Name *

First Name

Last Name

Date of Miracle

MM

DD

YYYY

Please check all that apply

I have a medical report

I have an eye-witness

I have a video and/or photograph to support

It was just Jesus and I

Other

Permission to share *

Yes, I am willing to have this testimony made available for print (LifePoint Testimony records, Social Media, blog, website)

Yes, I would be willing to share this testimony in person in front of the congregation

Yes, I would be willing to have the pastor or leadership share my testimony with the congregation

Yes, I am willing to have this testimony shared with the congregation as long as no identifying personal information is used

Yes, I am happy to be contacted for this testimony to be used for a shore video production by the LifePoint Media Team

I would prefer this testimony be kept completely confidential