Contact 2

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*

City*

State*

Zip Code*

Parish of residence*

Parent's Primary Phone Number*

Parent's Second Phone Number

Email Address*

Name of Child*

Child's Gender

Male

Female

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)

Hospital

Funeral Home

Funeral Home Contact Person (if known)

Funeral Home Phone Number (if known)

Assistance Required*

Financial for Funeral/Burial Expenses

Financial for Medical Expenses

Emotional Support for Parent(s) / Caretakers

Emotional Support for Sibling(s)

Emotional Support (General)

Message

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.