Confidential Crisis Form

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Confidential Life Crisis Information

Use this form to make important information available to the ministers in the event of life crises. All information is held in complete confidence and is not stored on the Internet. A professional staff member will receive an e-mail from which a permanent record will be made. You may wish to review this form and collect pertinent information before starting to enter anything.

Use the Tab key to move between boxes. Do not hit Enter to move between boxes, as that will automatically send the form--which you don't want to do until you are done. If you do so accidentally, you may back up your browser and continue.

Are you:
Submitting a Life Crisis Form for the first time [either online or on paper]
Making changes or corrections to a form already on file [enter only those fields that have changed]

Personal Background

What is your full name (required)?
What is your partner's/spouse's name, if any?
What is your mailing address?
At what telephone numbers are you and/or your partner most easily reached? (List as many as apply)

What is your e-mail address (required)?
What is your date of birth (mm/dd/yyyy)?

If no children, click here to continue.

Children (if any):

Names	Birthdates	Address, phone if not living at home

Have guardians been selected for minor-age children in case of death of parents?
Yes
No
Does not apply

Please list the names, addresses, and phone numbers for those guardians (if any).

Contact Information

Person(s) to contact in a crisis (other than family members listed above).

Name Phone Numbers Relationship

Is there an attorney who we should try to reach? If so, please provide a name, address, and phone number:

Is there a physician who we should try to reach? If so, please provide a name, address, and phone number:

Your preferred hospital:
Your blood type:
Any special medical instructions:

If you need to spend time in a long-term care facility, do you have preferences among places? Where?

Final Arrangements

Have you made a will?
Yes
No
If so, where is it located?

Do you have a living will?
Yes
No
If so, where is it located?

Funeral/Memorial Society in which you hold membership, if any (name and location):

Name, address, and phone number of funeral home that you have chosen or prefer:

Which arrangement do you wish?
Burial
Cremation

Which type of service do you prefer?
Memorial service
Funeral

Where do you wish burial or scattering of ashes?

Who will make funeral or memorial service arrangements?
I will
Someone else will: Who?

Which clergy do you wish to plan and conduct your service?

Where do you wish your funeral or memorial service to be held?

Are there persons you have asked or would want to participate in this service?

Do you have special music, hymns, poetry or writings you want included in this service?

Are there organizations to whom you would like memorial gifts made (names and addresses)?

If you need to spend time in a long-term care facility, do you have preferences among places? Where?

Even though Life Crisis File information is extremely important, it is not intended to replace the total planning of funeral or memorial services. Members and friends of First Universalist Church are strongly encouraged to talk with one of the ministers about their specific plans with respect to these services.

First Universalist Church of Minneapolis

Confidential Life Crisis Information

Revised: 10/15/07.