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	<title>First United Methodist Church of Wichita Falls - WELCOME! &#187; Hospitals</title>
	<atom:link href="http://fumcwf.org/archives/category/membership_care/hospitals/feed" rel="self" type="application/rss+xml" />
	<link>http://fumcwf.org</link>
	<description>. . . a Downtown Tradition of Bringing Faith to Life in Service and Word!</description>
	<lastBuildDate>Sun, 20 May 2012 21:23:44 +0000</lastBuildDate>
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		<title>Hospital Form</title>
		<link>http://fumcwf.org/archives/612</link>
		<comments>http://fumcwf.org/archives/612#comments</comments>
		<pubDate>Tue, 17 Feb 2009 12:44:57 +0000</pubDate>
		<dc:creator>tsims</dc:creator>
				<category><![CDATA[Hospitals]]></category>

		<guid isPermaLink="false">http://fumcwf.org/?p=612</guid>
		<description><![CDATA[<div style="padding-top:5px;padding-right:0px;padding-bottom:5px;padding-left:0px;;">
											<iframe
												style="height:25px !important; border:0px solid gray !important; overflow:hidden !important; width:460px !important;" frameborder="0" scrolling="no" allowTransparency="true"
												src="http://www.linksalpha.com/social?blog=First+United+Methodist+Church+of+Wichita+Falls+-+WELCOME%21&link=http%3A%2F%2Ffumcwf.org%2Farchives%2F612&title=Hospital+Form&desc=Here+you+can+share+with+us+information+about+a+current+or+upcoming+hospital+stay%3A&fc=333333&fs=arial&fblname=like&fblref=facebook&fbllang=en_US&fblshow=1&fbsbutton=1&fbsctr=1&fbslang=en&fbsendbutton=0&twbutton=1&twlang=en&twmention=fumcwf&twrelated1=fumcwf&twrelated2=&twctr=1&lnkdshow=show&lnkdctr=1&buzzbutton=0&buzzlang=en&buzzctr=0&diggbutton=0&diggctr=0&stblbutton=1&stblctr=0&g1button=0&g1ctr=1&g1lang=en-US">
											</iframe>
										</div>Here you can share with us information about a current or upcoming hospital stay:




Name 
 



e-Mail 
 



Who will the patient be? 



Myself
A Loved One

 [...]]]></description>
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												src="http://www.linksalpha.com/social?blog=First+United+Methodist+Church+of+Wichita+Falls+-+WELCOME%21&link=http%3A%2F%2Ffumcwf.org%2Farchives%2F612&title=Hospital+Form&desc=Here+you+can+share+with+us+information+about+a+current+or+upcoming+hospital+stay%3A&fc=333333&fs=arial&fblname=like&fblref=facebook&fbllang=en_US&fblshow=1&fbsbutton=1&fbsctr=1&fbslang=en&fbsendbutton=0&twbutton=1&twlang=en&twmention=fumcwf&twrelated1=fumcwf&twrelated2=&twctr=1&lnkdshow=show&lnkdctr=1&buzzbutton=0&buzzlang=en&buzzctr=0&diggbutton=0&diggctr=0&stblbutton=1&stblctr=0&g1button=0&g1ctr=1&g1lang=en-US">
											</iframe>
										</div><p>Here you can share with us information about a current or upcoming hospital stay:</p>
<div id='formBuilderCSSIDHospital'>
<form class='formBuilderForm ' id='formBuilderHospital' action='/archives/category/membership_care/hospitals/feed#formBuilderCSSIDHospital' method='post' onsubmit='return fb_disableForm(this);'><input type='hidden' name='formBuilderForm[FormBuilderID]' value='5' /><div id='formbuilder-5-page-1'><script type="text/javascript">

