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One-on-One Care Request
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One-on-One Care Request
1:1 Care Requests to Manage
First Name
First Name cannot contain special characters such as quotes, parentheses, etc.
First Name cannot contain emojis or special fonts.
First Name is required.
Last Name
Last Name cannot contain special characters such as quotes, parentheses, etc.
Last Name cannot contain emojis or special fonts.
Last Name is required.
Email
Email address is not valid
Email is required.
Campus
Anoka
Apple Valley
Blaine
Brainerd Lakes
Ham Lake
Lino Lakes
Maplewood
Minneapolis
Red Wing
Rochester
Spring Lake Park
Wayzata/Plymouth
White Bear Lake
Woodbury
Campus is required.
Mobile Phone
One-on-One Care
Birth Date
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Birth Date cannot be a future date.
Do you have children? If yes, please list the names and ages of your children
Do you have children? If yes, please list the names and ages of your children is required.
Please provide the name, mobile phone number, and email address of someone we can contact in case of an emergency (include their relationship to you as well).
Please provide the name, mobile phone number, and email address of someone we can contact in case of an emergency (include their relationship to you as well). is required.
Please tell us the city and state you live in to assist with matching you with a caregiver.
Please tell us the city and state you live in to assist with matching you with a caregiver. is required.
Please share with us your occupation
Please share with us your occupation is required.
What is the best time of day to contact you?
What is the best time of day to contact you? is required.
How do you believe a One-on-One Caregiver can be of encouragement to you?
How do you believe a One-on-One Caregiver can be of encouragement to you? is required.
Do you currently have anyone else (e.g., family member, professional counselor) caring for you? If yes, please give their name and contact information.
Do you currently have anyone else (e.g., family member, professional counselor) caring for you? If yes, please give their name and contact information. is required.
Are you currently part of a small group or serving team?
No
Yes
Are you currently part of a small group or serving team? is required.
How did you hear about our One-on-One Care ministry?
Eagle Brook website
Eagle Brook staff
Eagle Brook volunteer
Family member or friend
Other agency
Other
How did you hear about our One-on-One Care ministry? is required.
Please tell us the circumstances that prompted you to request meeting with a One-on-One Caregiver.
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