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Nr. leg.

________ Data nscrierii __________

CERERE DE NSCRIERE

Nume i prenume ( tutore reprezentant legal ) __________________________________________

Data i locul naterii ________________________________________ B.I. _____________________

Domiciliul legal ______________________________________________________________________

Domiciliul actual ____________________________________________________________________

Nume i prenume beneficiar ___________________________________________________________

Sex_____, Religie _____________, Naionalitatea_______________, Starea civil _______________

Data i locul naterii___________________________________________, Tel ___________________

Domiciliul legal______________________________________________________________________

____________________________________________________________________________________

Domiciliul actual_____________________________________________________________________

____________________________________________________________________________________

Studii___________________________________, Profesie ____________________________________

Ocupaie actual_____________________________________________________________________

Cunotine i deprinderi_______________________________________________________________

Venit brut realizat____________________________________________________________________

Copii (nume/prenume/data naterii) _____________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Diagnostic clinic_____________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Diagnostic funcional_________________________________________________________________

Boli anexe ___________________________________________________________________________

____________________________________________________________________________________

Tratament permanent________________________________________________________________
Nevoi speciale:
nsoitor ______________________________________________________________________
Asisten domiciliu____, servicii la domiciliu____, crucior____, triciclu____, motorciclu ____, proteze____,
orteze____, carje____, bastoane_____,alte dispozitive ajutatoare_______________

Motivul solicitrii:

Nevoi personale______________________________________________________________________

____________________________________________________________________________________

Implicare___________________________________________________________________________

Hobby______________________________________________________________________________

Semntura beneficiar

Concluzii___________________________________________________________________________

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Asistent social

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