St. John the Evangelist Anglican Church

St. John the Evangelist Anglican Church

60 Erie Street North, Leamington, ON N8H 2Z5 519-326-3111
Private and Confidential
Personal Information
(Please fill in separate sheet per person)
Full Name:

First NameLast Name
Birthdate:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail address:
example@example.com
Mailing Address if different from above:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone: House#:
Format: (000) 000-0000.
Cell#:
Format: (000) 000-0000.
Do you identify as

or Other
Pronouns preferred
Spouse/Common-Law/Partner's Name:

First NameLast Name
Spouse/Common-Law/Partner Status
Are they a member of the church:

If more room is needed or you want to add comments, please add them to the back of the sheet.
PICTURES
1) Do you give permission to have your picture taken and placed in church articles, vestry reports or in an email that is for members of the church?
2) Do you give permission to have your picture taken and placed in a brochure or on social media to advertise church events?
Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

FUNERAL