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Form "Nominate a sick child"

Before completing and sending us this form, please thoroughly read the information in the questions hereunder.

MY CONTACT DETAILS:
First name: (*)
Last name: (*)
Street + number: (*)
Postcode and place: (*)
Country: (*)
Telephone / Mobile: (*)
E-mail: (*)
Website:
I WOULD LIKE TO REFER A SICK CHILD:
Child’s first name: (*)
Child’s last name: (*)
Gender: Male
Female
(*)
Birthdate: (dd/mm/yyyy) (*)
Diagnosis: (*)
First & last name of the mother: (*)
First & last name of the father: (*)
Place and country of residence: (*)
Mother tongue and/or other language skills: English
Nederlands
Français
Deutsch
Español
Other
(*)
Phone / Mobile number parent(s) – over day time: (*)
Hospital where the child is treated: (*)
Place of hospital: (*)
Name primary care physician/specialist: (*)
Phone primary care physician/specialist: (*)
MY RELATION WITH THE CHILD:
Please tick as appropriate: primary care physician/specialist
biological mother/father
guardian
foster parent
family member
(foster) parent / guardian colleague
family friend/acquaintance
sick child (self)
other
(*)
How did you know about Beyond the Moon? (*)
OTHER SPECIFIC QUESTIONS AND/OR REMARKS:
Describe:
Copy the letters and/or numbers herein:

Thank you in advance for your interest in Beyond the Moon.
The personal data communicated by sending this form will exclusively be processed by Beyond the Moon, Zandstraat 27K, 2223 Schriek, Belgium. The only purpose of processing these data is to personally reply to your offer of support and/or to requests that you may have. Your personal data will at no time be used for commercial purposes, nor given out to third parties. The Belgian law of 8 December 1992 on the protection of personal data gives you the right to view and alter your details at any time. To update your personal details, please send us an e-mail.