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!

Your Name:   Phone #:

E-mail:

Demonstrator Name:  ID #:

Name of Organization / Individual:

REQUIRED: This address must belong to the recipient
Organization Address:

City:    Zip:

State:    Country:    

Your Affiliation with this Organization/ Individual:

Are you doing a Gold Canyon Fundraiser for this organization?YesNo

Please be specific as to that amount you are requesting: $  

Total goal amount to attain your specific need: $  

Individual's Birthdate:

Name of disease ailment:

Is this individual covered under health insurance? Yes No

Have you applied for any other grant programs:

Address that we can respond to your request:

Name:

Address:

City:    Zip:

State:    Country:    

Please give us an explanation of why you feel the Prayer Child Foundation should donate to this charity