Prayer Request & Praise Report

Please provide all necessary information so that we will be able to handle your prayer request or praise report. Once you have submitted this form. If you need immediate assistance, please call the church office during office hours at(217) 877-9529, extension 0.

Please provide the following contact information:

Submitter's Name

Submitter's Work Phone (xxx) 123-4567

Submitter's Home Phone (xxx) 123-4567

Submitter's E-mail

Prayer Request/Praise Report for (Name):

If Other:

Choose one of the following options:

I have read the Heartland Community Church Privacy Statement and intend this information to be considered . . .

I have read the Heartland Community Church Privacy Statement and agree/do not agree with its terms.

Please describe the prayer request or praise report. Include as much information as you believe is necessary. This information will be distributed according to your choices above.

Submitter's Name
Submitter's Work Phone	(xxx) 123-4567
Submitter's Home Phone	(xxx) 123-4567
Submitter's E-mail
Prayer Request/Praise Report for (Name):
If Other:

Prayer Request & Praise Report

Copyright © 2003 [Heartland Community Church]. All rights reserved. Revised: 04/20/04

Copyright © 2003 [Heartland Community Church]. All rights reserved.
Revised: 04/20/04