Register – Albinism Africa

KIVULI SUNSCREEN AID APPLICATION FORM

Beneficiary Details:

First Name

Surname

Date of Birth

Sex

Tel

Address

Country

Beneficiary's Next Of Kin/Guardian:

Next of Kin/Guardian Name

Next of Kin/Guardian Surname

Next of Kin/Guardian Email

Next of Kin/Guardian Telephone

Next of Kin/Guardian Address

Beneficiary Skin Conditions :

Any Skin Conditions

If Yes Please state the condition(s)

Other Requirements (For future use and or sharing with other charity organisations only):

Other Needs

Spectacles Sun Hat Medical Assistance - Cancer related School Fees Assistance

Any Special Message to us: