ࡱ                >  	                        (                {	                  bjbjzz                   Z   E      N                                                               f      f                                                         8                 V  x     >  ^$     n$      n$      n$      &  @  /)  L  {*     T     T      T      T      T      T      T  $   W    6Z     U                           #+                      &  @   &      #+      #+      U                          n$              n$  A  U     7      7      7      #+          n$            n$      T              7                                                      #+      T              7      7  R  wQ                                                                             WT      n$          `#            0      kR             T     U  0   V      R    Z      0  R  Z  <   WT                                                                              Z                    WT     #+      #+      7      #+      #+                                      #+      #+      #+      U      U                                      6                                     #+      #+      #+      V      #+      #+      #+      #+                                                                                          Z      #+      #+      #+      #+      #+      #+                                                              #+      #+      #+      f  $    :                                                                                                                                                                                                                                                                                                                                                                                                                                           PREUVE DU SINISTREASSURANCE CONTRE LES ACCIDENTS DU SPORTSSQ, Socit dassurance inc.Bien rpondre  toutes les questions, cest nous aider  mieux vous servir.Directives.  Le bless doit remplir la Dclaration de lassur頻, le grant de lquipe ou ladministrateur, la Dclaration du responsable du club, et le mdecin traitant, la Dclaration du mdecin traitant, qui se trouve  la page 2. Important.  Sil sagit de soins dentaires, il faut remplir le formulaire Soins dentaires en cas daccident du sport. Lassur doit tout dabord envoyer sa demande  lassureur de tout autre rgime dassurance maladie; si les frais ne sont pas rembourss intgralement, il fait alors parvenir  SSQ, Socit dassurance inc. tous les Relevs de prestations. Conservez une copie des factures de soins mdicaux, car nous ne vous retournerons pas loriginal.Nota  Vous pouvez remplir le formulaire au stylo (en majuscules).  Il faut cependant que TOUTES les parties signent et datent l'ORIGINAL avant que vous ne l'envoyiez, en y joignant les factures ORIGINALES,  lun des bureaux suivants de SSQ, Socit dassurance inc.:2020, rue University, bureau 1800, Montral (Qubec) H3A 2A5SSQ Place, 110, avenue Sheppard est, bureau 500, Toronto (Ontario)  M2N 6Y8800 - 6th Avenue S.W., suite 650, Calgary (Alberta) T2P 3G3Nous nacceptons pas les copies, les tlcopies et les courriels.Dclaration de lassur Police n FORMTEXT                                                                                   1 .       N o m   e t   p r  n o m   d e   l  a s s u r      F O R M T E X T            2 .     D a t e   d e   n a i s s a n c e  J      F O R M T E X T                    M      F O R M T E X T                    A      F O R M T E X T            3 .       S  i l   s  a g i t   d  u n   m i n e u r ,   n o m   e t   p r  n o m   d  u n   d e s   p a r e n t s   o u   d u   t u t e u r     F O R M T E X T             4 .       P r o f e s s i o n   d e   l  a s s u r  ,   o u t r e   s e s   a c t i v i t  s   s p o r t i v e s     F O R M T E X T             5 .       E m p l o y e u r     F O R M T E X T                         A d r e s s e         F O R M T E X T                                                                     R u e                                                                                                                                                                                 V i l l e                                                                                                       P r o v i n c e                                                         C o d e   p o s t a l   6 .       N o m   d e   l   q u i p e     F O R M T E X T            7 .       S p o r t     F O R M T E X T             8 .       D a t e   d e   l  a c c i d e n t  J      F O R M T E X T                    M      F O R M T E X T                    A        F O R M T E X T           9 .     