NEEDHELPINPERSONCONTACTREF We Would Love to Connect With You! Contact Us In-Person InfoAre you filling out this form for yourself or someone else?* Filling out for myself Filling out for someone else IP_ADDRESSWhich campus are you attending?* South West North Joplin Your DetailsYour DetailsYour Name* First Last This field is hidden when viewing the formDate of Birth* Month Day Year Other DetailsGender* Male Female Phone*By providing your phone number, you agree to receive texts from James River Church. Messaging and data rates may apply, message amounts vary.This field is hidden when viewing the formPerson InformationEmail* This field is hidden when viewing the formAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Birthday* MM slash DD slash YYYY Marital StatusSelect one...MarriedWidowedDivorcedSingleThis field is hidden when viewing the formMarital Status* Married Widowed Divorced Single Spouse's Name* First Last Spouse's Date of Birth* MM slash DD slash YYYY Spouse's Gender* Male Female What James River Campus do you attend?*South CampusWest CampusNorth CampusJoplin CampusOnline CampusI Do Not Attend James RiverThis field is hidden when viewing the formCare DetailsIndividual's DetailsWhat is the name of the member needing care?* First Last Their Phone Number*This field is hidden when viewing the formDo you have a church home?* Yes No I am looking for a church home Do you attend JRC? Yes No I attend* James River Church Other Which Campus* South West North Joplin Online Which Campus* South West North Joplin Online How Long Have You Been Attending? Additional Information/How Can We Help YouI Would Like More Info About: Life Groups Freedom Groups Soul Set Free Groups Joining a Dream Team (Volunteering) Counseling - Biblical Guidance Becoming a Christian / Getting Baptized I Have a Question Please Share Your Question*Counseling: Pre Marital Marital Parenting Finance Grief Marriage 911 Other This field is hidden when viewing the formNeed HelpPlease Note: If this is an urgent matter, please call the church office at 417-581-5433.Reason Requesting Care*Please identify the reason you are requesting care.Select one...Celebratory CircumstancesMedical NeedLossDisaster / AccidentalFamily / MarriageMental SupportFinancial NeedOtherPlease select the type of celebration*Select one...MarriageBirthNew Foster / Adopted ChildPlease select the type of medical need*Select one...Recent SurgeryUpcoming SurgeryHospitalizationNew Medical DiagnosisPlease select the type of bereavement*Select one...Illness or DiseaseAccidentMiscarriageStillbirthHomicideSuicideOtherPlease select the type of disaster*Select one...AccidentHouse FireNatural Disaster (storm, flood, etc.)OtherPlease select the type of family/marriage need*Select one...Marital IssuesAbuseDivorceChild Care NeedsWhat emotional symptoms have you or this individual been experiencing?*Select one...AnxietyDepressionSuicidal IdeationIntrusive ThoughtsOtherReason financial support is needed*Select one...Job LossChange In SalaryTemporary FurloughCompany ClosureOtherThis field is hidden when viewing the formLife Event/Hospitalization: I Am Currently In The Hospital I Have An Upcoming Surgery Birth of Baby Death in Family Emergency Situation Other Prayer RequestThis field is hidden when viewing the formMarriageMarriage Please Provide: - First & Last Name of the Couple - Date of Marriage - Couples Mailing AddressMarriage*This field is hidden when viewing the formBirthBirth Please Provide: - First & Last Name of the Parents - Date of Birth - Child's Gender - Family's Mailing AddressBirth*This field is hidden when viewing the formNew Foster / Adopted ChildNew Foster / Adopted Child Please Provide: - First & Last Name of the Parents - Date of Adoption/Foster - Child's Gender - Childs Age - Family's Mailing AddressNew Foster / Adopted Child*This field is hidden when viewing the formRecent SurgeryRecent Surgery Please Provide: - Type of Surgery - Back at home or still in the hospital? - Would this individual like for us to send them a recovery meal or flowers? - Home or Hospital Address (If the individual is still in the hospital, please include the room number.)Recent Surgery*This field is hidden when viewing the formUpcoming SurgeryUpcoming Surgery Please Provide: - Type of Surgery - Inpatient or Outpatient - Date and Time of Surgery - Would this individual like for us to send them a recovery meal or flowers? - Hospital AddressUpcoming Surgery*This field is hidden when viewing the formHospitalizationHospitalization Please Provide: - The reason this individual is hospitalized - Is this individual aware of this visitation request? - Hospital Name & Room Number - What are the hours of visitation? - Are we allowed to bring flowers?Hospitalization*This field is hidden when viewing the formNew Medical DiagnosisNew Medical Diagnosis Please Provide: - Name of the diagnosis - How can we support you or this individual?New Medical Diagnosis*This field is hidden when viewing the formLossPlease Provide: - If other, please explain below - Name of Deceased - Relationship to the Deceased - Spouse of the Deceased - Please let us know how we can support you or this individual's family during this time. - Would you like for us to send flowers? If so, please provide a name and best mailing address below.Loss*This field is hidden when viewing the formDisasterPlease Provide: - If other, please explain below - Details of the incident. - How can we support you or this individual or family during this time?Disaster*This field is hidden when viewing the formFamily/MarriageIMPORTANT: If this is a life threatening emergency, please dial 911.Please Provide: - Explain the situation and how we can help.Family/Marriage*This field is hidden when viewing the formMental SupportIMPORTANT: If this is a life threatening emergency, please dial 911.Please Provide: - A brief explanation - Are you or this individual ready to speak to someone?Mental Support*This field is hidden when viewing the formFinancial NeedPlease Provide: - If other, please explain below - Please explain how we can help you or this individualFinancial Need*This field is hidden when viewing the formOtherOther*This field is hidden when viewing the formSection BreakI Would Like To Share...* Praise Report Prayer Request Would You Like For Someone To Call And Pray With You?* Yes No Please Share Your Prayer Request*Praise ReportPlease Share Your Praise Report*Life GroupsTo get connected to a Life Group, click here!Recent HospitalizationDate of Hospitalization* Month Day Year Hospital Location*Circumstance of Hospitalization*Upcoming SurgeryDate of Surgery* Month Day Year Hospital Location*Type of Surgery*OtherIf you need immediate assistance please call the church at 417-581-5433.Please Give Us Details*CounselingOur approach to counseling is to use the Bible to address issues in the lives of individuals, couples, and families.Please Tell Us A Little Bit About Your Situation.*Pre-Marital CounselingFiancé's Name* First Last Fiancé's Gender* Male Female Fiancé's Date of Birth* MM slash DD slash YYYY Fiancé's Phone Number*Fiancé's Email* Fiancé's Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How long have you been engaged?*How long had you been dating prior to the engagement?*When are you getting married?*Is this your First or Second marriage? First Second Please Tell Us a Little Bit About Your Situation*QuestionThis field is hidden when viewing the formThis field is hidden when viewing the formCommentsEmailThis field is for validation purposes and should be left unchanged.
