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First Name *

Last Name *

Gender *

Language *

Country of Origin *

Country of Residence *

Phone *

WhatsApp Number (optional)

Date of Birth *

Email *

Please upload your recent full length photograph while standing. This photograph must not be older than one week. *

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Max file size: 5MB

Kindly, state your main reason for visiting the Christian Church Of All Nations - Barcelona. *

Do you have any health problems, physical ailments or disabilities? *

Yes
No

Please state the nature and all symptoms experienced *

Please upload your most recent medical report which clearly states the health problems you are facing *

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Max file size: 5MB

Please upload your most recent medical report which clearly states that you are completely healthy, because you may have a health problem that you are not aware of *

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Max file size: 5MB

Do you experience excessive body weakness? Do you have to lie down most of the time? *

Yes
No

Please explain and give us more details about your condition *

Can you walk and climb stairs normally without assistance from people or a walking aid? *

Yes
No

Do you take any medication? If so, what kind? *

Do you have any food allergy? If so, what kind?

What is your current address?

Enter a phone number of a friend or relative of yours.

Enter an email address of a friend or relative of yours. *

Have you visited the CCOAN - Barcelona in the past? *

Yes
No

Please, tell us the changes experienced in your life, health and career. *

Do you intend to come alone or accompanied by someone? *

Alone
Accompanied

Please list the names and email addresses of the people who intend to come with you *

IMPORTANT NOTICE

Please make sure to send your questionnaire only one time or else you delay the process and response time. Also the same email you use to communicate with us must be the email you will use during the complete registration process.

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QUESTIONNAIRE FORM

IMPORTANT NOTICE

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