JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Affiliation membre "adulte"
Le montant de la cotisation : 25 € est à payer sur le compte BE57 2600 2503 2335 de l'asbl JCHSH avec la communication : « Cotisation 20.. nom du membre ».
La cotisation couvre l’année civile : du 01-01-20.. au 31-12-20..
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Nom
*
EN MAJUSCULE SVP
Your answer
Prénom
*
EN MAJUSCULE SVP
Your answer
Sexe
*
F
M
Required
Date de naissance
*
MM
/
DD
/
YYYY
Adresse
*
Your answer
CP
*
Your answer
Localité
*
EN MAJUSCULE SVP
Your answer
GSM
*
UNIQUEMENT DES CHIFFRES
Your answer
Nationalité
*
Choose
AFG Afghanistan
ALB Albania
ALG Algeria
ASA American Samoa
AND Andorra
ANG Angola
AIA Anguilla
ANT Antigua and Barbuda
ARG Argentina
ARM Armenia
ARU Aruba
AUS Australia
AUT Austria
AZE Azerbaijan
BAH Bahamas
BRN Bahrain
BAN Bangladesh
BAR Barbados
BLR Belarus
BEL Belgium
BIZ Belize
BEN Benin
BER Bermuda
BHU Bhutan
BOL Bolivia
BIH Bosnia and Herzegovina
BOT Botswana
BRA Brazil
BRU Brunei Darussalam
BUL Bulgaria
BUR Burkina Faso
BDI Burundi
CAM Cambodia
CMR Cameroon
CAN Canada
CPV Cape Verde
CAY Cayman Islands
CAF Central African Republic
CHA Chad
CHI Chile
TPE Chinese Taipei
COL Colombia
COM Comoros
CGO Congo
COK Cook Islands
CRC Costa Rica
CIV Côte d'Ivoire
CRO Croatia
CUB Cuba
CYP Cyprus
CZE Czech Republic
PRK Democratic People's Republic of Korea
COD Democratic Republic of the Congo
TLS Democratic Republic of Timor-Leste
DEN Denmark
DJI Djibouti
DMA Dominica
DOM Dominican Republic
ECU Ecuador
EGY Egypt
ESA El Salvador
GEQ Equatorial Guinea
ERI Eritrea
EST Estonia
ETH Ethiopia
FSM Federated States of Micronesia
FIJ Fiji
FIN Finland
FRA France
PYF French Polynesia
GAB Gabon
GAM Gambia
GEO Georgia
GER Germany
GHA Ghana
GIB Gibraltar
GBR Great Britain
GRE Greece
GRN Grenada
GUM Guam
GUA Guatemala
GUI Guinea
GBS Guinea-Bissau
GUY Guyana
HAI Haiti
HON Honduras
HKG Hong Kong, China
HUN Hungary
ISL Iceland
IND India
INA Indonesia
IRQ Iraq
IRL Ireland
IRI Islamic Republic of Iran
ISR Israel
ITA Italy
JAM Jamaica
JPN Japan
JOR Jordan
KAZ Kazakhstan
KEN Kenya
KIR Kiribati
KOS Kosovo
KUW Kuwait
KGZ Kyrgyzstan
LAO Lao People's Democratic Republic
LAT Latvia
LBN Lebanon
LES Lesotho
LBR Liberia
LBA Libya
LIE Liechtenstein
LTU Lithuania
LUX Luxembourg
MAC Macao
MAD Madagascar
MAW Malawi
MAS Malaysia
MDV Maldives
MLI Mali
MLT Malta
MHL Marshall Islands
MTN Mauritania
MRI Mauritius
MEX Mexico
MON Monaco
MGL Mongolia
MNE Montenegro
MNT Montserrat
MAR Morocco
MOZ Mozambique
MYA Myanmar
NAM Namibia
NRU Nauru
NEP Nepal
NED Netherlands
NZL New Zealand
NCA Nicaragua
NIG Niger
NGR Nigeria
NFI Norfolk Island
NMI Northern Mariana Islands
NOR Norway
OMA Oman
PAK Pakistan
PLW Palau
PLE Palestine
PAN Panama
PNG Papua New Guinea
PAR Paraguay
CHN People's Republic of China
PER Peru
PHI Philippines
POL Poland
POR Portugal
PUR Puerto Rico
QAT Qatar
KOR Republic of Korea
MDA Republic of Moldova
ROU Romania
RUS Russian Federation
RWA Rwanda
SKN Saint Kitts and Nevis
LCA Saint Lucia
SAM Samoa
SMR San Marino
STP Sao Tome and Principe
KSA Saudi Arabia
SEN Senegal
SRB Serbia
SEY Seychelles
SLE Sierra Leone
SGP Singapore
SVK Slovakia
SLO Slovenia
SOL Solomon Islands
SOM Somalia
RSA South Africa
SSD South Sudan
ESP Spain
SRI Sri Lanka
VIN St Vincent and the Grenadines
SUD Sudan
SUR Suriname
SWZ Swaziland
SWE Sweden
SUI Switzerland
SYR Syrian Arab Republic
TJK Tajikistan
THA Thailand
MKD The Former Yugoslav Republic of Macedonia
TOG Togo
TGA Tonga
TTO Trinidad and Tobago
TUN Tunisia
TUR Turkey
TKM Turkmenistan
TKS Turks and Caicos Islands
TUV Tuvalu
UGA Uganda
UKR Ukraine
UAE United Arab Emirates
TAN United Republic of Tanzania
USA United States of America
URU Uruguay
UZB Uzbekistan
VAN Vanuatu
VEN Venezuela
VIE Vietnam
IVB Virgin Islands, British
ISV Virgin Islands, US
YEM Yemen
ZAM Zambia
ZIM Zimbabwe
GSM en cas d'urgence
UNIQUEMENT DES CHIFFRES
Your answer
Je déclare avoir pu prendre connaissance des statuts et règles et être d’accord avec ceux-ci.
*
OUI
Required
Je déclare sur l’honneur être apte à la pratique du jogging.
*
OUI
Required
J’autorise l’asbl JCHSH à utiliser mes données personnelles durant la période couverte par cette cotisation. Mes données personnelles seront effacées au plus tard 6 mois après celle-ci.
*
OUI
Required
J'effectue le paiement de la cotisation via
*
Virement BE57 2600 2503 2335
Carte bancaire :
https://pay.vivawallet.com/jchsh
Payconiq by Bancontact
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms