I. FAMILY INFO

FAMILY LAST NAME:  PHONE NUMBER:

ADDRESS:  CITY:  ZIP:

II. HUSBAND (OR SINGLE / WIDOWED MALE)                        DATE OF BIRTH

FIRST NAME:  MIDDLE:  MONTH:DAY:YEAR:

RELIGION:  BAPTIZED: YES NO   CONFIRMED: YES NO

MARRIED BY A PRIEST: YES NO   CURRENT MARITAL STATUS: SINGLE MARRIED SEPARATED DIVORCED WIDOWED

ATTENDS MASS: REGULARLY OCCASIONALLY SELDOM   OCCUPATION:

LIST SPECIAL SKILLS (TEACHER, MUSICIAN, ETC.):

IF THIS SPECIAL SKILL CAN BE USED BY YOUR PARISH, WOULD YOU BE WILLING TO HELP OUT
OCCASIONALLY?: YES NO

III. WIFE (OR SINGLE / WIDOWED FEMALE)                        DATE OF BIRTH

FIRST NAME:  MIDDLE:  MONTH:DAY:YEAR:

RELIGION:  BAPTIZED: YES NO   CONFIRMED: YES NO

MARRIED BY A PRIEST: YES NO   CURRENT MARITAL STATUS: SINGLE MARRIED SEPARATED DIVORCED WIDOWED

ATTENDS MASS: REGULARLY OCCASIONALLY SELDOM   OCCUPATION:

LIST SPECIAL SKILLS (TEACHER, MUSICIAN, ETC.):

IF THIS SPECIAL SKILL CAN BE USED BY YOUR PARISH, WOULD YOU BE WILLING TO HELP OUT
OCCASIONALLY?: YES NO

IV. CHILDREN IN HOUSEHOLD

CHILD 1 FIRST NAME:  MIDDLE:
LAST (IF DIFFERENT):  DATE OF BIRTH: MO:  DAY:  YEAR:
BAPTIZED: YES NO   FIRST COMMUNION: YES NO   CONFIRMED: YES NO   ATTENDS CCD: YES NO

CHILD 2 FIRST NAME:  MIDDLE:
LAST (IF DIFFERENT):  DATE OF BIRTH: MO:  DAY:  YEAR:
BAPTIZED: YES NO   FIRST COMMUNION: YES NO   CONFIRMED: YES NO   ATTENDS CCD: YES NO

CHILD 3 FIRST NAME:  MIDDLE:
LAST (IF DIFFERENT):  DATE OF BIRTH: MO:  DAY:  YEAR:
BAPTIZED: YES NO   FIRST COMMUNION: YES NO   CONFIRMED: YES NO   ATTENDS CCD: YES NO

CHILD 4 FIRST NAME:  MIDDLE:
LAST (IF DIFFERENT):  DATE OF BIRTH: MO:  DAY:  YEAR:
BAPTIZED: YES NO   FIRST COMMUNION: YES NO   CONFIRMED: YES NO   ATTENDS CCD: YES NO

CHILD 5 FIRST NAME:  MIDDLE:
LAST (IF DIFFERENT):  DATE OF BIRTH: MO:  DAY:  YEAR:
BAPTIZED: YES NO   FIRST COMMUNION: YES NO   CONFIRMED: YES NO   ATTENDS CCD: YES NO

CHILD 6 FIRST NAME:  MIDDLE:
LAST (IF DIFFERENT):  DATE OF BIRTH: MO:  DAY:  YEAR:
BAPTIZED: YES NO   FIRST COMMUNION: YES NO   CONFIRMED: YES NO   ATTENDS CCD: YES NO

CHILD 7 FIRST NAME:  MIDDLE:
LAST (IF DIFFERENT):  DATE OF BIRTH: MO:  DAY:  YEAR:
BAPTIZED: YES NO   FIRST COMMUNION: YES NO   CONFIRMED: YES NO   ATTENDS CCD: YES NO

V. OTHERS IN HOUSEHOLD

 OTHER 1 FIRST NAME:  MIDDLE:
LAST (IF DIFFERENT):  DATE OF BIRTH: MO:  DAY:  YEAR:
BAPTIZED: YES NO   FIRST COMMUNION: YES NO   CONFIRMED: YES NO   ATTENDS CCD: YES NO

 OTHER 2 FIRST NAME:  MIDDLE:
LAST (IF DIFFERENT):  DATE OF BIRTH: MO:  DAY:  YEAR:
BAPTIZED: YES NO   FIRST COMMUNION: YES NO   CONFIRMED: YES NO   ATTENDS CCD: YES NO

VI. GENERAL QUESTIONS

1. DOES ANYONE IN YOUR HOME SPEAK A LANGUAGE OTHER THAN ENGLISH? YES NO
   IF YES, WHICH LANGUAGE?
   IF YES, WOULD YOU BE WILLING TO SERVE AS A TRANSLATOR OCCASIONALLY? YES NO

2. DOES ANYONE IN YOUR HOME HAVE SPECIAL NEEDS? YES NO
   PLEASE SPECIFY

3. IS THERE ANYONE IN YOUR HOME WHO IS A SHUT-IN, WHO YOU WOULD LIKE SOMEONE TO BRING
   HIM/HER HOLY COMMUNION REGULARLY? YES NO

4. IF THE CHURCH DOES NOT RECOGNIZE YOUR MARRIAGE AS VALID, WOULD YOU LIKE TO BE
   CONTACTED CONCERNING A POSSIBLE VALIDATION/BLESSING? YES NO

"Most Blessed Sacrament Parish is a Roman Catholic community, inspired by Jesus in the Eucharist, to serve and reach out to all on our Journey of Faith with the guidance of the Holy Spirit"    (Parish Mission Statement)

(PLEASE CHECK YOUR PREFERENCES BELOW)

1. What practice or activity that you found successful in another parish would be an
   improvement for this parish?

2. Would you like to have someone contact you discuss any of the above?  YES NO

3. Would you like to discuss any matter with a priest?  YES NO

4. REMARKS: Is there any way not listed above that you could help the parish OR
   any way the parish could serve you better?  YES NO

IF YOU NEED ANY HELP IN FILLING OUT THIS SURVEY, PLEASE CALL THE RECTORY AT 245-2080.

IF YOU EXPERIENCE ANY TECHNICAL PROBLEMS WITH THIS FORM OR THE WEB SITE, PLEASE
SEND AN E-MAIL TO mailto:WEBMASTER@NEXTEON.COM OR CALL 781-231-3200.