Application for Funding

Child Details

Child's Name

Date of Birth

Age

Medical Condition

Parent 1's Name

Parent 2's Name

Tel. No

Address 1

Address 2

City

Postcode

Email

Resident In UK YesNo

Occupation

Parent 1

Parent 2

Your GP

Name

Address 1

Address 2

City

Postcode

Phone

Email

Your Consultant

Name

Address 1

Address 2

City

Postcode

Phone

Email

Treatment Details

What does your child require?

How do you expect the above to benefit your child?

Surgery / Treatment / Therapy Centre

Name

Address 1

Address 2

City

Country

Postcode

Phone

Email

Some Treatment Details

How long will the treatment/therapy take?

Expected travel date

Cost of the above

Funds raised to date?

Terms and Conditions

Will you give permission for a photograph and details to be used for our fund-raising purposes and the press? YesNo

How did you hear about us?

The above information is true, and I agree not to bring Just4Children into disrepute. We agree that any funds raised over our target may be used for other children. We understand that where possible all monies will be used as directed but where appropriate will be used for general purposes. Accept

Date

Signed