Registration

Resident information

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

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Parents/legal representative

Name

First name

Street

PLC

City

Telephone

E-Mail

Guardianship
NoYes

Name and telephone number of the guardian:

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Training center/employer

Vocational training (exact name of the apprenticeship/school)

Name

Street

PLC

City

Telephone

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Billing information

Name

First Name

Street

PLC

City

Telephone

E-Mail

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:

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Residence

Admission date

Resident until about

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Room

Double roomSingle room

If possible: together with

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Food

Full boardHalf board

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How did you learn about the casa?

acquaintanceInternetvocational teacherFiutscher vocational training fair

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