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? YesNo
May we publish your address in the Parish Directory? YesNo
May we publish your email in the Parish Directory? YesNo
How did you hear about St. Cyprian?
If you came from another parish, which one? __________________________________________________________________
INDIVIDUAL MEMBER INFORMATION:
ADULT 1
Role (Head of House, Husband, Wife, etc.)
Last Name (required)
First Name/Nickname (required)
Maiden Name (if applicable)
Gender ---MaleFemale
Date of Birth
Catholic? YesNo
Marital Status SingleMarriedDivorcedWidowed
If married, date of marriage?
If married, is it a Valid Catholic Marriage? UnknownYesNo
Baptized? ---YesNo
Sacrament of Reconciliation? ---YesNo
First Eucharist? ---YesNo
Confirmed? ---YesNo ____________________________________
Is there any member of your household that would like to be visited by a priest? ---YesNo ____________________________________
ADULT 2
Last Name
First Name/Nickname
Confirmed? ---YesNo
__________________________________________________________________
DEPENDENT CHILDREN
Child 1 Last Name(s)
Child 1 First Name
Specify Gender ---MaleFemale
------------------------------------------
Child 2 Last Name
Child 2 First Name
Child 3 Last Name
Child 3 First Name
Child 4 Last Name
Child 4 First Name
Child 5 Last Name
Child 5 First Name
Confirmed? ---YesNo ________________________________
Your Message
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