{"id":510,"date":"2017-01-16T07:30:55","date_gmt":"2017-01-16T06:30:55","guid":{"rendered":"https:\/\/www.sitemariahuis.be\/?page_id=510"},"modified":"2022-08-16T11:04:22","modified_gmt":"2022-08-16T09:04:22","slug":"aanvraag-opname","status":"publish","type":"page","link":"https:\/\/www.sitemariahuis.be\/index.php\/aanvraag-opname\/","title":{"rendered":"Aanvraag tot opname in Woonzorgcentrum en Kortverblijf"},"content":{"rendered":"<form action=\"mailto:socialedienst@sitemariahuis.be\" enctype=\"text\/plain\" method=\"post\">\nAanvraagdatum<br \/>\n<input maxlength=\"30\" name=\"Aanvraagdatum\" size=\"30\" type=\"text\"><br \/>\n[ezcol_1half]Naam<br \/>\n<input maxlength=\"30\" name=\"Familienaam\" size=\"80\" type=\"text\">[\/ezcol_1half] [ezcol_1half_end]Voornaam \/ <i>(Voornamen)<\/i><br \/>\n<input maxlength=\"30\" name=\"Voornaam\" size=\"80\" type=\"text\">[\/ezcol_1half_end]<\/p>\n<hr style=\"width: 100%; height: 2px; color: #336699; background-color: #336699; border: solid #336699 0px;\">\n<p>[ezcol_1quarter]Straat<br \/>\n<input maxlength=\"30\" name=\"Straat\" size=\"60\" type=\"text\">[\/ezcol_1quarter] [ezcol_1quarter]Huisnummer<br \/>\n<input maxlength=\"30\" name=\"Huisnummer\" size=\"10\" type=\"text\">[\/ezcol_1quarter] [ezcol_1quarter]Postnummer<br \/>\n<input maxlength=\"30\" name=\"Postnummer\" size=\"20\" type=\"text\">[\/ezcol_1quarter] [ezcol_1quarter_end]Gemeente<br \/>\n<input maxlength=\"30\" name=\"Gemeente\" size=\"60\" type=\"text\">[\/ezcol_1quarter_end]<br \/>\n[ezcol_1quarter]Telefoonnummer<br \/>\n<input maxlength=\"30\" name=\"Telefoonnummer\" size=\"60\" type=\"text\">[\/ezcol_1quarter] [ezcol_1quarter]GSM nummer<br \/>\n<input maxlength=\"30\" name=\"GSM nummer\" size=\"60\" type=\"text\">[\/ezcol_1quarter] [ezcol_1half_end]E-mail adres<br \/>\n<input maxlength=\"30\" name=\"E-mail adres\" size=\"80\" type=\"text\">[\/ezcol_1half_end]<\/p>\n<hr style=\"width: 100%; height: 2px; color: #336699; background-color: #336699; border: solid #336699 0px;\">\n<p>[ezcol_1quarter]Geslacht<br \/>\n<input checked=\"checked\" name=\"Geslacht\" type=\"radio\" value=\"Man\">Man<br \/>\n<input name=\"Geslacht\" type=\"radio\" value=\"Vrouw\">Vrouw<br \/>\n[\/ezcol_1quarter] [ezcol_1quarter]Geboorteland<br \/>\n<input maxlength=\"30\" name=\"Geboorteland\" size=\"60\" type=\"text\">[\/ezcol_1quarter] [ezcol_1quarter]Geboortedatum<br \/>\n<input maxlength=\"30\" name=\"Geboortedatum\" size=\"60\" type=\"text\">[\/ezcol_1quarter] [ezcol_1quarter_end]Geboorteplaats<br \/>\n<input maxlength=\"30\" name=\"Geboorteplaats\" size=\"60\" type=\"text\">[\/ezcol_1quarter_end]<br \/>\n[ezcol_1fifth]Mutualiteit<br \/>\n<input maxlength=\"30\" name=\"Mutumaliteit\" size=\"40\" type=\"text\">[\/ezcol_1fifth] [ezcol_1fifth]Code<br \/>\n<input