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 or Couple with Other Family Members (parent, grandchildren) living with them
Individual or 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
Home Phone Number
*
Mobile/Cell Phone Number
Work Phone Number
Occupation
Employer
Birthdate
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Religion
*
Catholic
non-practicing Catholic
Christian
None
Other
Select all Sacraments of Initiation you have received
*
Baptism
Communion
Confirmation
Marital Status
*
Single
Married
Divorced
Widowed
Wedding Anniversary
-
Month
-
Day
Year
Date
Where were you married (name of Church/Venue)
If married, is this your first marriage?
Yes
No
Highest Level of Education reached (Elementary or High School Grade, College Degree, Some College, etc)
*
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
*
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
Work Phone Number
Occupation
Employer
Birthdate
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Religion
*
Catholic
non-practicing Catholic
Christian
None
Other
Select all Sacraments of Initiation you have received
*
Baptism
Communion
Confirmation
Marital Status
*
Single
Married
Divorced
Widowed
Wedding Anniversary
*
-
Month
-
Day
Year
Date
Where were you married (name of Church/Venue)
*
If married, is this your first marriage?
*
Yes
No
Highest Level of Education reached (Elementary or High School Grade, College Degree, Some College, etc)
*
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
Date
Gender
*
Male
Female
Religion
*
Catholic
non-practicing Catholic
Christian
None
Other
Select all Sacraments of Initiation you have received
*
Baptism
Communion
Confirmation
Highest Level of Education reached (Elementary or High School Grade, College Degree, Some College, etc)
*
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
Date
Gender
Male
Female
Religion
Catholic
non-practicing Catholic
Christian
None
Other
Select all Sacraments of Initiation you have received
Baptism
Communion
Confirmation
Highest Level of Education reached (Elementary or High School Grade, College Degree, Some College, etc)
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
Date
Gender
Male
Female
Religion
Catholic
non-practicing Catholic
Christian
None
Other
Select all Sacraments of Initiation you have received
Baptism
Communion
Confirmation
Highest Level of Education reached (Elementary or High School Grade, College Degree, Some College, etc)
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
Date
Gender
Male
Female
Religion
Catholic
non-practicing Catholic
Christian
None
Other
Select all Sacraments of Initiation you have received
Baptism
Communion
Confirmation
Highest Level of Education reached (Elementary or High School Grade, College Degree, Some College, etc)
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
Date
Gender
Male
Female
Religion
Catholic
non-practicing Catholic
Christian
None
Other
Select all Sacraments of Initiation you have received
Baptism
Communion
Confirmation
Highest Level of Education reached (Elementary or High School Grade, College Degree, Some College, etc)
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
Date
Gender
Male
Female
Religion
Catholic
non-practicing Catholic
Christian
None
Other
Select all Sacraments of Initiation you have received
Baptism
Communion
Confirmation
Highest Level of Education reached (Elementary or High School Grade, College Degree, Some College, etc)
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
Date
Gender
Male
Female
Religion
Catholic
non-practicing Catholic
Christian
None
Other
Select all Sacraments of Initiation you have received
Baptism
Communion
Confirmation
Highest Level of Education reached (Elementary or High School Grade, College Degree, Some College, etc)
Are you homebound?
Yes
No
Ready to Submit?
Submit
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