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.

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.

Fields marked with * are required

(dd/mm/yy)
City of residence
State of residence
Country of residence
Should include city, state and country where applicable.
DECLARATION