Application for Support

    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 or Ireland 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

    What does your child require? SurgeryTreatmentTherapyEquipmentHolidayHome Adaption

    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

    Your Target for 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 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: