Expédition Agaguk - Registration Form



		Please, for security reasons, we hardly suggest you to fill up this form and to print it before send it by mail.

Registration Form

We suggest you to fill up this form and print it, after send it by mail. Si vous manquez de place dans l'un ou l'autre des espaces prévus à cet effet, vous pouvez joindre des feuilles supplémentaires. Durant les heures de bureau, toll free: 1-866-538-1588.

Name:
Address:
City:
Province/State:
Country:
Telephone at work:
Telephone at home:
Fax:
Courriel :
Experience related to kayaking or outdoor activities:
Restrictions physiques et allergies alimentaires :
Physical restrictions or medical info (ex.: allergies)
Plat détestés :
Date of birth:
Height:
Weight:
Gender:	M F
Occupation:
Person to call in case of emergency:
Phone number at work:
Phone number at home:
Packages of interest:
Planned date of stay:
Number of people planning to join or accompany you:

Expedition Agaguk
1062 Boreale street
Havre Saint-Pierre, Québec
G0G 1P0
Canada

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