Hospital Visitation Form

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Is any sick among you? Let him call for the elders of the church; and let them pray over him, anointing him with oil in the name of the Lord. – James 5:14

We want to be there for you as a Church family as you face challenges in life. Please complete this form and someone will make contact with you as soon as possible.

Member Name *

Member Phone# *

Member Mailing Address

Contact person name and phone#, if member unable to communicate

Hospital Name *

Room# *

Room Phone#

State of Condition/Prognosis *

Stable, will recover soon

Critical/ICU

Serious, not sure recovery time

Hospice care

Surgery

Unknown/Uncertain

Expected length of stay, if known

Hospital visiting hours, if special circumstances

Visitation schedule preference

Morning

Afternoon

Evening

Clear selection

Please list hospital visitation restrictions, policies, or special instructions for visitors, if applicable

Member gives permission for a representative of the church's Ministry of Care team to visit? *

Yes

Submit

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