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<!--[if gte mso 10]> <style> /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Tableau Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-parent:""; mso-padding-alt:0cm 5.4pt 0cm 5.4pt; mso-para-margin:0cm; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman";} </style> <![endif]--> <meta name=CREATED content="0;0"> <meta name=CHANGEDBY content="daniel "> <meta name=CHANGED content="20111125;16174000"> <meta name=DESCRIPTION content="Association de course pédestre à Coudoux : inscription Collines du Berger"> <meta name=KEYWORDS content="course, courir, jogging, course a pied, pedestre, hors stade, compétition, marathon, provence, Coudoux, nature, marcheur, randonnee, randonneur, challenge du pays d'Aix, association, club, collines du berger, rando, Coudoux olympique, challenge, Aix en Provence, Salon, entrainement, sport, sportifs, sportives"> <meta 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<u2:AlwaysShowPlaceholderText>false</u2:AlwaysShowPlaceholderText> <u2:Compatibility> <u2:UseFELayout/> </u2:Compatibility> <u2:BrowserLevel>MicrosoftInternetExplorer4</u2:BrowserLevel> </u2:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <u3:LatentStyles DefLockedState="false" LatentStyleCount="156"> </u3:LatentStyles> </xml><![endif]--><!--[if gte mso 9]><xml> <u4:shapedefaults u5:ext="edit" spidmax="1026"/> </xml><![endif]--><!--[if gte mso 9]><xml> <u6:shapelayout u7:ext="edit"> <u6:idmap u7:ext="edit" data="1"/> </u6:shapelayout> </xml><![endif]--> </head> <body bgcolor=white lang=FR link="#CC3300" vlink="#CC3300" style='tab-interval: 35.4pt' dir=LTR> <div class=WordSection1> <form> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 width="98%" style='width:98.0%;mso-cellspacing:0cm;mso-yfti-tbllook:1184;mso-padding-alt: 0cm 0cm 0cm 0cm'> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes'> <td width="16%" rowspan=2 style='width:16.0%;background:white;padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto;text-align:center'><a name="_x0000_i1025"></a><span style='font-size: 8.0pt;font-family:Arial;color:#FF6600'><img width=120 height=41 id="_x0000_i1025" src="modifiables/Macintosh%20HD:MAJ%20COOL:Site%20Web%20Cool:modifiables:../images/logos/logo_challengepa.gif" NAME=images1 align=BOTTOM border=0></span><span style='font-size:8.0pt; font-family:Arial;color:#333333'><o:p></o:p></span></p> </td> <td style='background:white;padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto;text-align:center'><b><span style='font-size:15.0pt;font-family:Arial; color:#FF6600'>Demande d'Inscription </span></b><span style='font-size:8.0pt; font-family:Arial;color:#333333'><o:p></o:p></span></p> </td> <td width="14%" rowspan=2 style='width:14.0%;background:white;padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><a name="_x0000_i1026"></a><span style='font-size:8.0pt;font-family:Arial; color:#FF6600'><img width=79 height=127 id="_x0000_i1026" src="modifiables/Macintosh%20HD:MAJ%20COOL:Site%20Web%20Cool:modifiables:../images/logocool_smileys/runner_coolvertorange.gif" NAME=images2 align=BOTTOM border=0></span><span style='font-size:8.0pt; font-family:Arial;color:#333333'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:1'> <td style='background:white;padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto;text-align:center'><b><span style='font-size:9.0pt;font-family:Arial; color:#333333'>29ème Course Pédestre de <span class=SpellE>Coudoux</span> - Les Collines du Berger : 5 février 2012</span></b><span style='font-size: 8.0pt;font-family:Arial;color:#333333'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:2'> <td colspan=3 style='background:white;padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto;text-align:center'><span style='font-size:8.0pt;font-family:Arial; color:#333333'>Remplissez ce formulaire puis imprimez le et envoyer le&nbsp; avant le 1 février 2012 avec votre chèque de 3 euros et votre certificat<o:p></o:p></span></p> <p class=MsoNormal align=center style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto;text-align:center'><span style='font-size:8.0pt;font-family:Arial; color:#333333'>médical ou la photocopie de votre licence à&nbsp;: <span class=SpellE>Coudoux</span> Olympique BP N°8 13111 <span class=SpellE>Coudoux</span> <o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:3'> <td colspan=3 valign=top style='background:white;padding:0cm 0cm 0cm 0cm'> <div align=center> <table class=MsoNormalTable border=0 cellpadding=0 width="90%" style='width:90.0%;mso-cellspacing:2.0pt;mso-yfti-tbllook:1184;mso-padding-alt: 0cm 0cm 0cm 