Our Lady of the Miraculous Medal Parish ( Office use only ) - Parish ID Number ____ Census and Registration Form Last Name Address Town Zip Phone P.O. Box or Mailing address Unlisted? Y ___ N ___ Seasonal Residence ? Summer __ Winter __ All Year __ Circle Prefered Address Title Mr, Mrs, Mr & Mrs, Ms, Dr. E-mail address Please use the space below to list ONLY family members living at home. If any member has a different last name, please write their full name in the respective space. Sacraments: Y/N? Name of Primary Household Members Maiden Nickname M / F DOB Religion Baptism 1st Comm Confirm

Name of Children or other adults living at home Grade Nickname M / F DOB Religion Baptism 1st Comm Confirm

Additional space may be found on the back of the form.

Type of Marriage as applies to Primary Household Member(s) Check the appropriate space R.C. Church Marriage ____ J/P Marriage ____ Non-Catholic Church Marriage ____ Date of Marriage ______Current Marriage Status check the appropriate space Married ___ Widowed ___ Divorce/Separated ___ Annulment ___ Single ___ Are you interested in discussing an annulment with someone? ___

Primary Household Member's Occupation Work Phone

Contribution Method Online ____ (See parish web page) Envelope ____ (Envelopes will be sent to your home).

Date Registered ______Our Lady of the Miraculous Medal Parish ( Office use only ) - Parish ID Number ____ Census and Registration Form Envelope or online contributions are necessary to qualify for Catholic School subsidy and reduction in CCD fees

Sacraments: Y/N? Name of Children or other adults living at home Grade Nickname M / F DOB Religion Baptism 1st Comm Confirm

Talents and Ministries Please indicate any area that you would be willing to serve __Lector __Altar Server __Usher/Greeter __Eucharistic Minister __Music Ministry __ Religious Education __Fund Raising __Finance/Budget __Computer Support __Crafts __Carpentry __Electric __Baking __Hospitality __Other: ______

Are Non-Catholic Members of the household interested in knowing more about the Catholic Faith? __Y __N

Office Comments:

Date Registered ______