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Formulaire de membership
Pour devenir membre du Centre de prévention et d'intervention pour victimes d'agression sexuelle / Form to become a member of the CPIVAS (Prevention and Intervention center for victims of sexual assault)
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* Indicates required question
Nom, prénom / Last name, First name
*
Your answer
Adresse / Address
*
Your answer
Courriel / E-mail address
*
Your answer
Téléphone / Phone number
*
Your answer
Consentez-vous à ce que nous communiquions avec vous par courriel? / Do you consent to us communicating with you through e-mails?
*
Oui / Yes
Non / No
Required
Consentez-vous à ce que nous vous contactions par téléphone au besoin? / Do you consent to us communicating with you through the phone, if needed?
*
Oui / Yes
Non / No
*
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