0cm'> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes'> <td width="53%" valign=top style='width:53.0%;padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><a name=Nom></a><span style='font-size:8.0pt;font-family:Arial; color:#333333'>Nom*:<br clear=all style='page-break-before:always'> <INPUT TYPE="TEXT" NAME="Nom" SIZE="34"> <span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> </td> <td colspan=2 valign=top style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto'><a name=Prenom></a><span style='font-size:8.0pt;font-family:Arial;color:#333333'>Prénom*:<br clear=all style='page-break-before:always'> <INPUT TYPE="TEXT" NAME="Prenom" SIZE="34"> <span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> <table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0 width="90%" style='width:90.0%;mso-cellspacing:0cm;mso-yfti-tbllook:1184;mso-padding-alt: 0cm 0cm 0cm 0cm'> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes'> <td style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><span style='font-size:8.0pt;font-family:Arial;color:#333333'>Né(e) le* :<o:p></o:p></span></p> </td> <td valign=top style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:center'><a name=JourNaissance></a><span style='font-size:8.0pt;font-family:Arial;color:#333333'><INPUT TYPE="TEXT" NAME="JourNaissance" SIZE="2" MAXLENGTH="2"> <span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> </td> <td valign=top style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:center'><a name=MoisNaissance></a><span style='font-size:8.0pt;font-family:Arial;color:#333333'><INPUT TYPE="TEXT" NAME="MoisNaissance" SIZE="2" MAXLENGTH="2"> <span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> </td> <td valign=top style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:center'><a name=AnneeNaissance></a><span style='font-size:8.0pt;font-family:Arial;color:#333333'><INPUT TYPE="TEXT" NAME="AnneeNaissance" SIZE="2" MAXLENGTH="2"> <span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:1;mso-yfti-lastrow:yes'> <td style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><span style='font-size:8.0pt;font-family:Arial;color:#333333'>&nbsp;<o:p></o:p></span></p> </td> <td valign=top style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:center'><span style='font-size: 8.0pt;font-family:Arial;color:#333333'>JJ<o:p></o:p></span></p> </td> <td valign=top style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:center'><span style='font-size: 8.0pt;font-family:Arial;color:#333333'>MM<o:p></o:p></span></p> </td> <td valign=top style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:center'><span style='font-size: 8.0pt;font-family:Arial;color:#333333'>AA<o:p></o:p></span></p> </td> </tr> </table> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman";display:none;mso-hide:all'><o:p>&nbsp;</o:p></span></p> <table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0 width="100%" style='width:100.0%;mso-cellspacing:0cm;mso-yfti-tbllook: 1184;mso-padding-alt:0cm 0cm 0cm 0cm'> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes'> <td width="35%" style='width:35.0%;padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><span style='font-size:8.0pt;font-family:Arial;color:#333333'>N° de licence :<o:p></o:p></span></p> </td> <td width="65%" style='width:65.0%;padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=right style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto;text-align:right'><a name=Licence></a><span style='font-size:8.0pt; font-family:Arial;color:#333333'><INPUT TYPE="TEXT" NAME="Licence" SIZE="26" MAXLENGTH="26"> <span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:1;mso-yfti-lastrow:yes'> <td style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><span style='font-size:8.0pt;font-family:Arial;color:#333333'>&nbsp;<o:p></o:p></span></p> </td> <td style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><span style='font-size:8.0pt;font-family:Arial;color:#333333'>&nbsp;<o:p></o:p></span></p> </td> </tr> </table> <span style='font-size:8.0pt;font-family:Arial;mso-fareast-font-family: "-ÿ3ÿ fg";mso-fareast-theme-font:minor-fareast;color:#333333;mso-ansi-language: FR;mso-fareast-language:FR;mso-bidi-language:AR-SA'><br clear=all style='page-break-before:always'> <br clear=all style='mso-special-character:line-break;page-break-before: always'> </span></td> </tr> <tr style='mso-yfti-irow:1'> <td valign=top style='padding:0cm 0cm 0cm 0cm'><span style='font-size:8.0pt; font-family:Arial;mso-fareast-font-family:"-ÿ3ÿ fg";mso-fareast-theme-font: minor-fareast;color:#333333;mso-ansi-language:FR;mso-fareast-language:FR; mso-bidi-language:AR-SA'><br clear=all style='page-break-before:always'> <br clear=all style='mso-special-character:line-break;page-break-before: always'> </span></td> <td colspan=2 valign=top style='padding:0cm 0cm 0cm 0cm'></td> </tr> <tr style='mso-yfti-irow:2'> <td valign=top style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto'><span style='font-size: 8.0pt;font-family:Arial;color:#333333'>Sexe : <INPUT TYPE="RADIO" NAME="Groupe de boutons Sexe" VALUE="Masculin"> <span style="mso-spacerun:yes"> </span>M&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;<INPUT TYPE="RADIO" NAME="Groupe de boutons Sexe" VALUE="Féminin"> &nbsp;&nbsp;&nbsp;&nbsp; &nbsp; F <o:p></o:p></span></p> <table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0 width="100%" style='width:100.0%;mso-cellspacing:0cm;mso-yfti-tbllook: 1184;mso-padding-alt:0cm 0cm 0cm 0cm'> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes'> <td style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><span style='font-size:8.0pt;font-family:Arial;color:#333333'>Certificat Médical, délivré le <o:p></o:p></span></p> </td> <td valign=top style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:center'><a name=JourCertif></a><span style='font-size:8.0pt;font-family:Arial;color:#333333'><INPUT TYPE="TEXT" NAME="JourCertif" SIZE="2" MAXLENGTH="2"> <span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> </td> <td valign=top style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:center'><a name=MoisCertif></a><span style='font-size:8.0pt;font-family:Arial;color:#333333'><INPUT TYPE="TEXT" NAME="MoisCertif" SIZE="2" MAXLENGTH="2"> <span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> </td> <td valign=top style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:center'><a name=AnneeCertif></a><span style='font-size:8.0pt;font-family:Arial;color:#333333'><INPUT TYPE="TEXT" NAME="AnneeCertif" SIZE="2" MAXLENGTH="2"> <span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:1;mso-yfti-lastrow:yes'> <td style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><span style='font-size:8.0pt;font-family:Arial;color:#333333'>&nbsp;<o:p></o:p></span></p> </td> <td valign=top style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:center'><span style='font-size: 8.0pt;font-family:Arial;color:#333333'>JJ<o:p></o:p></span></p> </td> <td valign=top style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:center'><span style='font-size: 8.0pt;font-family:Arial;color:#333333'>MM<o:p></o:p></span></p> </td> <td valign=top style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:center'><span style='font-size: 8.0pt;font-family:Arial;color:#333333'>AA<o:p></o:p></span></p> </td> </tr> </table> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman";display:none;mso-hide:all'><o:p>&nbsp;</o:p></span></p> <table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0 width="100%" style='width:100.0%;mso-cellspacing:0cm;mso-yfti-tbllook: 1184;mso-padding-alt:0cm 0cm 0cm 0cm'> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes'> <td width="20%" style='width:20.0%;padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><span style='font-size:8.0pt;font-family:Arial;color:#333333'>Club ou Entreprise :<o:p></o:p></span></p> </td> <td colspan=3 style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><a name=club></a><span style='font-size:8.0pt;font-family:Arial; color:#333333'><INPUT TYPE="TEXT" NAME="club" SIZE="62"> <span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:1'> <td style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><span style='font-size:8.0pt;font-family:Arial;color:#333333'>Adresse* : <o:p></o:p></span></p> </td> <td colspan=3 style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><a name=adresseligne1></a><span style='font-size:8.0pt;font-family: Arial;color:#333333'><INPUT TYPE="TEXT" NAME="adresseligne1" SIZE="62"> <span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:2'> <td style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><span style='font-size:8.0pt;font-family:Arial;color:#333333'>&nbsp;<o:p></o:p></span></p> </td> <td colspan=3 style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><a name=adresseligne2></a><span style='font-size:8.0pt;font-family: Arial;color:#333333'><INPUT TYPE="TEXT" NAME="adresseligne2" SIZE="62"> <span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:3'> <td style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><span style='font-size:8.0pt;font-family:Arial;color:#333333'>Code Postal* : <o:p></o:p></span></p> </td> <td