Health and Medical Support Program - HRH PRINCESS BELLE RACHEL FOUNDATION

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Health and Medical Support Program

A program Offered by HRH PRINCESS BELLE RACHEL FOUNDATION

Eligibility Criteria

To ensure fair and transparent selection, applicants must meet the following criteria:

Low-income individuals or families unable to afford medical treatment
Patients diagnosed with conditions requiring urgent intervention or continuous care
Valid identification and medical documents from a recognized health center or hospital

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Health and Medical Support Program

If the applicant is younger than 18, after filling out the application form, the legal guardian shall contact us additionally via email.

Application Form

Gender *

First Name *

Last Name *

Date of Birth

Phone number

National ID / Passport Number

Email Address *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Marital Status *

Single
Married
Widowed
Divorced

Number of Dependents *

Occupation / Source of Income

Monthly Income (in local currency)

Other Household Income (if any)

Do you currently receive any government or NGO assistance? *

Yes
No

If yes, please specify

Type of Medical Support Requested *

Medical Consultation
Surgery / Procedure
Medication Assistance
Diagnostic Tests (e.g., X-ray, Lab tests)

Describe Your Medical Condition or Health Concern *

Name of Hospital / Clinic / Doctor (if known)

Estimated Cost of Treatment (if known)

Have you received medical assistance from our foundation before?

Yes
No

If yes, when?

Medical report or doctor’s recommendation *

Drop your file here or click here to upload You can upload up to 1 files.

Medical report or doctor’s recommendation

Drop your file here or click here to upload You can upload up to 1 files.

Treatment estimate or quotation

Drop your file here or click here to upload You can upload up to 1 files.

CV / Resume *

Drop your file here or click here to upload You can upload up to 1 files.

Proof of income / financial statement

Drop your file here or click here to upload You can upload up to 1 files.

Identification document (ID card, passport, etc.)

Drop your file here or click here to upload You can upload up to 1 files.

Attachments (tick what you’re submitting)

CV / Resume of applicant/lead
Academic transcript / report card
Proof of enrollment or admission letter
Recommendation letter(s)
Proof of income / financial statement
Identification document (ID card, passport, etc.)

Other

How, where, or from whom did you hear about our foundation?

Date

Applicant’s Signature (Full name) *

Declaration *

I hereby declare that the information provided above is accurate and complete. I understand that providing false or misleading information may result in disqualification. I give permission to HRH Princess Belle Rachel Foundation to collect and store the submitted data and to verify the information provided. I consent to the processing of my personal data for application and coordination purposes. I agree to abide by the HRH Princess Belle Rachel Foundation’s policies, values, and code of conduct.

Name

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