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 or Ireland YesNo
Parent 1
Parent 2
Name
Phone
What does your child require? SurgeryTreatmentTherapyEquipmentHolidayHome Adaption
How do you expect the above to benefit your child?
Country
How long will the treatment/therapy take?
Expected travel date
Your Target for 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 if a Campaign raises insufficient funds or surplus funds, then the funds will be used if appropriate, to fund our child’s needs in accordance with Just Helping Children’s charitable objects. If in those circumstances Just Helping Children are unable to use all or part of the funds for the benefit of our child in accordance with Just Helping Children’s charitable objects, we understand then that any funds which cannot be used will be transferred to be used for the general charitable purposes of Just Helping Children.Accept
Date:
Signed:
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