ÿþ<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd"> <html xmlns="http://www.w3.org/1999/xhtml" xml:lang="fr-fr" lang="fr-fr" > <head> <meta http-equiv="Content-Type" content="text/html; charset=unicode" /> <meta http-equiv="Content-Language" content="fr"> <meta name="robots" content="index, follow" /> <meta name="keywords" content="centre, aere, vacance, mercredi, enfant, jeune, vacances, aéré, enfants" /> <meta name="title" content="Inscription du centre aéré Ste Therese - Agence ADOS" /> <meta name="description" content="Formulaire pour inscrire votre enfant au centre aéré de l'ecole Ste Therese et l'agence pour les jeunes ADOS" /> <meta name="generator" content="WEBSTORMING" /> <title>Inscription centre aéré</title> <script type="text/javascript" src="/media/system/js/mootools.js"></script> <script type="text/javascript" src="/media/system/js/caption.js"></script> <link rel="stylesheet" href="/templates/system/css/system.css" type="text/css" /> <link rel="stylesheet" href="/templates/123wd-j15-2/css/template.css" type="text/css" /> <!--[if lte IE 6]> <link rel="stylesheet" href="/templates/123wd-j15-2/css/ie6.css" type="text/css" /> <![endif]--> </head> <body class="body_bg"> <div id="page_bg"> <font face="Tahoma"> <!-- Logo --> </font> <div id="logo"> <table cellspacing="0" cellpadding="0"> <tr> <td> <font face="Tahoma"> <a href="/index.php">Sejours Scolaires ADOS</a> </font> </td> </tr> </table> </div> <font face="Tahoma"> <!-- /Logo --> <!-- Header --> </font> <div id="header"> <div class="header_img"> </div> <font face="Tahoma"> <!-- Pillmenu --> </font> <div id="pillmenu"> <font face="Tahoma"> <!-- User Help: Center menu replace float: left; or float: right; with : margin: 0 auto; --> </font> <table cellspacing="0" cellpadding="0" style="float: left;"> <tr> <td> </td> </tr> </table> <div class="clr"></div> </div> <font face="Tahoma"> <!-- /Pillmenu --> </font> </div> <font face="Tahoma"> <!-- /Header --> <!-- Pathway col --> </font> <div id="pathway_col"> <div class="pathway"> </div> <div class="search_box"> </div> <div class="clr"></div> </div> <font face="Tahoma"> <!-- /Pathway col --> <!-- Wrapper --> </font> <div id="wrapper"> <div id="content"> <div id="leftcolumn"> <div class="module_menu"> <div> <div> <div> <h3><font face="Tahoma">Menu</font></h3> <ul class="menu"> <li class="item1"> <a href="http://www.sejours-ados.fr/"> <span>Accueil</span> </a> </li> <li class="item2"> <a href="http://www.sejours-ados.fr/index.php?option=com_content&view=article&id=2&Itemid=2"> <span>Reglement du centre aéré</span> </a> </li> <li class="item3"> <a href="http://www.sejours-ados.fr/index.php?option=com_content&view=article&id=3&Itemid=3"> <span>Tarifs</span> </a> </li> <li id="current" class="parent active item5"> <a href="http://www.sejours-ados.fr/index.php?option=com_content&view=article&id=5&Itemid=5"> <span>INSCRIRE VOTRE ENFANT</span> </a> <ul> <li class="item6"> <a onclick="window.open(this.href,'targetWindow','toolbar=no,location=no,status=no,menubar=no,scrollbars=yes,resizable=yes,');return false;" target="_blank" href="http://www.sejours-ados.fr/insription-centre-pdf.pdf"> <span>Inscrire votre enfant sur le centre</span> </a> </li> <li class="item7"> <a href="http://www.sejours-ados.fr/inscription-centre-aere.htm"> <span>Inscrire votre enfant en ligne</span> </a> </li> </ul> </li> <li class="item4"> <a href="http://www.sejours-ados.fr/index.php?option=com_content&view=article&id=4&Itemid=4"> <span>Planning</span> </a> </li> </ul> </div> </div> </div> </div> <div style="width:140px;text-align:center;margin:0 auto;"> <table style="width:140px;text-align:left;" cellpadding="0" cellspacing="0"> <tr> <td><font class="f123_1" face="Tahoma">Designed by:</font></td> </tr> </table> <div> <table style="width:134px;height:30px;text-align:center;border:none;" cellpadding="0" cellspacing="0"> <tr> <td><font face="Tahoma"><a target="_blank" href="http://www.web-storming.fr"><img src="/templates/123wd-j15-2/images/creation-site-web-maroc-marrakech.jpg" style="width:150px;height:52px;" title="Createur de site Internet referencement google developpement site e-commerce" alt="Creation de site internet e-commerce Referencement Google" /></a> </font> </td> </tr> </table> </div> </div> </div> <div id="maincolumn_full"> <div class="nopad"> <table class="contentpaneopen"> <tr> <td class="contentheading" width="100%"> <font face="Tahoma"><b>Inscription centre aéré St Therese a Montpellier</b></font></td> <td align="right" width="100%" class="buttonheading"> &nbsp;</td> <td align="right" width="100%" class="buttonheading"> </td> <td align="right" width="100%" class="buttonheading"> </td> </tr> </table> <table class="contentpaneopen" width="733"> <tr> <td valign="top"> &nbsp;</td> </tr> <tr> <td valign="top"> <p> <p> </p> </p> <p class="MsoNormal" style="margin: 0cm 0cm 0pt;"><strong style="mso-bidi-font-weight: normal;"><span style="font-family: Tahoma;"> <font size="2">Inscrire votre enfant sur le centre</font></span></strong><span style="font-family: Tahoma;"><font size="2"><br /> </font><strong><font size="2"><br /> </font><font size="4">Inscription en ligne pour le Centre Aéré<br> </font></strong></span><span style="font-family: Tahoma;"><strong><font size="2"> (Le formulaire ci-dessous est à compléter pour valider l&#39;inscription)<br> &nbsp;</font></strong></span></p> <Form ACTION="http://www.sejours-ados.fr/cgi-bin/formmail-vf.pl" METHOD="POST"> <font face="Tahoma"> <input type=hidden name="recipient" value="karine.ados@wanadoo.fr,bw@web-storming.fr,beyw@hotmail.com,bw@web-storming.com"> <input type=hidden name="title" value="Inscription centre aere"> <input type=hidden name="subject" value="Inscription centre aere"> <input type=hidden name="required" value="Nom-enfant,Prenom-enfant,Adresse-enfant,Code-postal-enfant,Ville,Telephone-Urgence,Tel-domicile,emailparent,Ne-le,Nombre-enfants-a-charge,Nom-du-pere,Nom-de-la-mere,Nom-de-jeune-fille,Prenom-du-pere,Prenom-de-la-mere,Telephone-domicile-du-pere,Telephone-domicile-de-la-mere,Mobile-du-pere,Mobile-de-la-mere,Profession-du-pere,Profession-de-la-mere,Employeur-du-pere,Employeur-de-la-mere,Telephone-Employeur-du-pere,Telephone-Employeur-de-la-mere,No-de-Securite-sociale,No-CAF,Je-soussigne-Mr-Mme,Desire-inscrire-mon-enfant"> <input type=hidden name="redirect" value="http://www.sejours-ados.fr/reponse_formulaire.htm"> </font> <table border="0" width="95%" id="table1"> <tr> <td colspan="4" bgcolor="#D2D0B6"> <p align="center"><b><font face="Tahoma" size="2">&nbsp;<font color="#5CA80A">VOTRE ENFANT</font></font></b></td> </tr> <tr> <td width="25%"><font face="Tahoma" size="2">Nom</font></td> <td width="28%"> <input type="text" name="Nom-enfant" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> <td width="18%">&nbsp;</td> <td width="27%">&nbsp;</td> </tr> <tr> <td width="25%"><font face="Tahoma" size="2">Prénom</font></td> <td width="28%"> <input type="text" name="Prenom-enfant" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> <td width="18%">&nbsp;</td> <td width="27%">&nbsp;</td> </tr> <tr> <td width="25%"><font face="Tahoma" size="2">Adresse</font></td> <td width="28%"> <input type="text" name="Adresse-enfant" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> <td width="18%">&nbsp;</td> <td width="27%">&nbsp;</td> </tr> <tr> <td width="25%">&nbsp;</td> <td width="28%"> <input type="text" name="Adresse enfant suite ..." size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> <td width="18%">&nbsp;</td> <td width="27%">&nbsp;</td> </tr> <tr> <td width="25%"><font face="Tahoma" size="2">Code postal</font></td> <td width="28%"> <input type="text" name="Code-postal-enfant" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold"></td> <td width="18%"><font face="Tahoma" size="2">Ville</font></td> <td width="27%"> <input type="text" name="Ville" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> </tr> <tr> <td width="25%"><font face="Tahoma" size="2">Téléphone Urgence</font></td> <td width="28%"> <input type="text" name="Telephone-Urgence" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold"></td> <td width="18%"><font face="Tahoma" size="2">Tel domicile</font></td> <td width="27%"> <input