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PARISH REGISTRATION (v1.1)
Please complete this registration if you consider Immaculate Conception, Port Clinton,
your home parish during all or part of the year.

Name
(Husband)		    
                      (First)                                               (Middle)                                             (Last)
   
Date of Birth
 		                 Place of Birth 
       (mm/dd/yy)                                                                                               (City & State)
   
Sacramental or Other Information
Check all that apply		 Baptized   Catholic    RCIA    Reconciliation    First Eucharist    Confirmation
 
   
Name
(Wife)		    
                      (First)                                                 (Middle)                                  (Last - Maiden Name)
   
Date of Birth
 		                 Place of Birth 
          (mm/dd/yy)                                                                                             (City & State)
   
Sacramental or Other Information
Check all that apply		 Baptized   Catholic    RCIA    Reconciliation    First Eucharist    Confirmation
 
   
Address
 		          
                      (Street)                                                                    (City)                           (State)        (Zip Code)
   
Mailing Name
(e.g., Mr. & Mrs. John Doe)
   
Marital Status
Check those that apply		 Single   Married    Married by Priest/Deacon    Widowed    Other
   
If not married by priest/deacon, do you want it validated in church? (check one) Yes
 No
   
Seasonal/"Snowbird" Address
 		              
                      (Street)                                      (City)                     (State)           (Zip Code)
Please specify dates: From Date      To Date
   
Telephone No.
Emergency Telephone No.
Work Telephone No.
Primary Email Address
   
Do you want to receive parish envelopes?
(check one)		 Yes   No
   
Do you want to receive parish mailings?
(check one)		 Yes   No

Children or Dependents Living at Home

(First Child/Dependent)  
Name
 		    
                        (First)                                                (Middle)                                               (Last)
Relationship to head of household (son, daughter, etc.)
 
Gender (check one) Male     Female
Date of Birth
 		                 Place of Birth 
           (mm/dd/yy)                                                                                             (City & State)
Sacramental Information
Check all that apply		 Baptized   Catholic    Reconciliation    First Eucharist    Confirmation
   
(Second Child/Dependent)  
Name
 		    
                        (First)                                                  (Middle)                                                (Last)
Relationship to head of household (son, daughter, etc.)
 
Gender (check one) Male     Female
Date of Birth
 		                 Place of Birth 
           (mm/dd/yy)                                                                                             City & State)
Sacramental Information
Check all that apply		 Baptized   Catholic    Reconciliation    First Eucharist    Confirmation
   
(Third Child/Dependent)  
Name
 		    
                        (First)                                               (Middle)                                            (Last)
Relationship to head of household (son, daughter, etc.)
 
Gender (check one) Male     Female
Date of Birth
 		                 Place of Birth 
          (mm/dd/yy)                                                                                             (City & State)
Sacramental Information
Check all that apply		 Baptized   Catholic    Reconciliation    First Eucharist    Confirmation
   
(Fourth Child/Dependent)  
Name
 		    
                      (First)                                                  (Middle)                                              (Last)
Relationship to head of household (son, daughter, etc.)
 
Gender (check one) Male     Female
Date of Birth
 		                 Place of Birth 
           (mm/dd/yy)                                                                                             (City & State)
Sacramental Information
Check all that apply		 Baptized   Catholic    Reconciliation    First Eucharist    Confirmation
   
(Fifth Child/Dependent)  
Name
 		    
                        (First)                                                (Middle)                                               (Last)
Relationship to head of household (son, daughter, etc.)
 
Gender (check one) Male     Female
Date of Birth
 		                 Place of Birth 
           (mm/dd/yy)                                                                                             (City & State)
Sacramental Information
Check all that apply		 Baptized   Catholic    Reconciliation    First Eucharist    Confirmation

If you need to add additional children/dependents please submit your original form and fill out a new form. 
Thank you!



 
414 Madison Street           Port Clinton, Ohio 43452           419.734-4004