1. 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 :