Name in
Full...................................................................................................
Date of
Birth....................................................Place.....................................
Address..........................................................................................................
...........................................................................Tel.......................................
Length of
stay:
from..........................................To.......................................
Special diet /
allergies...................................................................................
Medications
not
permitted............................................................................
Other
information..........................................................................................
I have read and understood the Institutes's
rules on the preceeding pages and agree to abide by them.
Signature.......................................................................Date...................................
