Application form

for CuratioW Active Senior Home

Fill in the form below and click "Download PDF" — the document is generated on the server and downloaded to your device.

The data you enter is NOT stored on our server. It is passed only to the PDF-generating process and discarded immediately afterwards — the only remaining copy is the PDF file you download to your device.

Fields marked with an asterisk (*) are required.

1 Identification details

Residential address

Registered address (if different)

2 Caregivers (contact persons)
3 Room type and length of stay

Room type

Expected length of stay

4 Stay information

I consent to photographing and filming the resident during activities and events, and to publishing materials on the Facebook profile and website of CuratioW Active Senior Home.

The resident is under the care of a specialist clinic:

5 Pickup authorization

At least one person authorised to pick up the resident is required. You can authorise up to 10 people — provide first and last name for each.

6 Attachments

The following documents are attached:

I declare that I consent to the collection of the data above and that the information provided is accurate.

If you are sending the completed form by email, DO NOT sign the document. The signature is provided in person, in the presence of a staff member, at the time of admission.

Clicking opens the PDF save dialog.