1. Full name (in English)*
2. Date of birth (MM/DD/YYYY)*
3. Current location*
4. Phone number*
Preferred way to contact you? (Check your Telegram settings, as many have restricted incoming messages from unknown contacts)
TelegramWhatsAppOther
5. Email*
6. Date of last surgery (MM/DD/YYYY)*
7. Level of amputation*
RIGHT LEG/BELOW KNEERIGHT LEG/ABOVE KNEELEFT LEG/BELOW KNEELEFT LEG/ABOVE KNEERIGHT ARM/BELOW ELBOWRIGHT ARM/ABOVE ELBOWLEFT ARM/BELOW ELBOWLEFT ARM/ABOVE ELBOWOther
8. Do you have a U.S. visa?*
YesNoAlready in the U.S.
9. Do you have a foreign passport?*
YesNo
10. Are you a member of the Ukrainian Armed Forces?*
11. Do you have any chronic diseases?
12. Tell us your story
By completing and submitting this application on www.kinddeeds.org, I voluntarily consent to the processing of my personal data specified in the application. I also consent to the sharing (provision, transfer) of my personal data with third parties for the purpose of organizing charitable assistance. This application is only a preliminary request and does not guarantee prosthetic treatment.*
