
Preferred Name
Last Name / Maiden Name
Email Address
example@example.com
Disability
Religion
Language Spoken
Occupation / Place of Employment
Schooling
Sex
Male
Female
Date of Birth
/
Month
/
Day
Year
Have You Been Baptized
Yes or No
Have You Received 1st Reconciliation?
Yes or No
Have You Received 1st Communion?
Yes or No
Have You Received Confirmation?
Would You Like To Add Another Person or Child?
Yes
No
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Other / Child Information
First Name
Preferred Name
Last Name
Email Address
example@example.com
Disability
Religion
Language Spoken
Occupation / Place of Employment
Schooling
Sex
Male
Female
Date of Birth
/
Month
/
Day
Year
Have You Been Baptized?
Yes or No
Have You Received 1st Reconciliation?
Yes or No
Have You Received 1st Communion?
Yes or No
Have You Received Confirmation?
Yes or No
Would You Like To Add Another Child?
Yes
No
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Child Information
First Name
Preferred Name
Last Name
Email Address
example@example.com
Disability
Religion
Language Spoken
Occupation / Place of Employment
Schooling
Sex
Male
Female
Date of Birth
/
Month
/
Day
Year
Have You Been Baptized?
Yes or No
Have You Received 1st Reconciliation?
Yes or No
Have You Received 1st Communion?
Yes or No
Have You Received Confirmation?
Yes or No
Would You Like To Add Another Child?
Yes
No
Back
Next
Child Information
First Name
Preferred Name
Last Name
Email Address
example@example.com
Disability
Religion
Language Spoken
Occupation / Place of Employment
Schooling
Sex
Male
Female
Date of Birth
/
Month
/
Day
Year
Have You Been Baptized?
Yes or No
Have You Received 1st Reconciliation?
Yes or No
Have You Received 1st Communion?
Yes or No
Have You Received Confirmation?
Yes or No
Would You Like To Add Another Child?
Yes
No
Back
Next
Child Information
First Name
Preferred Name
Last Name
Email Address
example@example.com
Disability
Religion
Language Spoken
Occupation / Place of Employment
Schooling
Sex
Male
Female
Date of Birth
/
Month
/
Day
Year
Have You Been Baptized?
Yes or No
Have You Received 1st Reconciliation?
Yes or No
Have You Received 1st Communion?
Yes or No
Have You Received Confirmation?
Yes or No
Would You Like To Add Another Child?
Yes
No
Back
Next
Child Information
First Name
Preferred Name
Last Name
Email Address
example@example.com
Disability
Religion
Language Spoken
Occupation / Place of Employment
Schooling
Sex
Male
Female
Date of Birth
/
Month
/
Day
Year
Have You Been Baptized?
Yes or No
Have You Received 1st Reconciliation?
Yes or No
Have You Received 1st Communion?
Yes or No
Have You Received Confirmation?
Yes or No
Back
Next
Submit Your Registration Form
Click Back if you need to update or review any information. Click Submit to finalize your form and submit it to the church.
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