Progressive ~ Traditional ~ Open to All
Camarillo United Methodist Church
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General Information
Title
Mr.
Mrs.
Ms.
Dr.
Rev.
Rev. Dr.
Legal First Name
Legal Last Name
Legal Middle Name
Maiden Name
Nickname or Preferred Name
Salutation, if other than legal or preferred name
Gender
PLEASE SELECT
Male
Female
Non-binary
Marital Status
Single
Married
Divorced
Widowed
Birthdate
Race / Ethnicity
PLEASE SELECT
Asian
Black / African American
Hispanic / Latino American
Native American
Pacific Islander
White
Multi-Racial
Membership Information
Membership Status
PLEASE SELECT
Active Member
Preparatory Member (children of members)
Regular Attender, non-member
Visitor
No longer attending
Financial contributor but do not attend
Member of another UMC
Member of other denomination
Clergy
Are you baptized?
Yes
No
Baptismal Date, if you remember
If member of another church, please indicate name and city of the church.
Contact Information
Home Phone Number
Work Phone Number
Mobile Number
Please indicate if you wish any phone number to be unlisted.
Email
Alternate Email Address
Primary Address 1
Address 2
Country
City
State
Zip/Postal Code
Mailing Address, if other than primary address
Address 2
Country
City
State
Zip/Postal Code
Indicate information to EXCLUDE in church directory
Home number
Work number
Mobile number
Email address
Alt Email address
Primary address
Alt Address
Emergency Contact Name, Relationship, Phone Number and/or Email
Additional Family Information - children's names, relationship, contact info
Occupation / Employment / School Information
Occupational Status
Full-time
Part-time
Unemployed
Student
Retired
Occupation or Previous Occupation if retired
For children/youth/students: Name of School and Grade Level
Area of Interest
For Sunday Services
Greeter
Usher
Liturgist
Acolyte (youth)
Choir
Bell Choir
Media Team
Chancel Stewards
Hospitality
Ministry Teams & Committees
Staff Parish (HR)
Finance
Trustees
Mission
Endowment
Helping Hands
Worship
Senior Ministries
Adult Education
Youth Ministry
Children's Ministry
Caring Ministries
Prayer Teams
Volunteer Opportunities
Painting
Weeding/Gardening
Repair/Maintenance Work
Office/Clerical
Flower Deliveries
Homebound Visitation
Baking Cookies
Sunday Hospitality
Help with Funerals/Receptions
Sewing/Quilting
Blood Drive
Medical Supply Project
Small Groups
Mingles
Camping
Gardening
Cooking
Book Club
Exercise
Prayer Groups
Bible Study
Meditation
Sermon Discussions
Crafts
Women's Group (UMW)
Men's Group (UMM)
Social Justice
Disaster / Emergency Preparedness Info
Do you live alone?
Yes
No
Are you homebound?
Yes
No
Are you legally blind?
Yes
No
Do you speak another language (Yes, No)? If so, what language?
Residence Type
PLEASE SELECT
Single Family Home
Attached/Townhome
Apartment/Multi-Family Dwelling
Mobile Home
Number of floors in your home or apartment
Do you use a mobility tool? (Check all that apply)
Wheelchair
Walker
Cane
All the time
Some of the time
Most of the time
Do you require a special diet? If so, please indicate.
Medical Needs - severe cardiac, diabetic on insulin, homelessness, etc.
Do you rely on electricity for home medical treatments?
Yes
No
Have you registered with the County Emergency Dept for help in an evacuation?
Yes
No
Name of Family Physician and Number
Do you have pets?
No pets
1 pet
2 pets
3 or more pets
Do you have transportation in an emergency?
Yes
No, I will need transportation
No, but I will not need transportation
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