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:

Please tick one of the two boxes. If you disagree and/or do not tick any box, Beyond the Moon will unfortunately not be able to consider your application.

As young adult over the age of 16 / parent / guardian, I agree to freely fill in and sign this application form. I give my consent for Beyond the Moon to confidentially process all the personal and vital data provided in this form that is needed to assess the possible granting of a family vacation, and to carry out the full organisation of this vacation, should it be granted. I undertake to submit the "Patient Summary" (3 pages) to my / my child's primary care physician/specialist so that he/she can complete and sign it. I have the right to withdraw my consent to the processing of this data at any time.
As family member/friend/acquaintance/healthcare professional, I declare that I received the consent of the family or young adult over the age of 16 to fill in this application form on their behalf. I give my consent for Beyond the Moon to confidentially process all the personal and vital data provided in this form that is needed to assess the possible granting of a family vacation, and to carry out the full organisation of this vacation, should it be granted. Any additional forms needed to examine this application will be directly forwarded to the family by Beyond the Moon. I have the right to withdraw my consent to the processing of this data at any time.

My relation with the sick child

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:

I have known Beyond the Moon via

Question or remark

Contact & Bank account details

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