Hospitalization Notification Form

Hospitalization Notification Form

We are sorry to hear about the hospitalization of a church member. Please complete this form to notify the church administrator. We will reach out to provide prayer, support, and any assistance needed. If there are urgent needs, please contact the church office directly.
Contact Information of Person Submitting Notification:
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Hospitalized Member’s Information:

First NameLast Name
Relationship to You (e.g., Self, Family, Friend, etc.):
Is the hospitalized person a member of Global Impact Christian Ministries?

YesNo
Hospitalization Details:
Reason for Hospitalization (if known):
Date of Hospitalization:

MonthDayYear
Date
Hospital Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Room Number (if applicable):/
Support Needs:
Would you like a pastor or church member to visit the hospital?

YesNo
• Would you like the church to provide prayer support?

Type option 1Type option 2Type option 3Type option 4
Are there any other needs or special requests for the church?
Preferred Method of Contact for Follow-Up:
Type a question

Phone CallEmailIn-Person VisitOther
Thank you for informing us. A church representative will reach out to you shortly.
Disclaimer : By providing my phone number to “Global Impact Christian Ministries”, I agree and acknowledge that “Global Impact Christian Ministries” may send text messages to my wireless phone number for any purpose. Message and data rates may apply. Message frequency will vary, and you will be able to Opt-out by replying “STOP”.

Privacy Policy : No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.
Should be Empty:

Hospitalization Notification Form

Contact Information of Person Submitting Notification:

Hospitalization Details:

Support Needs:

Preferred Method of Contact for Follow-Up:

Thank you for informing us. A church representative will reach out to you shortly.