Application Form - La fondation Alecxange

INFORMATION ABOUT THE FAMILY

Name of parent / guardian*

Prénom Nom

Address*

Adresse postale Adresse ligne 2 Ville Province Code postal

Phone number*

Other phone number

Email*

Number of people in the immediate family*

Did a member of the family have to stop working?*

What are your current main sources of income?*

Total monthly income*

Wich organizations or foundations have supported financially? If don't have, write N/A*

Has there been a fundraiser like GoFundMe to organize for your family?

Date of fundraising

Amount raised

Please, write the name of a Leucan officer or social worker who knows your situation? If none, write N/A*

Name*

Prénom Nom

Age*

Date of diagnosis*

Type of cancer*

Please check the support you would like to receive.

A housekeeping service may be available depending on your needs and your region.*

* Temporarily suspended

Reference and contact information of the company in your area*

PROVIDE MORE OR LESS A PERIOD OF THREE WEEKS FOR THE PROCESSING OF YOUR REQUEST WHICH IS NOT RECURRENT. THANK YOU FOR YOUR UNDERSTANDING.

Phone

Ce champ n’est utilisé qu’à des fins de validation et devrait rester inchangé.