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'
Your answer
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.
Your answer
Last and First Name of Person(s) making the Visit/Contact *
Your answer
Instructions/Comments
Record helpful comments about the visit BUT not include confidential information about the visit. Your comments will be reviewed by the District Elder.
Your answer
Designation of Visitor *
Please select one or more when visit done as a team
Required
Type of Visit/Contact *
Use 'Other' if type not listed
Required
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'
Your answer
ALERT to District Elder
Please enter any 'alert/concern' info. BUT also contact directly the District Elder
Your answer
Last and First Name of Person entering information
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
Required
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