Asha Bhavan Centre

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DISABLED CHILD SPONSOR FORM

Your selected child details are as follows.

Name:

Surojit Mahapatra

Dob:

19/09/98

Age:

Gender:

Male

Disability:

Cerebral Palsied

Hailing from a family below the poverty line, Surojit is deprived of all the facilities required to fulfill his daily needs as a quadriplegic cerebral palsied child. Let us give some facilities to him.


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.