BULLETIN D’INSCRIPTION M A R C H E P O U R L’ E A U 2 0 1 6 o Je m’inscris au voyage et je règle la somme de 2500 € qui représente mes frais de voyage ainsi que mon don pour le KKL. Un reçu cerfa pour mon don me sera délivré. o Je m’inscris au voyage et je règle mes frais de voyage d’un montant minimum de 1790 €.

Nous avons le plaisir de vous proposer deux circuits, sous réserve d'un nombre de participants minimum par groupe : le premier (groupe A) correspond au niveau de difficulté classique de la Marche pour l'eau du KKL de France ; le second (groupe B) empruntera des parcours un peu plus faciles et plus courts. Nom : ........................................................................................................... Prénom : ............................................................................................................................ Adresse : ......................................................................................................................................................................................................................................................... C.P. : ......................................................................................................................... Ville : ............................................................................................................................ Téléphone domicile : ........................................................................................................ Mobile : ................................................................................................. Email : ............................................................................................................................................................................................................................................................... Date de naissance : ................................................................. Profession : ..................................................................................................................................... Nationalité : .................................................................................................................................................................................................................................................. N° de Passeport : ...................................................................................................................... Date d’expiration : ................................................................... (une validité de 6 mois minimum après la date d'entrée en Israël est obligatoire)

o Départ : 26 mars 2016 - vol LY 326, 22h30 - 5h o Sans billet d’avion Taille de Tee-shirt :

Retour : 3 avril 2016 - vol LY 323, 9h - 12h50

o S o M o L o XL o XXL

ASSURANCE RAPATRIEMENT OBLIGATOIRE : Compagnie d’assurance : ...................................................................................................................................................................................................................... N° de tél. : .............................................................................................. N° de police d’assurance : .........................................................................................

CERTIFICAT MÉDICAL OBLIGATOIRE ! REGIME ALIMENTAIRE CACHER : o Normal Je choisis :

o groupe A parcours plus dur

o Végétarien o Végétalien

o groupe B parcours moins dur / long

o Je désire partager la chambre avec : ........................................................................................................................................................................................ o Je désire une chambre single (avec supplément de 490 €)

o Je joins mon acompte de 1000 € (solde avant le 10 mars 2016) o Par chèque bancaire à l’ordre du KKL

o Par carte bancaire :

N° Date d’expiration :

Cryptogramme (au dos de la CB) :

! Bon voyage

Signature :

KKL – MPE : 11 rue du 4- Septembre, 75002 PARIS Tél : 01 42 86 88 88 - Fax : 01 42 60 18 13 – Mail : [email protected]

License N° AG075090001 - © Graphisme : Sydney Hazan 2016.

o Je joins la totalité de ma participation : ......................................................... €

BI MPE 2016.pdf

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