Name:

Gender:MaleFemale

Phone Number:

Email:

Please briefly describe your situation:

Have you accepted Jesus as your Lord and Savior?YesNo

When were you saved?

Have you been Baptized in Water?YesNo

If so, when:

Have you been Baptized in Holy Spirit?YesNo

If so, when:

Have you ever had deliverance?YesNo
If so, when:

Please briefly describe any prior deliverance experience:

Have you ever been exposed to, or engaged in any of the following?

AbortionAccident by FireAccident by WaterAddictionAdulteryAlcoholismAllergiesAngerAnorexiaAnxietyApathyArthritisAsthmaAstrologyBack ProblemsBitternessBlack/White MagicBlindnessBroken HeartBuddhismBulimiaCaffeineCancerChristian ScienceChronic BleedingChronic DiseaseChronic InfectionsCigarettesCompulsivenessCondemnationConsulting DeadControlConvulsionsCursing/ProfanityDeafnessDeath SeenDepressionDespairDrug UseDumbnessEnvyEpilepsyFantasyFearFree MasonryGluttonyGuiltHallucinationsHeart ProblemsHinduismHomosexualityHoroscopesIdol WorshipIncestIslamJealousyJehovah’s WitnessLazinessLonelinessLustMarijuanaMasturbationMedicationsMental AbuseMental IllnessMormonismMurderNervousnessNew AgeNicotineNight TerrorsNightmaresOccultOther AccidentsPainParanoiaPedophiliaPerfectionismPerversionPhysical AbusePlan-B PillPornographyPrideProstitutionRageRejectionResentmentRitual AbuseRitualsSeductionSelf-PitySelfishnessSexual DreamsShameSleep ParalysisSodomySuicidal ThoughtsTarot CardsTortureTraumaVowWitchcraft/WiccanYoga

If been exposed to, or engaged in something not listed above please explain:

I understand and hereby agree to assume all of the risks which may be encountered as part of deliverance ministry including any activities preliminary and subsequent thereto.

I, the undersigned do hereby hold harmless F.O.G. Deliverance Ministry and On Fire Ministries and their Elders, Deacons, Officers, Board of Trustees, Employees, Agents, and Volunteers from any and all liability, actions, causes of actions, claims, expenses, and damages on account of any and all injury, or perceived harm, to me or my property, even injury resulting in death during this and any subsequent visits.

I understand that F.O.G. Deliverance Ministry is staffed by people who are not trained or licensed professionals of counseling, therapy, or medical services. I understand that if I am currently taking medication, or operating under the advice of a professional service or health care provider, I will allow them (my medical doctor, therapist, counselor etc.) to confirm any results of prayer/deliverance received before altering any prescribed course of action.

I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the laws of the State of Washington, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto, and the terms of this release are contractual and not a mere recital.

I understand that this form, and all data recorded on it, is the sole property of On Fire Ministries and F.O.G. Deliverance Ministry. All content will be kept confidential for the sole purpose of my individual ministry. We will follow up with you regarding your testimony of how God touched you during your visit(s). Your full name will not be used in sharing the testimony.

I agree to the above terms and conditions

I agree to receive notifications of future events at On Fire Ministries.