MEMBER REGISTRATION FORM

Please complete the entire form if possible.

Member Name (last, first, middle initial):

__________________________________

Title:________

Suffix:________

Member Nickname:__________________________

Maiden Name:___________________________

Address Mail as:
_______________________________________

Relationship:______________________________

Marital Status (please circle one):
Married
Separated
Divorced/Remarried (Pending Annulment)
Divorced/Remarried (Need Annulment)
Single (Never Married)

Religion:_______________________

Handicapped? (please circle one):
Yes
No

Ethnicity:_____________________________

Language:____________________________

Occupation:____________________________

Location of Occupation:____________________________

Business Phone:________________________________

 Second Phone:__________________________________

Private/Unlisted Phone Number?
(please circle one):
Yes
No

Date of Birth(m/d/yyyy):________________________

Gender:_______________

Highest Grade:__________________

Baptism (m/d/yyyy):____________________________

Location of Baptism:____________________________

1st Communion (m/d/yyyy):_______________________

Location of 1st Communion:______________________

Confirmation (m/d/yyyy):_________________________

Location of Confirmation:__________________________

Marriage (m/d/yyyy):_____________________________

Location of Marriage:_____________________________

Penance (m/d/yyyy):______________________________

Location of Penance:______________________________