Name *

First Name

Last Name

Decisions made today:

I accepted Jesus as my Lord & Savior

I rededicated my life to Jesus

I received the baptism of the Holy Spirit

What's next?

I would like to be water baptized

I would like to become a member

I would like to join the online serve team

I would like to be contacted by a leader

I am going to be hospitalized on:

MM

DD

YYYY

The hospital is located at:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Confidential