Application Form for Medical Assistance for Children with Leukemia of Beijing Red Cross Society (1) Name, gender, date of birth, national photo, ID number, home address in the area where the household registration is located, contact telephone number, diagnosis and treatment of the disease in the hospital, expenses paid in the current year, medical expenses for obtaining social assistance, number of hospitalizations, and amount of medical expenses paid by this city. Whether the household registration is included in the reimbursement amount of children's medical insurance, whether the rural household registration is included in the reimbursement amount of the new rural cooperative medical system or children's medical insurance, the title, name, professional address and income of family members, and individual application for approval. See township (street) audit opinions and district and county Red Cross audit opinions. Stamp: year, month and day, note: 1 The above information is filled in by parents or legal guardians; 2. Relevant application materials and copies are attached (household registration book, street and township certificate, hospital certificate); 3. This form and related materials are made in duplicate, each for the county Red Cross Society and the city Red Cross Society 1 copy;

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