PARISHIONER REGISTRATION FORM

FAMILY INFORMATION

FAMILY / LAST NAME REQUIRED Please fill out this field. Please enter valid data.

Address 1 REQUIRED Please fill out this field. Please enter valid data.

Address 2 Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Email REQUIRED Please fill out this field. Please enter an email address.

Today's Date Please enter a date.

Languages spoken in the home, other than English Please enter valid data.

__________________________

Please select the total number of family members living in your home. Then fill in the information required for each member.

Total number of Family Members REQUIRED Please fill out this field.
Member 1
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth
  mm/dd/yyyy
  Please enter a date.
- Gender Male Female
- Marital Status REQUIRED Please fill out this field.
- If married, Church of Marriage Please enter valid data.
- Family Relation REQUIRED Please fill out this field.
- Occupation / Student Current Grade Please enter valid data.
- Religion REQUIRED Please fill out this field. Please enter valid data.
- Sacraments Baptism 1st Reconciliation 1st Eucharist Confirmation
- Email, if applicable Please enter an email address.
- Maiden Name, if applicable Please enter valid data.
- Comments
Member 2
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth
  mm/dd/yyyy
  Please enter a date.
- Gender Male Female
- Marital Status REQUIRED Please fill out this field.
- If married, Church of Marriage Please enter valid data.
- Family Relation REQUIRED Please fill out this field.
- Occupation / Student Current Grade Please enter valid data.
- Religion REQUIRED Please fill out this field. Please enter valid data.
- Sacraments Baptism 1st Reconciliation 1st Eucharist Confirmation
- Email, if applicable Please enter an email address.
- Maiden Name, if applicable Please enter valid data.
- Comments
Member 3
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth
  mm/dd/yyyy
  Please enter a date.
- Gender Male Female
- Marital Status REQUIRED Please fill out this field.
- If married, Church of Marriage Please enter valid data.
- Family Relation REQUIRED Please fill out this field.
- Occupation / Student Current Grade Please enter valid data.
- Religion REQUIRED Please fill out this field. Please enter valid data.
- Sacraments Baptism 1st Reconciliation 1st Eucharist Confirmation
- Email, if applicable Please enter an email address.
- Maiden Name, if applicable Please enter valid data.
- Comments
Member 4
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth
  mm/dd/yyyy
  Please enter a date.
- Gender Male Female
- Marital Status REQUIRED Please fill out this field.
- If married, Church of Marriage Please enter valid data.
- Family Relation REQUIRED Please fill out this field.
- Occupation / Student Current Grade Please enter valid data.
- Religion REQUIRED Please fill out this field. Please enter valid data.
- Sacraments Baptism 1st Reconciliation 1st Eucharist Confirmation
- Email, if applicable Please enter an email address.
- Maiden Name, if applicable Please enter valid data.
- Comments
Member 5
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth
  mm/dd/yyyy
  Please enter a date.
- Gender Male Female
- Marital Status REQUIRED Please fill out this field.
- If married, Church of Marriage Please enter valid data.
- Family Relation REQUIRED Please fill out this field.
- Occupation / Student Current Grade Please enter valid data.
- Religion REQUIRED Please fill out this field. Please enter valid data.
- Sacraments Baptism 1st Reconciliation 1st Eucharist Confirmation
- Email, if applicable Please enter an email address.
- Maiden Name, if applicable Please enter valid data.
- Comments
Member 6
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth
  mm/dd/yyyy
  Please enter a date.
- Gender Male Female
- Marital Status REQUIRED Please fill out this field.
- If married, Church of Marriage Please enter valid data.
- Family Relation REQUIRED Please fill out this field.
- Occupation / Student Current Grade Please enter valid data.
- Religion REQUIRED Please fill out this field. Please enter valid data.
- Sacraments Baptism 1st Reconciliation 1st Eucharist Confirmation
- Email, if applicable Please enter an email address.
- Maiden Name, if applicable Please enter valid data.
- Comments
Member 7
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth
  mm/dd/yyyy
  Please enter a date.
- Gender Male Female
- Marital Status REQUIRED Please fill out this field.
- If married, Church of Marriage Please enter valid data.
- Family Relation REQUIRED Please fill out this field.
- Occupation / Student Current Grade Please enter valid data.
- Religion REQUIRED Please fill out this field. Please enter valid data.
- Sacraments Baptism 1st Reconciliation 1st Eucharist Confirmation
- Email, if applicable Please enter an email address.
- Maiden Name, if applicable Please enter valid data.
- Comments

Our Lady of Mercy

2 Fremont Avenue

park Ridge, NJ 07656

phone: 201-391-5315

Fax: 201-391-5614

PARISHIONER REGISTRATION FORM