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Wilkes-Barre

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Do you live in the area year round or seasonally?

Year Round

Seasonally

May we share your personal information with our Parish Ministries?

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English

Spanish

1st Head of Household - Marital Status

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1st Head of Household - First Name

1st Head of Household - Last Name

1st Head of Household - Primary Phone Number

1st Head of Household - Additional Phone Number

1st Head of Household - Email Address

Receive Parish Emails?

Yes

No

1st Head of Household - Date of Birth

1st Head of Household - Occupation

1st Head of Household - Sacraments Completed

Baptism

1st Communion

Confirmation

1st Head of Household - Church of Baptism

City

State

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2nd Head of Household - Marital Status

Single

Married

Separated

Divorced

Widowed

2nd Head of Household - First Name

2nd Head of Household - Last Name

2nd Head of Household - Primary Phone Number

2nd Head of Household - Additional Phone Number

2nd Head of Household - Email Address

Receive Parish Emails?

Yes

No

2nd Head of Household - Date of Birth

2nd Head of Household - Occupation

2nd Head of Household - Sacraments Completed

Baptism

First Communion

Confirmation

2nd Head of Household - Church of Baptism

City

State

Additional Notes (If Applicable)

3rd Household Member - First Name

3rd Household Member - Last Name

3rd Household Member - Date of Birth

3rd Household Member - Occupation

3rd Household Member - Sacraments Completed

Baptism

1st Communion

Confirmation

3rd Household Member - Church of Baptism

City

State

Additional Notes (If Applicable)

4th Household Member - First Name

4th Household Member - Last Name

4th Household Member - Date of Birth

4th Household Member - Occupation

4th Household Member - Sacraments Completed

Baptism

1st Communion

Confirmation

4th Household Member - Church of Baptism

City

State

Additional Notes (If Applicable)

5th Household Member - First Name

5th Household Member - Last Name

5th Household Member - Date of Birth

5th Household Member - Occupation

5th Household Member - Sacraments Completed

Baptism

1st Communion

Confirmation

5th Household Member - Church of Baptism

City

State

Additional Notes (If Applicable)

I would like to learn more about:

Religious Education

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Contact info

226 S. Washington St.

Wilkes-Barre, PA 18701

(570) 823-7736. stnicholas@stnicholasrc.com

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