RCIA Registration Form

Information on this form is held in confidence and is not shared without your permission

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Maiden Name (if applicable): REQUIRED Please fill out this field. Please enter valid data.

Date of Birth: REQUIRED Please fill out this field. Please enter valid data.

Age: REQUIRED Please fill out this field. Please enter valid data.

Place of Birth: REQUIRED Please fill out this field. Please enter valid data.

Name of Father: REQUIRED Please fill out this field. Please enter valid data.

Name of Mother (include Maiden Name): REQUIRED Please fill out this field. Please enter valid data.

I. CONTACT INFORMATION

Street Address: REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Cell/Mobile: REQUIRED Please fill out this field. Please enter valid data.

Home Phone: (if different from above) Please enter valid data.

Occupation: REQUIRED Please fill out this field. Please enter valid data.

Email: (Main) REQUIRED Please fill out this field. Please enter an email address.

II. RELIGIOUS HISTORY

1. What, if any, is your present religious affiliation? REQUIRED Please fill out this field. Please enter valid data.

2. Have you ever been baptized? Yes No I am not sure

If you answered "Yes" to Question 2, please provide the following information:

(a) In what denomination were you baptized? REQUIRED Please fill out this field. Please enter valid data.

(b) Date of your baptism (or your approximate age when you were baptized): REQUIRED Please fill out this field. Please enter valid data.

(c) Baptismal name (if different from current name): Please enter valid data.

(d) Place of Baptism (name of church / denomination): REQUIRED Please fill out this field. Please enter valid data.

(e) Address of Place of Baptism: (Street Address) REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

(f) Location: (if you were baptized outside of the United States.) Please enter valid data.

3. If you were baptized as a Catholic, check those sacraments you have already received: Penance (Confession) Eucharist (First Communion) Confirmation

III. CURRENT MARITAL STATUS

1. Have you been married before? Yes (Please proceed to number 3) No (Please proceed to section IV. Family Information) I'm currently engaged (Please proceed to number 2)

2. Are you engaged to be married?

(a) Your Fiance(e)'s Name: Please enter valid data.

(b) Your Fiance(e)'s Current Religious Affiliation (if any): Please enter valid data.

(c) For you: This is my first marriage. I have been married before.

(d) For your Fiance(e): This is his/her first marriage. My fiance(e) has been married before.

3. Are you married?

(a) Your Spouse's Name: Please enter valid data.

(b) Your Spouse's Current Religious Affiliation (if any): Please enter valid data.

(c) For you: This is my first marriage. I have been married before.

(d) For your spouse: This is my spouse's first marriage. My spouse has been married before.

(e) Date of Marriage: Please enter valid data.

(f) Place of Marriage: (include locality (town, city, county, etc.), region (state, province, territory, etc), and country) Please enter valid data.

(g) Officiating Authority of Marriage: (civil government, non-Christian minister, Christian minister, Catholic cleric) Please enter valid data.

4. Are you married, but separated from your spouse? Yes No

5. Are you divorced and have not remarried? Yes No

6. Are you a widow/widower and have not remarried since your spouse's death? Yes No

IV. FAMILY INFORMATION

Please list names and ages of any children, or other dependents: ("N/A" if not applicable) REQUIRED Please fill out this field.