D a t e   d u   p r e m i e r   t r a i t e m e n t  J      F O R M T E X T                    M      F O R M T E X T                    A      F O R M T E X T            1 0 .     L i e u   d e   l  a c c i d e n t     F O R M T E X T             1 1 .     L  a c c i d e n t   s  e s t   p r o d u i t   p e n d a n t   u n e        F O R M C H E C K B O X         p r a t i q u e ,   u n e      F O R M C H E C K B O X         p a r t i e   o u   u n      F O R M C H E C K B O X         d  p l a c e m e n t   a u t o r i s  s                   D a t e   d e   d  p a r t   ( d e   l a   p r o v i n c e   d e   r  s i d e n c e )    J      F O R M T E X T                    M      F O R M T E X T                    A        F O R M T E X T           D a t e   d e   r e t o u r   ( d a n s   l a   p r o v i n c e   d e   r  s i d e n c e )  J      F O R M T E X T                    M      F O R M T E X T                    A      F O R M T E X T            1 2 .     D e s c r i p t i o n   d e   l a   b l e s s u r e     F O R M T E X T             1 3 .     D e s c r i p t i o n   d  t a i l l  e   d e   l  a c c i d e n t     F O R M T E X T                F O R M T E X T             1 4 .     N o m   e t   p r  n o m   d u   m  d e c i n   t r a i t a n t     F O R M T E X T                           A d r e s s e         F O R M T E X T                                                                         R u e                                                                                                                                                                             V i l l e                                                                                                     P r o v i n c e                                                           C o d e   p o s t a l   1 5 .     N o m ,   p r  n o m   e t   a d r e s s e   d e s   a u t r e s   m  d e c i n s   t r a i t a n t s     F O R M T E X T                F O R M T E X T             1 6 .     N o m   d e   l  h  p i t a l     F O R M T E X T            1 7 .     D a t e   d e   l  h o s p i t a l i s a t i o n  J      F O R M T E X T                    M      F O R M T E X T                    A      F O R M T E X T            1 8 .     A u t r e s   a s s u r a n c e s   h o s p i t a l i s a t i o n   o u   m a l a d i e        F O R M C H E C K B O X         O u i              F O R M C H E C K B O X         N o n  N o m   d u   r  g i m e / p o l i c e   n      F O R M T E X T             J  a t t e s t e   q u e ,      m a   c o n n a i s s a n c e ,   l e s   r e n s e i g n e m e n t s   p r  c  d e n t s   s o n t   e x a c t s   e t   c o m p l e t s .    (      F O R M T E X T             )            F O R M T E X T            J      F O R M T E X T                    M      F O R M T E X T                    A      F O R M T E X T            S i g n a t u r e   d u   b l e s s    o u ,   s  i l   e s t   m i n e u r ,   d  u n   d e s   p a r e n t s   o u   d u   t u t e u r  T  l  p h o n e  D a t e   A d r e s s e     F O R M T E X T                                                           R u e                                                                                                                                   Ville                                                   Province                            Code postalVeuillez joindre au prsent formulaire dment rempli lAutorisation de collecte, dutilisation et de divulgation de renseignement personnels.Dclaration du responsable du club1.   Nom de lquipe FORMTEXT                                                                                                                                           2 .       P o l i c e   n      F O R M T E X T             3 .       N o m   d e   l a   l i g u e   o u   d e   l  a s s o c i a t i o n     F O R M T E X T             4 .       S p o r t     F O R M T E X T            5 .     D a t e      l a q u e l l e   l e   j o u e u r   s  e s t   j o i n t      l   q u i p e  J      F O R M T E X T                    M      F O R M T E X T                    A      F O R M T E X T         6.   Jouait-il de faon rgulire au moment de laccident?                 FORMCHECKBOX  Oui       FORMCHECKBOX   Non7.   La blessure sest-elle produite pendant une activit autorise?    FORMCHECKBOX  Oui       FORMCHECKBOX   Non      Dans laffirmative, il sagit dune   FORMCHECKBOX  pratique, dune  FORMCHECKBOX  partie ou dun  FORMCHECKBOX  dplacement autoriss FORMTEXT                                                                                                           =  >  ?  ]  ^  _  `    	  	  	  	  
  Ͼqd\F3F3F3                  $h( hE CJ OJ QJ ^J mHsH *h( hE 5CJ OJ QJ \^J mHsH hqO hqO <hqO hK OJ QJ ^J  #hqO hK 5CJ ^J aJ nHtH hqO hK CJ ^J aJ nHtH  hqO hK CJ ^J aJ nHtH 0j    hqO hK CJ U^J aJ mH nH tHu  hqO hK CJ ^J aJ mHsH  hqO hK CJ ^J aJ mHsH hqO hK ^J mH	sH	 $j    hqO hj U^J mH nH u       =  ^  _  `                                                    R            M            C                       