maxlength=\"30\" name=\"Code\" size=\"40\" type=\"text\">[\/ezcol_1fifth] [ezcol_1fifth]Lidnummer<br \/>\n<input maxlength=\"30\" name=\"Lidnummer\" size=\"40\" type=\"text\">[\/ezcol_1fifth] [ezcol_2fifth_end]Adres<br \/>\n<input maxlength=\"30\" name=\"Adres\" size=\"80\" type=\"text\">[\/ezcol_2fifth_end]<\/p>\n<hr style=\"width: 100%; height: 2px; color: #336699; background-color: #336699; border: solid #336699 0px;\">\n<p>Huisarts<br \/>\n<input maxlength=\"30\" name=\"Huisarts\" size=\"80\" type=\"text\"><br \/>\n[ezcol_1quarter]Straat<br \/>\n<input maxlength=\"30\" name=\"Straat\" size=\"60\" type=\"text\">[\/ezcol_1quarter] [ezcol_1quarter]Huisnummer<br \/>\n<input maxlength=\"30\" name=\"Huisnummer\" size=\"10\" type=\"text\">[\/ezcol_1quarter] [ezcol_1quarter]Postnummer<br \/>\n<input maxlength=\"30\" name=\"Postnummer\" size=\"20\" type=\"text\">[\/ezcol_1quarter] [ezcol_1quarter_end]Gemeente<br \/>\n<input maxlength=\"30\" name=\"Gemeente\" size=\"60\" type=\"text\">[\/ezcol_1quarter_end]<br \/>\n[ezcol_1quarter]Telefoonnummer<br \/>\n<input maxlength=\"30\" name=\"Telefoonnummer\" size=\"60\" type=\"text\">[\/ezcol_1quarter] [ezcol_1quarter]GSM nummer<br \/>\n<input maxlength=\"30\" name=\"GSM nummer\" size=\"60\" type=\"text\">[\/ezcol_1quarter] [ezcol_1half_end]E-mail adres<br \/>\n<input maxlength=\"30\" name=\"E-mail adres\" size=\"80\" type=\"text\">[\/ezcol_1half_end]<\/p>\n<hr style=\"width: 100%; height: 2px; color: #336699; background-color: #336699; border: solid #336699 0px;\">\n<p>1ste contactpersoon<br \/>\n<input maxlength=\"30\" name=\"1ste contactpersoon\" size=\"80\" type=\"text\"><br \/>\n[ezcol_1quarter]Straat<br \/>\n<input maxlength=\"30\" name=\"Straat\" size=\"60\" type=\"text\">[\/ezcol_1quarter] [ezcol_1quarter]Huisnummer<br \/>\n<input maxlength=\"30\" name=\"Huisnummer\" size=\"10\" type=\"text\">[\/ezcol_1quarter] [ezcol_1quarter]Postnummer<br \/>\n<input maxlength=\"30\" name=\"Postnummer\" size=\"20\" type=\"text\">[\/ezcol_1quarter] [ezcol_1quarter_end]Gemeente<br \/>\n<input maxlength=\"30\" name=\"Gemeente\" size=\"60\" type=\"text\">[\/ezcol_1quarter_end]<br \/>\n[ezcol_1quarter]Telefoonnummer<br \/>\n<input maxlength=\"30\" name=\"Telefoonnummer\" size=\"60\" type=\"text\">[\/ezcol_1quarter] [ezcol_1quarter]GSM nummer<br \/>\n<input maxlength=\"30\" name=\"GSM nummer\" size=\"60\" type=\"text\">[\/ezcol_1quarter] [ezcol_1half_end]Verwantschap<br \/>\n<input maxlength=\"30\" name=\"Verwantschap\" size=\"80\" type=\"text\">[\/ezcol_1half_end]<\/p>\n<hr style=\"width: 100%; height: 2px; color: #336699; background-color: #336699; border: solid #336699 0px;\">\n<p>2de contactpersoon<br \/>\n<input maxlength=\"30\" name=\"2de contactpersoon\" size=\"80\" type=\"text\"><br \/>\n[ezcol_1quarter]Straat<br \/>\n<input