Application for Medical Expenses Assistance for Migrant Infants and Toddlers

1. Basic Information

Applicant	□ Migrant Child's Guardian
	□ Support Organization (organization that can communicate with the beneficiary and his/her guardian and manage the case)
Guardian's Information	Relation	Name		Nationality/ Visa status	Birthdate (yy.mm.dd)	Contact No.		Date of Entry to Korea
Organization's Information	Name of Organization		Officer In-charge / Position		Contact No.		E-mail Address

Child (0~7 years old)	Name	Gender	Nationality/ Visa status	Birthdate (yy.mm.dd)	Place of Birth	Date of Entry to Korea
		□ M □ F		( years old)
	Address

Economic Status	Average Monthly Income	□ Earned income ( won) □ Sponsored benefits ( won)
	Housing Status	□ Own house □ Jeonse □ Wolse □ Public housing □ Others ( ) □ Deposit ( won) □ Monthly rent ( won)
	Others	※ Fill in with additional information (such as housing and economic situation) if needed.

2. Health Information

Medical Facility	Name of Medical Facility		Department
	Address		Contact No.
	Treatment Period	yy mm dd ~ mm dd
	Total Medical Expenses	won
	Amount Paid	won

Application Details		Diagnosis
		Items Needed ※Check all that apply	□ Inpatient Surgery □ Medical Examination Expenses □ Outpatient Treatment □ Rehabilitation □ Others ( )
		Amount Needed	won ※ Maximun 3 million won
		Support from other organizations	Organization	Type of Support		Date		Amount
Reason for Application and/or Recommendation		1. Medical situation (current health status of the child, treatment progress, disability and inconvenience, future treatment plan, etc.) 2. Family and economic situation (child care and family situation, economic situation, etc.) 3. Need for support
Applying for Medical Expenses Assistance for Migrant Infants and Toddlers as above. 2024 mm dd
Applicant(□Father □Mother) :							(Signature)
Organization :							(Seal)
Attached Documents	Common				Additional documents for organization
	☐ Child and Parents' IDs (photocopy of passport or alien registration card)				☐ Statement of Facts (Attachment 1)
	☐ Child's birth certificate
	☐ Medical certificate or medical facility's referral
					☐ Organization's Business Registration Certificate/ID Number Certificate
	☐ 1 original receipt from medical facility
	☐ Personal Information Consent (Attachment 2)

※ Attachment 1. Statement of Facts

Statement of Facts

Child (0~7 years old)	Name	Gender	Nationality/ Visa status	Birthdate (yy.mm.dd)	Place of Birth	Date of Entry to Korea
		□ M □ F		( years old)
	Address

Guardian	Relation	Name	Nationaliy/ Visa status	Birthdate (yy.mm.dd)	Contact No.	Date of Entry to Korea

Child's □ father □ mother confirms economic situation as below.

1. Earned income (more than 3 months prior to the date of application)

Example)

1) Jan. 2024 Part-time job at construction site(OO won per day, OO hours per day) - 2,000,000 won

2. Others

Example)

1) Money borrowed from friends to pay for child's hospital bills - 5 million won > being repaid little by little

2) Sponsorship - None

3) Fixed expenses - 350,000 won per month for monthly rent, 200,000 won per month for baby formula, 500,000 won for child care for older children, remittances to home countries, etc.

2024     mm    dd

Name of Organization :

Officer In-charge :                           (Signature)

※ Attachment 2. Personal Information Consent

Collection • Use of Personal Information Consent

▪ Collection and Processing of Personal Information

Solidarity with Migrants places great importance on the protection of your personal information and complies with the 『Personal Information Protection Act』. We inform you of the purpose and method of using the personal information you provide and what measures are being taken to protect your personal information.

▪ Collection of Personal Information

In compliance with the Personal Information Protection Act, only personal information necessary for the provision of medical expenses assistance is collected.

▪ Items of personal information to be processed

[Collected Items] : case mentioned above

▪ Purpose of processing personal information

Personal information is collected for the following purposes. All information provided by the user will not be used for any purpose other than the following description, and prior consent will be sought if the purpose of use is changed.

[Purpose of Collection]: provision of medical expenses assistance, securing contact information and providing information for project execution

▪ Period of retention and use of personal information: 5 years

Consent to Provision of Personal Information

I consent.  □                     I do not consent.     □

Applicant's Name                        (Signature)

Guardian's Name                        (Signature)