Parishioner Registration Form

Saint Antonios

ANTIOCHIAN ORTHODOX CHURCH

Halifax NS Canada
Parishioner Information

Complete the below form to join the parish or to update your info.
Name*

PrefixFirst NameLast Name
E-mail*
Cell Phone Number:*
Home Phone Number:
Birth Date:*

DayMonthYear
Address:*

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
Marital Status*
Spouse Name

First NameLast Name
Spouse Birth Date:

DayMonthYear
Spouse E-mail
example@example.com
Number of Children living at home
Name
Child 1 name
Email
example@example.com
Date of Birth:

DayMonthYear
Name
Child 2 name
Email
example@example.com
Date of Birth:

DayMonthYear
Name
Child 3 name
Email
example@example.com
Date of Birth:

DayMonthYear
Name
Child 4 name
Email
example@example.com
Date of Birth:

DayMonthYear
Name
Child 5 name
Email
example@example.com
Date of Birth:

DayMonthYear
Name
Child 6 name
Email
example@example.com
Date of Birth:

DayMonthYear
YesNo
YesNo
YesNo
Monthly Postponed ChecksDirect monthly depositOther
Other method of contribution
Specify or inquire about other methods of contribution
For Monthly Direct Deposit please complete the

Pre-Authorized Payment Form

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Saint Antonios