Registration Form

COMITÉ JEUNESSE N.D.G.
5600, ch. Upper LachineH4A 2A7Téléphone : (514) 872-1765Fax: (514) 868-5252
Formulaire d’inscription
Registration Form
PARTICIPANT (Lettre moulée s.v.p./Please print)
Nom de Famille/Family Name
Prénom/First Name
Téléphone
----------------------------------------------------------------------------Adresse /Address
----------------------------------------------------------------------------App./Apt.
Ville/City
---------------------------------------Code Postal/Postal Code
---------------------------------------------------------------------------------------------Naiss./Birth date(a-y/m/j-d)
Âge
Sexe
------------ ------------ -----------J/D
M
A/Y
____M
---------------------------------------Expiration
____ F
-----------------
Problèmes médicaux/Medical problems
____ oui/yes
---------------- --------------------------------------No. assurance-maladie/Medicare card No.
____ non/no
------------------------------------------------------------Allergies
____ oui/yes ____ non/no
--------------------------------------------------------------------------------------------------Ecole/School
-----------------------------------
--------------------------------------------------------------------------------------------------Niveau/Grade
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Activité/Activity
Activité/Activity
Activité/Activity
----------------------------------------------------------------
PARENT/GARDIEN(NE)
-------------------------------------------------------------------
--------------------------------------------------------------
(Lettre moulée s.v.p./Please print)
Nom de famille/Family Name
Prénom/First Name
Téléphone (dom./home)
----------------------------------------------------------------------------Téléphone (trav./work)
----------------------------------------------------------------------------- ---------------------------------------Téléphone (cell.)
Paget/Pager
Ext.______________
--------------------------------------------
----------------------------------------------------------
URGENCE/EMERGENCY INFORMATION différent qu’au dessus/Different than above
----------------------------------------------------------
(Lettre moulée s.v.p./Please print)
Téléphone (dom./home)
Nom de famille/Family Name
Prénom/First Name
----------------------------------------------------------------------------Téléphone (trav./work)
----------------------------------------------------------------------------- ---------------------------------------Téléphone (cell.)
Paget/Pager
Ext.______________
--------------------------------------------
----------------------------------------------------------
----------------------------------------------------------
Réservé à l’administration/For office use only
Inscription/Registration Mode de paiement/Method of payment
Carte de membre/Membership card Comptant/Cash
____
Chèque
____
Montant payé/Amount Paid
Sous total/Sub total
Total
Reçu émis/Receipt Given
* Frais d’inscription sont non-remboursables.
*
Registration fees are non-refundable.
___________________________________________________________________
Signature
_________
_________
No. de membre/Member No.
---------------------------------------
________________________________________
Date