St. Andrew AME Church

St. Andrew AME Church 2009 Census (Please Print)

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Email Address: ______

Home Phone: ______Cell Phone: ______

Address: ______

City: ______State: ____ Zip: ______

Birth Date: ___/___/____

Occupation: ______Employer: ______

Please circle your answer to the following: (a) Are you Head of Household: Yes or No (b) Gender: Male or Female (c) Primary Service: 7:45am or 11:00am (d) Marital Status: Single/ Married/ Separated/ Divorced/ Widow(er) (e) Educational Status: High School/ Some College/ College Graduate/ Advanced Degree

Emergency Contact: ______

Emergency Contact Phone: ______

Other People living in your Household

(a) Name: ______Birth Date: ___/___/____ Relationship to you: ______Primary Service: 7:45am or 11am St Andrew Member: Y or N

(b)Name: ______Birth Date: ___/___/____ Relationship to you: ______Primary Service: 7:45am or 11am St Andrew Member: Y or N

(c)Name: ______Birth Date: ___/___/____ Relationship to you: ______Primary Service: 7:45am or 11am St Andrew Member: Y or N

If you have any comments you would like to express then please leave them on the back of this form (d)Name: ______Birth Date: ___/___/____ Relationship to you: ______Primary Service: 7:45am or 11am St Andrew Member: Y or N

If you have any comments you would like to express then please leave them on the back of this form