New Hope - Medical Help Application Form

(Heart / Cancer / Brain / Accident / Amputation / Kidney / Coma)

Name of the Applicant :

Applicants Membership number in New Hope Project :

Applicants Date of Birth

Age

Sex
Male Female Others

Address

Pin code

Mobile No

E mail

Name of the Mission field or place you work :

Have you ever Graduated from CALS :

Yes No

If yes , Course and year

Year you joined in New Hope Project :

Have you been paying new hope annual contribution / Donation regularly :

Yes No

If “No”, from Which year you have failed to give contribution ? Year :

Name of your area coordinator of New Hope Project? :

Have you ever got any other help from New Hope Earlier ?

Yes No

If yes for which you got help from New Hope?

and year

Nature of Sickness :

Name of the Hospital where Treatment taken :

Name of the Doctor, who treats you :

Medical Expenses thus far spent Rs:

(in words)

Average income of your Church / Monthly :

List of Medical records attached :

Doctor’s Prescription

Treatment case Sheet

Copy of Medical Bills Paid

Address Proof (Attach a copy). Aadhaar / Ration card / Voter ID / any other

Declaration

I, hereby declare that the above information is true to the best of my knowledge . If there is any false claim, I agree to repay it to New Hope.

Place

Your’s Faithfully

Date

Verified and forwarded by : Mr / Mrs.

District Co-coordinator , New Hope coordinator’s Signature

For Official use only

Verified by :

Rejected or Granted by board meeting on :

If granted, Granted Amount Rs :

(in words)

Secretary

Treasurer

Signature of Director / In charge (for the Board)