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Request Assistance Form
Request Form for assistance
Email address *
Have we helped your child before? *
Childs Full Name *
Your answer
Male or Female *
Date of Birth *
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Is Child on Medicaid *
Home Address (This is where we mail funds to) *
Your answer
City *
Your answer
State *
Zip Code *
Your answer
County *
Are you both the Child's Legal Guardian and Custodial Parent? *
Legal Gaurdian/Parents Name:
Your answer
Legal Guardian Address *
Your answer
Cell Phone *
Your answer
Childs Local Doctor *
Your answer
Local Doctors Phone Number *
Your answer
Out of town Doctor *
Your answer
Out of town Doctor Office Phone Number. *
Your answer
Out of Town Doctor Address (full address please) *
Your answer
Appointment Must be Emailed info@meredithsmiracles.org or Faxed to 334-222-2867 before Meredith's Miracles can provide help.
Start Appointment Date (Doctor paperwork must confirm your dates or file will be marked uncomplete! Doctor must note if child has to stay overnight for us to fund.) *
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How many days?
End Appointment Date *
MM
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DD
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YYYY
Additional Trip Details
Please give details about your trip and any other details you need to tell us so that we can assist you better.
Your answer
Child's Medical Conditions
Details you would like to share but this is NOT required.
Your answer
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