Name
First name
Street
PLC
City
Date of birth
Telephone
E-Mail
Are you able to handle daily tasks independently without any assistance? YesNo
If No, please provide explanation:
Have you ever committed a criminal offense? NoYes
Parents/legal representative
Guardianship NoYes
Name and telephone number of the guardian:
Training center/employer
Vocational training (exact name of the apprenticeship/school)
Billing information
First Name
Are you receiving benefits from the Invalidity Insurance (IV)? NoYes
Name and telephone number of the IV office:
Are you/parent/legal guardian receiving benefits from the Social Service (Social Welfare) (Billing)? NoYes
Name and telephone number of the social service:
Residence
Admission date
Resident until about
Room
Double roomSingle room
If possible: together with
Food
Full boardHalf board
How did you learn about the casa?
acquaintanceInternetvocational teacherFiutscher vocational training fair
Comment
