Beyond the Moon

Help us

"Help us" 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 want to support BEYOND THE MOON: (multiple options possible)
Make a donation
Become a "Caring Heart"
Order "Change for Children" money collection box/envelopes
Organise a fundraising activity
Make an in-kind donation
Increase the awareness by using your banner on my website
Advertise my logo on your website
Implement the payroll giving project in my company
Build the network of sponsors and doctors
Set up a product sharing/marketing campaign
Put forward a family - submit a wish request
I regularly want to receive your "Newsletter" by e-mail
Include BEYOND THE MOON in my will

Other specific questions:

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:
First name*:
Last name*:
Gender*:	male female
Title*:
Date of birth*:

Street + Number*:
Postal code*:
City*:
Country*:
E-mail*:
Phone:

Language*:	Nederlands Français English Deutsch Español

How did you find out about the BEYOND THE MOON website?*
Magazine/brochure/newspaper. Specify:
E-mail from friend or colleague
Word of mouth
Via the company/my employer. Specify:
Through a family who was granted a BEYOND THE MOON wish. Name:
Internet search engine. Specify:
Link from another website. Specify:
Other. Specify:
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. Thank you for your support !