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["华南理工大学学生爱心基金救助申请表"]
["姓名"," ",null,"性别",null,"出生年月",null,"学历","□本科生 □研究生"]
["学院",null,null,"学号",null,null,"班级"]
["所患疾病",null,null,"首次确诊时间",{"$nulls":3},"联系电话"]
["票据总额（元）",null,null,"医保报销金额",{"$nulls":3},"申请年度"]
["之前的申请记录",null,null,"申请年度：                           资助金额："]
["家庭详细地址"]
["家庭基本信息",null,"家庭成员",null,"与本人关系",null,"工作单位",null,"联系方式"]
[]
[]
[]
["申请理由"]
[]
[]
[]
["本人承诺以上所述情况属实，如有虚假，后果自负。"]
["学生本人签名：                                              日期："]
["学院意见：\n\n\n\n\n签章：                                                      日期："]
["学生工作部（处）意见：\n\n\n\n\n签章：                                                      日期："]
["爱心基金管理小组意见：\n\n\n\n\n\n\n成员签名：                                                  日期："]

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