Adult's Name (required)
Relationship to Child (required)
Email Address (required)
Adult's Birth Date (required)
Phone Number (required)
Mailing Address (required)
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2nd Adult's Name
Relationship to Child
Email Address
Adult's Birth Date
Phone Number
Mailing Address (if different)
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).
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. (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.
Family Information
Your Family Story: 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. (required)
Living Children: Please share a little about the living child/children in your home.(required)
How will Mercy's Gift impact your family? (required)
Is there a financial need? If so, please explain the situation/need. (required)
Attach a family photo. (required)
How did you hear about Mercy's Gift? (required)
I agree that TeamMercy.org may use our likeness/image in promotional material. (required)
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