Last name*

First name*

Address*

City*

Province/State*

Postal Code/Zip Code*

Phone work*

Phone home*

Cellular

Email*

Date of birth*

Reason of stay*

Date of entrance*

Date of departure*

In case of emergency, please notify

Name*

Telephone*

List of names of people who live at the same address and who accompany you during your stay.

Name

Date of birth (Year / month / day)

Name

Date of birth (Year / month / day)

Name

Date of birth (Year / month / day)

Name

Date of birth (Year / month / day)

Name

Date of birth (Year / month / day)

Question : 5+8*