NORTHSHORE UNITED CHURCH OF CHRIST
Information Survey
In an effort to keep our Church records current, we are requesting that every household please fill
out this form and return to the Church office. (This information is for office use only and will not be
distributed except through the periodic publishing of our church directory. The utmost security will be used to
protect your personal information.) Thank you
Household Information
Last Name:
____ Wedding Anniversary (if Applicable)
Home Phone:
Individual Information
Name (first, middle, last)
Preferred Name
Work Phone
Cell Phone
Birth Date
E-Mail
Employer /School
Name (first, middle, last)
Preferred Name
Work Phone
Cell Phone
Birth Date
E-Mail
Employer /School
Name (first, middle, last)
Preferred Name
Work Phone
Cell Phone
Birth Date
□
_
_
_
_
Emergency Contact (name & phone)
E-Mail
Employer /School
Name (first, middle, last)
Preferred Name
Birth Date
/_____
Check to request no listing in directory
E-mail Address
Mailing Address:
Work Phone
/
Cell Phone
E-Mail
Employer /School
PLEASE LIST ADDITIONAL FAMILY MEMBERS ON THE BACK OF THIS PAGE