Restoring The Lost Smile

Child Beneficiary Registration

Please complete all sections carefully. All fields marked with * are required. If you're registering on behalf of a child, please provide accurate information.

Step 1 of 6: Personal Details17% Complete

Section A: Personal Details

Please provide the child's personal information as accurately as possible.

Full Name *

Email Address *

Gender *

Date of Birth *

Birth Certificate Number

Place of Birth *

County *

Sub-County *

Ward

Religion

Languages Spoken

Select or type languages the child speaks

Passport Photo

Upload a clear passport-style photo of the child (max 5MB)

Max 1 file, up to 5MB each. JPEG/PNG only.

Volunteer Endorsement

Select the volunteer who endorsed your application.

Endorsing Volunteer *

This is the volunteer from our organization who referred you to this program.

Additional Notes (Optional)

RTLSRC