Features | Vishwanadha Trust | Medical Relief
Viswanadha Foundation
Application to the Foundation
Medical Relief
1. Name in full :
2. Postal Address with pin code :
3. E-mail ID : Telephone No. with STD code : or Mobile No if any. :	*
4. Date of Birth :
5. Married or Single :
6. Staying separately or with parents :
7. Nature of illness and treatment : suggested
8. Details of treatment sought to be : provided with full address of the Hospital or the Nursing Home concerned
9. Probable period of treatment :
10. Any financial assistance provided : and / or applied for from any other source If so, details thereof :
11. Name with full address, E-mail ID : & Tel Nos. of the guardian	*
12. Details of financial assistance : sought towards charges payable to the Hospital, and for maintenance
13. Name & address of the Bank and : the SB A/c No of the applicant / guardian to which financial assistance, if sanctioned, is to be remitted	*
14. Detailed request of the guardian : for financial assistance
(Here - against column 14 - enter the request of the guardian in English if made in English, or transcribed in English if made in Telugu or any other language. The guardian may specifically state the possibility of curing the ailment through the treatment sought to be provided, the minimum financial assistance sought under different heads of expenditure, etc. The guardian may furnish a Photostat copy of the report of the Hospital indicating the expenditure on treatment, to the Foundation by post. In the event of there being some financial assistance from any other source, the fact of such assistance is to be stated specifically. If the said assistance is not sufficient, it is open to request for financial assistance to supplement the said financial assistance, payable every month and / or in lump sum. After column 14 is filled in, please delete all the matter within brackets.)
Click to file the Application