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