New Census Form

Please take a moment to tell us all about your family.

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New to St. John Berchmans Parish Existing Parishioner(s) of St. John Berchmans

Family Information

Family (Last) Name: *

Address: *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number: *

Family Email: *

Do You Use Church Envelopes: *

Yes No

If Yes, Envelope #: *

If No, Would You Like Envelopes: *

Yes No

Head(s) of Household Information

Adult 1

First Name: *

Middle Name: *

Last Name: *

Maiden Name, If Applicable: *

Cell Phone Number: *

Email: *

Occupation: *

Religion: *

Baptized: *

Yes No

Received 1st Communion: *

Yes No

Confirmed *

Yes No

Shut-In *

Yes No

Adult 2

First Name: *

Middle Name: *

Last Name: *

Maiden Name, If Applicable: *

Cell Phone Number: *

Email: *

Occupation: *

Religion: *

Baptized: *

Yes No

Received 1st Communion: *

Yes No

Confirmed: *

Yes No

Shut-In *

Yes No

Other(s) Living in Household Information

Person 1

First Name: *

Middle Name: *

Last Name: *

Gender: *

Male Female

Date of Birth: *

Ethnicity: *

African American Caucasian Hispanic Other

If Other: *

Religion: *

Baptized: *

Yes No

Received 1st Communion: *

Yes No

Confirmed: *

Yes No

Shut-In *

Yes No

Person 2

First Name: *

Middle Name: *

Last Name: *

Gender: *

Male Female

Date of Birth: *

Ethnicity: *

African American Caucasian Hispanic Other

If Other: *

Religion: *

Baptized: *

Yes No

Received 1st Communion: *

Yes No

Confirmed: *

Yes No

Shut-In: *

Yes No

Person 3

First Name: *

Middle Name: *

Last Name: *

Gender: *

Male Female

Date of Birth: *

Ethnicity: *

African American Caucasian Hispanic Other

If Other: *

Religion: *

Baptized: *

Yes No

Received 1st Communion: *

Yes No

Confirmed: *

Yes No

Shut-In: *

Yes No

Person 4

First Name: *

Middle Name: *

Last Name: *

Gender: *

Male Female

Date of Birth: *

Ethnicity: *

African American Caucasian Hispanic Other

If Other: *

Religion: *

Baptized: *

Yes No

Received 1st Communion: *

Yes No

Confirmed: *

Yes No

Shut-In: *

Yes No

Person 5

First Name: *

Middle Name: *

Last Name: *

Gender: *

Male Female

Date of Birth: *

Ethnicity: *

African American Caucasian Hispanic Other

If Other: *

Religion: *

Baptized: *

Yes No

Received 1st Communion: *

Yes No

Confirmed: *

Yes No

Shut-In: *

Yes No

Any Additional Comments: *

Thank you for helping keep our records as up-to-date as possible, please continue to keep us updated so we can better serve you.

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