Application For Assistance
Please complete this application to apply for assistance from The RescYOU Group. If you need any assistance in completing the form, please contact Reecie Gilmore @ 361-944-4226.
* - Denotes required field.
Name of Parent / Caregiver*
Name of Second Parent / Caregiver
Street / PO Box*
Parish of residence*
Parent's Primary Phone Number*
Parent's Second Phone Number
Name of Child*
Child's Date of Birth*
Child's Date of Loss*
Please List Siblings
Any other person(s) impacted that may need assistance?
Religious Affiliation (if applicable)
Child's school (if applicable)
Child's Grade (if applicable)
Funeral Home Contact Person (if known)
Funeral Home Phone Number (if known)
Did you receive a RescYOU Resource Folder*
How did you hear about The RescYOU Group?
Application prepared by:*
Application prepared by Phone Number*
Application prepared on:*
We keep your personal information private and secure. Your information will be protected and treated with sensitivity. All contact information is used for the sole purpose of The RescYOU Group.