Beyond the Moon

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"Caring Hearts" form

Please print the form below, fill it in and send it back to us either by fax at +32 15 23 36 82 or by post at the following address:
BEYOND THE MOON, Zandstraat 27k, 2223 Schriek, Belgium.

Thank you.

Yes, I become a 'Caring Heart' and transfer EUR monthly (minimum 5 EUR) to the account of BEYOND THE MOON vzw - nr 001-4712970-10. I include my name and address as a reference with every transfer.

I regularly would like to receive the Newsletter by e-mail

Please complete all fields marked with a * to allow us to contact you as soon as possible and to regularly inform you of our activities.

Company:
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Gender*:	male female
Title*:
Date of birth*: (dd/mm/yyyy)

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Language*:	Nederlands Français English Deutsch Español

How did you find out about the BEYOND THE MOON website?*
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Through a family who was granted a BEYOND THE MOON wish. Name:
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Your details will be added to our database but will not be given out to third parties. You have the right to view and alter your details at any time. We thank you for your financial support !