Uber Eats/Instacart Gift Card Request Form
Requests for gift cards are accepted from families in the Houston area (at Texas Children's Hospital, MD Anderson, or Memorial Hermann) who have previously applied for and received financial assistance from Addi’s Faith Foundation. Gift cards are meant to support families that are in the hospital for treatment, so please only apply during admission or when an admission is scheduled. Requests may be submitted once per month up to three times. Gift cards are distributed weekly. Please allow 1-3 days for an electronic gift card to be received via email.
Today's Date:
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Month
-
Day
Year
Name of person completing this form:
First Name
Last Name
Relationship to patient:
Child's Name:
First Name
Last Name
Email Address:
Hospital:
Admission/Clinic Date:
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Month
-
Day
Year
Date
Gift Card Preference:
Uber Eats
Instacart
Have you previously applied and received financial assistance from Addi's Faith?
Yes
No
Submit
Should be Empty: