Mercy’s Gift

Team Mercy Logo Blue copy

 

 

 

 

Mercy’s Gift Application

Mother: _______________                     Father: _______________

Date of Birth: ___________                      Date of Birth: ___________

Phone: ________________                     Phone: _______________

e-mail: ____________________________________________

email: _____________________________________________

Address: ___________________________________________

Address: (if different)___________________________________

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. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Living Children: Please share a little about the living child/children in your home?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Child(ren) applying for Mercy’s Gift fund:  Please include name of school, activity, therapist, etc. where funds will be used, the activity address, phone number, contact name, and website, where applicable.  Please also include the cost of tuition per month, semester, or session for the activity/ies.  
Child’s Name: ____________________    Date of Birth: _________

Activity: _____________________________________________

Location: ____________________________________________                    

Activity Contact Person/phone/email: ________________________________________________________________________________

_____________________________________________________
Feel free to copy this page for each child applying for Mercy’s Gift

Please include

____ Family Contact Info

____ Family Story

____ Living Child(ren)’s activities 

____ Please submit a family photo. 

____ I agree TeamMercy.org may use our likeness/image in promotional material. 
submit completed form to:
TeamMercy.org 

c/o Mercy’s Gift 

1079 W. Round Grove Rd. Suite 300-504, 

Lewisville, TX 75067 
or email complete form to  info@teammercy.org