End of Life Planning Form

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One of the functions of the Worship & Ministry and Care & Counsel’s working group on End of Life Issues (known as ELI) is to assist Members, Attenders, and their families as they make the arrangements necessary at the time of death of a loved one. One of the major concerns expressed by those who must make the decisions after the death of a loved one is, “What would he/she have wanted?” The Care & Counsel Committee created this End Of Life Planning form so that you can answer that question for your loved ones and for the CHFM while you are “of sound mind and in good health and not in anticipation of death, but mindful of the certainty thereof….” We suggest that you discuss your answers with those closest to you as you fill out the form. We suggest that you give your loved ones a copy to keep as a reminder. We also ask that you return one signed and dated hard copy of the form to the Clerk of the Care & Counsel Committee so that it will be available to CHFM when we are called on to assist your family when death occurs. You should keep a signed and dated copy with your files.

Please download the form from the bottom of this page. You can then print out and complete the End of Life Planning form by hand or you can choose to type your answers into the fillable PDF form from your desktop, ipad, or laptop. To open and complete the fillable PDF form, you will need Adobe Reader (the latest version is recommended). If you do not have it installed on your computer, you may download the latest version free of charge from http://get.adobe.com/reader/otherversions. You must sign and date the form by hand.

The End of Life Planning Form contains sensitive identification data that is required in order to obtain a death certificate. PLEASE DO NOT EMAIL your completed form to Care & Counsel. See the information in the form for where to send it. If you have questions about any item in this questionnaire, a member of ELI or Care & Counsel will be ready to discuss it with you; feel free to contact us at [email protected].

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