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St. Mary's Catholic Church

Independence, MO • Founded in 1823

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Parish Registration

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Family Information

Last Name *

Mailing Address *

Address 1 *

Address 2

City *

State *

ZIP code *

Family Email Address *

Emergency Phone Number *

Home Phone Number *

Individual Member Information #1

Name *

Name

Previous Parish

Name and City, State

Role

Head of House

Husband

Wife

Gender

Male

Female

Date of Birth

Month

Day

Year

Email

Work Phone

Cell Phone

Ethnicity

Occupation & Employer

Baptism

Baptized?

Yes

No

Catholic?

Yes

No

Confirmation

Confirmed?

Yes

No

Catholic?

Yes

No

Marital Information

Marital Status

Single

Married

Separated

Divorced

Annulled

Date of Marriage

Month

Day

Year

Were you married by a Catholic priest?

Yes

No

Are there any members of your household who would like to be visited by a priest?

Yes

No

Individual Member Information #2 (Optional)

name

Name and City, State

Previous Parish

Name and City, State

Role

Head of House

Husband

Wife

Gender

Male

Female

Date of Birth

Month

Day

Year

Email

Work Phone

Cell Phone

Ethnicity

Occupation & Employer

Baptism

Baptized?

Yes

No

Catholic?

Yes

No

Confirmation

Confirmed?

Yes

No

Catholic?

Yes

No

Marital Information

Marital Status

Single

Married

Separated

Divorced

Annulled

Date of Marriage

Month

Day

Year

Were you married by a Catholic priest?

Yes

No

Are there any members of your household who would like to be visited by a priest?

Yes

No

Dependent Children Information (dependents living with you)

Child #1

Relationship

Son

Daughter

Mother

Father

Other

First Name

Last Name

Gender

Male

Female

Date of Birth

Month

Day

Year

Sacraments Received:

Baptism

Eucharist

Reconciliation

Confirmation

Child #2

Relationship

Son

Daughter

Mother

Father

Other

First Name

Last Name

Gender

Male

Female

Date of Birth

Month

Day

Year

Sacraments Received:

Baptism

Eucharist

Reconciliation

Confirmation

Child #3

Relationship

Son

Daughter

Mother

Father

Other

First Name

Last Name

Gender

Male

Female

Date of Birth

Month

Day

Year

Sacraments Received:

Baptism

Eucharist

Reconciliation

Confirmation

Child #4

Relationship

Son

Daughter

Mother

Father

Other

First Name

Last Name

Gender

Male

Female

Date of Birth

Month

Day

Year

Sacraments Received:

Baptism

Eucharist

Reconciliation

Confirmation

Child #5

Relationship

Son

Daughter

Mother

Father

Other

First Name

Last Name

Gender

Male

Female

Date of Birth

Month

Day

Year

Sacraments Received:

Baptism

Eucharist

Reconciliation

Confirmation

Child #6

Relationship

Son

Daughter

Mother

Father

Other

First Name

Last Name

Gender

Male

Female

Date of Birth

Month

Day

Year

Sacraments Received:

Baptism

Eucharist

Reconciliation

Confirmation

Child #7

Relationship

Son

Daughter

Mother

Father

Other

First Name

Last Name

Gender

Male

Female

Date of Birth

Month

Day

Year

Sacraments Received:

Baptism

Eucharist

Reconciliation

Confirmation

Child #8

Relationship

Son

Daughter

Mother

Father

Other

First Name

Last Name

Gender

Male

Female

Date of Birth

Month

Day

Year

Sacraments Received:

Baptism

Eucharist

Reconciliation

Confirmation

Child #9

Relationship

Son

Daughter

Mother

Father

Other

First Name

Last Name

Gender

Male

Female

Date of Birth

Month

Day

Year

Sacraments Received:

Baptism

Eucharist

Reconciliation

Confirmation

Child #10

Relationship

Son

Daughter

Mother

Father

Other

First Name

Last Name

Gender

Male

Female

Date of Birth

Month

Day

Year

Sacraments Received:

Baptism

Eucharist

Reconciliation

Confirmation

Do you have any additional information you would like to share with us?

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St. Mary's Catholic Church • 600 N. Liberty St. • Independence, MO 64050

(816) 252-0121

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