Mercy Ships | Mercy Ships PAT Kit Signup

Patient Admission Kit Registration Form

Don't forget to get the approval of your church or group leader(s) before signing up!

Upon registering, a Mercy Ships representative will contact you to walk you through the entire Patient Admission Kit process. PAT smile

Email Address: *

Contact First Name: *

Contact Last Name: *

Address: *

City: *

State/Province/Region: *

Zip/Postal Code: *

Phone: *

Position in Church: *

Church or Group name: *

How did you hear about this program?:

Please select your kit assembly option::

  Group Assembly
  Cash donation only to cover the cost of the kits
  Donate some or all of the items on the supply list

Estimated number of kits you wish to donate and/or assemble: *

Word Verification: *

Type the words you see below into the Word Verification box.

CAPTCHA Word Verification

Please enter the words you see in the box, in order and separated by a space. This helps prevent automated programs from abusing this service.

If you are not sure what the words are, either enter your best guess or click the reload button next to the distorted words.

Visually impaired users can click the audio button to hear a set of digits that can be entered instead of the visual challenge.

* denotes required field