maxlength=\"30\" name=\"Straat\" size=\"60\" type=\"text\">[\/ezcol_1quarter] [ezcol_1quarter]Huisnummer<br \/>\n<input maxlength=\"30\" name=\"Huisnummer\" size=\"10\" type=\"text\">[\/ezcol_1quarter] [ezcol_1quarter]Postnummer<br \/>\n<input maxlength=\"30\" name=\"Postnummer\" size=\"20\" type=\"text\">[\/ezcol_1quarter] [ezcol_1quarter_end]Gemeente<br \/>\n<input maxlength=\"30\" name=\"Gemeente\" size=\"60\" type=\"text\">[\/ezcol_1quarter_end]<br \/>\n[ezcol_1quarter]Telefoonnummer<br \/>\n<input maxlength=\"30\" name=\"Telefoonnummer\" size=\"60\" type=\"text\">[\/ezcol_1quarter] [ezcol_1quarter]GSM nummer<br \/>\n<input maxlength=\"30\" name=\"GSM nummer\" size=\"60\" type=\"text\">[\/ezcol_1quarter] [ezcol_1half_end]Verwantschap<br \/>\n<input maxlength=\"30\" name=\"Verwantschap\" size=\"80\" type=\"text\">[\/ezcol_1half_end]<\/p>\n<hr style=\"width: 100%; height: 2px; color: #336699; background-color: #336699; border: solid #336699 0px;\">\n<p>[ezcol_1fifth]<\/p>\n<p style=\"text-align: right;\">Plaatsing<\/p>\n<p>[\/ezcol_1fifth] [ezcol_1fifth]<input name=\"Plaatsing\" type=\"checkbox\" value=\"Hoogdringend\">Hoogdringend[\/ezcol_1fifth] [ezcol_1fifth]<input name=\"Plaatsing\" type=\"checkbox\" value=\"Semi dringend\">Semi dringend[\/ezcol_1fifth] [ezcol_1fifth]<input name=\"Plaatsing\" type=\"checkbox\" value=\"Preventief\">Preventief[\/ezcol_1fifth] [ezcol_1fifth_end][\/ezcol_1fifth_end][ezcol_1fifth]<\/p>\n<p style=\"text-align: right;\">Huidig verblijf[\/ezcol_1fifth] [ezcol_1fifth]<input name=\"Huidig verblijf\" type=\"checkbox\" value=\"Thuis\">Thuis[\/ezcol_1fifth] [ezcol_1fifth]<input name=\"Huidig verblijf\" type=\"checkbox\" value=\"Familie\">Familie[\/ezcol_1fifth] [ezcol_1fifth]<input name=\"Huidig verblijf\" type=\"checkbox\" value=\"Ziekenhuis\">Ziekenhuis<br \/>\n<input maxlength=\"30\" name=\"Ziekenhuis\" size=\"40\" type=\"text\">[\/ezcol_1fifth] [ezcol_1fifth_end][\/ezcol_1fifth_end]<\/p>\n<p>[ezcol_1fifth]<\/p>\n<p style=\"text-align: right;\">Aanvraag<\/p>\n<p>[\/ezcol_1fifth] [ezcol_1fifth]<input name=\"Aanvraag\" type=\"checkbox\" value=\"Enkel in WZC\">Enkel in WZC[\/ezcol_1fifth] [ezcol_1fifth]<input name=\"Aanvraag\" type=\"checkbox\" value=\"Open\">Open[\/ezcol_1fifth] [ezcol_1fifth]<input name=\"Aanvraag\" type=\"checkbox\" value=\"Gesloten\">Gesloten[\/ezcol_1fifth] [ezcol_1fifth_end]<input name=\"Aanvraag\" type=\"checkbox\" value=\"KV\">KV &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; <input name=\"Aanvraag\" type=\"checkbox\" value=\"DVC\">DVC[\/ezcol_1fifth_end][ezcol_1fifth]<\/p>\n<hr style=\"width: 20%; height: 2px; color: #ffffff; background-color: #ffffff; border: solid #FFFFFF 0px;\">\n<p>[\/ezcol_1fifth] [ezcol_1fifth]<input name=\"Aanvraag\" type=\"checkbox\" value=\"Andere plaatsen: Voorkeur:\">Voorkeur:<input