The following information is needed about each member for the confidential use of the Recorder of Newtown Monthly Meeting. But, items judged sensitive can be left blank.

Full name of member: Phone:

Date of birth: E-mail:

Place of birth:

Present address:

Father’s name:

Mother’s maiden name:

If married

Spouse name:

Date of marriage:

Place of marriage:

Spouse religious affiliation:

Date of birth:

Place of birth:

Father’s name:

Mother’s maiden name:

List children’s full names and birth dates below or on the back of this sheet.