Parish Registration Form

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

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.

Member #1

Title (Mr., Mrs., Miss, Ms., Dr., etc.) REQUIRED Please fill out this field. Please enter valid data.

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

Maiden Name Please enter valid data.

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

Have you ever been a member of another parish in the Diocese of Harrisburg? If so, what Parish? REQUIRED Please fill out this field. Please enter valid data.

Sex (M/F) REQUIRED Please fill out this field. Please enter valid data.

Date of Birth REQUIRED Please fill out this field. Please enter a date.

Marital Status REQUIRED Please fill out this field. Please enter valid data.

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

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

Primary Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Cell Phone Number Please enter a phone number.

Primary Email REQUIRED Please fill out this field. Please enter an email address.

Please include the name of the Church where the sacrament was received.

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

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

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

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

Member #2

Title (Mr., Mrs., Miss, Ms., Dr., etc.) Please enter valid data.

First Name Please enter valid data.

Maiden Name Please enter valid data.

Last Name Please enter valid data.

Sex (M/F) Please enter valid data.

Date of Birth Please enter a date.

Marital Status Please enter valid data.

Religion Please enter valid data.

Occupation Please enter valid data.

Primary Phone Number Please enter a phone number.

Secondary Phone Number Please enter valid data.

Primary Email Please enter an email address.

Please include the name of the Church where the sacrament was received.

Baptism Please enter valid data.

Penance Please enter valid data.

First Communion Please enter valid data.

Confirmation Please enter valid data.

Child #1

First Name Please enter valid data.

Last Name if different Please enter valid data.

Religion Please enter valid data.

Sex (M/F) Please enter valid data.

Date of Birth Please enter a date.

Current Grade and School Please enter valid data.

Please include the name of the Church where the sacrament was received.

Baptism Please enter valid data.

Penance Please enter valid data.

First Communion Please enter valid data.

Confirmation Please enter valid data.

Child #2

First Name Please enter valid data.

Last Name if different Please enter valid data.

Religion Please enter valid data.

Sex (M/F) Please enter valid data.

Date of Birth Please enter a date.

Current Grade and School Please enter valid data.

Please include the name of the Church where the sacrament was received.

Baptism Please enter valid data.

Penance Please enter valid data.

First Communion Please enter valid data.

Confirmation Please enter valid data.

Child #3

First Name Please enter valid data.

Last Name if different Please enter valid data.

Religion Please enter valid data.

Sex (M/F) Please enter valid data.

Date of Birth Please enter a date.

Current Grade and School Please enter valid data.

Please include the name of the Church where the sacrament was received.

Baptism Please enter valid data.

Penance Please enter valid data.

First Communion Please enter valid data.

Confirmation Please enter valid data.

Additional Household Member

First Name Please enter valid data.

Last Name if different Please enter valid data.

Religion Please enter valid data.

Sex (M/F) Please enter valid data.

Date of Birth Please enter a date.

Current Grade and School Please enter valid data.

Occupation Please enter valid data.

Please include the name of the Church where the sacrament was received.

Baptism Please enter valid data.

Penance Please enter valid data.

First Communion Please enter valid data.

Confirmation Please enter valid data.

Additional Household Member

First Name Please enter valid data.

Last Name if different Please enter valid data.

Religion Please enter valid data.

Sex (M/F) Please enter valid data.

Date of Birth Please enter a date.

Current Grade and School Please enter valid data.

Occupation Please enter valid data.

Please include the name of the Church where the sacrament was received.

Baptism Please enter valid data.

Penance Please enter valid data.

First Communion Please enter valid data.

Confirmation Please enter valid data.

Grown Children (in case of emergency) Please enter valid data.

Comments:

Email REQUIRED Please fill out this field. Please enter an email address.

Our Mother of Perpetual Help

The Redemptorists, Ephrata, PA

Parish Registration Form

PLEASE FILL IN ALL REQUIRED FIELDS