Mercy’s Gift Application Form

Parent Information - At least one parent's information is required.

Parent Name (required)

Mother/Father (required) MotherFather

Email Address (required)

Parent Date of Birth (required)

Phone Number(required)

Address(required)

2nd Parent's Name

Mother/Father MotherFather

Parent Date of Birth

Email Address

Phone Number

Address (if different)

Family Information

Your Family Story (required) Do you have a child awaiting delivery with a fatal diagnosis, a child living with a terminal illness, or a child who has died? Please tell us their story.

Living Children (required) Please share a little about the living child/children in your home.

Children Applying for Mercy's Gift Fund

For each child, please include name of school, activity, therapist, etc. where funds will used, the activity address, phone number, contact name, and website where applicable. Please include the cost of tuition per month, semester, or session for the activity(activities).

First Child's Name (required) Date of Birth (required)

Name of the school, activity, therapist, etc. where funds will used (required)

Activity address, phone number, contact name, and website where applicable (required)

Cost of tuition per month, semester, or session for the activity(ies) (required)

Second Child's Name Date of Birth

Name of the school, activity, therapist, etc. where funds will used

Activity address, phone number, contact name, and website where applicable

Cost of tuition per month, semester, or session for the activity(ies)

Third Child's Name Date of Birth

Name of the school, activity, therapist, etc. where funds will used

Activity address, phone number, contact name, and website where applicable

Cost of tuition per month, semester, or session for the activity(ies)

Fourth Child's Name Date of Birth

Name of the school, activity, therapist, etc. where funds will used

Activity address, phone number, contact name, and website where applicable

Cost of tuition per month, semester, or session for the activity(ies)

Attach a family photo (required max-size 6mb)

How did you hear about Mercy's Gift

I agree that TeamMercy.org may use our likeness/image in promotional material. YesNo