MERCY’S GIFT APPLICATION FORM
Funding for extracurricular, academic, or mental health activity. Please fill out the form below and have a family  photo ready to upload (required). You can also download and print the PDF form and mail it to us.

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

Parent Name *


Mother/Father *


Email Address *


Parent Date of Birth *


Phone Number *


Address *

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 *


Date of Birth *




Family Information