Nez-Care

First name (as stated on passport/ID)

Call sign

Surname (as stated on passport/ID)

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Correspondence address (if different from residential address)

Relationship to applicant

If the applicant does not submit this application, name of contact person

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E-mail

Emergency contact person

Personal information We ask you to answer the questions below truthfully. We will treat this information confidentially. I have previously used the services of Nez-Care

And

Nee

Gender

Man

Woman

My weight

The nature of your situation: Senior / physical disability, namely:

What care do you need during your holiday?

Please provide a clear description of your care needs. If you have a care plan, please upload it here.

What tools do you need for this?

Otherwise, namely:

Can you stand independently (possibly with an aid or supported by 1 or 2 people)

Can you walk at least 10 meters? (possibly with an aid or supported by 1 or 2 people)

I use a wheelchair

My wheelchair is foldable

Consent to use of images: I give permission to share photos in which I appear via the Social Media Channels and the website of Nez Care SARL.

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Option 1

Nez-Care 2025 Registration Form

Nez-Care 2025 Registration Form

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