maxlength=\"30\" name=\"Voorkeur\" size=\"40\" type=\"text\">[\/ezcol_1fifth] [ezcol_3fifth_end]<\/p>\n<hr style=\"width: 20%; height: 2px; color: #ffffff; background-color: #ffffff; border: solid #FFFFFF 0px;\">\n<p>[\/ezcol_3fifth_end]<\/p>\n<hr style=\"width: 100%; height: 2px; color: #336699; background-color: #336699; border: solid #336699 0px;\">\n<p>Motivatie tot plaatsing &#8211; gezondheidstoestand &#8211; gezinssituatie<br \/>\n<textarea cols=\"110\" name=\"Motivatie tot plaatsing\" rows=\"4\"><\/textarea><\/p>\n<p><input type=\"reset\" value=\"Beginwaarden\"><br \/>\n<input type=\"submit\" value=\"Verzenden gegevens\"><\/p>\n<\/form>\n","protected":false},"excerpt":{"rendered":"<p>Aanvraagdatum [ezcol_1half]Naam [\/ezcol_1half] [ezcol_1half_end]Voornaam \/ (Voornamen) [\/ezcol_1half_end] [ezcol_1quarter]Straat [\/ezcol_1quarter] [ezcol_1quarter]Huisnummer [\/ezcol_1quarter] [ezcol_1quarter]Postnummer [\/ezcol_1quarter] [ezcol_1quarter_end]Gemeente [\/ezcol_1quarter_end] [ezcol_1quarter]Telefoonnummer [\/ezcol_1quarter] [ezcol_1quarter]GSM nummer [\/ezcol_1quarter] [ezcol_1half_end]E-mail adres [\/ezcol_1half_end] [ezcol_1quarter]Geslacht Man Vrouw [\/ezcol_1quarter] [ezcol_1quarter]Geboorteland [\/ezcol_1quarter] [ezcol_1quarter]Geboortedatum [\/ezcol_1quarter] [ezcol_1quarter_end]Geboorteplaats [\/ezcol_1quarter_end] [ezcol_1fifth]Mutualiteit [\/ezcol_1fifth] [ezcol_1fifth]Code [\/ezcol_1fifth] [ezcol_1fifth]Lidnummer [\/ezcol_1fifth] [ezcol_2fifth_end]Adres [\/ezcol_2fifth_end] Huisarts [ezcol_1quarter]Straat [\/ezcol_1quarter] [ezcol_1quarter]Huisnummer [\/ezcol_1quarter] [ezcol_1quarter]Postnummer [\/ezcol_1quarter] [ezcol_1quarter_end]Gemeente [\/ezcol_1quarter_end]\u2026<\/p>\n<p class=\"continue-reading-button\"> <a class=\"continue-reading-link\" href=\"https:\/\/www.sitemariahuis.be\/index.php\/aanvraag-opname\/\">Lees meer&#8230;<i class=\"crycon-right-dir\"><\/i><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-510","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.sitemariahuis.be\/index.php\/wp-json\/wp\/v2\/pages\/510","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.sitemariahuis.be\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.sitemariahuis.be\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.sitemariahuis.be\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.sitemariahuis.be\/index.php\/wp-json\/wp\/v2\/comments?post=510"}],"version-history":[{"count":153,"href":"https:\/\/www.sitemariahuis.be\/index.php\/wp-json\/wp\/v2\/pages\/510\/revisions"}],"predecessor-version":[{"id":8192,"href":"https:\/\/www.sitemariahuis.be\/index.php\/wp-json\/wp\/v2\/pages\/510\/revisions\/8192"}],"wp:attachment":[{"href":"https:\/\/www.sitemariahuis.be\/index.php\/wp-json\/wp\/v2\/media?parent=510"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}