Life Crisis Information

Basic Information

Today's Date

Does this information replace/update your previous information?

Name

Address

Home Phone

Cell Phone

This address will receive a confirmation email

Birth Date

Social Security Number

Children's Information

1. Name

Birth Date

Address if not living with you

Phone if different than yours

2. Name

Birth Date

Address if not living with you

Phone if different than yours

3. Name

Birth Date

Address if not living with you

Phone if different than above

Other children

In case of a crisis, who we should contact:

1. Name

Relationship

Address

Phone

2. Name

Relationship

Address

Phone

Please list (up to) three close friends who could help during a crisis:

1. Name

Address

Phone

2. Name

Address

Phone

3. Name

Address

Phone

Medical Information

Physician’s Name

Address

Phone

Do you have Advance Directives (Living Will, Power of Attorney, Do Not Resuscitate Order, etc.)?

Where located?

Any special medical notes

Legal Information

Attorney’s Name

Address

Phone

Do you have a will?

Where is it located?

Name of executor/executrix of will

Address

Phone

Where are vital papers (insurance policies, bank books, etc.) located?

Who has access?

If you have minor children, who is to be appointed legal guardian(s) in case both parents die?

Description

Providing the information requested on this form is purely voluntary – it is included in your New Member/Friend packet simply because this is the most opportune time to gather information from you. While filling out this form may cause you some discomfort, these are questions we all need to face, never knowing when or where a crisis may occur. Having this information available for our Minister can help reduce the confusion if/when a crisis should occur.

Life Crisis Information

Description

Please Fix the Following