DATE _____________________________________ NAME____________________________________________________________________________________ M or F

ADDRESS ______________________________________________ CITY, STATE, ZIP_______________________________________ HOME PHONE _________________________________________ BUSINESS PHONE _____________________________________ OCCUPATION _________________________________________ LANGUAGES __________________________________________ HANDICAP ____________________________________________ ETHNICITY / RACE _____________________________________

RELIGION__________________________ BIRTH DATE _______________________ BAPTISM: yes _____ no _____ PENANCE: yes _____ no _____ FIRST COMMUNION: yes _____ no _____ CONFIRMATION: yes _____ no _____ MARRIAGE: yes _____ no _____ E-MAIL ADDRESS __________________

PLEASE CIRCLE THE FOLLOWING:
Marital Status:
Priest / Other / Separated / Divorced / Widow / Single / Annulment

WOULD YOU LIKE THE CATHOLIC VIRGINIAN SUBSCRIPTION? YES / NO

NAME AND PLACE OF YOUR FORMER PARISH ( IF PARISH IS LOCAL, WE WILL NOTIFY THEM OF YOUR TRANSFER) : _____________________________________________________________________________

CHILD'S NAME ________________________________________ BIRTH DATE ____________________MALE____FEMALE____ SCHOOL ______________________________________________ GRADE ________

BAPTISM: yes _____ no _____ PENANCE: yes _____ no _____ FIRST COMMUNION: yes _____ no _____ CONFIRMATION: yes _____ no _____

CHILD'S NAME ________________________________________ BIRTH DATE ____________________MALE____FEMALE____ SCHOOL ______________________________________________ GRADE ________

BAPTISM: yes _____ no _____ PENANCE: yes _____ no _____ FIRST COMMUNION: yes _____ no _____ CONFIRMATION: yes _____ no _____

CHILD'S NAME ________________________________________ BIRTH DATE ____________________MALE____FEMALE____ SCHOOL ______________________________________________ GRADE ________

BAPTISM: yes _____ no _____ PENANCE: yes _____ no _____ FIRST COMMUNION: yes _____ no _____ CONFIRMATION: yes _____ no _____

CHILD'S NAME ________________________________________ BIRTH DATE ____________________MALE____FEMALE____ SCHOOL ______________________________________________ GRADE ________

BAPTISM: yes _____ no _____ PENANCE: yes _____ no _____ FIRST COMMUNION: yes _____ no _____ CONFIRMATION: yes _____ no _____

CHILD'S NAME ________________________________________ BIRTH DATE ____________________MALE____FEMALE____ SCHOOL ______________________________________________ GRADE ________

BAPTISM: yes _____ no _____ PENANCE: yes _____ no _____ FIRST COMMUNION: yes _____ no _____ CONFIRMATION: yes _____ no _____

CHILD'S NAME ________________________________________ BIRTH DATE ____________________MALE____FEMALE____ SCHOOL ______________________________________________ GRADE ________

BAPTISM: yes _____ no _____ PENANCE: yes _____ no _____ FIRST COMMUNION: yes _____ no _____ CONFIRMATION: yes _____ no _____