RCIA Registration Form

Name (First, Middle, Last) REQUIRED Please fill out this field. Please enter valid data.

Your Mailing Address:

Street: REQUIRED Please fill out this field. Please enter valid data.

City, State, and Zip Code: REQUIRED Please fill out this field. Please enter valid data.

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

Best Contact Phone Number: REQUIRED Please fill out this field. Please enter valid data.

Information about your Marriage:

Marital Status: Never Married Married Divorced, not remarried Divorced, and re-married Widow/widower

If married: Name of your Spouse: Please enter valid data.

Is your spouse Catholic? Yes No

Date and Location of your marriage: Please enter valid data.

Your date of birth REQUIRED Please fill out this field. Please enter valid data.

Have you or your spouse ever been married before? No, this is the first marriage for both of us Yes, I was previously married Yes, my spouse was previously married

Are you a member of any church? Yes No

If you have been baptized in any church, please complete this section. We also ask that you provide us with a certificate of your previous baptism within the first few weeks of the program.

Have you ever been baptized in any faith? REQUIRED Yes No I'm not sure Please fill out this field.

If yes, name of the Church where you were baptized: Please enter valid data.

Address of the Church of your baptism Please enter valid data.

Name of the minister (if known): Please enter valid data.

Spirituality Needs:

In order to help our team meet your needs, please answer the following:

Describe your faith background: REQUIRED Please fill out this field.

What is your reason for your interest in this program? REQUIRED Please fill out this field.

What do you hope to get out of this process? REQUIRED Please fill out this field.

Please reate your relationship with Jesus Christ today:

On a scale of 1 to 5, with 1 being low and 5 high, select the number that you feel best describes your personal relationship with Jesus.

1 2 3 4 5

Immaculate Heart of Mary
Parish

Burlington, Kentucky

RCIA Registration Form

RCIA Registration Form

Catholic Inquiry Program

Spirituality Needs: