Record of CCRC Congregational Care Visit
Please complete this SECURE on-line form accurately for each Visit or Significant Conversation (e.g. telephone call or in-coffee shop visit). Also complete the Form if you were declined or refused a Visit. Please read the instructions for each item, particularly with respect to the 'Date'
Press 'submit' at the bottom of the form to send it securely to the Congregation Care records database. Enter all items; Incomplete entries will prevent submission. If necessary, a paper copy may be submitted to the CCRC office for entry.
NOTIFY the District Elder if you've entered an 'ALERT for Elder'.
Thank you for participating in CCRC Congregation Care!
(form revision date: 2017.06.28)
Date (YYYY/MM/DD) of Visit/Contact
If you are uncertain about date formats, use e.g September 19, 2016. Also enter date if 'Declined/Refused'
Last, then First Name of Person(s) Visited/Contacted
FAMILY NAME (in CAPITAL, UPPER CASE LETTERS) , then First Name(s); no comma and leave space between names.
Last and First Name of Person(s) making the Visit/Contact
Record helpful comments about the visit BUT not include confidential information about the visit. Your comments will be reviewed by the District Elder.
Designation of Visitor
Please select one or more when visit done as a team
Type of Visit/Contact
Use 'Other' if type not listed
Assist with Appointment
Electronic: E-mail, Facebook etc. exchange
My /our home
Personal Care Home (PCH)
Providing Direct Care in Home
Duration of Visit
Enter only the number of minutes but do not include the word 'minutes' e.g. 75 ; If more than 3 hours, enter the number of hours, not minutes, and include the word 'hours'- e.g. '5 hours'
ALERT to District Elder
Please enter any 'alert/concern' info. BUT also contact directly the District Elder
Last and First Name of Person entering information
Same as the Visiting Person
Elder District of Person(s) Visited/Contacted
District A: VanderWal, K; District B: Brinkman, J; District C: VanLeeuwen, J; District D: Kiers, J; District E: Harris, R; District F: Visser L; District G: Doornbos, J; District H: VanHeyst, B
Unassigned / Visitor / Seeker
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This form was created inside of Covenant Christian Reformed Church.