Firm application for a hiporehabilitation stay

Date of hiporehabilitation stay

Date:

First name and last name:

Phone:

E-mail:

First name and last name:

Date of birth:

Diagnosis:

Sleep time of the child:

Previous hiporehabilitation experience:

Siblings who you would like to join the HR program: yes no

Sibling's age:

Number of adults:

Number of children with food and bed:

Number of children without food and bed:

Room number(s):

Room category:

Special diet and number:

Space for your notes