2026 Infants and Toddlers Health Rights Support Project Application Form

2026 영유아 건강권 지원사업_신청서(영문)

1. Basic Information

Applicant		□ Migrant Child's Guardian □ Support Organization (organization that can communicate with the applicant and his/her guardian and manage the case)
Child's Name				Gender		□ Male □ Female
Birthdate				Nationality/Visa Status
Address				Report of Birth		□ Completed □ Not Completed
Guardian's Information	Name/Visa Status	※ If you do not have a visa, please write 'Undocumented' (Father) / (Mother) /		Guardian's Contact No.		(Father) (Mother)
	Nationality	(Father) (Mother)		Date of Entry to Korea		(Father) (Mother)
Name of Organization				Name of Person-in-charge/ Position
Organization's Contact No.				Organization's E-mail Address
Economic Situation		Average Monthly Income	□ Wages ( won) □ Donations ( won)
		Housing Status	□ Own house □ Jeonse □ Wolse □ Public housing □ Other : □ Deposit ( won) □ Monthly rent ( won)
		Family Members	※ Example) Family of 7/ Raising 4 infants and toddlers. Partial support for grandparents' child rearing expenses
		Debt Status	※ Please write down your debt (unpaid utility bills, personal debt, etc.) or if you need to provide additional information. Example) Bankbook Balance 200,000won
		Child's Health Insurance Status	□ Subscribed		Monthly Premium	won
			□ Suspended (※ Brief description of reason for suspension)
			□ Not Subscribed (※ Brief description for non-subscription)
		Other	□ Single- parent family □ Illness·Disability of Family Member/s □ Head of Household is a Minor □ Multiple children (2 or more children)

Medical Facility	Name of Medical Facility			Department
	Treatment Period
	Diagnosis	Disease : Injury :
	Other	□ Rare and Incurable Disease - Disease's Name : □ Disability - Type of Disability : - Disability Diagnosis Name:
	Items for Application ※ Check all that apply	□ Inpatient Surgery □ Medical Examination Expenses □ Outpatient Treatment □ Rehabilitation Treatment □ Others :
	Medical Expenses	Total Amount Medical Expenses	won
		Total Amount Paid	won
		Amount Applied For ※ Maximum 3 million won	won
	Source of Other Support
	Support Date/Support Amount
Reason for Application and/or Recommendation	1. Medical Status (current health status of the child, treatment progress, disability and discomfort, future treatment plans, etc.) 2. Family and Economic Situation (child care and family situation, economic situation, etc.) 3. Need for Support
I hereby apply for the migrant infant and toddler medical support as above. Year 2026 Month Day
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
	☐ Child's birth certificate
	☐ Medical opinion statement or diagnosis certificate				☐ Organization's Business Registration Certificate / ID Number Certificate
	☐ Original receipt from medical facility
	☐ Personal Information Collection, Use and 3rd Party Provision Consent Form

2. Health Information

2026 영유아 건강권 지원사업 신청서