Contact Form - New Registration Request - Immaculate Heart of Mary Parish

Immaculate Heart of Mary Parish

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Immaculate Heart of Mary Parish Registration Form

* Indicates required field

Current Date *

Name *

First

Last

Date of Birth *

Marital Status *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Spouse's Name *

Spouse's Maiden Name *

Spouse's Date of Birth *

Number of Children *

Child's Name *

Child's Date of Birth *

Child's Name *

Child's Date of Birth *

Child's Name *

Child's Date of Birth *

Child's Name *

Child's Date of Birth *

Employer's Name *

Employer's Address *

Line 1

Line 2

City

State

Zip Code

Country

Spouse's Employer's Name *

Spouse's Employer's Address *

Line 1

Line 2

City

State

Zip Code

Country

Sacraments Received (you) *

Baptism Holy Eucharist Confirmation Marriage in Church None

Sacraments Received (spouse) *

Baptism Holy Eucharist Confirmation Marriage in Church None

Are your children in need of Sacraments? *

Baptism Holy Eucharist Confirmation

Are you and your family currently attending Mass and receiving the Sacraments regularly? *

Yes No

Do you have any medical problems the church should be aware of? *

Do you or your family need special consideration of services? *

Walker Wheelchair Oxygen Other None

Do you or anyone in your family need home visitation with Eucharist and prayer? *

Yes No

Emergency Contact Information *

Would you like information about our CCD Program? *

Yes No

Would you like information about RCIA (Right of Christian Initiation) Program? *

Yes No

Do you or anyone in your family have a problem getting to Mass or receiving the Sacraments? *

Yes No

What special skills do you have to offer? *

What special skills does your spouse have to offer? *

Check which ministries or organizations you are interested in being a part of. *

Eucharistic Minister Lector Altar Server Greeter Usher Choir Parish Council Finance Committee Stewardship Committee Grounds/Maintenance Bereavement Liturgy Religious Education Teacher Youth Ministry RCIA Home Visitation Hospital Visitation Nursing Home Visits After School Program School Athletic Program School Volunteer Home and School Altar and Rosary Family Life Garden Club Senior Citizens Social Concerns Renewal Golf League Knights of Columbus

Would you be willing to help out at our annual Parish Family Fesitval held each June? *

Set-up or Tear Down Work a booth Clean up Parking

Comments/Concerns/Notes *

Submit

Contact Info: 4490 Norquest Blvd., Austintown, OH 44515 / P: 330-793-9988 / F: 330-799-9269