Apply For Services

To apply for services click to download our application for services for Mom or Dad

Please note that your information is saved on our server as you enter it.

Mother’s General Information
Mother's Name*

First Name
First
Last Name
Last
Email Address*

Email Address
Preferred Phone*
- Cell
- Work
- Home
Which number should we use to contact you?
Preferred Cell Phone Number
Preferred Work Phone Number
Preferred Home Phone Number
Alternate Phone
- Cell
- Work
- Home
Alternate Cell Phone
Alternate Work Phone
Alternate Home Phone
Address*

Street Address
Street Address
Address Line 2
Address Line 2
City
City State
Zip Code
ZIP Code
Age
Date of Birth*
Date Format: MM slash DD slash YYYY
Marital Status
- Married
- Single
- Separated
Fathers General Information
Father's Name*

First Name
First
Last Name
Last
Email Address*

Email Address
Preferred Phone*
- Cell
- Work
- Home
Which number should we use to contact you?
Preferred Cell Phone Number
Preferred Work Phone Number
Preferred Home Phone Number
Alternate Phone Preferrence
- Cell
- Work
- Home
Alternate Cell Number
Alternate Work Phone
Alternate Home Number
Is your address same as above?*
Address*

Street Address
Street Address
Address Line 2
Address Line 2
City
City State
Zip Code
ZIP Code
Age
Age
Date of Birth*

Date of Birth
Date Format: MM slash DD slash YYYY
Who is the patient?*
- Mother
- Father
Diagnosed Illness*
Please describe the diagnosed Illness.
Medical Considerations:
- wheelchair
- oxygen
- other
How did you learn about Let There Be Mom?*
Power of Attorney
THE FOLLOWING QUESTIONS ARE TO BE ANSWERED BY THE PATIENT
Do you have a Power of Attorney?*
- Yes
- No
Are they currently acting on your behalf?*
- Yes
- No
- N/A
Name*

First Name
First
Last Name
Last
Address*

Street Address
Street Address
Address Line 2
Address Line 2
City
City State
Zip Code
ZIP Code
Email Address*

Email Address
Phone
Home Phone
Date of Birth

Date of Birth
Date Format: DD slash MM slash YYYY
Family Information
Number of dependent children (under the age of 18):
Number of dependent children (under the age of 18):
Children under the age of 18
Total Number of children:
Total Number of children, including those over 18:
Total Number of children
Names and ages of children:
Names and ages of children:
Name Age
Do the listed children reside with both biological parents?
- Yes
- No
Please Explain:*
Additional Information
Please explain your children’s understanding of your diagnosis.*
Please tell us why establishing your legacy is important to you.*
Please explain your prognosis as you understand it.*
Required Signatures
I understand and agree:

1) That no promises or assurances whatsoever have been made to me by any representative of the Let There Be Mom organization regarding providing any services to me or my family;

2) That granting services of any kind is contingent upon approval by the Let There Be Mom organization and my physician, as well as full compliance with all conditions, qualifications, and restrictions designated by the Let There Be Mom organization;

3) That all individuals with parental or custodial rights for the children must approve participation with the Let There Be Mom organization and sign all necessary documents before services can begin; and

4) That full disclosure of anyone having power-of-attorney over me must be made and they must complete the appropriate documents before the Let There Be Mom organization will consider offering services to me. I promise that the information provided by me is true and complete to the best of my knowledge.
Patient’s Signature
Patient’s Signature
Power of Attorney Signature
Power of Attorney Signature
Phone
This field is for validation purposes and should be left unchanged.