Household Registration Form
Select the choice that best describes your household
Individual
Couple
Couple with minor children at home
Individual Adult with minor children at home
Individual with Other Family Members (parent, grandchildren) living with them
Couple with Other Family Members (parent, grandchildren) living with them
Individual with minor children AND Other Family Members (parent, grandchildren) living with them
Couple with minor children AND Other Family Members (parent, grandchildren) living with them
Head of Household Information
Title
Mr.
Mr. & Mrs.
Mrs.
Ms.
Miss
Dr.
Sr.
Fr.
Deacon
Select One
Name
*
First Name
Last Name
Nickname / Preferred Name
Maiden Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Primary Phone Number
*
Format: (000) 000-0000.
Can the Primary Phone Number be listed in our parish directory?
*
Yes
No
Mobile/Cell Phone Number
Format: (000) 000-0000.
Work Phone Number
Format: (000) 000-0000.
Occupation
Employer
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Religion
*
Catholic
non-practicing Catholic
Christian
None
Other
Select all Sacraments of Initiation you have received
*
Baptism
Communion
Confirmation
Not yet baptized
Marital Status
*
Single
Married
Divorced
Widowed
Wedding Anniversary
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Where were you married (name of Church/Venue)
If married, is this your first marriage?
Yes
No
Are you homebound?
*
Yes
No
Emergency Contact
*
Name someone living outside your home as an emergency contact
Relationship to you
*
What is their relationship to you?
Emergency Contact Phone Number
*
Format: (000) 000-0000.
Space for Additional Emergency Contacts
if you would like to provide additional emergency contacts, enter info here.
Spouse Information
Title
Mr.
Mr. & Mrs.
Mrs.
Ms.
Miss
Dr.
Sr.
Fr.
Deacon
Select One
Name
*
First Name
Last Name
Nickname / Preferred Name
Maiden Name
Email
example@example.com
Mobile/Cell Phone Number
Format: (000) 000-0000.
Work Phone Number
Format: (000) 000-0000.
Occupation
Employer
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Religion
*
Catholic
non-practicing Catholic
Christian
None
Other
Select all Sacraments of Initiation you have received
*
Baptism
Communion
Confirmation
Not yet baptized
Marital Status
*
Single
Married
Divorced
Widowed
Wedding Anniversary
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Where were you married (name of Church/Venue)
*
If married, is this your first marriage?
*
Yes
No
Are you homebound?
*
Yes
No
Minor Child 1 - Information
Title
Mr.
Mr. & Mrs.
Mrs.
Ms.
Miss
Dr.
Sr.
Fr.
Deacon
Select One
Name
*
First Name
Last Name
Nickname / Preferred Name
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Religion
*
Catholic
non-practicing Catholic
Christian
None
Other
Select all Sacraments of Initiation you have received
*
Baptism
Communion
Confirmation
Not yet baptized
Are you homebound?
*
Yes
No
Minor Child 2 - Information
Title
Mr.
Mr. & Mrs.
Mrs.
Ms.
Miss
Dr.
Sr.
Fr.
Deacon
Select One
Name
First Name
Last Name
Nickname / Preferred Name
Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Religion
Catholic
non-practicing Catholic
Christian
None
Other
Select all Sacraments of Initiation you have received
Baptism
Communion
Confirmation
Not yet baptized
Are you homebound?
Yes
No
Minor Child 3 - Information
Title
Mr.
Mr. & Mrs.
Mrs.
Ms.
Miss
Dr.
Sr.
Fr.
Deacon
Select One
Name
First Name
Last Name
Nickname / Preferred Name
Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Religion
Catholic
non-practicing Catholic
Christian
None
Other
Select all Sacraments of Initiation you have received
Baptism
Communion
Confirmation
Not yet baptized
Are you homebound?
Yes
No
Minor Child 4 - Information
Title
Mr.
Mr. & Mrs.
Mrs.
Ms.
Miss
Dr.
Sr.
Fr.
Deacon
Select One
Name
First Name
Last Name
Nickname / Preferred Name
Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Religion
Catholic
non-practicing Catholic
Christian
None
Other
Select all Sacraments of Initiation you have received
Baptism
Communion
Confirmation
Not yet baptized
Are you homebound?
Yes
No
Other Family Member 1 - Information
Title
Mr.
Mr. & Mrs.
Mrs.
Ms.
Miss
Dr.
Sr.
Fr.
Deacon
Select One
Name
First Name
Last Name
Nickname / Preferred Name
Relationship to Head of Household
Parent
Sibling
Adult Child
Grandchild
Niece/Nephew
Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Religion
Catholic
non-practicing Catholic
Christian
None
Other
Select all Sacraments of Initiation you have received
Baptism
Communion
Confirmation
Not yet baptized
Are you homebound?
Yes
No
Other Family Member 2 - Information
Title
Mr.
Mr. & Mrs.
Mrs.
Ms.
Miss
Dr.
Sr.
Fr.
Deacon
Select One
Name
First Name
Last Name
Nickname / Preferred Name
Relationship to Head of Household
Parent
Sibling
Adult Child
Grandchild
Niece/Nephew
Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Religion
Catholic
non-practicing Catholic
Christian
None
Other
Select all Sacraments of Initiation you have received
Baptism
Communion
Confirmation
Not yet baptized
Are you homebound?
Yes
No
Other Family Member 3 - Information
Title
Mr.
Mr. & Mrs.
Mrs.
Ms.
Miss
Dr.
Sr.
Fr.
Deacon
Select One
Name
First Name
Last Name
Nickname / Preferred Name
Relationship to Head of Household
Parent
Sibling
Adult Child
Grandchild
Niece/Nephew
Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Religion
Catholic
non-practicing Catholic
Christian
None
Other
Select all Sacraments of Initiation you have received
Baptism
Communion
Confirmation
Not yet baptized
Are you homebound?
Yes
No
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Time & Talent Section
"Stir into flame the gift of God you have received" - 2 Timothy 1:6
Consider participating in one of our many ministries. Please check all interests that may apply, H=Head of Household, S=Spouse, Y=Youth
Liturgy Commission
Rows
H
S
Y
Liturgy Commission Member
Liturgical Season Planning Teams
Arts and Environment - church decorations
Children's Liturgy of the Word Cathechist
Eucharistic Adoration
Lector/Reader
Eucharistic Minister
Communion to the Homebound
Hospitality Ministry
Servers (adult/youth)
Music Ministry - Choir
Music Ministry - Cantor
Music Ministry - Instrumentalist
If you selected Music Ministry -Instrumentalist:
what instrument(s) do you play?
Christian Service Ministries
Rows
H
S
Y
Christian Service Commission member
Food Drive (Collect/Transport)
Giving Tree Christmas Program with Rock Church
St. Vincent de Paul Society
St. Vincent de Paul Metal Recycling
Food Preparation (funerals, receptions, respite)
Volunteer for other charitable organizations
Tithing Committee
Christian Formation Ministries
Rows
H
S
Y
Christian Formation Commission member
Sacramental Preparation - Marriage and more
Order of Christian Initiation for Adults (OCIA)
Peace and Justice Ministry
Respect Life Ministry
Bible Study
Small Faith Communities - Parent Faith Support
PSR Teacher or Aide
Vacation Bible School volunteers
Missionary Discipleship Ministries
Rows
H
S
Y
Missionary Discipleship Commission member
Prayer Groups
Contemplative Prayer Ministry
Jonah Prayer Ministry*
*(requires pastor approval)
Rosary Groups
Retreat Opportunities
Stewardship Committee
Welcoming New Parishioners
Health Commission Ministries
Rows
H
S
Y
Health Ministry Commission member
Blood Pressure Screenings (R.N.'s)
Blood Drives
Divorce Care Ministry
Ministries of Consolation/GriefShare
Friday Friends (widows/widowers)
Exercise Programs
Good Samaritan Driving Program
Social Commission
Rows
H
S
Y
Social Commission member
Pickleball
Bunco
Donut Sunday Hosts
Parish-Wide Receptions/Social Events
Annual Pasta Dinner Hosts
Fish Fries
Pancake Breakfast benefit for Youth Group
Trunk or Treat
Sensational Seniors
Advent Glow
Happy Birthday Jesus Party
Youth Commission
Rows
H
S
Y
Youth Commission / Youth Group member
Youth Prayer Groups
Youth Spiritual/Social/Service Activities
Youth Retreats (Confirmation/Steubenville)
Administration and Finance Commission
Rows
H
S
Y
Administration and Finance Commission member*
*(requires pastor approval)
Budget/Strategic Planning/Capital Improvements*
*(requires pastor approval)
Money Counters
Annual Catholic Appeal Worker
General Skills Willing to Share
Rows
H
S
Y
IT/Technical Support
Website Support
Audio-Video
Gardening (Parish Grounds)
Hauling (personal truck)
General Household Skills (Carpentry, painting, etc)
If you selected General Household Skills:
what is your skill? (Carpentry, Electrical, Plumbing, etc)
Other gifts/skills:
is there a gift/skill you have that we did not list? let us know!
enter your initials to complete this form:
*
Ready to Submit?
A member of Mary, Mother's Missionary Discipleship Commission will be in touch with you to setup a time for a short visit. What is your preferred method of contact?
*
Phone call
Text
Email
Submit
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