Address:  *

Phone (Day):  *

Phone (Evening/Weekend):  *

Phone (Cell):

Email Address:  *

Occupation:

Life Status:  * Married  Single  Divorced/single  Separated  Widowed  Divorced/remarried 

If Married: Was your marriage witnessed by a priest or deacon in the Catholic Church?  *  yes   no 

Birth Date:  *

City/State of Birth  *

Baptism Status:  *  Non-Baptized   Baptized Christian   Baptized Catholic, seeking First Eucharist and Confirmation 

(If Baptized Non-Catholic, Denomination)

Baptism Date:

Church/City/State of Baptism:

Father's Name:

Mother's Name:

Name of Spouse:

Does your spouse have a former marriage?  yes   no 

If Yes: Has an annulment been granted?  yes 

Religion of Spouse:

If Catholic: was 1st Communion received?  yes   no 

If Catholic: was Confirmation received?  yes   no 

What prompted your interest in RCIA?  *

   

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