Claremont Healing Rooms Prayer Request Form

Please indicate whether you are:*

First Time GuestReturning Guest

Name*

First NameLast Name

Address*

Street Address

CityState

Zip Code

Foreign City (If outside of United States)

Foreign Country (If outside of United States)

Cell Phone Number*

Foreign Phone Number (Outside of United States)

Country CodePhone Numer

Email*

Please select your preferred appointment time in order of preference. Appointments are scheduled on a first-come, first-served basis. We do our best to honor your time preference. However, if your first preferred time is already filled, we will go to your second and third preferences. If you cannot make a time slot, mark it as "unavailable."

6:45 PM (Pacific Time)*

7:20 PM (Pacific Time)*

8:00 PM (Pacific Time)*

Age, if Minor

If under 18 Guardian's signature is required

Please select all that apply:*

Received Christ as my Lord & SaviorBaptized / Filled with Holy Spirit

Name of Church you attend*

Marital Status*

MarriedSingleChildren

Are you currently under Doctor or other Professional Care?*

YesNo

Prayer request: what Illness or condition are you requesting prayer for.*

LEGAL LIABILITY RELEASE

I agree, by checking "I agree" I do hereby release Claremont Healing Rooms and their volunteers or staff from any liability, for any harm or perceived harm resulting from my voluntary receiving prayer ministry on this and subsequent visits. I understand that these Claremont Healing Rooms is staffed by volunteers representing the broad body of Christ who reflect many denominations and churches. They are not trained or licensed professionals of counseling, therapy, or medical services. I understand that if I am currently taking medication, or operating under the advice of a professional service provider, I will allow them (my medical doctor, therapist, counselor, etc.) to confirm any results of prayer received before altering any prescribed course of action. I acknowledge and agree that if I report any instance of, or plan to, harm myself or others, Claremont Healing Rooms will contact the proper professionals. I further understand that this form and all data recorded on it is the sole property of Claremont Healing Rooms. All content will be held in confidence for the sole purpose of providing Christian healing prayer and ministry to me.

I AGREE TO THE LEGAL LIABILITY RELEASE TERMS ABOVE

I AM THE LEGAL GUARDIAN AND I GIVE PERMISSION FOR THE ABOVE MINOR TO RECEIVE PRAYER MINISTRY.

LEGAL GUARDIAN'S FULL NAME

First NameLast Name

GUARDIAN'S RELATIONSHIP TO THE MINOR

Please verify that you are human*

Country