Admission request · Pasitos de Luz

The child

First name(s)Last name(s)

Date of birthWhat does the child need? Is there a diagnosis?

Person making the request

First name(s)Last name(s)

Relationship to the child

Photo of the child (optional)

It helps us recognize the child on the day of the assessment. You can also attach a birth certificate, health card or any medical report. Only the team handling your request can see them.

Attach a photo or documentTake it with your phone, drag it here, paste it with Ctrl + V · choose a fileJPG, PNG, HEIC, GIF or PDF · up to 4.0 MB each · 3 files maximum

Phone / WhatsAppEmail (optional)

NeighborhoodMunicipality

How did you hear about us?I agree that Pasitos de Luz (Mamás Unidas por la Rehabilitación de sus Hijos A.C.) may use these details only to attend to my request, including the health information of the child, and to contact me. Please read the privacy notice.

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