Most Holy Virgin Mary who, willing to inspire me with the fullest confidence, has been willing to take the sweet name of Mother of Perpetual Succour, I, (your name), acknowledge that my sins render me unworthy to be admitted among the number of your privileged children.
Nevertheless, desirous of enjoying your merciful favour, I cast myself at your feet and, humbly prostrate before you, I consecrate to you my heart in order that, after God, I may love you above all things.
O my Sovereign Lady, deign to receive me among the number of your favoured children, take me under your protection, succour me in all my spiritual and temporal wants, but especially at the hour of my death. O Mother of Perpetual Succour, I know that you love me more than I can love myself, therefore I entrust all my interests to your care; dispose of me, and all that belongs to me, according to your good pleasure. O my Mother, bless me, and by your powerful intercession support my weakness, so that having been faithful in serving you during this life, I may praise you, love you, and thank you eternally in the next. Amen.