THIS IS A PRIVATE RECORD AND WILL BE KEPT CONFIDENTIAL For Office Use Only

Holy Rosary Parish < PO Box 206 < Edmonds, WA 98020-0206 Date ________________________

Parish Registration Card Envelop No. ___________________

PLEASE PRINT CLEARLY Home Phone (Unlisted o)

Last Name ( )

Address City Zip

E-mail address Circle Preference (i.e. Mr. & Mrs. Joe Jones / Joe & Mary Jones) Mr. & Mrs. / Mr. / Mrs. / Ms. / Miss / First Name & First Name

Member 1 (Head of Household) Male o Female o Member 2 Male o Female o

First Name MI (Maiden Name) First Name MI (Maiden Name)

Date of Birth Work Phone Date of Birth Work Phone ( ) ( ) M______D______Y____ Cell Phone M____D______Y____ Cell Phone

( ) ( )

Occupation (If retired please print retired and give previous occupation) Occupation (If retired please print retired and give previous occupation)

Employer Employer

Baptized: Catholic o Other o__________________ Baptized: Catholic o Other o_________________ Specify Specify

1^st Eucharist o 1^st Reconciliation o Confirmed o 1^st Eucharist o 1^st Reconciliation o Confirmed o

Special Needs or Interests (handicapped, homebound) Special Needs or Interests (Handicapped, Homebound)

Never Married o Married o Widowed o Separated o Divorced o Re-Married o

Marriage Date--M_______D_______Y_______ Married in Catholic Church--Yes o No o

Children (Including children under 22, if in school) Baptized 1^st 1^st Confirmed

Catholic or Eucharist Reconciliation

name of

denomination

Name/School Sex Grade Date of Birth

*Include last name of child and circle it if different than parent’s name above.

Special Needs of children (handicapped, homebound)

Other Adults Living in the Home Relationship