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1. Question: Occupation
1. Input - Point Value: 0

All	90 Days	Last Month	Last 7 Days	Notes
Number of Responses: Average: Median Point Value: Median Response:	No Records	No Records	No Records	Sample Notes For Researcher Records Selected for this range start: end: o1=0.000 CI-0.000 Increase your sample to: 422

XX1

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2. Question: Word of Faith Member?
1. Yes - Point Value: 1
2. No - Point Value: 0

All	90 Days	Last Month	Last 7 Days	Notes
Number of Responses: Average: Median Point Value: Median Response: No Answers for this question have been collected. More Results are needed.	No Records	No Records	No Records	o1=0.000 CI-0.000 Increase your sample to: 422

XX2

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3. Question: Home church location and pastor\\\'s name?
1. Input - Point Value: 0

All	90 Days	Last Month	Last 7 Days	Notes
Number of Responses: Average: Median Point Value: Median Response: No Answers for this question have been collected. More Results are needed.	No Records	No Records	No Records	o1=0.000 CI-0.000 Increase your sample to: 422

XX3

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4. Question: Date Of Your Loss (MM/DD/YYYY)
1. Input - Point Value: 0

All	90 Days	Last Month	Last 7 Days	Notes
Number of Responses: Average: Median Point Value: Median Response:	No Records	No Records	No Records	o1=0.000 CI-0.000 Increase your sample to: 422

XX4

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5. Question: Type Of Loss:
1. Spouse - Point Value: 0
2. Child - Point Value: 0
3. Parent - Point Value: 0
4. Limb/Bodily Function - Point Value: 0
5. Sight - Point Value: 0
6. Pet - Point Value: 0
7. Home - Point Value: 0
8. Other Family Member - Point Value: 0
9. Friend - Point Value: 0
10. Divorce - Point Value: 0
11. Organ - Point Value: 0
12. Hearing - Point Value: 0
13. Job - Point Value: 0
14. Money - Point Value: 0
15. Other - Point Value: 0

All	90 Days	Last Month	Last 7 Days	Notes
Number of Responses: Average: Median Point Value: Median Response: No Answers for this question have been collected. More Results are needed.	No Records	No Records	No Records	o1=0.000 CI-0.000 Increase your sample to: 422

XX5

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6. Question: Person to Notify in Case of Emergency
1. Input - Point Value: 0

All	90 Days	Last Month	Last 7 Days	Notes
Number of Responses: Average: Median Point Value: Median Response: No Answers for this question have been collected. More Results are needed.	No Records	No Records	No Records	o1=0.000 CI-0.000 Increase your sample to: 422

XX6

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7. Question: Known Health Conditions (Emergency Use Only) (Please Include Condition and Medication/Dosage Taken
1. Input - Point Value: 0

All	90 Days	Last Month	Last 7 Days	Notes
Number of Responses: Average: Median Point Value: Median Response:	No Records	No Records	No Records	o1=0.000 CI-0.000 Increase your sample to: 422

XX7

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8. Question: Our Policy: It is the policy of this organization to provide equal opportunity to the overcoming loss group experience without regard to race, color, religion, national origin, gender, sexual preference, age, or disability. However, this is a faith-based, Christian organization and we will deal with all subjects from that perspective and vantage point. Thank you for completing this application and for your interest. You will be notified of your admission into the class a minimum of two (2) weeks prior to the start date of the class.
1. Agree - Point Value: 0
2. Disagree - Point Value: 0

All	90 Days	Last Month	Last 7 Days	Notes
Number of Responses: Average: Median Point Value: Median Response: No Answers for this question have been collected. More Results are needed.	No Records	No Records	No Records	o1=0.000 CI-0.000 Increase your sample to: 422

XX8

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9. Question: Hold Harmless Agreement and Signature: By submitting this application, I affirm that the facts set forth in it are true and complete. I hereby agree to release Word of Faith Family Worship Cathedral volunteers, members, subsidiaries, affiliates, agents, officers, assigns, employees, and any affiliated groups from any and all liabilities, damages, claims, fines, causes of action, including but not limited to negligence, gross negligence, deficiencies, illness, injury, death, personal and/or property damage, property theft, costs and expenses or other loss incurred, based upon, arising out of or otherwise related to my participation in such ministry experiences. (Please Print Full Name)
1. Input - Point Value: 0

All	90 Days	Last Month	Last 7 Days	Notes
Number of Responses: Average: Median Point Value: Median Response:	No Records	No Records	No Records	o1=0.000 CI-0.000 Increase your sample to: 422

XX9

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10. Question: What Loss Are You Experiencing?
1. Input - Point Value: 0

All	90 Days	Last Month	Last 7 Days	Notes
Number of Responses: Average: Median Point Value: Median Response:	No Records	No Records	No Records	o1=0.000 CI-0.000 Increase your sample to: 422

XX10