Full Name(*) Your email (*) Phone (*) Arrival Day (*) Departure Date (*) Wich activitie or lodging are you interested?(*)
BY OTHER SIDE TO ENSURE OVERALL SAFETY YOU MUST BRING YOUR DOCTOR`S AUTHORIZATION STATING THAT YOU MAY PARTICIPATE IN THE FOLLOWING ACTIVITIES:
PPlease complete the following form:
Age Diagnostics (Specify dates, How long have you been in your actual situation) Profession/ ocupation Have you ever done any physical activities or sport? YES/NO Which ones? Use technical aids? (like wheel chair, walkes *specify type*, Brace orthopedic devices *specify type*) Cheek if you are dependent or independent in activities like:-DRESSING -BATHING/TAKING A SHOWER -EATING -SPHINCTER CONTROL -TRANSFER (bed-chair/ chair-car/ ascending-descending stairs) Check previous medical conditions (like hypertension, diabetes, surgery, others) Specify Taking any medication? Allergies? Skin lessions? Where? Comments or extra specifications
(*) Mandatory
