The Prayer Child Foundation

Request Form

By filling out this form you agree to allow the Prayer Child Foundation to use your story for marketing purposes. Please fill the form out completely!

Incomplete Information Will Not Be Considered

* indicates the field is required

Name of Individual Making Request:

*First Name:

*Last Name:

*Email:

*Your Relationship to Donation Recipient:

*Who Referred You to the Prayer Child Foundation?

Are you doing a Gold Canyon Fundraiser for this organization? No Yes

Gold Canyon Demonstrator

First Name:

Last Name:

ID #:

Information for Donation Recipient:

Recipient address must belong to the recipient and the name must be a legal name (no nicknames please)

*First Name:

*Last Name:

*Street:

*City:

*Zip Code:

*State:

*Country:

*Donor Recipient's Date of Birth:

*Name of Disease or Description of illness:

Amount Requesting:

Specify what these funds will be used for:

Is the individual covered under health insurance? No Yes

If you would like to send pictures, please send with the child's name to info@prayerchild.org

Address that the response should be sent:

This address is where any correspondence will be sent. Please verify the address is correct to prevent returned checks and mail.

*First Name:

*Last Name:

*Street:

*City:

*Zip Code:

*State:

*Country:

*Please give a detailed explanation of why this person should receive a grant from the Prayer Child Foundation. Please be as specific as possible as to the exact need, and why you are requesting assistance: