ࡱ> a  $bjbj rM\M\ 8NT$,R    $Z_&['m+o+o+o+o+o+o+$-r0J+E'#^$''+  +((('@  m+('m+((*+ PlXx (d*Y++0,*0(0+0+T''('''''++(''',''''0'''''''''$ : BULLETIN DINSCRIPTION Formation Rfrent Handicap Du 5 au 9 dcembre 2016 la Maison des Sports Ploufragan A retourner :  HYPERLINK "mailto:pascal.durand@drjscs.gouv.fr" \t "_blank" pascal.durand@drjscs.gouv.fr;  HYPERLINK "mailto:contact.crbh@gmail.com%20et" contact.crbh@gmail.com et angelique.lebriand@ffsa.asso.fr CIVILITE du Stagiaire Nom: FORMTEXT       Prnom: FORMTEXT       Date de naissance: FORMTEXT      / FORMTEXT      ./ FORMTEXT       Pays de naissance:  FORMTEXT       Commune de Naissance:  FORMTEXT       Adresse complte(adresse laquelle sera envoye l attestation de formation) :  FORMTEXT        FORMTEXT       Tel: FORMTEXT      / FORMTEXT      / FORMTEXT      / FORMTEXT      / FORMTEXT       Mail:  FORMTEXT      @ FORMTEXT       Profession: FORMTEXT       tes-vous en situation de Handicap?  FORMCHECKBOX OUI  FORMCHECKBOX NON Si un de nos contacts recherche des personnes qualifies, acceptez-vous que vos coordonnes lui soient diffuses?  FORMCHECKBOX OUI  FORMCHECKBOX NON Activit professionnelle / exprience Votre structure ou club:  FORMTEXT $:;w  1 2 R S h ӾrgWH?hy5CJaJ h;&whQR6B* aJ ph6]jh;&whK!-B* Uph6]h;&whw"B* ph6]%jh;&whK!-6B* UaJ ph6]h;&whw"6B* aJ ph6]hK!-jhK!-Uh;&whA6B* aJ ph6]h;&why6B* aJ ph6]hyhy6CJaJhy5CJ$aJ hQR5CJ$aJ h'hQRaJ(h;&whQRB*aJ(phjh;&wUmHnHu;wS i F 6 T | v$ &( xa$gdt$ &( xa$gdQR $ ( a$gdw" $ & xa$gdQR$ &"( xa$gdQR $xa$gdQR$d^a$gdw" $a$gd(.$ & F a$gd h i n o y z   4 6 8 B D l n   $ & yljNhyUaJ jhyUaJ hyaJ jhQRUaJ jbhQRUaJ jhQRUaJ jvhQRUaJ h|hQRaJ jhQRUaJ mHnHujhQRUaJ jhQRUaJ hQRaJ h|hQR5CJaJ *& ( 2 4 d f z | ~ ( , . B D F P R T V j l n x z | sfjhtUaJ j.htUaJ jhtUaJ hQRaJ jhtUaJ mHnHuj>htUaJ htaJ jhtUaJ h|hQRaJ h|hyaJ jhyUaJ hyaJ jhyUaJ mHnHujhyUaJ (    " $ & ( < > @ J L N P \ r t 'ڳڪڝڐڃ} hyaJ jvhtUaJ jhtUaJ jhtUaJ h|hQRaJ jhtUaJ jhtUaJ jhtUaJ htaJ hQRaJ jhtUaJ jhtUaJ mHnHu1 Sz0 $xa$gdQR$ ( xa$gdy $a$gdw" $da$gdw"$ ( da$gdw" $xa$gdy$ ( a$gdw"$ ( xa$gdQR $ & xa$gdQR'(6789=>LMNO256@A艹vpcvaUj htUaJ htaJ jhtUaJ h|hQRaJ h|hy5CJaJ hy5CJaJ hw"hw"CJaJ hyCJaJ jn hK!-UaJ jhK!-UaJ jnhK!-UaJ jhK!-UaJ jhK!-UaJ hyaJ jhyUaJ #      Diplme(s)d encadrement sportif:  FORMTEXT        FORMTEXT        FORMTEXT       Avez-vous dj encadr des sportifs handicaps?  FORMCHECKBOX OUI  FORMCHECKBOX NON Si Oui, avec quel Handicap?  FORMCHECKBOX  Mental  FORMCHECKBOX  Visuel  FORMCHECKBOX  Psychique  FORMCHECKBOX  Auditif  FORMCHECKBOX  Moteur Financement par un organisme (besoin d une convention):  FORMCHECKBOX  Oui  FORMCHECKBOX Non Nom et adresse de l employeur:  FORMTEXT        FORMTEXT       Tel: FORMTEXT      / FORMTEXT      / FORMTEXT      / FORMTEXT      / FORMTEXT       Mail:  FORMTEXT      @ FORMTEXT       Remarque(s):  FORMTEXT        FORMTEXT             "$NPRThjlvxz|.02NPRT\^z|~ڱڤڞԇ}Ԕp}jN hK!-UaJ jhK!-UaJ j hK!-UaJ jhyUaJ hw"aJ jV htUaJ j htUaJ h|hQRaJ jf htUaJ hyaJ htaJ hQRaJ jhtUaJ jhtUaJ mHnHu,   2 4 P R T V p r L!P!R!n!һҮҡҘwqgqjh(.UaJ h(.aJ h|h(.aJ h(.h(.CJ aJ jhK!-UaJ h|haJ jRhK!-UaJ j hK!-UaJ jN hK!-UaJ jhUaJ haJ jhK!-UaJ j hK!-UaJ hyaJ jhyUaJ %0 !"<"######wu dgdQR $da$gdt $da$gd(.$ &( xa$gd(.$ &( xa$gd(.$ ( da$gd(. $xa$gd(. $`a$gdy $a$gd $`a$gd n!p!r!t!!!!!!!!!!"""""""*","."8":"<"F"H"\"^"`"j"l"n"p"""""""""""ϵޥϘޥϋޥ~ޥqj6h(.UaJ jh(.UaJ jFh(.UaJ jh(.UaJ jh(.UaJ mHnHujVh(.UaJ jhK!-UaJ h(.aJ h|h(.aJ jh(.UaJ jhK!-UaJ jVhK!-UaJ ,""""""""""""""# # ###2#4#H#J#L#V#X#Z#\#p#r#t#~##################潝zjh(.UaJ jh(.UaJ hth(.aJ hw"aJ jh(.UaJ jh(.UaJ h|h(.aJ j&h(.UaJ jh(.UaJ h(.aJ jh(.UaJ jh(.UaJ mHnHu0#########$$ $ $hK!-jhK!-UhthtCJaJ jh(.UaJ jh(.UaJ mHnHu ###$$$$ $ $ $da$gdt dgdQR21h:pQR. 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