Application

Application

Are you all both in agreement for a Reversal? *	Yes No
Do you currently belong to another reversal support group: *	Yes No
If yes please provide the name *
Are you currently on their waiting list for funding? *	Yes No
Please tell us in your own words why you are seeking a reversal. Please not this bears no effect on the decision to fund you or not, we just would like to pair up like minded women and men on their journey. Some of us have gone through a divorce, remarried and have step children and some of us have not, we just want to support you in all aspects: *
Name *
Date of Birth: *
Spouse/FiancÃ©e Name: *
Date of Birth: *
Address: *
Phone Number: *
E-Mail: *
Your Occupation: *
Spouses/FiancÃ©e Occupation: *
Name and ages of your children: *
Type of Reversal you are seeking: Tubal Reversal or Vasectomy Reversal *
Name, Address & Phone # of the Dr. you are planning on using: *
Website: *
Price of the Reversal: *
Do you currently belong to a church? *	Yes No
Church Name:
Address:
Pastors Name:
By signing this document you agree that all of the above information is complete, honest and true. Vision of Faith Reversal Ministry does not endorse any one particular physician. There is no guarantee that the reversal surgery will result in pregnancy. All members funded in this group agree that surgery has known and unknown risks involved and Vision of Faith will not be held liable for those risks. The couple both acknowledge and accept all responsibility for the surgery and its outcome. We will not be responsible for any additional costs associated with the surgery and or travel expenses.	True False
Applicant: *
Co-Applicant *
Date: *

Vision of Faith