width="22%" style='width:22.0%;padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><a name="Code_Postal"></a><span style='font-size:8.0pt;font-family: Arial;color:#333333'><INPUT TYPE="TEXT" NAME="Code Postal" SIZE="13" MAXLENGTH="5"> <span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> </td> <td width="8%" style='width:8.0%;padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:center'><span style='font-size: 8.0pt;font-family:Arial;color:#333333'>Ville* : <o:p></o:p></span></p> </td> <td width="50%" style='width:50.0%;padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><a name=Ville></a><span style='font-size:8.0pt;font-family:Arial; color:#333333'><INPUT TYPE="TEXT" NAME="Ville" SIZE="37"> <span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:4;mso-yfti-lastrow:yes'> <td style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><span style='font-size:8.0pt;font-family:Arial;color:#333333'>Adresse e-mail l* : <o:p></o:p></span></p> </td> <td colspan=3 style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><a name=e-mail></a><span style='font-size:8.0pt;font-family:Arial; color:#333333'><INPUT TYPE="TEXT" NAME="e-mail" SIZE="62"> <span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> </td> </tr> </table> <span style='font-size:8.0pt;font-family:Arial;mso-fareast-font-family: "-ÿ3ÿ fg";mso-fareast-theme-font:minor-fareast;color:#333333;mso-ansi-language: FR;mso-fareast-language:FR;mso-bidi-language:AR-SA'><br clear=all style='page-break-before:always'> <br clear=all style='mso-special-character:line-break;page-break-before: always'> </span></td> <td colspan=2 valign=top style='padding:0cm 0cm 0cm 0cm'><span style='font-size:8.0pt;font-family:Arial;mso-fareast-font-family:"-ÿ3ÿ fg"; mso-fareast-theme-font:minor-fareast;color:#333333;mso-ansi-language:FR; mso-fareast-language:FR;mso-bidi-language:AR-SA'><br clear=all style='page-break-before:always'> <br clear=all style='mso-special-character:line-break;page-break-before: always'> </span></td> </tr> <tr style='mso-yfti-irow:3'> <td colspan=3 valign=top style='padding:0cm 0cm 0cm 0cm'></td> </tr> <tr style='mso-yfti-irow:4'> <td colspan=3 valign=bottom style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=right style='mso-margin-top-alt:auto;text-align: right'><span style='font-size:7.5pt;font-family:Arial;color:#333333'>*: zones obligatoires </span><span style='font-size:8.0pt;font-family:Arial; color:#333333'><o:p></o:p></span></p> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 width="100%" style='width:100.0%;mso-cellspacing:0cm;mso-yfti-tbllook: 1184;mso-padding-alt:0cm 0cm 0cm 0cm'> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes'> <td style='background:#FF6600;padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto; text-align:center'><b><span style='font-family:Arial;color:white'>POUR LES MOINS DE 18 ANS </span></b><span style='font-size:8.0pt;font-family: Arial;color:#333333'><o:p></o:p></span></p> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 width="100%" style='width:100.0%;mso-cellspacing:0cm;mso-yfti-tbllook: 1184;mso-padding-alt:0cm 0cm 0cm 0cm'> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes'> <td colspan=2 style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:center'><span style='font-size: 8.0pt;font-family:Arial;color:#333333'>Autorisation Parentale<o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:1'> <td colspan=2 style='padding:0cm 0cm 0cm 0cm'> <p class=bodytext1>Je soussigné ..................................... autorise mon fils, ma fille mineure à participer à l'épreuve pédestre du 5 février 2012 à Coudoux et dégage les organisateurs de toute responsabilité en cas d'incident.</p> </td> </tr> <tr style='mso-yfti-irow:2'> <td width="62%" valign=top style='width:62.0%;padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><span style='font-size:8.0pt;font-family:Arial;color:#333333'>Fait à <o:p></o:p></span></p> </td> <td width="38%" valign=top style='width:38.0%;padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><span style='font-size:8.0pt;font-family:Arial;color:#333333'>le <o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:3;mso-yfti-lastrow:yes'> <td colspan=2 valign=top style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><b><span style='font-size:8.0pt;font-family:Arial;color:#333333'>Signature : </span></b><span style='font-size:8.0pt;font-family:Arial;color:#333333'><o:p></o:p></span></p> </td> </tr> </table> <span style='font-size:8.0pt;font-family:Arial;mso-fareast-font-family: "-ÿ3ÿ fg";mso-fareast-theme-font:minor-fareast;color:#333333;mso-ansi-language: FR;mso-fareast-language:FR;mso-bidi-language:AR-SA'><br