Application for Support

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

Address 1

Address 2

City

Postcode

Phone

Email

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?

Name

Address 1

Address 2

City

Country

Postcode

Phone

Email

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: