Name / Nom *

Gender / Sexe *
Male Female

Phone / Téléphone *

Email / Courriel *

Date of birth / Date de naissance *
MM 01 02 03 04 05 06 07 08 09 10 11 12 DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

# ACSA (If Available)

---

Address / Adresse

Address 1 / Adresse 1 *

Address 2 / Adresse 2

City / Ville *

State / Province *
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nunavut Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon

Country / Pays *
Canada USA

Zip code / Code postal *

---

Parent information / Information sur le parent

Name of parent / Nom du parent *

Phone / Téléphone *

Email / Courriel *

---

Camp details / Détails du camp

Session *
Session 1 [Jul. 18th - Jul. 22th 2011]
Session 2 [Jul. 25th - Jul. 29th 2011]
Session 3 [Aug. 1st - Aug. 5th 2011]

Package / Forfait *
5 Day Camp [679.99 CAD] 5 Day Camp with Lodging [1359.99 CAD] 3 Day Camp [429.00 CAD] 2 Day Camp [259.00 CAD]

Payment Info

We accept payment by check.
Payable to * 9210-3761 quebec inc *

Send payment to:
D-STRUCTURE
local 30
2480 chemin ste-foy, quebec,
QC, G1V 1T6
Canada

*Paypal payment available on the next page.

Notes

Security Code: *
Reload Image