Confidential Life Crisis Form for UUCV
This form is for the confidential use of the Minister and others authorized to access this information at the Unitarian Universalist Church of Ventura.  Please complete the form with information you would like to have on file with the Minister.  You may wish to complete only some parts of this form and leave others blank.  We encourage you to share this with your family.

Please update this form as needed.  Having this information on file will enable your church to serve you and your family in the event of a death or other crisis.

Please call the church office at 805-644-3898 if you would like assistance from the Minister in completing this form or to facilitate a family discussion regarding making decisions.
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Email *
Name *
Spouse or Partner's Name if applicable
Address *
City, State, Zip Code *
Phone Number
Birth Date *
MM
/
DD
/
YYYY
Names and birth dates of children at home
Names, relation, addresses, and phone numbers of persons who can help in a crisis and/or who should be notified
Who has a key to your home?
Physician's name, address, and phone number
Do you have an Advanced Directive?
Clear selection
Do you have a Power of Attorney for Health Care?
Clear selection
Who is listed as your Power of Attorney for Health Care? (please list name and phone number)
Where are these documents located?
When were these documents completed?
Attorney’s name, address, and phone number
Military service?
Clear selection
If so, where are discharge papers?
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