€¦ · Web viewParent’s Name ans first name Mother : Father : Phone numbers Home : Cell. : Home : Cell. : Emails Complete Address CHildren’s Name (s), First name(s) Please specify

Du 6 au 11 août 2017From August 6th until 11th, 2017

Registration FormParent’s Name ans first name

Mother :      Father :     

Phone numbers Home :      Cell. :      

Home :      Cell. :      

Emails            

Complete Address

CHildren’s Name (s), First name(s) Please specify : Hémophiliac, brother, sister Age

We will use the transportation from Montreal We will use the transportation from Quebec city

We will use the transportation from (stop between Mtl and QC) : BeforeJune 1st

AfterJune 1st

Number of children with a bleeding disorder       X 90 $ X 115 $      

Number of sibling       X 140 $ X 165 $      

Total      

I have included a cheque in the amount of: $      

I autorize the debit of $       on my credit card Visa Master Card

Card holder name :      

Number :       Expiration      /       Signature : _________________________

Deadline for registration : June 1 st , 2017 Register before June 1st and receive a $25 reduction on your child’s registration.Book your transportation by bus from Montreal or Quebec.REIMBOURSEMENT - There is no reimboursement after June 15th.

Detailed information package wil be forwarded to you upon registration abd payment reception. For information : Marie-Josée Royer, Programs coordinator

Return address: Canadian Hemophilia Society – Quebec Chapter2120, Sherbrooke Street East, Office 514, Montreal (Quebec) H2K 1C3

Tel : 514 848-0666, Toll free : 1-877-870-0666, Email : [email protected], Fax : 514-904-2253