Apply for Assistance

Thank you for contacting The Little Fighters Charitable Trust. It is our mission to provide support to children (or parents of children/young people) that have been diagnosed with a life threatening illness. Taking a few moments to complete this form will help us assess how best to provide support.

Please fill in your details below or alternatively you can download a PDF version on the form here. Once completed, please return this completed PDF form to: info@littlefighterstrust.co.nz

Assistance Application

First name

Last name

Ethnicity

Relationship to paitent

Home phone

Cell phone

Email

Address

First name

Last name

Age

Ethnicity

If yes, please specify

Diagnosis

Medical diagnosis paperwork attahced

General patient / family background

If yes, please specify

Type of fundraising

Amount raised to date

Donations in kind

Total target fundraising amount

If yes, please specify

If other, please specify:

I confirm this application to be true and correct:

Name

Date

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