type="text" name="Tel-domicile" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> </tr> <tr> <td width="25%"><font face="Tahoma" size="2">e-mail</font></td> <td width="28%"> <input type="text" name="emailparent" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold"></td> <td width="18%">&nbsp;</td> <td width="27%">&nbsp;</td> </tr> <tr> <td width="25%"><font face="Tahoma" size="2">Ne-le</font></td> <td width="28%"> <input type="text" name="Ne-le" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> <td width="18%"><font face="Tahoma" size="2">Sexe</font></td> <td width="27%"><font face="Tahoma"><font size="2">Garçon </font> <input type="checkbox" name="Garcon" value=" "><font size="2">Fille </font> <input type="checkbox" name="Fille" value=" "></font></td> </tr> </table> <p class="MsoNormal" style="margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin-bottom: 0pt"> <font face="Tahoma" size="2"> <br> &nbsp;</font></p> <table border="0" width="95%" id="table2"> <tr> <td colspan="4" bgcolor="#E0DFCB"> <p align="center"><b><font face="Tahoma" size="2">&nbsp;<font color="#5CA80A">SITUATION FAMILIALE DE L&#39;ENFANT</font></font></b></td> </tr> <tr> <td colspan="2"><font face="Tahoma" size="2">Situation familiale des parents</font></td> <td colspan="2"><font face="Tahoma"> <font size="2">Marié </font> <input type="checkbox" name="Marie" value=" "><font size="2">&nbsp; Veuf </font> <input type="checkbox" name="Veuf" value=" "><font size="2">&nbsp; Divorcé </font> <input type="checkbox" name="Divorce" value=" "><font size="2">&nbsp; Célibataire </font> <input type="checkbox" name="Celibataire" value=" "></font></td> </tr> <tr> <td><font face="Tahoma" size="2">Nombre d&#39;enfants a charge</font></td> <td> <input type="text" name="Nombre-enfants-a-charge" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> <td>&nbsp;</td> <td>&nbsp;</td> </tr> <tr> <td colspan="2"><font face="Tahoma" size="2">Père</font></td> <td colspan="2"><font face="Tahoma" size="2">Mère</font></td> </tr> <tr> <td><font face="Tahoma" size="2">Nom</font></td> <td> <input type="text" name="Nom-du-pere" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> <td><font face="Tahoma" size="2">Nom</font></td> <td> <input type="text" name="Nom-de-la-mere" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> </tr> <tr> <td>&nbsp;</td> <td>&nbsp;</td> <td><font face="Tahoma" size="2">Nom de jeune fille</font></td> <td> <input type="text" name="Nom-de-jeune-fille" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> </tr> <tr> <td><font face="Tahoma" size="2">Prénom </font></td> <td> <input type="text" name="Prenom-du-pere" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> <td><font face="Tahoma" size="2">Prénom </font></td> <td> <input type="text" name="Prenom-de-la-mere" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> </tr> <tr> <td><font face="Tahoma" size="2">Téléphone domicile</font></td> <td> <input type="text" name="Telephone-domicile-du-pere" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> <td><font face="Tahoma" size="2">Téléphone domicile</font></td> <td> <input type="text" name="Telephone-domicile-de-la-mere" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> </tr> <tr> <td><font face="Tahoma" size="2">Mobile</font></td> <td> <input type="text" name="Mobile-du-pere" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> <td><font face="Tahoma" size="2">Mobile</font></td> <td> <input type="text" name="Mobile-de-la-mere" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> </tr> <tr> <td><font face="Tahoma" size="2">Profession</font></td> <td> <input type="text" name="Profession-du-pere" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> <td><font face="Tahoma" size="2">Profession</font></td> <td> <input type="text" name="Profession-de-la-mere" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> </tr> <tr> <td><font face="Tahoma" size="2">Employeur</font></td> <td> <input type="text" name="Employeur-du-pere" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> <td><font face="Tahoma" size="2">Employeur</font></td> <td> <input type="text" name="Employeur-de-la-mere" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> </tr> <tr> <td><font face="Tahoma" size="2">Téléphone Employeur</font></td> <td> <input type="text" name="Telephone-Employeur-du-pere" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold"></td> <td><font face="Tahoma" size="2">Téléphone Employeur</font></td> <td> <input type="text" name="Telephone-Employeur-de-la-mere" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold"></td> </tr> </table> <p class="MsoNormal" style="margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin-bottom: 0pt"> <font face="Tahoma" size="2"> <br> &nbsp;</font></p> <table border="0" width="95%" id="table3"> <tr> <td colspan="2" bgcolor="#E2DFCC"> <p align="center"><b><font face="Tahoma" size="2">&nbsp;<font color="#5CA80A">L&#39;ENFANT ET SA SANTE</font></font></b></td> </tr> <tr> <td width="42%"><font face="Tahoma" size="2">N° de Sécurité sociale</font></td> <td width="57%"> <input type="text" name="No-de-Securite-sociale" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> </tr> <tr> <td width="42%"><font face="Tahoma" size="2">N° CAF</font></td> <td width="57%"> <input type="text" name="No-CAF" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> </tr> <tr> <td width="42%"><font face="Tahoma" size="2">Ecole</font></td> <td width="57%"> <input type="text" name="Ecole" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> </tr> <tr> <td valign="top" width="42%"><font face="Tahoma" size="2">Allergies médicaments déclarées<br> (joindre certificats médicaux)</font></td> <td width="57%"> <font face="Tahoma"> <textarea rows="6" name="Allergies medicaments declarees (joindre certificats medicaux)" cols="23"></textarea></font></td> </tr> <tr> <td valign="top" width="42%"><font face="Tahoma" size="2">Personnes autorisées a récupérer l&#39;enfant</font></td> <td width="57%"> <font face="Tahoma"> <textarea rows="6" name="Personnes autorisees a recuperer l enfant" cols="23"></textarea></font></td> </tr> <tr> <td valign="top" width="42%"><font face="Tahoma" size="2">Régime alimentaire</font></td> <td width="57%"> <font face="Tahoma"> <textarea rows="6" name="Regime alimentaire" cols="23"></textarea></font></td> </tr> <tr> <td valign="top" width="42%"><font face="Tahoma" size="2">Autres renseignements</font></td> <td width="57%"><font face="Tahoma"> <textarea rows="6" name="Autres renseignements" cols="23"></textarea></font></td> </tr> </table> <p class="MsoNormal" style="margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin-bottom: 0pt"> <font face="Tahoma" size="2"> <br> &nbsp;</font></p> <table border="0" width="95%" id="table4"> <tr> <td width="94%" colspan="2" align="center" bgcolor="#F0EEE1"> <font face="Tahoma" size="2"><b>&nbsp;<font color="#5CA80A">INSCRIPTIONS</font></b></font></td> </tr> <tr> <td width="43%"><font face="Tahoma" size="2">Je soussigné Mr/Mme </font></td> <td width="51%"> <input type="text" name="Je-soussigne-Mr-Mme" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> </tr> <tr> <td width="43%"><font face="Tahoma" size="2">Désire inscrire mon enfant</font></td> <td width="51%"> <input type="text" name="Desire-inscrire-mon-enfant" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> </tr> <tr> <td colspan="2"><font face="Tahoma" size="2">Sur les journées centre aéré : (cocher les cases en jaune correspondant aux journées pendant lesquelles votre enfant sera présent sur le centre aéré)</font></td> </tr> </table> <p class="MsoNormal" style="margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin-bottom: 0pt"> &nbsp;</p> <table border="0" width="95%" id="table5"> <tr> <td colspan="6" bgcolor="#F0EEE1" valign="top"><b> <font face="Tahoma" size="2">&nbsp;SEPTEMBRE</font></b></td> </tr> <tr> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="M 09/09/09" value=" "><font size="2">M 09/09/09</font></font></td> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="M 16/09/09" value=" "><font size="2">M 16/09/09</font></font></td> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="M 23/09/09" value=" "><font size="2">M 