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Family Name

Date of Registration

FAMILY INFORMATION

Last Name(s) (required)

First Name(s) (required)

Your Email (required)

Address (required)

Address2

City

State

Zip

Phone Number with Area Code

May we publish your name in the Parish Directory?

May we publish your address in the Parish Directory?

May we publish your email in the Parish Directory?

How did you hear about St. Cyprian?

If you came from another parish, which one?


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INDIVIDUAL MEMBER INFORMATION:

ADULT 1

Role (Head of House, Husband, Wife, etc.)

Last Name (required)

First Name/Nickname (required)

Maiden Name (if applicable)

Gender

Date of Birth

Catholic?

Martial Status

If married, date of marriage?

If married, is it a Valid Catholic Marriage?

Baptized?

Sacrament of Reconciliation?

First Eucharist?

Confirmed?

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Is there any member of your household that would like to be visited by a priest?

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ADULT 2

Role (Head of House, Husband, Wife, etc.)

Last Name

First Name/Nickname

Gender

Maiden Name (if applicable)

Date of Birth

Catholic?

Baptized?

Sacrament of Reconciliation?

First Eucharist?

Confirmed?

__________________________________________________________________

DEPENDENT CHILDREN

Child 1 Last Name(s)

Child 1 First Name

Specify Gender

Date of Birth

Baptized?

Sacrament of Reconciliation?

First Eucharist?

Confirmed?

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Child 2 Last Name

Child 2 First Name

Specify Gender

Date of Birth

Baptized?

Sacrament of Reconciliation?

First Eucharist?

Confirmed?

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Child 3 Last Name

Child 3 First Name

Specify Gender

Date of Birth

Baptized?

Sacrament of Reconciliation?

First Eucharist?

Confirmed?

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Child 4 Last Name

Child 4 First Name

Specify Gender

Date of Birth

Baptized?

Sacrament of Reconciliation?

First Eucharist?

Confirmed?

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Child 5 Last Name

Child 5 First Name

Specify Gender

Date of Birth

Baptized?

Sacrament of Reconciliation?

First Eucharist?

Confirmed?

________________________________

Your Message