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    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).

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    Family Information

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    I agree that TeamMercy.org may use our likeness/image in promotional material. (required)

    YesNO