Your full name*

City of residence*

Contact phone number*

Email*

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Who is applying*

I am applying personallyA relative or close personA representative (volunteer, social worker, etc.)

What kind of assistance do you need?*

Physical rehabilitationPsychological supportMedical equipmentTransport / transferOther

Briefly describe your request*

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How did you hear about our foundation?*

Social media (Instagram / Facebook, TikTok)Google searchFrom friends / relativesMedia (news, articles, TV)Public events / activitiesOther

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