Classic Ministry Survey
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Name: *
Address:
Phone:
Email Address:
Marital Status:
Gender:
Date of Birth
MM
/
DD
/
YYYY
LIVING SITUATION + EMERGENCY CONTACT
Do you live alone?
If no, with whom do you live?
In the event of an emergency, if you need help or become ill or disabled, is there someone to whom you could turn to for assistance?
If Yes, Who? 
Relationship:
Address:
Telephone #
Do you experience any problems with where you live?
If Yes, what are the problems?
Please answer the following question with a number.
During the past week, how many times did you have someone visit you?
During the past week, how many times did you visit someone else?
During the past week, how many times did you go shopping?
During the past week, how many times did you talk/video call with a friend or relative on the phone?
Please rate your health:
Clear selection
Approximately how often do you attend religious services?
Clear selection
Would you like to receive any of the following religious services in your home?
DO YOU NEED? (check all boxes that apply)
CAN YOU PROVIDE? (check all boxes that apply)
Other Need(s) You Have:
Other Ministry You Can Provide:
Please identify or list any programs the church (or classic ministry group) should provide for members of this group:
Please let us know what you like to do for fun (i.e. Eating Out, Bus Tours, Day Trips, Movies, Being in Nature, Book Club, etc):
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