NOMINATE A SICK CHILD

Beyond the Moon is a non-profit organisation that is committed to safeguarding and respecting the privacy of all its website users. We ensure that the personal information you provide to us is treated confidentially. Accessing and using this website, as well as sending this form duly filled in, imply the acceptance of the Beyond the Moon privacy policy.

 

We only accept applications for European-based families. Before completing and sending this form, please thoroughly read the information in the questions hereunder:

Who qualifies according to our selection criteria?
Who can nominate a family with a sick child?

 

* compulsory fields

This form was filled in by:



 

Your contact details:  

 

Contact details of the family with the sick child:

 

Contact details of the primary care physician and hospital where the child is treated:

 

Other: