Form – New maternity unit for the hospital of Saint-Jean-de-Dieu in Boko

Please note: from 2024, filling in the National Register Number is mandatory to obtain a tax certificate.

Name *

First Name *

E-mail *

Street

Zip Code

Town

Country

National Register Number

Choose the number of times you want to contribute to realize the purchase of the product *

	for a baby scale € 25,00
	for performing 1 delivery € 50,00
	for a mother-child starter pack € 75,00
	for a contribution for an incubator (costs 1000 euros) € 150,00

Method of payment *

Total amount *

Total

€