Report of the student / ward • Beneficiary

The ward's form

    General information

    sex

    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

    Foundation name (s)

    Attachments

    Please attach legible

    photos / scans of the following

    documents

    ID card / Child's birth certificate

    Certificate of disability