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CHSQ Family weekend 24 au 26 mars 2017 Registration Form Total
NAME FIRST NAME AGE (children) Telephone : Cell phone : I need transportation from Quebec City from Montreal City (The CHSQ will contact you) Please, indicate specific allergies of any individual : I have physical limitations or a young baby and I need easy access to a room. I would appreciate help with my baggage when I arrive. Registration fees Number Total Adult x $60 Child from 13 to 17 years old of age x $40 Child from 6 to 12 years old of age x $35 Child from 3 to 5 years old of age x $25 Child from 0 to 2 years old of age Friend of a child under 18 years of age with a bleeding disorder. (only one per family who meets CHSQ admission criteria) + $125 After the February 27, 2017 registration deadline A supplemental fee of $25 per family will be added + $25 Total registration fees $ ________ I have included a check to the order of the CHSQ for the amount of $ ________ I autorize the amount of $ _______________________ be debited from my credit card Visa Master Card Name on the card: ___________________________________________________________________________________ Number : ___________________________ Expiration : ______/______ Signature : _____________________________ Please, return your registration form along with your payment to the following address : Register ASAP ! There are only 180 places available. First come, first served ! Your payment confirms your registration. Deadline for registration : February 27, 2017 Société canadienne de l’hémophilie – Section Québec 2120, rue Sherbrooke Est, bureau 514, Montréal, QC H2K 1C3 : Fax : Information : Toll-free :
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