Quilt Form Page

*Recipient Information :*
Recipient Name:
Email:
Address:

City:
State:
Zip:
Phone:
*Sponsor Information :*
Sponsor Name:
Sponsor's relationship to recipient:
Email:
Address

City
State
Zip
Phone
Date of Request:

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.