Date of Census:	Race: (Caucasian, African American, Hispanic, Other):	Married by Priest: Yes No
Family (Last) Name:	Use Envelopes: Yes No	Do You Want Church Envelopes: Yes No
Address:	City:	Zip:
Home Phone #:	His Cell Phone #:	Her Cell Phone #:
His Occupation:	Her Occupation:	Family E-mail:
LIST ALL THOSE LIVING WITH YOU:	Date of Birth	Religion	Baptism	1st Communion	Confirmation	Shut In
Husband (Full Name):	Yes No	Yes No	Yes No	Yes No
Wife (Full Maiden Name):	Yes No	Yes No	Yes No	Yes No
FULL NAMES OF THE CHILDREN LIVING WITH YOU:	Date of Birth	Religion	Baptism	1st Communion	Confirmation	Shut In
Yes No	Yes No	Yes No	Yes No
Yes No	Yes No	Yes No	Yes No
Yes No	Yes No	Yes No	Yes No
Yes No	Yes No	Yes No	Yes No
Yes No	Yes No	Yes No	Yes No
Yes No	Yes No	Yes No	Yes No
Yes No	Yes No	Yes No	Yes No
Yes No	Yes No	Yes No	Yes No
Yes No	Yes No	Yes No	Yes No

WHAT CHURCH PARISH DID YOU BELONG TO

BEFORE MOVING TO ST. JOHN BERCHMANS:_________________________________________________________ CITY:__________________________