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St. Paul Lutheran Church Head of Household Census Form Date information provided: __________________ Gender: ___M ___F Ethnicity Member Status: ___Active Mem., ___Inactive Mem., ___Active Non-Mem. Participant, ___Prospective Mem. Name: (First) ___________________ (Middle) _________________ (Last) Maiden Name or Also Known As (Nickname): Name of Mother & Father Name of Stepmother &/or Stepfather: Legal Guardian: Your Mailing Address: ____________________________________________ Apt./Unit#: City/State/Country: _______________________________________________ Zip Code: Your Physical Address: ____________________________________________ Apt./Unit#: City/State/Country: _______________________________________________ Zip Code: Phone #': Cell ______________________

Home ______________________ Work ______________________

Preferred E-mail address: Date of Birth: _____________________ Location (e.g. Hospital) of Birth: City / State or Country of Birth: Marriage / Blessing Information: Current Status (check one): ____ Married ____ Divorced ____ Widowed ____ Partnered _____ Single Name of Spouse/Partner: Date of Ceremony: Place of Ceremony: City/State/Country of Ceremony: Baptism Information: Date of Ceremony: ____________________________ Denomination: Place of Ceremony: City/State/Country of Ceremony: _ Revised on: 9/1/17


Communion Information: (For 1st Communion only) Date of Ceremony: ______________________________ Denomination: Place of Ceremony: City/State/Country of Ceremony: Confirmation Information: Date of Ceremony: ______________________________ Denomination: Place of Ceremony: City/State/Country of Ceremony: Church Membership History (Including St. Paul) – Name of Church; City, State/Country; Dates

Primary Emergency Contact Information: Name of Contact: Address: ____________________________________________ Relationship: Phone #': Cell ______________________

Home ______________________Work ______________________

Secondary Emergency Contact Information: Name of Contact: Address: _________________________________________________ Relationship: Phone #': Cell ______________________

Home ______________________Work ______________________

Names of Household Members: (Please attach additional names, if necessary) Name

Gender

Age

___________________________________________________________________ ___________ ____________ ___________________________________________________________________ ___________ ____________ ___________________________________________________________________ ___________ ____________ ___________________________________________________________________ ___________ ____________ ___________________________________________________________________ ___________ ____________

Revised on: 9/1/17

Head of Household form  
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