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Inscriptions 2022-2023 Groupe Gym adulte
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NOM
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Your answer
Prénom
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Your answer
DATE DE NAISSANCE
*
MM
/
DD
/
YYYY
NUMERO AVS
*
Your answer
NATIONALITE
*
Your answer
ADRESSE POSTALE
Numéro + Rue
*
Your answer
NPA + Ville
*
Your answer
COORDONNEES
TELEPHONE 1
*
Your answer
MAIL 1
*
Your answer
Profession
INFORMATIONS SANTE
Allergies, diabéte, informations importantes pour les entraîneurs
informations particulières
*
Your answer
Nom et numéro assurance complémentaire
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SIGNATURE
En cochant cette case ci dessous, je certifie l'exactitude des données ci dessus
SIGNATURE
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Je signe
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