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R.C.I.A. REGISTRATION and QUESTIONNAIRE 23/24
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Information on this form is held in confidence.
NAME (First, Middle, Last)
*
Your answer
MAIDEN NAME (if applicable)
Your answer
DATE OF BIRTH
*
MM
/
DD
/
YYYY
AGE
*
Your answer
PLACE OF BIRTH (city, state, country)
Your answer
Please deliver or mail to the parish office (attn: DPE) an original of your birth certificate.
(a copy can be made at the office, so the original can be returned to you)
NAME OF FATHER
Your answer
NAME OF MOTHER
Your answer
I. CONTACT INFORMATION
MAILING ADDRESS
*
Your answer
PHONE NUMBER
*
Your answer
EMAIL
*
Your answer
OCCUPATION
Your answer
II. RELIGIOUS HISTORY
CURRENT RELIGIOUS AFFILIATION (if any)
Your answer
HAVE YOU EVER BEEN BAPTIZED?
*
Yes
No
Maybe
If yes, please deliver or mail to the parish office (attn: DPE) an original of your Baptism certificate.
(a copy can be made at the office, so the original can be returned to you)
If yes baptized, as Catholic? or what denomination?
Your answer
If yes baptized, what date or your approximate age when baptized?
Your answer
If yes, was baptismal name different from current name? (if so, what name?)
Your answer
If baptized, name of church/parish/denomination (and address if known)
Your answer
If baptized as a Catholic, have you received any other sacrament? (Confession? Communion? Confirmation? please list which)
Your answer
III. MARITAL STATUS
I am engaged to be married.
*
Yes
No
If engaged, fiancé(e)'s name
Your answer
Would this be your fiancé(e)'s first marriage, or was married before?
Your answer
fiancé(e)'s religious affiliation (if any)
Your answer
MARRIED (in your past and/or presently)?
*
Yes
No
If currently married, spouse's name
Your answer
Spouse's religious affiliation (if any)
Your answer
Is this a first marriage, or have you been married before?
Your answer
Is this spouse's first marriage, or has spouse been married before?
Your answer
Date of (current) Marriage
MM
/
DD
/
YYYY
Place of Marriage (city, state, country)
Your answer
Officiating Authority of Marriage (civil government, non-Christian minister, Christian minister, Catholic cleric)
Your answer
If married, are you separated?
Yes
No
Clear selection
Are you divorced?
*
Yes
No
Are you a widow/widower?
*
Yes
No
If a widow/widower, have you remarried since your spouse's death?
Yes
No
Clear selection
IV. FAMILY INFORMATION
List the relationship, name, and age of any children or other dependents (e.g., Daughter - Jane - 17 ; Stepson - John - 5).
Your answer
V. GENERAL QUESTIONS
1. What or who has led you to want to know more about the Catholic Faith?
*
Your answer
2. Please describe the type of religious education you have received, as a child and as an adult.
*
Your answer
3. What contact have you had with the Catholic Church to date?
*
Your answer
4. What are some of the questions or concerns you have about the Catholic Church?
*
Your answer
5. At this point in time, which of the following statements best describes your present feelings and thoughts about the possibility of joining the Catholic Church?
*
I need much more information about the Catholic Church before I would consider joining.
I am considering joining, but I am still unsure about it.
I am fairly sure that I would like to join, but still need time to study and pray about it.
I am fairly sure that I want to join the Catholic Church.
Is Internet access available in your home for faith education use?
*
Yes
No
Emergency Contact Name and Phone #
*
Your answer
Today's date
*
MM
/
DD
/
YYYY
Expect further information about the program from the Director of Parish Evangelization and/or the RCIA Coordinator.
Thank you and may God bless!
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