Fiche d'identification
Identification form
Nom *
Last name
Your answer
Prénom *
First name
Your answer
Date de naissance *
Birthday
MM
/
DD
/
YYYY
Adresse *
Address
Your answer
Ville *
City
Your answer
Code Postal *
Zip code
Your answer
Email *
Your answer
Téléphone *
Phone
Your answer
Langue *
Avez-vous des problèmes de santé physique, émotionnels ou comportementaux qui directement ou indirectement vous limitent dans la pratique d'activité physiques ? (ex. problèmes respiratoires, cardiaques, diabètes, vision, limitations de vos mouvements, blessures ou opérations, etc.) *
Do you have any issue physcial, mental or behavioral that would limit you in engaging in any type of physical activity (ex : respiratory problems, heart problems, diabetes, vision, movements, injuries or past operations, etc.)
Your answer
Profession
Occupation
Your answer
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