Request edit access
Registration Form - Formulaire d'adhésion
Welcome to the Canadian Club of Belgium! Bienvenue au Club Canadien de Belgique!
Payment Amount/Montant du paiement *
Please pay the amount of your dues to/Merci de faire le virement sur le compte: BE87 3630 1334 2994. You can also pay by credit card through PayPal, using the secured link on our membership page: http://www.ccbcanada.be/membership.html
Your answer
Payment Date / Date de paiement *
MM
/
DD
/
YYYY
Are you a new or existing member? Etes-vous un nouveau membre ou un membre existant? *
Last Name / Nom de famille *
Your answer
First Name / Prénom *
Your answer
Full name of spouse/partner (if applicable) / Nom du (de la) conjoint(e)
Your answer
How many children? / Combien d'enfants?
Your answer
Full names of children (if applicable) / Noms complets des (de l') enfant(s)
Your answer
Full names of children (if applicable) / Noms complets des (de l') enfant(s)
Your answer
Ages of children? / Age des enfants?
Your answer
Full names of children (if applicable) / Noms complets des (de l') enfant(s)
Your answer
Full names of children (if applicable) / Noms complets des (de l') enfant(s)
Your answer
Street Address / Adresse postale *
Your answer
City / Ville *
Your answer
Post code / Code postal *
Your answer
Country (if not Belgium) / Pays (si autre que la Belgique)
Your answer
Email / Adresse électronique
Your answer
Phone / Téléphone: *
Your answer
Gender / Sexe
Please indicate your age category / Indiquez votre catégorie d’âge
Would you like to volunteer for a one-off activity? Voulez-vous devenir bénévole pour un de nos événements?
Are you interested in supporting one of the kids at les Salanganes, a charity for troubled kids (+/- €30)? Voudriez-vous supporter un des enfants aux Salanganes, une charité pour enfants en difficultés (+/- €30)?
Membership Type/Catégorie d'adhésion *
CCB Corporate memberships are open to all organizations, Canadian or non-Canadian, in Belgium or around the world, which support the club's mission and want to connect with CCB members. Each corporate membership includes two (2) individual memberships. In addition, corporate members receive the following: • Your logo and website link on the first page of the CCB website • A write up on the links page of the CCB website • An opportunity to sponsor a CCB event or activity • A corporate listing in the annual CCB directory • Your logo in the monthly CCB newsletter, which goes to over 300 email addresses, along with participation in our 'corporate member of the month' which is a write up in one of the monthly newsletters *As our membership year is September to August, after February 1st new individual and couple or family memberships are reduced by 50%. This offer is not available to renewing members, students, corporate memberships or those living outside Belgium.
Required
Nationality / Nationalité
Your answer
How did you find out about the CCB? / Comment avez-vous connu l’existence du CCB? *
Required
What Province or Territory in Canada are you from? / De quelle province ou territoire du Canada provenez-vous ? *
Required
CCB Membership Directory / Répertoire des membres *
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms