Visitor’s Questionnaire

The DiVineyard Church Of His Presence welcomes visitors from all over the world to witness the power of God Almighty working through the Holy Spirit, by His Word. Many people travel from across the globe to witness the mighty power of Jesus Christ and receive a touch from heaven, through his servant John Chibwe.

For all international visitors who would like to visit The DiVineyard Church Of His Presence, please complete the form below and wait for confirmation before coming.

First Name (required):
Last Name (required):
Email (required):
Passport Number (required):
Language(s) (required):
Phone Number (required):
Phone Number 2:
Gender (required):
Age (required):
Country of Residence (required):
Nationality (required):
Next of Kin (required):
Next of Kin Phone (required):
Next of Kin Email:
Are you having any sickness? YesNo
Briefly state the nature of the sickness, signs and symptoms. Please provide all necessary information:
Please state the period you have been suffering from this sickness?
Provide a list of all the medication you are taking / have taken as a result of this sickness:
Are you having any spiritual problems? YesNo
If so, please specify:
How has the problem/ condition affected your daily living?
Have you ever been hospitalized? If so when?
If you are HIV positive, please indicate your status:
*All HIV patients should bring their most recent original medical results when their visit is confirmed. Please note that only a confirmatory report clearly indicating that the patient is HIV I, II OR III positive is required and it must be typed on the hospital’s letterhead. It must be a government recognized hospital in your country. You cannot come without the correct medical report.
Are you using any form of brace? YesNo
Are you using any form of walking aid (crutch, stick, etc.) or wheelchair? YesNo
Are you using any medical device to support your health condition? YesNo
Are you limping? YesNo
Do you still go about your daily activities normally without using any aids or assistance from other people? YesNo
Can you walk normally/ climb stairs without assistance? YesNo
Do you experience body weakness? YesNo
Have you had any surgery or other therapy as a result of the problem/ condition? If so, please give details.
Is any part of your body swollen? If so, where?
Do you have any open wound? If so, where?
Are you on a special diet? If so, please state details:
Do you have any other sickness or problems. If so, please list all symptoms, treatments and medications:
Do you intend to come alone or accompanied? (If you will be accompanied, please ask each of those with you to also submit this questionnaire, indicating in the additional information section that they intend to come with you) (required)
How did you hear about The DiVineyard Church Of His Presence?
Additional information (Please state the period/month you intend to visit):
Please tick the box (required)