5/8/22, 10:12 PM NGO Working for Congenital Heart Disease Children | Child Heart Foundation

 01140519163 (tel:+919667608855 ) 011-40519163

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CHF HRIDAAN™ is our financial assistance program for parents who find it difficult to
organise funds for the heart treatment of their child

Parent/ Guardian can fill the following form, upload the documents and

our team will contact you.

REGISTRATION FORM
To

The Trutees,

Child Heart Foundation,

130, Uday Park, New Delhi,

Sub: Request for Financial support.

Dear Sir / Madam,

This is to seek the medical treatment help from your trust for my child.

Name Of Child

OSEMWEGIE-ERO SAMUEL OSAROBO

D/0 or S/O

Date Of Birth

11/26/2019 

Welcome to Child Heart Foundation, if you

Sex need help simply reply to this message, we
are online and ready to help.
(https://danamojo.org/dm/child-heart-foundation)
MALE
Customer Support 51 minutes ago

Photo Of Child 2

s || 4 patientsChoose File
(https://pages.razorpay.com/pl_FCKoRejfKqoG8m/view)
are receiving IMG_2022050…310
financial assistance(2).jpg
for their cost of outstation travel to access follow up treatments || 75 Doctors from different parts of India
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5/8/22, 10:12 PM NGO Working for Congenital Heart Disease Children | Child Heart Foundation

Resident Of Address  01140519163 (tel:+919667608855 ) 011-40519163

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1, UMOSU LANE, OKUNMAGIAGIEMWE

District

UHUNMWODE

State

EDO STATE

Pin Code

234

Mobile Number

08036925942

Email

osemwegie.iredia@uniben.edu

Referred By

PROF. SADOH WILSON

Aadhar No

Please share a few details about the child (early symptoms, geographical location, Financial Position
and Number of family Members
,
STATE, NIGERIA. WE HAVE RAISED ABOUT ONE MILLION, THREE HUNDRED THOUSAND AND WE ARE A FAMILY OF
FIVE. SAMUEL HAS THREE ELDER SISTERS (INWINOSA, OSAYABAMWE AND OSARIMIEFAN)

Medical History of the family if any

Welcome to Child Heart Foundation, if you

need help simply reply to this message, we
are online and ready to help.
Due to financial constraint, I and
(https://danamojo.org/dm/child-heart-foundation) my family are unable to afford the treatment of my child. Therefore, I
request you to grant me any financial help. Please find herewith Customer Support 51 minutes ago

2
Letter from Pediatrician who referred the patient to child heart foundation (Optional)

(https://pages.razorpay.com/pl_FCKoRejfKqoG8m/view)
s || 4 patients are receiving financial assistance for their cost of outstation travel to access follow up treatments || 75 Doctors from different parts of India
https://www.childheartfoundation.com/chf-hridaan 2/5
5/8/22, 10:12 PM NGO Working for Congenital Heart Disease Children | Child Heart Foundation
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Statement form / Waiting Period Risk Form

Choose File Sam cart.pdf

Aadhaar Card / Voters Id of father

Choose File NIC.jpg

Aadhaar Card / Voters Id of Mother

Choose File No file chosen

Income and Residential Certificate signed and attested by Local MLA/ MP/ SARPANCH

Choose File No file chosen

Medical Report

Choose File sam medical report.pdf

Estimate Letter Of Doctor

Choose File Cost Estimati…, Nigeria.pdf

Informed Consent Form

Choose File No file chosen

SUBMIT

Patient Informed Consent

click to download (https://drive.google.com/file/d/1ny9kYLWb2cQEyk0QaA7xzOwaqmZbanyP/view )

Income and Residential Address Certificate

click to download (https://drive.google.com/file/d/1cElE6lGU4Kkzb0VldX2JOOIQcngPpSQI/view )

Statement Form and Waiting Period Risk form

click to download (https://drive.google.com/file/d/1EYl3IfNXjDIE4n06F3-yyFlK9UUXy01D/view?usp=sharing )

Welcome to Child Heart Foundation, if you

need help simply reply to this message, we
are online and ready to help.
(https://danamojo.org/dm/child-heart-foundation)
Customer Support 51 minutes ago

(https://pages.razorpay.com/pl_FCKoRejfKqoG8m/view)
s || 4 patients are receiving financial assistance for their cost of outstation travel to access follow up treatments || 75 Doctors from different parts of India
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5/8/22, 10:12 PM NGO Working for Congenital Heart Disease Children | Child Heart Foundation

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day, today she turn 1-year-old.
Ayantika recently underwent her Pacemaker
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 ADDRESS: 130, UDAY PARK, NEW DELHI ‒110 049 (INDIA)

 PHONE: 011-40519163 (tel:01140519163) ,    MOBILE: +91-9999142268 (tel:+919999142268).   
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Welcome to Child Heart Foundation, if you

need help simply reply to this message, we
are online and ready to help.
(https://danamojo.org/dm/child-heart-foundation)
Customer Support 51 minutes ago

(https://pages.razorpay.com/pl_FCKoRejfKqoG8m/view)
s || 4 patients are receiving financial assistance for their cost of outstation travel to access follow up treatments || 75 Doctors from different parts of India
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