Enrollment Form

Saint Patrick Parish

ParishPay Enrollment Form

Print this page and
Return this completed form to the parish office.

First Name: ____________________________________________________

Middle Name: __________________________________________ (optional)

Last Name: ____________________________________________________

Street: ________________________________________________________

City: _______________________ State: ______ Zip: _________________

Email: ________________________________________________ (optional)

Phone: ________________________________________________________

Monthly Amount: $_____________________.00

Special Collection Amount (per collection): $_____________________.00

Easter Collection Amount: $_____________________.00

Christmas Collection Amount: $_____________________.00

Chosen Four Digit Pin (personal identification number):________________

Payment Type (circle one): Checking Savings Other bank account
MasterCard Discover Visa American Express

If using a bank account:

Bank Routing #: ________________________________________________

Bank Account#: _________________________________________________

If using a credit card:

Credit Card# ___________________________________________________

Name on Card: __________________________________________________

Expiration Date: (mm) ________ / (yy) _________