General information

sex

ManWoman

First name and last name of the child

The child's date of birth

Diagnosis

Description of the disease

How can we help

Cost

Place - stay / rehabilitation / operation -

name of the center / hospital (if applicable)

E-mail

Contact number

Parents' names

I use / do not use the help of other Foundations

YesNot

Foundation name (s)

Attachments

Prosimy o załączenie czytelnych zdjęć/skanów następujących dokumentów

Dowód osobisty/Akt urodzenia dziecka(typ plików jpg|jpeg|png , rozmiar nie więcej niż 5120kb)

Orzeczenie o niepełnosprawności(typ plików jpg|jpeg|png , rozmiar nie więcej niż 5120kb)

I consent to the processing and disclosure of my / my child's personal data by the data administrator of the Beneficjum Foundation based in Warsaw 00-833, ul. Sienna loc. 1, in accordance with the Act of August 29, 1997 on the protection of personal data. Provides personal data voluntarily and declares that they are true. I have read the content of the information clause, including information about the purpose and methods of processing personal data and the right to access my data and the right to process itI accept the PRIVACY POLICY and GDPR