RCIA Enrollment Form

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

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

Address | Domicilio 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.

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

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

Home Phone Number Please enter a phone number.

Work Phone Number Please enter a phone number.

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

Language spoken -Mark all that apply English Spanish Tagalog

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

Father's Full Name REQUIRED Please fill out this field. Please enter valid data.

Mother's Maiden Name REQUIRED Please fill out this field. Please enter valid data.

If baptized, complete Name and mailing address of church of baptism; (Needed for permanent records in the parish)

Please check all applicable items: I am single

I was married before Civil Only Church

Church Name Please enter valid data.

Presently Separated I am divorced, but not remarried I am divorced and remaried Permanently Separated but not divorced

For Married Participants Married by Civil Ceremony Married in another Denomination Married in the Catholic Church

Name of the Church Please enter valid data.

Spouse baptized Yes No

If Yes, in what Church Please enter valid data.

SACRAMENTS - Have you been baptized? REQUIRED Yes No I don't know Please fill out this field.

If Yes, In what Religion? Please enter valid data.

How old where you? Please enter an integer (number).

Have you been Confirmed REQUIRED Yes No I don't know Please fill out this field.

If yes, name of the Church Please enter valid data.

Have you received First Holy Communion in the Catholic Church REQUIRED Yes No Please fill out this field.

Any Comment, question or special note you want to add.

The previous information is accuarate to the best of my knowledge,

I Agree Please select this field.