 ( ( $If      gdqO  a  kd    $$If   F t0   *                                  
t  *6                          4   4 
l al p                ytqO   d      $If   ]gdqO l                 d  $If   ]gdqO l                 $If   gdK l                  	  n  |      B                                                                                            _            U                         
 < ( $If   {  kdp   $$If   l 4                    0  +<* &                         
t  0                                      C*6                           4 
l ae f4 $If    m   $If   ^m gd(   ( $If    ( $If    	
  
  
    m  n  u  \  v  y  |  ~            ǲǠ}iT?T*?T(h( hK CJ OJ QJ ^J aJ mHsH (h( hgx< CJ OJ QJ ^J aJ mHsH (h( hE CJ OJ QJ ^J aJ mHsH &h( hVO 5CJ OJ QJ \^J aJ  &h( hK 5CJ OJ QJ \^J aJ  h( hE CJ OJ QJ ^J  "h( hE 5CJ OJ QJ \^J  (h( hE @CJ OJ QJ ^J mHsH $h( hE CJ OJ QJ ^J mHsH $h( hgx< CJ OJ QJ ^J mHsH $h( hK CJ OJ QJ ^J mHsH              	      $  A  B        ss]K6                             (h( hE CJ OJ QJ ^J aJ mHsH "h( hE 5CJ OJ QJ \^J  *h( hE 5CJ OJ QJ \^J mHsH (h( hlH CJ OJ QJ ^J aJ mHsH "h.- CJ OJ QJ ^J aJ mHsH (h? hE CJ OJ QJ ^J aJ mHsH "h? CJ OJ QJ ^J aJ mHsH (h? h? CJ OJ QJ ^J aJ mHsH (h( hE CJ OJ QJ ^J aJ mHsH (h( hgx< CJ OJ QJ ^J aJ mHsH          N  v                                      Q            K            <                             $&d If   P      $If      kd  $$If   l 4\ <*                	               '               
            	 
t  
      C*6                                                    4 
l ae f4p
         ( $&d If   P      $( $If   a$  ( $If                   
        N  P  d  ׿wdU>d                                                       -j    h( hE CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  $h( hE CJ OJ QJ ^J mH	sH	 0j    h= 5OJ QJ U\^J mH nH sH	u 5j+  h( hE 5OJ QJ U\^J mH	sH	&h( hE 5OJ QJ \^J mH	sH	 /j    h( hE 5OJ QJ U\^J mH	sH	.h( hE 5CJ OJ QJ \^J aJ mH	sH	  h( hE CJ OJ QJ ^J aJ d  f  h  r  t  v                              ζΣnXnBnn                                 *j    h= CJ OJ QJ U^J mH nH u +j  h( hE CJ OJ QJ U^J %j    h( hE CJ OJ QJ U^J $h( hE CJ OJ QJ ^J mH	sH	 h( hE CJ OJ QJ ^J  $h( hE CJ OJ QJ ^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3je  h( hE CJ OJ QJ U^J mH	sH	 v    ,  .                              m            e                                                                                                                                           ( $If   z  kd;  $$If   l 4K\ 	&"<* 	                                                                 
t  C*6                                                    4 
l ae f4   $&d If   P    	  $$If   a$                          (  *  .        ֭iQBB                                           h( hE CJ OJ QJ ^J  .j    h= CJ OJ QJ U^J mH nH sH	u 3j  h( hE CJ OJ QJ U^J mH	sH	-j    h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 $h( hE CJ OJ QJ ^J mH	sH	 *j    h= CJ OJ QJ U^J mH nH u %j    h( hE CJ OJ QJ U^J +jO  h( hE CJ OJ QJ U^J            b  d  x  z  |                ֱmUB                                                $h( hE CJ OJ QJ ^J mHsH .j    h= CJ OJ QJ U^J mH nH sH	u 3j  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 -j    h( hE CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  *j    h= CJ OJ QJ U^J mH nH u %j    h( hE CJ OJ QJ U^J +j  h( hE CJ OJ QJ U^J      b                                            B                                                                   T  kd)  $$If   l 4=0 <*                                  
t  C*6                            4 
l ae f4   $&d If   P      $If   T  kdH  $$If   l 4=0 Q<* X                                 
t  C*6                            4 
l ae f4                 
                
       "  ,  .  F  H  \  ζΣΣvζΣgXΣ>ζΣΣ3j  h( hE CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  h( hE CJ OJ QJ ^J  3jw  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mHsH $h( hE CJ OJ QJ ^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3j  h( hE CJ OJ QJ U^J mH	sH	                                               |                                                                                                                                                                                               $&d If   P    	  $If   gdoSs T  kd
  $$If   l 4=0 <*                  7%                
t  C*6                            4 
l ae f4  $&d 'd If   P    Q               0  F  n                          b            \            M            D            M                         	  $$If   a$   $&d If   P      $If   A  kd^  $$If   l 4  <*C*                
t  C*6                4 
l ae f4   $If   T  kd  $$If   l 4n0 7<*>                 &                
