Census to Identify Deaf and Hard-of-Hearing Persons
Within the Roman Catholic Diocese of Syracuse
Catholic Deaf Community of the Syracuse Diocese
 1119 Elm Street
 Utica NY 13501

As the Catholic Deaf Ministry of the Syracuse Diocese continues its mission, we need to identify whom we will serve, where they live, and the services they need. The result will be kept confidential, but will be used to make decisions about how best to serve the Catholic Deaf and Hard-of-Hearing within the Diocese of Syracuse. We ask you to complete this form and return it as soon as possible. You can print it out, fill it in by hand and mail to us; or copy all the text into your e-mail program, set your keyboard to typeover and fill in the info, and e-mail to syrdeaf@juno.com. If there's an annoying frame up at the top of this page, hit your right mouse button and select "open page in new frame" or similar thing..

        FAMILY MEMBERS:                                                          (Please X for each)
Name                                                   Date of Birth                   Deaf / H-of-H / Hearing


         TELEPHONE:                         (Voice or TTY?)
         Do you regularly attend Mass? YES       NO
         Does your parish offer any services for the Deaf/Hard of Hearing?  YES     NO
Is there anyone you know who is qualified to interpret any liturgies for our Catholic services and/or programs?

       NAME                                 Telephone

Does anyone in the family wish preparation for any of the following sacraments?
         Reconciliation (Confession)
In what other areas do you have an interest or a need?

_____ Religious Education   _____ Bible Study        _____ Retreats
_____ Engaged Encounter   _____ Marriage Encounter  _____ Formation for Ministry Program
_____ Cursillo           _____ Pastoral Care (hospitals/homebound, etc.)
_____ Natural Family Planning instruction       Other:

Do you know of any deaf or H-of-H persons in hospitals or nursing homes of whom we should be aware?

         Name________________________________ Location _________________________
How do you wish to contribute to the life of the parish community: (e.g. lector (reader), eucharistic minister, catechist (teacher), usher, parish council, etc.)

How far would you be willing to travel to have Deaf Services available (circle one)

         0-10 miles   10-15 miles  15-20 miles  over 20 miles   Wish to stay in home parish

If you know of anyone who has not received this form and would like to be included in the results, please add their name and address here:

Thank you for sharing this info with us!!

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