First Name(s): Mailing Address - Clover Sites

220 East Butler St. * Loudonville, Ohio 44842 Phone: 419.994.4396 * Fax: 419.994.5263 Family Name: _________________________________

First Name(s): ____________________________

Mailing Address: __________________________________________________________________________ City: _____________________________ State: ______________________ Zip Code: __________________ Is this a seasonal address? Y/N

If Yes, dates you are in our area: ____/_____ to ____/_____

Phone Number: (______)________________________ Family Email: _____________________________________________________________________________ Individual Member Information Full Legal Name: _________________________________________ Nickname:_________________________________

Individual Member Information Full Legal Name: _________________________________________ Nickname:________________________________

Maiden Name:_____________________________

Maiden Name:_____________________________

Male/ Female

Male/ Female

Date of birth: ___/____/____

Date of birth: ___/____/____

Personal Email: ____________________________

Personal Email: ____________________________

Work Phone: ______________________________ Cell Phone: ________________________________

Work Phone: ______________________________ Cell Phone: _______________________________

Occupation: _______________________________

Occupation: _______________________________ Employer: ________________________________

Employer__________________________________

Sacramental Information

Sacramental Information Baptized?

Y/N

Date: ____/____/____

Baptized?

Y/N

Date: ____/____/____

Catholic?

Y/N

Other? _________________

Catholic?

Y/N

Other? _________________

Name of Church: ___________________________

Name of Church: ___________________________

City/State: ________________________________

City/State: ________________________________

First Eucharist: Y/N

First Eucharist: Y/N

Date: ____/____/____

Date: ____/____/____

Name of Church: ___________________________

Name of Church: ___________________________

City/State: ________________________________

City/State: ________________________________

Confirmed?

Confirmed?

Y/N

Date: ____/____/____

Y/N

Date: ____/____/____

Name of Church: ___________________________

Name of Church: ___________________________

City/State: ________________________________

City/State: ________________________________

Marital Status: Separated

Marital Status: Separated

Single Divorced

Married Annulled

Single Divorced

Wedding Date: ____/____/____

Wedding Date: ____/____/____

Valid Catholic Marriage?

Valid Catholic Marriage?

Y/N

Married Annulled

Y/N

Name of Church: ___________________________

Name of Church: ___________________________

City/State: ________________________________

City/State: ________________________________

Dependent Child Information Full Legal Name: _________________________________________ Nickname:__________________________ Male/ Female

Date of birth: ___/____/____

Son

Daughter

Sacramental Information Baptized?

Y/N

Date: ____/____/____

Catholic?

Y/N

Other? _________________

Name of Church: ___________________________ City/State: ________________________________ First Eucharist: Y/N

Date: ____/____/____

Name of Church: ___________________________ City/State: ________________________________ Confirmed?

Y/N

Date: ____/____/____

Name of Church: ___________________________ City/State: ________________________________

Dependent Child Information Full Legal Name: _________________________________________ Nickname:__________________________ Male/ Female

Date of birth: ___/____/____

Son

Daughter

Sacramental Information Baptized?

Y/N

Date: ____/____/____

Catholic?

Y/N

Other? _________________

Name of Church: ___________________________ City/State: ________________________________ First Eucharist: Y/N

Date: ____/____/____

Name of Church: ___________________________ City/State: ________________________________ Confirmed?

Y/N

Date: ____/____/____

Name of Church: ___________________________ City/State: ________________________________

Dependent Child Information Full Legal Name: _________________________________________ Nickname:__________________________ Male/ Female

Date of birth: ___/____/____

Son

Daughter

Sacramental Information Baptized?

Y/N

Date: ____/____/____

Catholic?

Y/N

Other? _________________

Name of Church: ___________________________ City/State: ________________________________ First Eucharist: Y/N

Date: ____/____/____

Name of Church: ___________________________ City/State: ________________________________ Confirmed?

Y/N

Date: ____/____/____

Name of Church: ___________________________ City/State: ________________________________