Mercy’s Gift Application Form

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.

Family Information

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).