RCIA Registration Questionnaire

The information that you provide on the RCIA Questionnaire is considered personal and confidential and will be treated with the utmost respect.

We feel blessed that you have submitted this information and someone will be in touch with you.

Thank you.

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Maiden Name REQUIRED Please fill out this field. Please enter valid data.

Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Date of Birth REQUIRED

00/00/0000

Please fill out this field. Please enter a date.

Place of Birth (City, State & Zip) REQUIRED Please fill out this field. Please enter valid data.

Home Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Cell Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Email REQUIRED Please fill out this field. Please enter an email address.

Are you Catholic? REQUIRED Yes No Please fill out this field.

SACRAMENTS RECEIVED: (Check all that apply.) Baptism Penance/Reconciliation Communion/Eucharist Confirmation None of the Above

Baptism Info--Name of Church REQUIRED

(Type NA if Not Applicable)

Please fill out this field. Please enter valid data.

Baptism-Year of Baptism REQUIRED Please fill out this field. Please enter valid data.

Baptism--City/State REQUIRED Please fill out this field. Please enter valid data.

Are you presently married? REQUIRED Yes No Please fill out this field.

If you answered YES, is this your First Marriage? REQUIRED Yes No Not Applicable Please fill out this field.

If this is NOT your first marriage, will you be seeking an annulment? REQUIRED Yes, I am or will be seeking an annulment. No, I will not be seeking an annulment. Not sure yet. Not Applicable Please fill out this field.

If this is NOT your first marriage, how many times have you been married (counting your present marriage)? REQUIRED Have been married 2 times (counting present marriage) Have been married 3 or more times (counting present marriage) Not Applicable Please fill out this field.

If this is NOT your first marriage, how many times have you been divorced? REQUIRED I have been divorced one time. I have been divorced two or more times. Not applicable. Please fill out this field.

Immaculate Conception

Catholic Church

RCIA Registration Questionnaire

RCIA Registration Questionnaire