23/09/09</font></font></td> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="M 30 /09/09" value=" "><font size="2">M 30 /09/09</font></font></td> <td width="40%" colspan="2" valign="top">&nbsp;</td> </tr> <tr> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td width="40%" colspan="2" valign="top">&nbsp;</td> </tr> <tr> <td width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="40%" colspan="2" valign="top">&nbsp;</td> </tr> <tr> <td colspan="6" bgcolor="#F0EEE1" valign="top"><b> <font face="Tahoma" size="2">&nbsp;OCTOBRE</font></b></td> </tr> <tr> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="M 08/10/09" value=" "><font size="2">M 08/10/09</font></font></td> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="M 15/10/09" value=" "><font size="2">M 15/10/09</font></font></td> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="M 22/10/09" value=" "><font size="2">M 22/10/09</font></font></td> <td width="14%" valign="top">&nbsp;</td> <td width="40%" colspan="2" valign="top">&nbsp;</td> </tr> <tr> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="40%" colspan="2" valign="top">&nbsp;</td> </tr> <tr> <td width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="40%" colspan="2" valign="top">&nbsp;</td> </tr> <tr> <td colspan="6" bgcolor="#F0EEE1" valign="top"><b> <font face="Tahoma" size="2">&nbsp;VACANCES DE LA TOUSSAINT</font></b></td> </tr> <tr> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="L 26/10/09" value=" "><font size="2">L 26/10/09</font></font></td> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="M 27/10/09" value=" "><font size="2">M 27/10/09</font></font></td> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="M 28/10/09" value=" "><font size="2">M 28/10/09</font></font></td> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="J 29/10/09" value=" "><font size="2">J 29/10/09</font></font></td> <td width="40%" colspan="2" valign="top"><font face="Tahoma"> <input type="checkbox" name="V 30/10/09" value=" "><font size="2">V 30/10/09</font></font></td> </tr> <tr> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td bgcolor="#FFFF66" width="17%" valign="top">&nbsp;</td> <td width="22%" valign="top">&nbsp;</td> </tr> <tr> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="L 02/11/09" value=" "><font size="2">L 02/11/09</font></font></td> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="M 03/10/09" value=" "><font size="2">M 03/11/09</font></font></td> <td width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="40%" colspan="2" valign="top">&nbsp;</td> </tr> <tr> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="40%" colspan="2" valign="top">&nbsp;</td> </tr> <tr> <td width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="40%" colspan="2" valign="top">&nbsp;</td> </tr> <tr> <td colspan="6" bgcolor="#F0EEE1" valign="top"><b> <font face="Tahoma" size="2">&nbsp;NOVEMBRE</font></b></td> </tr> <tr> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="M 18/11/09" value=" "><font size="2">M 18/11/09</font></font></td> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="M 25/11/09" value=" "><font size="2">M 25/11/09</font></font></td> <td width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="40%" colspan="2" valign="top">&nbsp;</td> </tr> <tr> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="40%" colspan="2" valign="top">&nbsp;</td> </tr> <tr> <td colspan="6" valign="top">&nbsp;</td> </tr> <tr> <td colspan="6" bgcolor="#F0EEE1" valign="top"><b> <font face="Tahoma" size="2">&nbsp;DECEMBRE</font></b></td> </tr> <tr> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="M 02/12/09" value=" "><font size="2">M 02/12/09</font></font></td> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="M 09/12/09" value=" "><font size="2">M 09/12/09</font></font></td> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="M 16/12/09" value=" "><font size="2">M 16/12/09</font></font></td> <td width="14%" valign="top">&nbsp;</td> <td width="40%" colspan="2" valign="top">&nbsp;</td> </tr> <tr> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="40%" colspan="2" valign="top">&nbsp;</td> </tr> <tr> <td