Requestor's Name *

First Name

Last Name

Requestor's Phone # *

(###)

###

####

Church Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pastor's Name *

First Name

Last Name

Pastor's Phone

(###)

###

####

Has your project been approved by Church Board? *

Yes

No

ACS/Project Leader's Name *

First Name

Last Name

ACS/Project Leader's Phone # *

(###)

###

####

Organization's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Person *

First Name

Last Name

Contact's Phone # *

(###)

###

####

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Name of Church/ACS Center *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of ACS Leader/Director *

First Name

Last Name

Phone of ACS Director/Leader *

(###)

###

####

This Report is submitted for the following activity/activities (Please check all applicable boxes) *

A copy of completed Report should be sent to your Pastor(s), Personal Ministries Leader, ACS Federation President and ACS Federation Coordinator. Please also keep a copy for your files.

Adventist Community Services Agency

Adventist Disaster Response

Crisis Care

Inner City - Community Development

Local Church Ministries

Medical/Dental Clinic

Tutoring/Mentoring

Youth Empowered to Service (YES)

Other

Date

MM

DD

YYYY

Contact Person *

First Name

Last Name

Phone

(###)

###

####

Contact Person *

First Name

Last Name

Contact Phone # *

(###)

###

####

Date of Request *

Please submit your request at least three (3) weeks prior to event

MM

DD

YYYY

Arrival Time *

Hour

Minute

Second

AM PM

Physical Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Departure Time *

Hour

Minute

Second

AM PM

Contact Name *

First Name

Last Name

Contact Phone # *

(###)

###

####

Date Requested *

Please submit your request at least three (3) calendar weeks prior to the event

MM

DD

YYYY

Arrival Time *

Hour

Minute

Second

AM PM

Departure Time *

Hour

Minute

Second

AM PM

Physical Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country