Student Care Request

Our Student Life staff provides shepherding and guidance for students in difficult times.

First Name*
Last Name*
Spouse Name (if applicable)
Local Church*
Contact Information
Phone Number*
Email*
Spouse Phone Number
Spouse Email Address
Reason for Request
Urgency of Request
1 = not urgent and just looking for guidance; 5 = major concern that effects all of life
- 1
- 2
- 3
- 4
- 5
What is your concern?*
What have you done about this concern?*
Have you spoken to your church about this concern?*
- Yes
- No
Additional Comments
Please provide dates and times when you are available to meet*

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