Family name

First name

Street

Zip code/ town

Phone number (private)

Phone number (office)

E-mail:

Mobil:

Nationality:

since
when in Switzerland?:

Children:

Date of birth:

Name

Date

Name

Date

Name

Date

Name

Date

Allergies or disabilities

Pets

Public transportation

Tram/Bus number

Tram/Bus stop:

others:

I am member of the Swiss Red Cross Basle Cantonal Association

Yes

No? I apply for a membership here.

Remarks