Become a dreamer
About the Golden Fish
Contacts

Application

Thank you for the trust you express in us by submitting your application. Filling out the form will take approximately 15 minutes. If you have questions or encounter problems, call us at +420 223 012 660. We will contact you no later than five working days after you submit your application.

Form

I am a child who wants to make a wish

I am a parent or a guardian

Unable to make a choice? Call us at +420 223 012 660.

Are you aged 15 years or older? If not, the application must be completed by your legal guardian.

General information about you

What is your name?*

E-mail address*

Telephone number*

Where did you learn about the Golden Fish?*

To what e-mail address do you want us to send an application receipt confirmation?*

Personal Information

Date of birth*

Sex*

Boy

Girl

Other

Diagnosis*

Your address (street, number, city)*

Temporary address

Home telephone number

Siblings

Parents / legal guardians

Fill in information for at least one parent

Father (name and surname)

Mother (name and surname)

Father's telephone number

Mother's telephone number

Father's e-mail address

Mother's e-mail address

Parents' address*

Are both parents the child's legal guardians?*

Yes

Other legal guardians (other than parents)

Is your legal guardian someone else other than your parents?*

Yes

Contact for the child's physician

Name of your doctor*

The doctor's telephone number

Hospital, clinic, or health facility where you are receiving treatment*

Name of clinic or department

Address

If I am below the age of 15 years, I certify that I submit this application form with the consent of my legal guardian.

+420 223 012 660 [email protected]

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