Census/Registration Form St

Welcome to St. Agnes Parish!

Census/Registration Form

St. Agnes Church 2314 3rd Ave. PO Box 349 Scottsbluff, Nebraska 69363-0349 308-632-2541

Today’s date______(for office use) Env.#______

Family Last name______StreetAddress______Mailing address (if different)______City/State/Zip______Phone #1______To whom does phone belong?______Phone #2______To whom does phone belong?______Email Address 1)______2)______

Head of Household Last name______First name______Title: (circle one) Mr. Mrs. Ms. Miss Dr. Other______Marital Status: Church married_____Married_____Single____Separated____Divorced____Widowed_____ Gender: M___F___ Maiden name______Birth date______

Sacraments (if received check and date) Baptism______date______First Communion_____date______Confirmation______date______Marriage______date______Reconiliation______date______Religious affiliation: ______Catholic ______Other (please list)______Education: grades completed______degree______Occupation______Place of work______Location______Phone #______

Ministries/Talents you are experienced with______Ministries/Talents you would like more information on______

Spouse Last name______First name______Title: (circle one) Mr. Mrs. Ms. Miss Dr. Other______Marital Status: Church married_____Married_____Single____Separated____Divorced____Widowed_____ Gender: M___F___ Maiden name______Birth date______

Sacraments (check and date if received) Baptism______date______First Communion_____date______Confirmation______date______Marriage______date______Reconiliation______date______Religious affiliation: : ______Catholic ______Other (please list)______Education: grades completed______degree______Occupation______Place of work______Location______Phone #______

Ministries/Talents you are experienced with______Ministries/Talents you would like more information on______

(Continued on back) Children (List only children/dependents living at home.)

1) Name______Gender______Birthdate______

Sacraments (check and date if received) Baptism_____date______First Communion____date______Confirmation______date______Reconiliation______date______

School______Grades completed (at end of last school year)______

Please return completed form to the address at the top of this form or to the collection basket.

Additional Comments/Concerns: