Aid Request Form

(If you have trouble filling in the form on line, download a form: click here).

ABOUT THE PERSON WHO NEEDS OUR HELP:

(official) Name of the person that needs help

Age of the person that needs help

Gender/Sexual orientation of the person that needs help

Phone number of the person that needs help

Address of the person that needs help

Current job of the person that needs help

Job history of the person that needs help

Education history of the person that needs help

HEALTH & LIVING CONDITION

Living condition (family, partner, living place?)

What are the urgent problems?

ABOUT THE AID

What kind of help does the person need?

Specify the amount of money you think is needed

Please send us HIV test result and/or photo of ARV*

Please send us a photo of the ID of the person who needs help*

ABOUT THE VOLUNTEER OF BC FOCAL POINT:

Name of BC focal point / volunteer

Phone number of BC focal point / volunteer (required)

Email address of BC focal point / volunteer (required)

Anything more we need to know?

* Attached documents to prove recipient ID and HIV status (this is for documentation only)

Please send with this form:

* Documents to prove recipient ID and HIV status (this is for documentation only)