Blessed Teresa Parish Registration Form
Date *

MM		/
DD		/
YYYY
Name *

First
Last
Address *

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Phone Number *

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###		-
####
Email

Marriage Information

Please Select One
 Married 
 Divorced 
 Widow/Widower 
Date of Marriage
Name of Church
Valid Catholic Marriage?
 Yes 
 No 
Would anyone in your family like to speak with a Priest?
To select more than one, hold the control key down while selecting.

Individual Member and Sacramental Information

Name #1

First
Last
Maiden Name
Role in Family
 Head of House 
 Husband 
 Wife 
Gender
 Male 
 Female 
Date of Birth mm/dd/yyyy
Parish Status
 Active 
 Inactive 
Baptized
To select more than one, hold the control key down while selecting.
Date of Baptism
(if known or parish)
Date of 1st Reconciliation
(if known or parish)
Date of 1st Eucharist
if known or parish
Date of Confirmation
(if known or parish)
Occupation/Employer
First Language
Name #2

First
Last
Maiden Name
Role in Family
 Head of House 
 Husband 
 Wife 
Gender
 Male 
 Female 
Date of Birth mm/dd/yyyy
Parish Status
 Active 
 Inactive 
Baptized
To select more than one, hold the control key down while selecting.
Date of Baptism
(if known or parish)
Date of 1st Reconciliation
(if known or parish)
Date of 1st Eucharist
if known or parish
Date of Confirmation
(if known or parish)
Phone Number Work/Cell

###		-
###		-
####
First Language

Dependent Children Information

Please fill in all applicable information
Child #1

First
Last
Gender
 Male 
 Female 
Date of Birth mm/dd/yyyy
Grade/Middle/High School
(Graduation year?)
Baptized
To select more than one, hold the control key down while selecting.
Date of Baptism
(if known or parish)
Date of 1st Reconciliation
(if known or parish)
Date of 1st Eucharist
if known or parish
Date of Confirmation
(if known or parish)
Child #2

First
Last
Gender
 Male 
 Female 
Date of Birth mm/dd/yyyy
Grade/Middlel/High School
(Graduation year?)
Baptized
To select more than one, hold the control key down while selecting.
Date of Baptism
(if known or parish)
Date of 1st Reconciliation
(if known or parish)
Date of 1st Eucharist
if known or parish
Date of Confirmation
(if known or parish)
Child #3
Gender
 Male 
 Female 
Date of Birth mm/dd/yyyy
Grade/Middle/High School
(Graduation year?)
Baptized
To select more than one, hold the control key down while selecting.
Date of Baptism
(if known or parish)
Date of 1st Reconciliation
(if known or parish)
Date of 1st Eucharist
if known or parish
Date of Confirmation
(if known or parish)
Child #4

First
Last
Date of Baptism
(if known or parish)
Gender
 Male 
 Female 
Date of Birth mm/dd/yyyy
Grade/Middlle/High School
(Graduation year?)
Baptized
To select more than one, hold the control key down while selecting.
Date of Baptism
(if known or parish)
Date of 1st Reconciliation
(if known or parish)
Date of 1st Eucharist
if known or parish
Date of Confirmation
(if known or parish)
If more children, please add info here.
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