PLANÈTE KART-O-MANIA CAMP DE JOUR

Feuille d’inscriptions

Information sur Parent ou Gardien : Planete Kart-O-Mania
Information on Parent or legal gardien : 8255, Boul St-Michel

Montreal, Quebec H1Z 3^E4                       

Nom/Name : _______________________________________________________________________. 

Prenom/First name :_________________________________________________________________. 

Statut/Status {pere,mere-father,mother}:_________________________________________________. 

Adresse/Address:____________________________________________________________________. 

Ville/City:_______________________________.                Prov/State:_____________________________. 

Pays/Country:____________________________.                Code Postal/Postal code:__________________. 

Telephone #:           Maison/Home {      }_________________________________________________.                                 

                                Travail/Work {      }__________________________________________________. 

                                Telecopieur/Fax {      }________________________________________________. 

Courier electronique/E mail: __________________________________________________________. 

Occupation :_______________________________________________________________________. 

Information sur enfant :

Childs informations : 

Nom/Name :______________________________________________________________________. 

Prenom/First Name :_______________________________________________________________. 

Age:_________________________________.      Birthday: A/Y_______.M_______.J/D________. 

Niveau scolaire/School grade _____________.       Ecole/School :___________________________. 

Langue parle/spoken language :_____________.   Sex : M/F :______________________________. 

Medicare (Assurance Maladie) :_____________.  

Basee sur l’age de votre enfant sur la premiere journee du camp indiquez le groupe d’age qu’il ou elle fera part. 

Based on your childs age on the first day of camp indicate which age group he or she will be part of.