Call request form Dutch Caribbean

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This form is for residents of Bonaire, Sint Eustatius and Saba. By filling out this form, you are requesting a staff member from the Unplanned Pregnancy Information Centre to call you. Our staff members speak English and Dutch.

Fiom needs your personal data to deliver its services. We use your data only for the purposes for which you provided it, and it will be deleted once the service provision has ended.

I have read and understood the Privacystatement and give Fiom permission to process my personal data.

I hereby declare that I understand that this service is intended for people dealing with an unintended pregnancy and needing support. Incorrect use, such as entering someone else's phone number, can be harmful. Misuse will not be tolerated and may result in further action.

Information about the processing of your personal data
We use your data to respond to your enquiry, after which it will be deleted. Your personal data will not be shared with third parties.

Why is this data requested?
With your consent, we use your data because otherwise we would not be able to respond to your enquiry.

How long do we retain your data?
Once we have answered your enquiry, your data will be removed from our systems.

Personal data

First name

You don't have to enter your official name.

Surname

You don't have to enter your official name.

Indicate which day you want to be called:

Monday

Tuesday

Wednesday

Thursday

Friday

Due to the time difference between the Dutch Caribbean and the Netherlands, we will call you in the morning. We will do this on the next workday chosen by you. Please note, we will call anonymous (without caller id).

Phone number

We will use your email only to confirm your form is well received.

Call request form Dutch Caribbean

Personal data

Ik heb direct hulp nodig