Respite stay, courtesy of Fairmont Château Montebello

Before completing this form, please consult the Fairmont Château Montebello availability calendar by clicking here.

Registration form – « Une histoire de coeur » between Le Fairmont Château Montebello and Leucan

Please be sure to to indicate three date options included in the availability calendar.

Your name(Required)

First name Last name

Your email(Required)

Your phone number(Required)

Name of your deceased child(Required)

Date of death(Required)

How many times have you taken part in this stay?(Required)

Participants

Please enter the age group and full names of each participant, including yourself.

Number of adults (anyone aged 18 or over) who will be attending the stay(Required)

Number of children aged between 0 and 17 who will be attending the stay(Required)

Name

First name Last name

Age

Name

First name Last name

Age

Name

First name Last name

Age

Name

First name Last name

Age

Name

First name Last name

Age

Name

First name Last name

Age

Name

First name Last name

Age

Name

First name Last name

Age

Date selection

Please indicate in order of priority the date of arrival of your choice and the number of nights (1 to 2 consecutive nights). If you have to do more than 500 km (one way), an additional overnightnight stay is offered.

First choice(Required)

Number of overnight stays(Required)

Second choice(Required)

Number of overnight stays(Required)

Third choice(Required)

Number of overnight stays(Required)

I, the undersigned, (name of the participant) accept the terms and conditions of this activity on behalf of the family members listed above.(Required)

First name Last name