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Membership Form
Name
Address
Mobile No / Landline
Email
Age
Date of Birth
Sex
Martial Status
Date of Accident
Treatment Details
Bed/Pressure sore/ History of bed/Pressure sore
Cause of Injury
Level of Injury(Quadriplegic/Paraplegic)
Present Conditions(Activities of Daily leaving details: Dependent/Independent
Bladder/Bowel Management (Self/Assisted)
Wheelchair details

Escort Details
Below details required for Participating in Annual
Active Rehabilitation Program (Organized once in a year 1or 2 or 3 days)

Name
Sex
Relationship with wheelchair user
Contact No
Nos. of Escorts
   
How do you came to about the workshop
Accommodation
Attending the workshop
Expectation from the workshop
Remarks/Comments
 

 

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