PARISHIONER REGISTRATION FORM St. Bernadette Catholic Church 1343 Wheeling Road Lancaster, Ohio 43130 Tel: 740-654-1893 Family Name: _________________________________________________ Previous Parish Registered: _________________________________ Need Contribution Envelopes: _________________________________ ADULT MALE First Name.......: _________________________________________ Nickname.........: _________________________________________ Last Name........: _________________________________________ Suffix...........: Jr. Sr. I II Other: _________________ Title............: Mr. Dr. Other: ________________________ Date of Birth....: ______________ Occupation.......: _________________________________________ Census Information Marital Status.: Married Single Divorced Widowed Clergy Other Languages: _________________________________________ Religion.......: Catholic Inactive Catholic Other: __________________________________ RCIA...........: Yes No Sacraments Received Baptism........: Yes No 1st Communion..: Yes No Confirmation...: Yes No Married in a Catholic Church: Yes No Place..........: _________________________________________ Date...........: ______________ ADULT FEMALE First Name.......: _________________________________________ Nickname.........: _________________________________________ Last Name........: _________________________________________ Maiden Name......: _________________________________________ Title............: Mrs. Miss Ms. Dr. Other: ____________ Date of Birth....: ______________ Occupation.......: _________________________________________ Census Information Marital Status.: Married Single Divorced Widowed Clergy Other Languages: _________________________________________ Religion.......: Catholic Inactive Catholic Other: __________________________________ RCIA...........: Yes No Sacraments Received Baptism........: Yes No 1st Communion..: Yes No Confirmation...: Yes No HOME ADDRESS Street: _____________________________________________________ City..: _____________________________________________________ State.: ______________ Zip...: ______________ MAILING ADDRESS (if different that Home Address) Street: _____________________________________________________ City..: _____________________________________________________ State.: ______________ Zip...: ______________ PHONE Home.: (____) ____-______ Other: (____) ____-______ EMAIL Address(1): ________________________________________________ Address(2): ________________________________________________ Publish Information: Yes No Name, address, phone numbers and e-mail addresses may be distributed to church and school members. Number of Children.: ____ Please list only children, still living at home, from oldest to youngest. Those over 23 years of age are considered adults and should register as an adult unless there are special circumstances. Please give date fir Sacraments, if known. Child #1: First Name: ________________________________________________ Last Name.: ________________________________________________ DOB.......: ______________ Sex.......: Male Female School....: ________________________________________________ Grade.....: ______________ Catholic..: Yes No Sacraments Baptism.......: ______________ 1st Communion.: ______________ Reconciliation: ______________ Confirmation..: ______________ Child #2: First Name: ________________________________________________ Last Name.: ________________________________________________ DOB.......: ______________ Sex.......: Male Female School....: ________________________________________________ Grade.....: ______________ Catholic..: Yes No Sacraments Baptism.......: ______________ 1st Communion.: ______________ Reconciliation: ______________ Confirmation..: ______________ Child #3: First Name: ________________________________________________ Last Name.: ________________________________________________ DOB.......: ______________ Sex.......: Male Female School....: ________________________________________________ Grade.....: ______________ Catholic..: Yes No Sacraments Baptism.......: ______________ 1st Communion.: ______________ Reconciliation: ______________ Confirmation..: ______________ Child #4: First Name: ________________________________________________ Last Name.: ________________________________________________ DOB.......: ______________ Sex.......: Male Female School....: ________________________________________________ Grade.....: ______________ Catholic..: Yes No Sacraments Baptism.......: ______________ 1st Communion.: ______________ Reconciliation: ______________ Confirmation..: ______________ Child #5: First Name: ________________________________________________ Last Name.: ________________________________________________ DOB.......: ______________ Sex.......: Male Female School....: ________________________________________________ Grade.....: ______________ Catholic..: Yes No Sacraments Baptism.......: ______________ 1st Communion.: ______________ Reconciliation: ______________ Confirmation..: ______________ Child #6: First Name: ________________________________________________ Last Name.: ________________________________________________ DOB.......: ______________ Sex.......: Male Female School....: ________________________________________________ Grade.....: ______________ Catholic..: Yes No Sacraments Baptism.......: ______________ 1st Communion.: ______________ Reconciliation: ______________ Confirmation..: ______________ Child #7: First Name: ________________________________________________ Last Name.: ________________________________________________ DOB.......: ______________ Sex.......: Male Female School....: ________________________________________________ Grade.....: ______________ Catholic..: Yes No Sacraments Baptism.......: ______________ 1st Communion.: ______________ Reconciliation: ______________ Confirmation..: ______________ Child #8: First Name: ________________________________________________ Last Name.: ________________________________________________ DOB.......: ______________ Sex.......: Male Female School....: ________________________________________________ Grade.....: ______________ Catholic..: Yes No Sacraments Baptism.......: ______________ 1st Communion.: ______________ Reconciliation: ______________ Confirmation..: ______________