Parish Registration Form

Immaculate Conception Catholic Church Parish Regisgration Form

In order that we may serve you better, please complete this form as fully as possible.

Do you wish to receive contribution envelopes? (Annual boxed set) REQUIRED

Please select one.

Yes No Please fill out this field.

Do you wish to receive information about contributing electronically? (Faith Direct) REQUIRED

Please select one.

Yes No Please fill out this field.

Street Address REQUIRED

Please include Apt#, Lot#, Trlr#, etc.

Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Mailing Address (If different from street address) Please enter valid data.

City Please enter valid data.

State

Zip Please enter a zip code.

Family/Primary Telephone REQUIRED Please fill out this field. Please enter a phone number.

Phone Type REQUIRED Please fill out this field.

Unlisted? REQUIRED

If yes is selected, we will not list your number in the parish directory.

Please fill out this field.

Email REQUIRED Please fill out this field. Please enter an email address.

Would you prefer to receive correspondence via email including personal financial statements? Yes No

Single Person or Head of Household

Select Preferred Salutation

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Maiden or Middle Name (if applicable) Please enter valid data.

Please Select (if applicable) Maiden Name Middle Name

Date of Birth REQUIRED

MM/DD/YYYY

Please fill out this field. Please enter a date.

Occupation Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Preferred Language REQUIRED English Spanish Other Please fill out this field.

If other, please specify. Please enter valid data.

Religion REQUIRED Catholic Jewish Protestant Other Please fill out this field.

If other, please specify. Please enter valid data.

Sacraments Received

Please select all that apply.

Baptism First Communion Reconciliation Confirmation

Ethnicity (optional for Diocesan Statistics) Caucasian (White, Anglo) Hispanic African American Other

If other, please specify. Please enter valid data.

Current Marriage Status

Please select one. REQUIRED Married Single Widowed Priest or Religious Please fill out this field.

Married in: REQUIRED Catholic Church Other Church Civil Not Married Please fill out this field.

If married, please include the date.

MM/DD/YYYY

Please enter a date.

Marriage Dissolution Annulment Civil Divorce Separated N/A

Please provide date of dissolution if applicable.

MM/DD/YYYY

Please enter a date.

Spouse (if applicable)

Select Preferred Salutation

First Name Please enter valid data.

Last Name Please enter valid data.

Maiden or Middle Name (if applicable) Please enter valid data.

Please Select (if applicable) Maiden Name Middle Name

Date of Birth

MM/DD/YYYY

Please enter a date.

Occupation Please enter valid data.

Phone Number Please enter a phone number.

Preferred Language English Spanish Other

If other, please specify. Please enter valid data.

Religion Catholic Jewish Protestant Other

If other, please specify. Please enter valid data.

Sacraments Received

Please select all that apply.

Baptism First Communion Reconciliation Confirmation

Ethnicity (optional for Diocesan Statistics) Caucasian (White, Anglo) Hispanic African American Other

If other, please specify. Please enter valid data.

Children (under 18) living in your household. Please include first & last name, gender, date of birth, school grade and all sacraments received.