in English - Holy Family Cluster

Holy Family Cluster
Confidential Census Form
Please fill out and return this form to:
Holy Family Cluster Office
608 2nd Avenue NE
Clarion, Iowa 50525
Or email to: dbq039sec@archdbq.org
Or fax to: 515-532-2153
Dear Parishioner,
Please take time to complete and return the following census form as early as possible. The information helps our
Cluster and parishes plan more effectively for the needs of our parishioners.
The following information is needed for our parishes’ census records. In addition, with the upcoming pictorial
directory, we can ensure that your information is up to date and correct. Statistical information from the parish census
records is also provided to the Archdiocese of Dubuque for planning the needs of the Archdiocese. The information
you provide is confidential and is for the sole use of the Cluster and its parishes. If you prefer some or all of your
contact information to remain private and not appear in the pictorial directory, please indicate such on the form.
Please be sure to list all the members of your family who will be listed under your membership and answer questions to
the best of your knowledge. Only include adult children if they are living at home or still in school. If they prefer to
have their own membership, please have them fill out their own form. If you are no longer a member of the parish or
attend elsewhere, please contact the office so we can remove you from our database.
You will find instructions listed on the sheet, however, if you need additional help, please call the Cluster office at
515-532-3586 and we will be glad to assist you.
Completed forms can be placed in the box located in the entry of each church during Mass. The box will be removed
following each Mass to assure confidentiality. You may also drop off or mail your completed form to the Holy Family
Cluster Office, 608 2nd Avenue NE, Clarion, Iowa 50525. In addition, you can email the form to
dbq039sec@dbqarch.org or fax it to our office at 515-532-2153. Additional copies of this form can be found on the
home page of our website (holyfamilycluster.org) or by contacting the Cluster office during business hours.
God Bless,
Fr. Jerry Blake and the Holy Family Cluster Staff
Please circle your parish
Sacred Heart Parish
St. John Parish
St. Francis Xavier Parish
Contact Information
Family Last Name:___________________________________
Address: (Street)_____________________________________
(City, State, Zip Code)______________________________
Home Phone (Landline only):___________________________
Family Email Address:_________________________________
For Office Use Only:
Envelope Number:_____________________
Date Received:________________________
Your address and phone number are
published in our Pictorial Directory. If you
prefer certain parts of your contact
information not be listed, please list that
here:________________________________
Individual Member Information: Adults
Adult Family Member #1
First Name/Nickname:____________________________
Cell Phone Number:______________________________
Maiden Name:____________ Gender:
Female
Occupation/Employer:____________________________
Role (Husband/Wife/Head of House):________________
Work Phone Number:_____________________________
Date of Birth:__________ Religion:_________________
If you are not Catholic, would you be interested in
learning more about the faith? Yes
No
Marital Status:___________________________________
If married, date & location of marriage:______________
_______________________________________________
Ethnic Origin:_________ Primary Language:__________
Sacraments:
Baptism (place/date if known):______________________
Confirmed?
Yes
No
Male
Email (Personal):________________________________
Mass Attendance (circle one): Daily Weekly Monthly Occasionally Seldom Holidays
Adult Family Member #2
First Name/Nickname:____________________________
Cell Phone Number:______________________________
Maiden Name:____________ Gender:
Female
Occupation/Employer:____________________________
Role (Husband/Wife/Head of House):________________
Work Phone Number:_____________________________
Date of Birth:__________ Religion:_________________
If you are not Catholic, would you be interested in
learning more about the faith? Yes
No
Marital Status:___________________________________
If married, date & location of marriage:______________
_______________________________________________
Ethnic Origin:_________ Primary Language:__________
Sacraments:
Baptism (place/date if known):______________________
Confirmed?
Yes
No
Male
Email (Personal):________________________________
Mass Attendance (circle one): Daily Weekly Monthly Occasionally Seldom Holidays
Individual Member Information: Children
(If no children in the home, skip to last page)
This includes all children in the household, as well as adult children who still live at home or are currently attending college.
If you have an adult child living at home and they would like to be registered separately,
please contact us and we will send you another form.
Child #1
First Name / Nickname:____________________________
Gender:
Male
Female
Current Age:_________
Date of Birth:____________ Religion:______________
Attends Youth Faith Formation Classes?
Yes
No
Sacraments (Please include date and/or place if known):
Baptism___________________________________
1st Reconciliation___________________________
1st Communion_____________________________
Confirmation_______________________________
Child #2
First Name / Nickname:____________________________
Gender:
Male
Female
Current Age:_________
Date of Birth:____________ Religion:______________
Attends Youth Faith Formation Classes?
Yes
No
Sacraments (Please include date and/or place if known):
Baptism___________________________________
1st Reconciliation___________________________
1st Communion_____________________________
Confirmation_______________________________
Child #3
First Name / Nickname:____________________________
Gender:
Male
Female
Current Age:_________
Date of Birth:____________ Religion:______________
Attends Youth Faith Formation Classes?
Yes
No
Sacraments (Please include date and/or place if known):
Baptism___________________________________
1st Reconciliation___________________________
1st Communion_____________________________
Confirmation_______________________________
Child #4
First Name / Nickname:____________________________
Gender:
Male
Female
Current Age:_________
Date of Birth:____________ Religion:______________
Attends Youth Faith Formation Classes?
Yes
No
Sacraments (Please include date and/or place if known):
Baptism___________________________________
1st Reconciliation___________________________
1st Communion_____________________________
Confirmation_______________________________
Child #5
First Name / Nickname:____________________________
Gender:
Male
Female
Current Age:_________
Date of Birth:____________ Religion:______________
Attends Youth Faith Formation Classes?
Yes
No
Sacraments (Please include date and/or place if known):
Baptism___________________________________
1st Reconciliation___________________________
1st Communion_____________________________
Confirmation_______________________________
Child #6
First Name / Nickname:____________________________
Gender:
Male
Female
Current Age:_________
Date of Birth:____________ Religion:______________
Attends Youth Faith Formation Classes?
Yes
No
Sacraments (Please include date and/or place if known):
Baptism___________________________________
1st Reconciliation___________________________
1st Communion_____________________________
Confirmation_______________________________
Please use a separate sheet if you have additional children.
Recall that the Holy Spirit has given each of us personal gifts to use for the building up the Christian community and
our world. If you are interested in volunteering, currently volunteer or would like more information on one of the many
opportunities listed below, please check all that apply and include the name of the family member.
Please note, not all of these opportunities are available in each parish.
FAITH FORMATION
Youth Faith Formation Teacher
( ) _______________________________________
Youth Faith Formation Substitute Teacher
( ) _______________________________________
RCIA (Rite of Christian Initiation of Adults)
Sponsor:
( ) _______________________________________
Team Member:
( ) _______________________________________
LITURGY
Altar Server
( ) _______________________________________
Lector (Weekday or Weekend)
( ) _______________________________________
Usher (includes Greeting and Gift Bearer)
( ) _______________________________________
Extraordinary Minister of Holy Communion
( ) _______________________________________
Rosary Leader
( ) _______________________________________
Sacristan
( ) _______________________________________
MUSIC
Cluster Choir
( ) _______________________________________
Cantor / Song Leader
( ) _______________________________________
Organist
( ) _______________________________________
Musician (please include instrument you play)
( ) _______________________________________
ADDITIONAL MINISTRIES & ORGANIZATION
Communion Minister to the Homebound and Care Center
( ) _______________________________________
Parish Life Committee
( ) _______________________________________
Social Justice Committee
( ) _______________________________________
Stewardship Committee
( ) _______________________________________
Parish Leadership (determined by election)
( ) _______________________________________
Prayer Chain
( ) _______________________________________
Sewing Mission
( ) _______________________________________
Building/Grounds Committee
( ) _______________________________________
Cluster Fall Festival Committee
( ) _______________________________________
Mother Theresa Group
( ) _______________________________________
OTHER ABILITIES OR INTERESTS
Please list any other interests or abilities you may have that you would be willing to share with your parish and Cluster.
This might include youth group, office help, helping with parish dinners, cooking, general handyman skills, etc:
________________________________________________________________________________________________________
________________________________________________________________________________________________________