Miracle for Mateo
501c3 Non-Profit

Release Form
Miracle for Mateo provides funding for families who have a child receiving medical treatment in the Tri-State area (NJ, PA and DE) and are struggling financially due to their child's life threatening illness and lengthy hospitalization.
Could you please send a picture of your child to Miracle for Mateo?*   Yes   No    
*Please email a picture to miracleformateo@gmail.com if at all possible. Thank you.

Does Miracle for Mateo Non-Profit Organization have your permission?
To use any information provided in this application or information discussed throughout the exploratory process as a means to determine whether Miracle for Mateo will support your family at this time. *   Yes   No    
To use parent’s names, children’s names, the experiences/situations described within the application and/or any photographs taken by Miracle for Mateo or provided by the applicant for promotional pieces published by Miracle for Mateo.*
Yes    No    
Do you agree to write a letter of acknowledgement to Miracle for Mateo if we are able to assist you and your family through this difficult time?*    Yes   No    

Please sign below if you release Miracle for Mateo Non-Profit Organization and its affiliates from any and all claims for damages, slander, invasion of privacy and/or any other claims resulting from or based on the use of your name(s), photograph(s) and/or testimonial(s).

I hereby represent that I am of full legal age and have every right to contract in the above regard. I hereby represent that this Release Form and Authorization has been fully explained to me and I fully understand the Application for Funding and Support and the Release Form.

Parent(s) Signature(s)*
Print Name(s)*

Please either submit online or return to
Miracle for Mateo, P.O. Box 101, Shiloh, NJ 08353
Thank you.

Parent Portion Of Application

Worker and/or Child Life Specialist Portion