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Fomulaire inscription
 

Fomulaire inscription

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    Fomulaire inscription Fomulaire inscription Document Transcript

    • VENDREDI 21 FEVRIER 2014 aux Champs libres Le geste et la geste artistiques en psychiatrie Formation, pratiques professionnelles, politique(s)… FORMULAIRE D’INSCRIPTION à envoyer à : buee.lucie@hotmail.fr M. Mme Prénom : …………………………………………................. Nom : ……………………………………………………………….................. Date de naissance : …………................ Adresse personnelle : ............................................................................................ .................................................................................................................................. Tél. : ………….................................................................................................. Mél. : …………….............................................................................................. Adresse professionnelle : ................................................................................... Etablissement : ...........................................................…………………….......... Unité de Recherche/Unité/ Service. . . . . . . . . . . . . . . ………………………........... Tél. professionnel : ……………………………………………………............ Mél. professionnel : ……………………………………………………........... Fiche à envoyer à : buee.lucie@hotmail.fr