Family Last Name Name:

Date:

Head of Household (Formal first name, MI & Maiden if applicable):

HOH Male/Female: HOH Male/Female: Male Female

Head of Household Nickname:

Spouse / Fiancé Name: (Formal first name, MI & Maiden if applicable):

Spouse / Fiancé Male/Female: Spouse / Fiancé Male/Female: Male Female

Spouse/Fiancé Nickname:

Martial Status: Martial Status:SingleEngagedMarriedDivorcedAnnulmentWidowed

Street Address:

Apartment or Unit #:

City:

State:

ZIP Code:

Head of Household HOME Phone #:

Spouse / Fiancé HOME Phone #:

Head of Household WORK Phone #:

Spouse / Fiancé WORK Phone #:

Head of Household MOBILE Phone #:

Spouse / Fiancé MOBILE Phone #:

Head of Household E-mail:

Spouse / Fiancé E-Mail:

Emergency Contact Name:

Emergency Contact Relationship:

Emergency Contact Phone:

May we publish your contact information? May we publish your contact information? Yes No

May we give your name / address to the Diocese if requested by them? May we give your name / address to the Diocese if requested by them? Yes No

Do you wish to receive the diocesan newspaper, The Miscellany? Do you wish to receive the diocesan newspaper, The Miscellany? Yes No

Please note any special needs (e.g., physically challenged, shut-in, etc.):