clear=all style='page-break-before:always'> <br clear=all style='mso-special-character:line-break;page-break-before: always'> </span></td> </tr> <tr style='mso-yfti-irow:1;mso-yfti-lastrow:yes'> <td style='padding:0cm 0cm 0cm 0cm'></td> </tr> </table> <span style='font-size:8.0pt;font-family:Arial;mso-fareast-font-family: "-ÿ3ÿ fg";mso-fareast-theme-font:minor-fareast;color:#333333;mso-ansi-language: FR;mso-fareast-language:FR;mso-bidi-language:AR-SA'><br clear=all style='page-break-before:always'> <br clear=all style='mso-special-character:line-break;page-break-before: always'> </span></td> </tr> <tr style='mso-yfti-irow:5'> <td valign=top style='padding:0cm 0cm 0cm 0cm'></td> <td colspan=2 valign=top style='padding:0cm 0cm 0cm 0cm'> <div align=right> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 width="90%" style='width:90.0%;mso-cellspacing:0cm;mso-yfti-tbllook:1184;mso-padding-alt: 0cm 0cm 0cm 0cm'> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes'> <td style='background:#FF6600;padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto; text-align:center'><b><span style='font-family:Arial;color:white'>POUR LES NON LICENCIÉS </span></b><span style='font-size:8.0pt;font-family: Arial;color:#333333'><o:p></o:p></span></p> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 width="100%" style='width:100.0%;mso-cellspacing:0cm;mso-yfti-tbllook: 1184;mso-padding-alt:0cm 0cm 0cm 0cm'> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes'> <td width="100%" style='width:100.0%;padding:0cm 0cm 0cm 0cm'> <p class=bodytext1>La présentation d'un certificat médical de non contre indication à la pratique de la course à pied en compétition datant de moins d'un an ou de sa copie est obligatoire, conformément aux lois n°84.610 du 16/07/1984 et n°99.223 du 22/03/1999.</p> </td> </tr> <tr style='mso-yfti-irow:1'> <td valign=top style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:center'><span style='font-size: 8.0pt;font-family:Arial;color:#333333'>Lieu, date et signature : <o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:2;mso-yfti-lastrow:yes'> <td valign=bottom style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><span style='font-size:7.5pt;font-family:Arial;color:#333333'>L'organisateur décline toute responsabilité envers les personnes ayant fait une fausse déclaration en s'inscrivant. </span><span style='font-size:8.0pt; font-family:Arial;color:#333333'><o:p></o:p></span></p> </td> </tr> </table> <span style='font-size:8.0pt;font-family:Arial;mso-fareast-font-family: "-ÿ3ÿ fg";mso-fareast-theme-font:minor-fareast;color:#333333;mso-ansi-language: FR;mso-fareast-language:FR;mso-bidi-language:AR-SA'><br clear=all style='page-break-before:always'> <br clear=all style='mso-special-character:line-break;page-break-before: always'> </span></td> </tr> <tr style='mso-yfti-irow:1;mso-yfti-lastrow:yes'> <td style='padding:0cm 0cm 0cm 0cm'></td> </tr> </table> </div> </td> </tr> <tr style='mso-yfti-irow:6;mso-yfti-lastrow:yes'> <td valign=top style='padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><span style='font-size:8.0pt;font-family:Arial;color:#333333'>&nbsp;<o:p></o:p></span></p> </td> <td width="28%" valign=top style='width:28.0%;padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><span style='font-size:8.0pt;font-family:Arial;color:#333333'>&nbsp;<o:p></o:p></span></p> </td> <td width="19%" valign=top style='width:19.0%;padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto'><a name=Annuler></a><span style='font-size:8.0pt;font-family:Arial; color:#333333'><INPUT TYPE="RESET" NAME="Annuler" VALUE="Annuler"> <span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> </td> </tr> </table> </div> </td> </tr> <tr style='mso-yfti-irow:4;mso-yfti-lastrow:yes'> <td valign=top style='background:white;padding:0cm 0cm 0cm 0cm'> <p class=MsoNormal align=center style='mso-margin-top-alt:auto;mso-margin-bottom-alt: auto;text-align:center'><span style='font-size:8.0pt;font-family:Arial; color:#FF6600'>&nbsp;</span><span style='font-size:8.0pt;font-family:Arial; color:#333333'><o:p></o:p></span></p> </td> <td colspan=2 valign=top style='background:white;padding:0cm 0cm 0cm 0cm'> <div style='mso-element:para-border-div;border:solid #FF6600 1.0pt; padding:1.0pt 1.0pt 1.0pt 1.0pt'> <p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto; border:none;mso-border-alt:solid #FF6600 1.0pt;padding:0cm;mso-padding-alt: 1.0pt 1.0pt 1.0pt 1.0pt'><span style='font-size:8.0pt;font-family:Arial; color:#333333'>&nbsp;<o:p></o:p></span></p> </div> </td> </tr> </table> </form> <p>&nbsp;</p> </div> </body> </html>