Prayer Quilt Request Form

Recipient Information :

Recipient Name *

Recipient Email

Recipient Address 1

Recipient Address 2

Recipient City

Recipient State

Recipient Zip

Recipient Phone

Sponsor Information :

Sponsor Name *

Sponsor Email

Sponsor Address 1

Sponsor Address 2

Sponsor City

Sponsor State

Sponsor Zip

Sponsor Phone

Date of Request

Month

Day

Year

Situation/Reason for Quilt:

**Prayer Request for:

Please submit a photo of the recipient by mail to:

Jerusalem Baptist Church,
Prayer Quilt Ministry
3203 US Highway 601 South,
Mocksville, NC 27028.

Or email a digital photo to:
info@jbcmocksville.org

**Please make sure that the recipient has been asked and is
ready to accept a prayer quilt, and the prayers requested are
those of the recipient.

Jerusalem Baptist Church