Packet Request

Please mail me a free copy of the Medicine Box^® Packet. I want to share these instructions with my church (or other interested group) so that we can consider contributing to the Medicine Box^® program. Click here for more information about how to help.

Note: Though the information on the web site and and the packet are essentially the same, the packet has additional materials such as a large full color poster, smaller 8 1/2 x 11 two-color posters printed on brown stock, and a folder. The 16-page booklet includes pages that can be copied and used as bulletin inserts.

   If your web browser does not support forms, e-mail your request for a free Medicine Box Packet to jyoung@gbgm-umc.org.

Your Information

   An asterisk (*) before an entry means that you must answer this question before sending the form.

*Name:

*Street Address:

Apartment, Box, or Rural Route Number:

*City: State:

*Country: Zip:

Phone Number:

*Your E-mail:

Name of your local church:

Annual Conference (United Methodists only):

Contact Person

Your church's Medicine Box contact person:

Check here if same as above or fill in information below:

Name:

Street Address:

Apartment or Box Number:

City: State:

Country: Zip:

Phone Number:

E-mail:

If you are ready to send your request, click this button:

To erase your answers from this form, click this button: