Vacation request for a sick child

Beyond the Moon handles every application with the necessary diplomacy, while taking our privacy policy into account, and according to a well-considered list of selection criteria.

* compulsory fields

I declare that I have read and understand the selection criteria.

I declare that I have read the Beyond the Moon privacy policy (see below link in the dark banner) and I accept it.

My contact details:

Contact details of the sick child:

Diagnosis

Mobile phone (mother or father)

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

Other:

I have known Beyond the Moon via

Explanation, question or remark

Date

VACATION REQUEST FOR A SICK CHILD

Contact & Bank account details

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