width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="40%" colspan="2" valign="top">&nbsp;</td> </tr> <tr> <td colspan="6" bgcolor="#F0EEE1" valign="top"><b> <font face="Tahoma" size="2">&nbsp;VACANCES DE NOEL</font></b></td> </tr> <tr> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="L 21/12/09" value=" "><font size="2">L 21/12/09</font></font></td> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="M 22/12/09" value=" "><font size="2">M 22/12/09</font></font></td> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="M 23/12/09" value=" "><font size="2">M 23/12/09</font></font></td> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="J 24/12/09" value=" "><font size="2">J 24/12/09</font></font></td> <td width="40%" colspan="2" valign="top">&nbsp;</td> </tr> <tr> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td width="40%" colspan="2" valign="top">&nbsp;</td> </tr> <tr> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="L 28/12/09" value=" "><font size="2">L 28/12/09</font></font></td> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="M 29/12/09" value=" "><font size="2">M 29/12/09</font></font></td> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="M 30/12/09" value=" "><font size="2">M 30/12/09</font></font></td> <td width="14%" valign="top"><font face="Tahoma"> <input type="checkbox" name="J 31/12/09" value=" "><font size="2">J 31/12/09</font></font></td> <td width="40%" colspan="2" valign="top">&nbsp;</td> </tr> <tr> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td bgcolor="#FFFF66" width="14%" valign="top">&nbsp;</td> <td width="40%" colspan="2" valign="top">&nbsp;</td> </tr> <tr> <td width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="14%" valign="top">&nbsp;</td> <td width="40%" colspan="2" valign="top">&nbsp;</td> </tr> <tr> <td colspan="6" valign="top"><font face="Tahoma" size="2">Je soussigné </font> <input type="text" name="Je soussigne" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"><font face="Tahoma" size="2"> autorise le directeur du centre (ou son représentant),</font></td> </tr> <tr> <td colspan="6" valign="top"><font face="Tahoma" size="2">­à faire pratiquer tous les soins ou interventions chirurgicales en cas de besoin ,<br> ­à faire apparaître mon enfant sur tout support (photos, vidéos& ) utilisés exclusivement pour illustrer les activités du centre (article de presse, expositions, etc& ).</font></td> </tr> <tr> <td colspan="6" valign="top"><font face="Tahoma"> <input type="checkbox" name="Lecture du Reglement" value="VALIDE"></font><font face="Tahoma" size="2">En cochant cette case je reconnais avoir pris connaissance du <b><a href="http://www.sejours-ados.fr/index.php?option=com_content&view=article&id=2&Itemid=2"> <font color="#5CA80A">règlement du centre</font></a></b>, et déclare y adhérer sans réserve.</font></td> </tr> <tr> <td colspan="6" valign="top">&nbsp;</td> </tr> <tr> <td valign="top" width="14%"><font face="Tahoma" size="2">Fait à :</font></td> <td colspan="2" valign="top"> <input type="text" name="Fait a" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> <td colspan="3" valign="top" rowspan="2"><font face="Tahoma" size="2"> Signature du représentant légal :<br> Le fait de cocher cette case équivaut à signer électroniquement ce formulaire</font><font face="Tahoma"><input type="checkbox" name="Signature representant legal" value="VALIDE"></font></td> </tr> <tr> <td valign="top" width="14%"><font face="Tahoma" size="2">Le :</font></td> <td colspan="2" valign="top"> <input type="text" name="Le" size="22" style="font-family: Tahoma; color: #666666; font-weight: bold; background-color:#99CCFF"></td> </tr> <tr> <td colspan="6" valign="top"><font face="Tahoma"> La passation de la commande vaut acceptation des présentes conditions générales</font></td> </tr> <tr> <td colspan="6" valign="top">&nbsp;</td> </tr> </table> <p class="MsoNormal" style="margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin-bottom: 0pt"> &nbsp;</p> <p class="MsoNormal" style="margin-left: 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