Registration English / Aanmelden

Registration form English

I have read and agree to the terms and conditions (these can be found at the bottom of the website) *

Yes
No

Do you declare that both parents consent to this registration and the treatment by the occupational therapist? *

Yes
No

Name of parent/caregiver *

E-mail address parent/caregiver *

Parent/caregiver phone number *

Child's first and last name *

Child's date of birth *

Address and house number *

Postal code *

Place of residence *

Insured with *

General practitioner's name *

Name of school *

Group *

Help request for (occupational) therapy *

Other comments

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