<p> Welcome to St. Agnes Parish!</p><p>Census/Registration Form</p><p>St. Agnes Church 2314 3rd Ave. PO Box 349 Scottsbluff, Nebraska 69363-0349 308-632-2541</p><p>Today’s date______(for office use) Env.#______</p><p>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)______</p><p>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______</p><p>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 #______</p><p>Ministries/Talents you are experienced with______Ministries/Talents you would like more information on______</p><p>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______</p><p>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 #______</p><p>Ministries/Talents you are experienced with______Ministries/Talents you would like more information on______</p><p>(Continued on back) Children (List only children/dependents living at home.)</p><p>1) Name______Gender______Birthdate______</p><p>Sacraments (check and date if received) Baptism_____date______First Communion____date______Confirmation______date______Reconiliation______date______</p><p>School______Grades completed (at end of last school year)______</p><p>2) Name______Gender______Birthdate______</p><p>Sacraments (check and date if received) Baptism_____date______First Communion____date______Confirmation______date______Reconiliation______date______</p><p>School______Grades completed (at end of last school year)______</p><p>3) Name______Gender______Birthdate______</p><p>Sacraments (check and date if received) Baptism_____date______First Communion____date______Confirmation______date______Reconiliation______date______</p><p>School______Grades completed (at end of last school year)______</p><p>4) Name______Gender______Birthdate______</p><p>Sacraments (check and date if received) Baptism_____date______First Communion____date______Confirmation______date______Reconiliation______date______</p><p>School______Grades completed (at end of last school year)______</p><p>Please return completed form to the address at the top of this form or to the collection basket.</p><p>Additional Comments/Concerns:</p>