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