Request help

1

About the person submitting the request

Tell us how we can contact you and your relationship to the person who needs support.

Who is submitting this request? * Full name of the person submitting this request * Relationship to the person who needs support Email address * Best phone number or WhatsApp/Telegram contact

2

About the person who needs support

Basic information helps us understand whether the request may fit the Foundation mission.

Country * State, region, and city Full name of the person who needs support * Age Primary diagnosis or disability description * Is there a parent, guardian, or authorized representative who can sign documents if needed?

3

Household and financial situation

Approximate information is enough at this stage. Please do not send financial documents yet.

Household and family situation Who currently provides daily care or practical support? Approximate monthly household income Major monthly expenses and financial pressure

Main sources of income or support Employment income Disability benefits or public assistance Family support Charity or community support No stable income Other

4

Requested support

Describe the practical need and the outcome that would help.

5

Consent and acknowledgement

All items are required before the request can be recorded.

I confirm that the information provided is accurate to the best of my knowledge. I understand that submitting this form does not guarantee assistance. I authorize the Foundation to contact me about this request and to ask for additional information later. If I am submitting for another person, I confirm that I am authorized to share this information or am acting in good faith to seek help. I consent to the Foundation securely retaining this request and contacting me about it.

Read the Privacy Policy before submitting. This form is not monitored as an emergency service.

Foundation

Future work

Take action

Tell us what support is needed

Before you submit

About the person submitting the request

About the person who needs support

Household and financial situation

Requested support

Consent and acknowledgement