XX red cross angel project

XXXX congenital heart disease fund application form

Child's name: gender: date of birth: year month day.

Mailing address: city, county (district)

Contact person: telephone/mobile phone:

E-mail:

Date of application: year month day

Be sure to know when you apply.

1. This application form is made by Guangxi Red Cross Foundation, and the right of interpretation belongs to Guangxi Red Cross Foundation;

2. The relief target is children with congenital heart disease who need surgery in poor families under 0/4 years old in Guangxi/KLOC; Each person only needs to be rescued once, and the treatment effect of the same disease is basically the same, and the treatment scheme with low funding cost;

3. The subsidy amount shall not exceed 50% of the total hospitalization expenses, and the maximum amount shall be RMB ten thousand Yuan only (￥ 10000.00). The money was directly allocated by Guangxi Red Cross Foundation to the hospital for treating children;

4. All children's application materials are filled in by their legal guardians to ensure the authenticity and integrity of all materials; After the application materials are sent to the Red Cross Society at or above the county (district) level for preliminary examination, they will be reported to Guangxi Red Cross Foundation for approval step by step. After the approval, the legal guardian of the child will take the child and the Notice of Funding to the designated hospital (cooperative hospital) for treatment, and then you can get corresponding assistance.

5. Submitting this application form does not mean that you have passed the examination, obtained the qualification of funding or the maximum amount of funding;

6. Guangxi Red Cross Foundation is responsible for the final review and approval of all application materials;

7. If there are false, forged or concealed acts in the application materials, Guangxi Red Cross Foundation will recover all the funds it has obtained, and if the circumstances are serious, it will be investigated for legal responsibility according to law;

8. The guardians of all funded children have the responsibility and obligation to provide the necessary information such as words, photos and videos to the donors;

9. The guardians of all funded children have the responsibility and obligation to cooperate with Guangxi Red Cross Foundation in public welfare publicity and interview activities, and agree to use photos, videos and other materials free of charge.

I confirm that I have read and understood all the above terms and conditions, and agree to all the reporting requirements.

Signature (handprint) of the child's guardian: year month day.

Fund application form

Name and gender of the child

Date of birth, date of birth, nationality

identifier

Location of registered permanent residence (city) (county/district)

Family habitual residence

disease diagnosis

Medical expenses budget family self-funded budget

Attending physician of visiting hospital

The initial hospitalization time is from year month day to year month day.

The situation in the area where the family is located

Total annual household income, household population

Per capita annual income of local family labor force population

Neighborhood committees or township (town) governments where families often live.

The telephone number of the person in charge

County (District) level Red Cross opinions:

Official seal:

Time: Year Month Day City Red Cross Opinions:

Official seal:

Time: Year Month Day

Brief introduction of children's medical situation

Introduction to the treatment process for children: (Please refer to the precautions and be as detailed as possible)

1. Are you in the hospital now?

2. When was the child diagnosed? Where is the confirmed hospital?

3. Which hospital was treated after diagnosis? How is the treatment effect?

Child guardian's statement for help:

1. What is the cost of child treatment? How much does it cost to complete the treatment?

2. What is the family's economic situation? How much medical expenses can you afford?

Annex I: Identification Certificate

A copy of the child's identity certificate (household registration book/birth certificate/ID card) is posted on:

Copy of the applicant's (legal guardian of children) identity certificate (household registration book and ID card) paste location:

Annex II: Diagnosis of Children's Diseases

Examination report when children are diagnosed:

Other physical examination reports

Annex III: Proof of the financial situation of the children's family

A family poverty certificate issued by the village committee or neighborhood committee where the child's household registration is located or his habitual residence and signed and confirmed by the civil affairs department at or above the county (district) level:

certificate

Upon verification, the applicant's family has a population of * * *, with an annual income of about RMB yuan and a per capita income of RMB yuan, belonging to a family and unable to bear the medical expenses for the treatment of congenital heart disease alone.

This certificate.

Village Committee/Community Committee: Civil affairs departments at or above the county (district) level.

(Seal) (Seal)

Time: Year Month Day Time: Year Month Day

Other family financial difficulties proof materials.