Parish Registration SJERC Parish Registration Form Today's Date* Date Format: MM slash DD slash YYYY Name* First Last Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Contribution EnvelopesYesNoElectronic DebitYesNo"Catholic Review" magazineHome deliveryPick up in lobbyHousehold InformationMarital Status*MarriedSingleWidowedDivorcedMarried by priest/deacon?YesNoWedding Date Date Format: MM slash DD slash YYYY Wedding Church/City, StateMale Head of Household / HusbandName First Last Date of Birth Date Format: MM slash DD slash YYYY Check if Sacrament received: Baptism Reconciliation First Eucharist Confirmation Catholic?YesNoOccupationCell PhoneEmail Ministry I would like to be involved in: (Please call me)Female Head of Household / WifeName (Include Maiden Last Name) First Last Date of Birth Date Format: MM slash DD slash YYYY Check if Sacrament received: Baptism Reconciliation First Eucharist Confirmation Catholic?YesNoOccupationCell PhoneEmail Ministry I would like to be involved in: (Please call me)Children in HouseholdPlease complete for each individual child and send an email to Cynthia.Herrera@sjerc.org if more than four children need to be enrolled.Name Child #1 First Last Date of Birth Date Format: MM slash DD slash YYYY SexMaleFemaleSpecial NeedsCheck if Sacrament received: Baptism Reconciliation First Eucharist Confirmation Date of BaptismDate of ReconciliationDate of First EucharistDate of ConfirmationCatholic?YesNoName of Child #2 First Last Date of Birth Date Format: MM slash DD slash YYYY SexMaleFemaleCheck if Sacrament received: Baptism Reconciliation First Eucharist Confirmation Date of BaptismDate of ReconciliationDate of First EucharistDate of ConfirmationCatholic?YesNoName of Child #3 First Last Date of Birth Date Format: MM slash DD slash YYYY SexMaleFemaleSpecial NeedsCheck if Sacrament received: Baptism Reconciliation First Eucharist Confirmation Date of BaptismDate of ReconciliationDate of First EucharistDate of ConfirmationCatholic?YesNoName of Child #4 First Last Date of Birth Date Format: MM slash DD slash YYYY SexMaleFemaleSpecial NeedsCheck if Sacrament received: Baptism Reconciliation First Eucharist Confirmation Date of BaptismDate of ReconciliationDate of First EucharistDate of ConfirmationCatholic?YesNo
