Refer A Case – Aremolekun Care Foundation

Know a child that needs help ?

If you know of a child that is in need of reconstructive surgery, skin graft or severe malaria, typhoid, please fill in the form below.

Full Name

Full Name of the child

Relationship to the child

Gender of the child

Male Female

Age

Date of Birth

Parents/Guardian Contact Number

Referral Person's Contact Number

Contact Email Address

Home Address

Hospital Address

Medical Condition of the child

Is this a Doctor's referral ?

Yes No

How did you hear about Aremolekun Care Foundation

Photograph of the child

Do you have the permission of the parents?

Yes No