A’awen – Treatment Support Request Form

Please take some time to fill up the form for us to process your application

Received From :

Government Private Individual

Applicant Name :

Applicant Phone Number :

Applicant Email :

Date :

PERSONAL INFORMATION

Patient Name :

Nationality :

Medical Facility File Number ( if any ):

Maritial Status :

Patient Phone Number :

Address :

INCOME ( AED/MONTHLY )

Total Income : .00 AED

Commitments :

Total Family Members :

FINANCIAL & FAMILY BACKGROUND

DETAIL OF SUPPORT REQUIRED

REQUIRED DOCUMENTS FOR ALL FAMILY MEMBERS

A written letter explaining the health, social and financial status.

Medical report with treatment plan and the estimated cost (recent report).

Copy of the passport, residency, and ID card of the patient, the primary income earner and the rest of his family

UAE National ID

Salary certificate from the workplace of the patient or primary income earner (or equivalent).

Bank statement for the last 6 months (or equivalent)

Lease agreement (if the person is not the owner of the residence)

NOTES

Did you apply to any other charity?

Yes No

If yes, please state the name and the amount received.

I confirm all the given information is correct.

I confirm I have provided all the documents listed in the application and understand an incomplete application will be rejected.

Not readable? Change text.

Make a Donation

When you donate you are not only giving a gift, you are giving the gift of life. Transform someone’s life today and help us heal our society, one donation at a time. With your support, no solution is out of sight or out of reach.

Donate