Participation Form

Personal Information

First Name Last Name Date of Birth Email Address Telephone Number Emergency Contact (Full Name and Phone)

Medical Information

Do you have food or beverage allergies or intolerances?

No Yes

Do you have textile or chemical allergies or intolerances?

No Yes

Do you have any important health issues or medical conditions?

No Yes

Do you have any medical equipment?

No Yes

I confirm that I have provided all relevant information concerning my state of health. I authorize The Third House, a non-profit organization, to use this data only in cases of medical necessity or security, in accordance with the GDPR.

Règlement extérieur de l'ASBL The Third House

I confirm that I have read and understood this document

CHARTE de l'ASBL The Third House

I confirm that I have read and understood this document

Thank You!

Participation Form

Personal Information

Medical Information

Règlement extérieur de l'ASBL The Third House

CHARTE de l'ASBL The Third House