function toggleVis(boxid)
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function toggleVisOn(boxid) 
{
		document.getElementById(boxid).setAttribute("class", "formBuilderHelpTextVisible");
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<div class='formBuilderField single_line_text_box' id='formBuilderFieldName' title='You must enter your name.' ><a name='formBuilderFieldName'></a>
<span id='formBuilderErrorSpaceformBuilderFieldName'></span>
<div class='formBuilderLabelRequired'>Name </div>
<div class='formBuilderInput'><input type='text' name='formBuilderForm[Name]' value='' id='fieldformBuilderFieldName' onblur="fb_ajaxRequest('http://fumcwf.org/wp-content/plugins/formbuilder/php/formbuilder_parser.php', 'formid=5&amp;fieldid=22&amp;val='+document.getElementById('fieldformBuilderFieldName').value, 'formBuilderErrorSpaceformBuilderFieldName')"/> </div>
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<div class='formBuilderField single_line_text_box' id='formBuilderFieldEmail' title='You must enter your email address.' ><a name='formBuilderFieldEmail'></a>
<span id='formBuilderErrorSpaceformBuilderFieldEmail'></span>
<div class='formBuilderLabelRequired'>e-Mail </div>
<div class='formBuilderInput'><input type='text' name='formBuilderForm[Email]' value='' id='fieldformBuilderFieldEmail' onblur="fb_ajaxRequest('http://fumcwf.org/wp-content/plugins/formbuilder/php/formbuilder_parser.php', 'formid=5&amp;fieldid=23&amp;val='+document.getElementById('fieldformBuilderFieldEmail').value, 'formBuilderErrorSpaceformBuilderFieldEmail')"/> </div>
</div>
<div class='formBuilderField selection_dropdown' id='formBuilderFieldpatient' title='Please let us know who will be in the hospital.' ><a name='formBuilderFieldpatient'></a>
<span id='formBuilderErrorSpaceformBuilderFieldpatient'></span>
<div class='formBuilderLabelRequired'>Who will the patient be? </div>
<div class='formBuilderSelect'>
<select name='formBuilderForm[patient]'>
<option value='0' selected = 'selected'></option>
<option value='1' >Myself</option>
<option value='2' >A Loved One</option>
</select>
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<div class='formBuilderField single_line_text_box' id='formBuilderFieldpatient_name' title='' ><a name='formBuilderFieldpatient_name'></a>
<span id='formBuilderErrorSpaceformBuilderFieldpatient_name'></span>
<div class='formBuilderLabel'><b>Patient's Name (if different than yourself)</b> </div>
<div class='formBuilderInput'><input type='text' name='formBuilderForm[patient_name]' value='' id='fieldformBuilderFieldpatient_name' onblur="fb_ajaxRequest('http://fumcwf.org/wp-content/plugins/formbuilder/php/formbuilder_parser.php', 'formid=5&amp;fieldid=26&amp;val='+document.getElementById('fieldformBuilderFieldpatient_name').value, 'formBuilderErrorSpaceformBuilderFieldpatient_name')"/> </div>
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<div class='formBuilderField single_line_text_box' id='formBuilderFieldhospital' title='Please tell us which hospital the stay will be at.' ><a name='formBuilderFieldhospital'></a>
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<div class='formBuilderLabelRequired'>What is the hospital name? </div>
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</div>
<div class='formBuilderField large_text_area' id='formBuilderFieldother_info' title='Please help us to know more about the situation.' ><a name='formBuilderFieldother_info'></a>
<span id='formBuilderErrorSpaceformBuilderFieldother_info'></span>
<div class='formBuilderLabelRequired'>Other Info (Dates, Times, Procedures) </div>
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<div class='formBuilderField selection_dropdown' id='formBuilderFieldshare_info' title='Please select YES or NO.' ><a name='formBuilderFieldshare_info'></a>
<span id='formBuilderErrorSpaceformBuilderFieldshare_info'></span>
<div class='formBuilderLabelRequired'>May we share this info with the church? </div>
<div class='formBuilderSelect'>
<select name='formBuilderForm[share_info]'>
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<option value='1' >YES</option>
<option value='2' >NO</option>
</select>
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</div>
<div class='formBuilderField selection_dropdown' id='formBuilderFieldpastoral_visit' title='Please select YES or NO.' ><a name='formBuilderFieldpastoral_visit'></a>
<span id='formBuilderErrorSpaceformBuilderFieldpastoral_visit'></span>
<div class='formBuilderLabelRequired'>If possible, would you like a pastor to visit the patient? </div>
<div class='formBuilderSelect'>
<select name='formBuilderForm[pastoral_visit]'>
<option value='0' selected = 'selected'></option>
</select>
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</div><input type='hidden' name='PAGE' value='http://fumcwf.org/archives/category/membership_care/hospitals/feed' />
<div class='formBuilderSubmit'><input type='submit' name='Submit' value='Send!' /></div>
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