inscription – Fondation Merso

Preferred days

Preferred start date

Disability or physical limitations

Psychological / cognitive needs

Memory difficulties Diagnosed dementia Confusion / disorientation Anxiety Depression Other

Regular medical follow-up

Yes No

Current treatments

Allergies

Special diet

Special needs

Personality / behavior to be aware of

Do you authorize the center to arrange transport if necessary?

Yes No

Photos taken for internal activities

Yes No

I authorize the center to contact medical services if necessary *

Registration at the Center