Register for a Website

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ELIGIBILITY TO REGISTER
Applicants must complete the online form below.
Applicants must have a medical crisis, sickness or disability.
Applicants must attach a referral letter from a medical professional or a supporting organisation, or arrange for the letter to be sent to alleviate.charity@gmail.com
Applicants must agree to the terms and conditions as provided below.

Please complete the form below to apply for a website.

Application Form
* indicates required field

First Name:*

Last Name:*

Email:*

Re-enter Email:*

Address (Street, City, Postcode):*

Please give a brief description of the health crisis:*

Please attach a referral letter from your doctor or supporting organisation:

Acceptable file types: doc,docx,pdf,txt,gif,jpg,jpeg,png.
Maximum file size: 1mb.

Phone Contacts:*

Please feel welcome to ask any questions:

By checking the boxes below, I agree to the terms and conditions of receiving the free website service.*

I agree to inform Alleviate when the website is no longer required, so that the service can be terminated.
I agree to Alleviate contacting me regularly about the website service.

Would you like us to set up a Go Fund Me account for you?

Yes
No

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