Saint Rose of Lima Catholic Church
Parishioner Registration

 

Please print this form, neatly print the required information and return the form to the St. Rose Parish Office. The required fields are marked with an asterisk.  All information furnished is confidential.

 * Please indicate if this is a new registration or a renewal:  New      Renewal

Family Information

*Family Name:  

*Street:  

*City:                                                       *State:                                            *Zip:   

*Home Phone Number:                                                                            Work Phone Number:   

Email Address:

Marital Status:  Married in the Catholic Church      Civil Marriage      Single

 

Second Language:                                                              Ethnicity: 

Mr.
First/Last Name Date of Birth Baptized Confirmed First Eucharist Occupation
    Yes / No Yes / No Yes / No  

Talents/Ministries:

Mrs./Ms.

First/Last Name Date of Birth Baptized Confirmed First Eucharist Occupation
    Yes / No Yes / No Yes / No  

Talents/Ministries:

Children Living at Home
First/Last Name Date of Birth Baptized Confirmed First Eucharist School/Grade
    Yes / No Yes / No Yes / No  
    Yes / No Yes / No Yes / No  
    Yes / No Yes / No Yes / No  
    Yes / No Yes / No Yes / No  
    Yes / No Yes / No Yes / No  
    Yes / No Yes / No Yes / No  
Extended Family Living at Home
First/Last Name Date of Birth Baptized Confirmed First Eucharist Occupation/School
    Yes / No Yes / No Yes / No  
    Yes / No Yes / No Yes / No  
    Yes / No Yes / No Yes / No  
I would like more information about or contact from:
Religious Education RCIA Life Teen School Deacon Clergy: Priest

Other:

I am interested in automatic withdrawal for contributions: No       Yes