Le Patro
Fort-Coulonge/Mansfield

Fort-Coulonge/Mansfield, for all our youths!!

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Registration


Daycare service :

Choice of date:

June 27 th to July 1 nd
July 4 th to July 8 th
July 11 th to July 15 th:
July 18 th to July 22 rd:
July 25 th to July 29 th:
August 1 nd to August 5 th:
August 8 th to August 12 th:

Child's family name :
Child's first name :
age :
# Medical insurance number :
Expiration date :
Date of birth :
Adress :
City : include postal code
Phone : include regional code
# Emergency phone number : include regional code
Email :

Additional notes :

In case of emergency, if I can't be reached, I autorise the Patro staff to take the necessary actions to assure my child's healt :
Autorisation :

Parent's name :

*You have to click the send button to send the form and give authorisation to the Patro staff to take necessary actions for your childs health if you can't be reached. Don't forget your paiement.

Before you send the form make sure that all fields are filled out. Click send


Send your payement to :
Patro de Fort-Coulonge/Mansfield
209 ch. De la Passe c.p. 100
Masfield (Québec)
J0X-1R0
Phone: (819) 683-3347
Fax: (819) 683-3546

Last update : 2010-11-08

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Visitors since mai 2008 : 20901

[ Français | Home | Mission | Objectives | Pastoral Resources | Activities | Rentals | Our team | How to find us | Installations | Contact-us | How to help? | Pictures | Links ]