Partnership – Sponsor’s Form

Road to Recovery is committed in meeting the healthcare needs of patients and community based rehabilitation. We appreciate your commitment and let's walk together to bring life changing care to everyone who needs it.

This application form is to be completed by sponsors who are interested in partnering with Road to Recovery Rehabilitation Clinic. Be assured that your personal information is respected and not shared externally.

Furthermore, it will not be used for any purpose other than for which your consent has been given. The information submitted on this form will be treated by the organization as strictly private and confidential.

Fields marked with * are required

Title

First Name *

Last Name *

Date of birth *

(dd/mm/yy)

Phone Number *

Your Email *

Address *

City *

City of residence

State *

State of residence

Country *

Country of residence

Occupation *

Sector of Activity

Brief description of business

Full Name of Next of Kin

Next of Kin Email

Next of Kin Phone number

Next of Kin Address

Should include city, state and country where applicable.

I hereby certify that the foregoing particulars are correct to the best of my knowledge. *

I Accept

DECLARATION

Partnership – Sponsor’s Form

FULL AND ACCURATE COMPLETION OF THIS FORM WILL SPEED UP THE PROJECT APPROVAL PROCESS

Please note that the minimum number of patients for sponsorship is 200 persons.