Last Name First Name Middle Name Nickname
Students Place of Birth: ______________________________________________ Date of Birth: _________________________
City State Mo./Day/Yr.
Sex: Male _______ Female ________ Social Security Number: ________________________________________
Ethnic Background (for Diocesan Statistics only): African-American _______ Asian _______ Caucasian _________
Hispanic _____ Native American ______ Multi-Racial ________ Other: ________________________________________
Parents are: married ______ separated _______ divorced _______ other ________________________________
Student lives with: both parents _______ mother ______ father ______ other ________________________________
Last School Attended: _______________________________________________________ Phone No:_______________________________
Date (Mo/Day/Yr) Name of Church Church Location (City/State)
Baptism: _______________________ ______________________________________________ ___________________________________________
First Penance: _______________________ ______________________________________________ __________________________________________
First Communion: ______________________ ______________________________________________ __________________________________________
Confirmation: _______________________ ______________________________________________ __________________________________________
INFORMATION REGARDING THE FAMILY
Family Name: _________________________________________________________ Home Phone: ______________________
Guardian: __________________________________________________________________ Home Phone: _________________________
Home Address: _________________________________________________________________________ Zip: ____________________
Name of Parish: ___________________________________________________________________________ Envelope Number: ____________________
Father : _______________________________________________________________________________________ ________________________________
Last Name First Name Middle Name Religion
Birthplace (City/State): ______________________________________________________ Occupation: _________________________________________
Business Address: _________________________________________________________________________ Phone: _______________________________
Mother: ______________________________________________________________________________________ ________________________________
Maiden Name First Name Middle Name Religion
Birthplace (City/State): ________________________________________________________ Occupation: ______________________________________
Business Address: _________________________________________________________________________ Phone: ________________________________
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