Intake Form - Yes We Can Youth Clinics

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Thank you for considering Yes We Can Youth Clinics.

You can start the registration process by filling in the intake form below. Once we receive your application, your dedicated case manager will carefully review it and contact you within 24 hours to discuss next steps. We encourage you to check our current waiting times in advance.

If you have any questions before completing the form, you can reach us by phone Monday to Friday from 9:00 a.m. to 10:00 p.m. and on Saturday and Sunday from 10:00 a.m. to 4:00 p.m. (Central European Time) via +31 (0)85 02 01 222. Outside these hours, your call will be forwarded; please note that answering may take a little longer than usual. If we cannot pick up right away, leave a message and we will call you back as soon as possible. You can also reach us via our contact form.

For more information about the costs of our programme, please visit our investment & insurance page.

Rest assured: all your questions, registration documents, and personal information will be treated with the highest level of confidentiality and care.

Who would you like to register? *

I want to register myself I want to register someone else

Please specify

First name *

Middle name

Surname *

Telephone no. (including country code) *

Email address *

First name

Middle name

Surname

Date of birth

Gender

Male Female Other Prefer not to say

Nationality

Does dual nationality apply?

Yes
No

Second nationality

Country of residence

Address

Postcode/ZIP code

City

Please share why you would like to contact us *

First name

Middle name

Surname

Telephone no. (including country code)

Email address

Date of birth

Gender

Male Female Other Prefer not to say

Nationality

Does dual nationality apply?

Yes
No

Second nationality

Country of residence

Address

Postcode/ZIP code

City

Please share why you would like to contact us *

I consent *

By submitting this form, I consent to the processing of my personal data for the purpose of handling this registration with Yes We Can Clinics and/or the relevant insurer. My data will be processed and retained in accordance with applicable legal requirements. It will not be used for other purposes or shared with third parties without my consent. I understand that I may request access or deletion of my data at any time. For more information, please see our privacy policy..

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