Chaplain Request Form

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Thank you for considering me as your Chaplain. It is an honor to utilize my gifts and abilities to support you. Please complete this form so I can better understand the nature of your request and how I may be of service to you.

Email *

Your First and Last Name
*

Email address for all correspondences *

Phone number
*

Location of service (Where will these services be performed)
*

Requested Date
*

YYYY

Requested Time
*

Time

Please select the service(s) you are seeking. Select all that apply *

Marriage Ceremony (up to 2 due-diligence counseling sessions are required)

Hospice Chaplaincy

Funeral Service (Eulogy & family support)

Speaker: Contextual bible teaching that will edify and encourge your audience

Speaker: Motivational presentation to individuals who desire more out of life. Topic can be catered to your event theme, as long as it is within my scope of knowledge.

Christian Counseling

Guest Panelist: Participate and contribute to a panel discussion of any topic that I have experience in.

Moderator or Mistress of Ceremony: Serve as your event facilitator whether it be casual or formal

Christening (Baby Dedication)

Prison Ministry

Disaster Relief

Crisis Support

Required

Additional Requests or Comments

***Please Note*** This submission is not a scheduled booking. This is your request for services. I will review all submitted requests within 48 hrs and respond timely with availability and a quote for services (if applicable). Should you decide to book, you will receive an email with further instructions. Please confirm that you have read this statement and understand this process. *

Yes, I understand that submitting this form is not a scheduled booking.

No, I do not understand and I will email hellojuanitab@gmail.com for more understanding.

A copy of your responses will be emailed to the address you provided.

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