The following form is for parishioners of St. Peter Claver Church/School.  We are very concerned that our people
          have their basic needs met.  We will contact you based on the information you provide.  Please complete
          the form as completely and accurately as possible:

Last Name:  
First Name:  
MI:  
Church Attending in New Orleans:  
     
Pre-Hurricane Street Address:  
Pre-Hurricane Street Address 2:  
Pre-Hurricane City:  
Pre-Hurricane State:  
Pre-Hurricane Zip:  
     
Current Street Address:  
Current Street Address 2:  
Current City:  
Current State:  
Current Zip:  
     
Current Land Line Phone Number:  
(10 digits, no dashes | if none, enter 0000000000)
Current Cell Phone Number:  
(10 digits, no dashes | if none, enter 0000000000)
     
Current E-mail Address:  
(separate multiple addresses by comma)
(leave blank if none)
Are you planning to return to the New Orleans area?   Yes   No
Are you planning to remain at your present location?   Yes   No
Are you presently employed?   Yes   No
Do you have any missing family members?   Yes   No
Have you registered with FEMA?   Yes   No
Have you registered with the Red Cross?   Yes   No

Do you have any of the following
sacraments pending in your home church?

   Baptism  Confirmation  Marriage

Do you need help with any of the following?

  
Food   Legal Assistance
Clothing   Public Assistance
Housing   Medical Care
Schools   Prescriptions
Employment   Locating a Church
Other (add comments below)

Comments:
Other Adult Members of Household:

 

    First Name   Last Name   Religion (if applicable)
1      
2      
3      
4      

 
Children in Household:

 

    First Name   Last Name   Age   Grade   Previous School   Current School
1            
2            
3            
4