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MERCY FUND APPLICATION

MERCY FUND APPLICATION

Please fill out the following health declaration form in order to participate in our activity. Submissions are valid up to 24 hours prior to the activity.

First Name

Last Name

Email

Referred by:

Household Income:

Income shown is:

Gross (before taxes)

Net (after taxes)

Income Source(s)

Earned Income

SSI / SSD

Alimony

Other

If "Other" Income Source, please describe:

Please share in a few words how this might make a difference for you:

Session(s) Applying For: (Check all that apply):

Rewind Session

Coaching Session

Thanks for submitting!

We'll get back to you very soon!

Address:

8152 SW Hall Blvd. #1062

Beaverton, OR 97008

Phone: (503) 332-6416

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