Prayer Request and Registration

Prayer Request/Registration

To send in your Prayer requests, participate to the Zoom Healing Clinic, or come in person please complete the Prayer Request form

Prayer Request/Registration form for The Healing Clinic

First Name *

Last Name *

Phone Number *

Email Address *

Street Address

City

State/Province

Country

Are you going to attend the physical event in the US ? *

What was the Diagnosis ? * (Please mention the Name of the Problem / Condition or give us the details of your medical diagnosis.) *

What are your symptoms and things that you could not do ? * *

How long have you been suffering with this condition ? * (Example 10 years or 15 years 6 months) *

Share your picture of previous conditions (Please share any evidence you might have of your illness, i.e. doctors' diagnosis, pictures of illness i.e. wounds, lumps, etc. Please note, you can upload up to 5 files.)

No file chosen

Disclaimer and Consent * I authorize the Healing Clinic Team to access the Contact/Health information that I have submitted through the Registration form for the purpose of filtering and further communication. *I accept the Terms and Conditions.

Prayer Request/Register for The Healing Clinic with Pastor Samuel

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Participants register to attend the Healing Clinic at their own volition.

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Attending the Healing Clinic is not a guarantee that you will be healed.

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In attending the Healing Clinic you agree to indemnify the Healing Clinic and all its related assigns of any and all forms of liability.

4

For participants who are healed, your testimonies are at your own volition and are not forced nor coerced.

5

In attending the Healing Clinic, you are made aware that the entire services are recorded and all footage collected is the property of the Healing Clinic and will be published at the Healing Clinic discretion and broadcasted or re-broadcasted by the Healing Clinic or any of its related assigns at any given time.

6

In attending the Healing Clinic, you are waiving your right to privacy.

Prayer Request/Registration

Prayer Request/Registration form for The Healing Clinic

Prayer Request/Register for The Healing Clinic with Pastor Samuel

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Ways to participate to the Healing Clinic

4 ways to receive prayer at the healing Clinic