Health Ministry Visitation Request

If you, or someone you know, is in need of a visit from one of our Health Ministry volunteers, please complete this form and click "Submit." The request will be sent to our Health Ministry coordinators who will contact you within one week.

Our ministry cannot provide "hand-on" care or provide transportation.

The Catholic Area Faith Community of Jesus Our Living Water is able to provide this ministry free of charge due to the generosity of time and talent by our Health Ministry volunteers and parishioners' contributions to their parish general collection.

Your Name Your Name * First Last
Your Phone Number Your Phone Number * - ### - ### ####
Your Email Address *
Name of Individual to be Visited by a Health Ministry Volunteer - if other than the name above. Name of Individual to be Visited by a Health Ministry Volunteer - if other than the name above. First Last
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Their Phone Number Their Phone Number * - ### - ### ####
Reason for the Visitation Request *