Prayer List Request Form

PLEASE NOTE THAT THE NAMES WILL REMAIN ON THE PRAYER LIST FOR ONE (1) MONTH.

Person Placing Request PLEASE NOTE THAT THE NAMES WILL REMAIN ON THE PRAYER LIST FOR ONE (1) MONTH.

Person Placing Request First Last
Your Email
Your Phone Your Phone - ### - ### ####
Name to be Placed on the Prayer List Name to be Placed on the Prayer List First Last
Relationship to Person Placing Request:
Prayer Request (Optional)
By checking this box, I certify and acknowledge that I have read and verified that all the information above is complete and accurate.
ANY DETAILS ABOUT HEALTH, FINANCIAL AND OTHER PERSONAL MATTERS WILL BE PUBLISHED ONLY IF THE INDIVIDUAL SUBMITTING THIS FORM IS THE SAME PERSON WHOSE NAME WILL BE PLACE ON THE PRAYER LIST, UNLESS THE INDIVIDUAL IS EXTREMELY ILL, OR NOT AN ADULT, IN WHICH IN THIS CASE THIS PERMISSION WILL BE GIVEN TO AN APPROPRIATE CAREGIVER, GUARDIAN OR FAMILY MEMBER.

ANY DETAILS ABOUT HEALTH, FINANCIAL AND OTHER PERSONAL MATTERS WILL BE PUBLISHED ONLY IF THE INDIVIDUAL SUBMITTING THIS FORM IS THE SAME PERSON WHOSE NAME WILL BE PLACE ON THE PRAYER LIST, UNLESS THE INDIVIDUAL IS EXTREMELY ILL, OR NOT AN ADULT, IN WHICH IN THIS CASE THIS PERMISSION WILL BE GIVEN TO AN APPROPRIATE CAREGIVER, GUARDIAN OR FAMILY MEMBER. By checking this box, I acknowledge that I have read and understand the above, and I hereby consent to the disclosure of the name and special intention listed above and authorize the necessary procedures stated in this Form.
I AUTHORIZE CORPUS CHRISTI CATHOLIC CHURCH TO RELEASE ANY INFORMATION THE PARISH DEEMS APPROPRIATE.

Signature of the Person Submitting This Prayer Request.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.