Home Registration for the Leucan bereaved couples week-end

Registration for the Leucan bereaved couples week-end

Auberge du Lac-à-l'Eau-Claire, Mauricie - April 22 to 24, 2022 - 75$ fee per adult
First name*
Last name*
Name of the deceased child*
Date of death*
MM slash DD slash YYYY
Telephone*
Email*
Have you moved in the past 6 months? If so, please provide us with your new address so we can update your file
Have you participated in that week-end before?
Do you need financial support to cover the cost of the activity ($75 per adult, for a total of $150) or for travel expenses (gas card)?
- Yes
- No
Since you will be given a choice of activities to attend to during the week-end, are there any particular subjects you would find important to discuss during your stay?
To take part in this week-end, at least one member of your couple must participate in one of the activities offered throughout the stay
- I confirm that we will be attending one of the activities

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