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


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

Your contact details:  * required fields


Contact details of the family with the sick child:


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

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.