subject_line
PRAYER REQUEST FORM
V-Kol Media / TheCRY / Faytene TV
First Name
*
Last Name
*
Street Address
Address Line 2
City
*
Prov or State
*
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
----
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
_____________
Other
Postal Code / Zip Code
*
Country
*
Phone Number
Email Address
*
Purpose of Contact
Please indicate the
primary
reason why you are contacting us:
*
I would like prayer.
I would like to share a testimony.
I would like to give my life to Jesus.
I would like to be connected to a church.
Other
Please indicate your communications preferences.
*
I would like someone to contact me to pray for me in real time if possible.
I would like someone to contact me to share how I can give my life to Christ.
I do not want a contact, please simply pray for my request. Thank you.
I do not want a contact, I just want to share my testimony to encourage you.
I do not want contact.
If applicable, please share more. What is your prayer request or what is your testimony?
If you shared a testimony, do you give us permission to share this testimony with our supporters and viewers?
*
Yes. Absolutely!
Yes, but please keep my name anonymous.
No.
Not applicable.
Would you like someone from a nearby church to contact you so that you can connect with people of faith, and a fellowship we know of, in your own community?
*
Yes please.
No thank you.
How did you hear about this?
*
Praying for You on TV
Facebook Live
YouTube
A Direct Communication from V-Kol
A Friend
Other
I acknowledge that I am contacting you of my own free choice. I also recognize that this is a free service offered in Christian love by V-Kol Media Ministries.
I release V-Kol Media Ministries from demand or liability related to interactions that I may have with any volunteer or team member that may contact me in response to this form.
I recognize that V-Kol Media Ministries does not offer professional counselling services, medical advice or psychiatric advice and that any action taken as a result of my interactions with a volunteer or staff person is my own personal choice.
V-Kol Media Ministries shall not be held liable for any action I may take as a result of this or any other related communication with a volunteer or staff member representing the ministry.
*
I agree
I do not agree.
If you checked "I do not agree" our team will
NOT
be in contact with you, even if you requested it in prior preferences. Thank you for understanding.
V-Kol Media Ministries
Box 21045
Quispamsis, NB
E2E 4Z4
v-kol.com
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