office@just4children.org 0800 169 1601
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
Parent 1
Parent 2
Name
Phone
What does your child require?
How do you expect the above to benefit your child?
Country
How long will the treatment/therapy take?
Expected travel date
Cost of the above
Funds raised to date?
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
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