Congregant Check-In

THANK YOU for checking-in on your neighbors, friends and congregation during this time. For each congregant whom you call that has an identifiable need, please complete this form so we can best assess needs. Melissa Leibowitz wil be in touch.

* Your Full Name

* Your Phone #

* Your Email

Please complete the information below.

* Congregant Name

* Congregant Phone #

* Congregant Email

* Please describe the congregant's need, e.g. frozen meals, food from ShopRite, medication pick-up, etc. Please include as much detail as possible.

* Would congregant like follow up call?

Please list their emergency contact.

Account Details

Enter your name and e-mail address for your confirmation:

*E-mail

*First Name

*Last Name

Payment Information

Account

Online Fee:

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Comments

Increase the amount by 3% to cover credit card fees. Please select YES to increase your payment.

Total: