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First Name *
Last Name
Email Address *
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Donation Total: $100.00
Date Submitted :
Time Submitted :
Information Given By :
Callers Phone :
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Sick – Home Information
Name :
Address :
City :
State :
Zip :
Phone :
Member of New Faith Baptist : YesNo
Deacon : YesNo
Ministries Active In (Separate by Coma) :
Sick – Hospital Information
Name of Hospital :
Room :
Bed :
Type of Illness :
Additional information :
