REQUEST A PRAYER

(APPLICATION)

You are not alone—we believe no prayer is too big or too small in the fight for hope and healing. If you, or someone you know, may benefit from our services, please fill out the application form below.

Section 1: Patient & Family Information

Child's Name:

Sex:

Child's Birthday

Month

Day

Year

Parent/Guardian Name:

Phone:

Email:

Address:

Patient's Siblings Names/Ages:

Does the patient have medical insurance?

Yes

Do you use Facebook or some other form of social media, where we can follow your child's journey?

Yes

If yes, please provide further information:

How did you hear about PK's Prayers?

Section 2: Medical Information

Child's Diagnosis:

Date of Diagnosis:

Month

Day

Year

Is the child undergoing active treatment?

Yes

Other

Treating Physician Name:

Hospital Name:

Other locations receiving treatment:

Social Worker Name:

Phone:

Social Worker Email Address:

Section 3: Your Child's Story

Please share your child's story below. You may provide as much or as little detail as you feel comfortable.

Section 4: Prayer Request

We understand how overwhelming your child’s diagnosis is. Worrying about finances should never be part of that burden.

During PK’s medical journey, our family was blessed with the financial means for me, her mother, to be present at every appointment, every treatment, every therapy session... and every tough and beautiful moment in between.

Had our circumstances been different, PK’s PRAYER would have been simple: to have her parents by her side.

We believe no parent should ever have to choose between being with their child and keeping up with financial responsibilities.

It would bless us deeply to extend that support to you. At PK’s Prayers, no request is too big or too small. Please share below how PK’s Prayers can assist your family as you KEEP ON in this journey with your child.

Your family's specific prayer request:

Section 5: Media Release

**Signing the Media Release is a requirement. We will not be able to process an application without this.

PK’s PRAYERS is devoted to supporting children and families affected by DIPG/DMG from the moment of diagnosis through every step of their journey. Guided by FAITH & PK, we provide financial, spiritual, and emotional support - believing that no prayer is too big or too small in the fight for HOPE and HEALING.

By signing below, I hereby grant permission to PK’S PRAYERS, to

use: photographs and/or digital images, including video, of my child for use in news releases, education and/or promotional materials. These materials might include printed or electronic publications, websites or other electronic communications and will be used for the activities related

to PK’S PRAYERS mission, programs, services and events.

I further consent that our names and identities may be revealed by descriptive text or commentary for some projects. I understand that there will be no financial or other remuneration for either the initial or subsequent use of these photos/videos.

I understand this authorization shall continue until terminated in writing.

Child's Name:

Parent/Guardian Name:

Today's Date

Month

Day

Year

Parent/Guardian Signature:

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Lastly, how can our team at PK's Prayers pray for your family?