Registration Form

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Holy Family Church
2729 Center Road
Poland, Ohio 44514
330-757-1545

Family Name (Last):_____________________________________First:_________________________Spouse:_______________________________

(A) Title:   Mr./Mrs.   Mr.   Mrs.   Miss   Dr./Mrs.       (B) P.O. Box_______Street Address:______________________________________________________________

City/State________________________________Zip:_______________(C) Phone:____________________________Unlisted?   Y   N

(D) Marital Status:   Chu. Mar.   Mar.   Sing.   Dev.   Sep.    Wid.      #Children at home_____      Will use envelopes?   Y   N

Circle attendance:   Frequent      Regular      Occasional       Seldom

Comments/remarks:

Date Registered____________ Envelope #____________

	Head	Spouse	Dependent Child	Dependent Child	Dependent Child	Dependent Child	Dependent Child	Other
MEMBER INFORMATION
First Name
Last Name (if different)
Gender	(M) (F)	(M) (F)	(M) (F)	(M) (F)	(M) (F)	(M) (F)	(M) (F)	(M) (F)
Religion
Birth Date	____/____/____	____/____/____	____/____/____	____/____/____	____/____/____	____/____/____	____/____/____	____/____/____
Baptism Date	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___
Reconciliation Date	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___
First Communion Date	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___
Confirmation Date	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___
Marriage Date	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___	(Y) (N) ___/___/___
Maiden Name

	Head	Spouse	Dependent Child	Dependent Child	Dependent Child	Dependent Child	Dependent Child	Other
MEMBER INFORMATION
Occupation
Employer
Business Phone
School Grade
Personal Alternate Address
Dates for Above (mm/dd)	___/___thru___/___	___/___thru___/___	___/___thru___/___	___/___thru___/___	___/___thru___/___	___/___thru___/___	___/___thru___/___	___/___thru___/___
Ministries/talents
Ministries/talents
Would like to volunteer for