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Visitation Ministry Request Form

- ANY URGENT REQUEST FOR A CLERGY
  PLEASE CALL THE OLM RECTORY
  201-391-5315
- The maximum number of form submissions has been reached. This form is currently not available.
  
  Fill out the form below to request a phone call or a visit.
  
  First Name of Person in Need of a Call or Visit REQUIRED Maximum 100 characters Please fill out this field. Please enter valid data.
  
  Last Name of Person in Need of a Call or Visit REQUIRED Please fill out this field. Please enter valid data.
  
  Address of Person in Need of a Call or Visit REQUIRED Maximum 100 characters Please fill out this field. Please enter valid data.
  
  Address of Person in Need of a Call or Visit 2 Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Phone Number of Person in Need of a Call or Visit REQUIRED Please fill out this field. Please enter valid data.
  
  Name of Person Requesting the Call or Visit REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number of Person Requesting the Call or Visit REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email of Person Requesting the Call or Visit REQUIRED Please fill out this field. Please enter an email address.
  
  Relationship to Person in Need of the Call or Visit REQUIRED Maximum 100 characters Please fill out this field. Please enter valid data.
  
  Have you notified the person to be called? REQUIRED Yes No Please fill out this field.
  
  Request REQUIRED Phone Call from Visitation Ministry Home visit from Visitation Ministry Receive Holy Communion from Eucharistic Minister Receive a (Non-Urgent) visit from a Deacon or Priest Please fill out this field.
  
  Additional Information about the Parishioner in Need of a Call
  
  Submit
  
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Our Lady of Mercy

2 FREMONT AVENUE
PARK RIDGE, NJ 07656

Visitation Ministry Request Form