Registration form
for the summer camp in Godinne, Belgium from July 13 to 21, 2019
Personal Data
First name *
Your answer
Surname *
Your answer
Gender
Birthdate *
MM
/
DD
/
YYYY
Address
Street
Your answer
Street (2)
Your answer
ZIP *
Your answer
City *
Your answer
Country *
If your country is not in the list, choose "Other" and enter your country name in the comment field
Contact
E-Mail *
Your answer
Phone *
Format: +33 1 234 567 89
Your answer
Practice
Dojo
Your answer
Ordination *
First sesshin
Stay
Duration *
If your arrival and departure dates are not in the proposed choice, choose "Other" and enter the dates in the comment field
Rate *
Samu choice
Comments
Your answer
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