Asha Bhavan Centre

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DISABLED CHILD SPONSOR FORM

Your selected child details are as follows.

Name:

Sonamoni Khatun

Dob:

15/05/01

Age:

Gender:

Female

Disability:

Severe Cerebral Palsy

Sonamoni is severely affected with Cerebral Palsy. Her mother died and his father is suffering from post polio related problems. The only earning member of the family is the elder brother and who is unable to meet the needs of Sonamoni other than the bare minimum one. Sonamoni needs special help to lead a normal life.


PLEASE CHOOSE THE TYPE OF SPONSORSHIP

		for 1 year.
		for life time(18 years).
Your Sponsorship Amount will be used for cure and care of your selected child for the respective time.

Your Donations are tax exempted u/s 80(g)

PLEASE GIVE YOUR PARTICULARS HERE

Name in Full

Address

Phone Number Work

Fax Number

Phone Number Home

Mobile Phone Number

Email ID

Age

Gender

Male

Female

Spouse's Name(if any)

Number of Children(if any)

Girl(s)

Boy(s)

Any special comments/Suggestions

PLEASE GIVE YOUR PAYMENT DETAILS


Cheque/DD No.	:
Dated	:
on Bank	:	Favouring Asha Bhavan Centre payable at Kolkata.