Epiphany Parish / Parroquia de Epifania
2524 S. Keeler Avenue. Chicago, Illinois 60623
Telephone (773) 521-1112 www.epiphanychicago.org
Epiphany Parish Survey Form (information is confidential – office use ONLY)
This survey and registration will help the staff of Epiphany parish continue its mission to serve your family better.
FAMILY INFORMATION
Your Name:
〇Mr. 〇 Miss 〇 Mrs.
□ Baptism
Today’s Date
/
(First Name)
(Middle Initial)
□ First Communion
Date of birth:
/
Month
/
□ Confirmation
/
□ Married through the Catholic Church
____________________________
Day /
Year
Spouse Name:
〇 Mr. 〇 Miss
〇 Mrs. (First Name)
□ Baptism
□ First Communion
(Only if female – Maiden Name)
(Last Name)
_____________________________
Occupation
Other Language
/
Date of birth:
/
Month /
(Middle Initial)
/
Day /
□ Confirmation
□ Married through the Catholic Church
___________________________
Year
(Only if female – Maiden Name)
(Last Name)
_____________________________
Occupation
Other Language
1.- Home Phone Number______________________Language preference for phone messages
□ English □Spanish
2.- Emergency Phone Number________________________E-mail_______________________________
Home Address:
Address
Are you married by the Catholic Church?
City
〇Yes
State
Zip Code
〇No
If no, would you like to be married by the Church ? 〇Yes 〇No
Do you need help on an annulment? 〇Yes 〇No
Do you rent an apartment or are you the owner of a house? 〇Rent 〇Own Do you want your house blessed? 〇 Yes 〇No
Does your child attend catholic school?: 〇Yes 〇No
Public school? 〇 Yes 〇 No
Does your child attend catechism? 〇 Yes 〇No
Do you need to speak to us about Sacraments (baptism, confirmation.) or Catechism for your children?
〇 Yes 〇No
Do you know if your grandparents or any elderly in your home may need a prayer, communion or anointing of sick?
〇 Yes 〇No
Do you have Sunday Envelopes? 〇 Yes 〇 No Do you want to speak with the priest? 〇 Yes 〇No
Did you know you can claim your contribution on your income tax forms? 〇 Yes 〇No
Please Check ONE from the following options:
______We are registered parishioners and desire to continue as such.
______We are registered parishioners and desire to continue, even though we do not attend Mass on a regular basis.
Please explain why you do not attend Mass_________________________________________________________
______We are registered parishioners, but do not attend Mass. We do wish to remain on the parish files
Please explain why you no longer attend Mass_____________________________________________________
______We are currently registered members, but wish to be removed from the parish files.
Please explain why you wish to be removed from our parish file________________________________________
Epiphany Parish / Parroquia de Epifania
2524 S. Keeler Avenue. Chicago, Illinois 60623
Telephone (773) 521-1112 www.epiphanychicago.org
NAME OF YOUR CHILDREN UNDER THE AGE OF 21 YEARS OLD:
Name:
Date of birth:
(First Name)
□ Baptism
(Middle Initial)
□ First Communion
(Last Name)
□ Confirmation
Name:
□ Baptism
(Middle Initial)
□ First Communion
(Last Name)
□ Baptism
(Middle Initial)
□ First Communion
(Last Name)
□ Baptism
(Middle Initial)
□ First Communion
(Last Name)
□ Baptism
(Middle Initial)
□ First Communion
(Last Name)
□ Baptism
(Middle Initial)
□ First Communion
(Last Name)
(Middle Initial)
(Last Name)
Sex: O Male O Female
/
/
Sex: O Male O Female
/
/
Sex: O Male O Female
□ Married through the Catholic Church
Date of birth:
(First Name)
/
Month / Day / Year
□ Confirmation
Name
/
□ Married through the Catholic Church
Date of birth:
(First Name)
Sex: O Male O Female
Month / Day / Year
□ Confirmation
Name:
/
□ Married through the Catholic Church
Date of birth:
(First Name)
/
Month / Day / Year
□ Confirmation
Name:
Sex: O Male O Female
□ Married through the Catholic Church
Date of birth:
(First Name)
/
Month / Day / Year
□ Confirmation
Name:
/
□ Married through the Catholic Church
Date of birth:
(First Name)
Sex: O Male O Female
Month / Day / Year
□ Confirmation
Name:
/
□ Married through the Catholic Church
Date of birth:
(First Name)
/
Month / Day / Year
/
/
Sex: O Male O Female
Month / Day / Year
OFFICE USE ONLY
Env.Given ___________________ Env. # ____________Date entered: _________________
______