t  C*6                            4 
l ae f4 \  ^  `  j  l  p                                        ζΣΣgζΣΣMζ΁Σ                              3j
  h( hE CJ OJ QJ U^J mH	sH	3j&
  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 h( hE CJ OJ QJ ^J  $h( hE CJ OJ QJ ^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3j'	  h( hE CJ OJ QJ U^J mH	sH	 n  p    ,  j                            p            g            p                                                                                                                                 	  $$If   a$   $&d If   P      $If   z  kd	  $$If   l 4=\ <*                                   8                 J                
t  C*6                                                    4 
l ae f4        (  *  ,  j  n  p                                ζΣ΁gζΣ΁MζΣ΁                                   3j  h( hE CJ OJ QJ U^J mH	sH	3jn  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 h( hE CJ OJ QJ ^J  $h( hE CJ OJ QJ ^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3j  h( hE CJ OJ QJ U^J mH	sH	               &  (  <  >  @  J  L  P        ζΣΐgζΐPA                                         h( hE CJ OJ QJ ^J  -j    h( hE CJ OJ QJ U^J mH	sH	3jI  h( hE CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  $h( hE CJ OJ QJ ^J mH	sH	 $h( hE CJ OJ QJ ^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3jV  h( hE CJ OJ QJ U^J mH	sH	     &  N              y            j                                                                                                                                                                            $&d If   P     	!V $If   z  kd  $$If   l 4=\ xL~"<*                                   2                                 
t  C*6                                                    4 
l ae f4 N  P  z  |    t                            \            R            C            :                      	  $$If   a$   $&d If   P    
   Y $If   A  kd  $$If   l 4= <* C*                
t  C*6                4 
l ae f4  !V  $If   T  kd  $$If   l 4=0 x<*                  "                
t  C*6                            4 
l ae f4                 
  (  *  F  H  J              οοΰο|ΰm\I                                               $h( hE CJ OJ QJ ^J mH	sH	  h( hE @CJ OJ QJ ^J  h( h!y CJ OJ QJ ^J  3j  h= h= CJ OJ QJ U^J mH	sH	3j  h= h= CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  h( hE CJ OJ QJ ^J  -j    h( hE CJ OJ QJ U^J mH	sH	3j,  h= h= CJ OJ QJ U^J mH	sH	           
          2  4  6  :  <  N  P  d  f  h  p  r  t    ջՐv\K                                h( hE @CJ OJ QJ ^J  3j  h( hE CJ OJ QJ U^J mH	sH	3jQ  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sH	u 3j  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 -j    h( hE CJ OJ QJ U^J mH	sH	                                $  &  6  8  L  N  P  X  ˴o˴Uo˴;o    3j  h( hE CJ OJ QJ U^J mH	sH	3j  h( hE CJ OJ QJ U^J mH	sH	.j    h= CJ OJ QJ U^J mH nH sH	u 3j/  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 -j    h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	  h( hE @CJ OJ QJ ^J   h( hgx< @CJ OJ QJ ^J X  Z  \  ^                    0  2  4  >  @  D  F  Z  \  ^  h  j        ³賙gM               3j  h( hE CJ OJ QJ U^J mH	sH	3j#  h( hE CJ OJ QJ U^J mH	sH	.j    h= CJ OJ QJ U^J mH nH sH	u 3j@  h( hE CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  $h( hgx< CJ OJ QJ ^J mH	sH	 $h( hE CJ OJ QJ ^J mH	sH	 -j    h( hE CJ OJ QJ U^J mH	sH	   \  ^                  [            O            8                                                      $&d 'd If   P    Q     	!V $If     kd  $$If   l 4 \ E#<*                                   5                                 
t  C*6                                                    2  2   2 29 2 2  4 
l ae f4   $&d If   P           B  D  l                                      B                                                                   T  kd  $$If   l 4=0 <*                                  
t  C*6                            4 
l ae f4   $&d If   P      $If   T  kd  $$If   l 40 	<* 	                                  
t  C*6                            4 
l ae f4 l  n          0                                      M                        >                                 $&d If   P    T  kdV  $$If   l 4=0 <*                                  
t  C*6                            4 
l ae f4  $&d 'd If   P    Q      $If   A  kd|  $$If   l 4  g<* (                
t  C*6n              4 
l ae f4               
       "  ,  .  0  2  ζΧ}c}K}8                                      $h( hE CJ OJ QJ ^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sHu 3j  h( hE CJ OJ QJ U^J mHsH-j    h( hE CJ OJ QJ U^J mHsH$h( hE CJ OJ QJ ^J mHsH h( hE CJ OJ QJ ^J  .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3j  h( hE CJ OJ QJ U^J mH	sH	 0  2      f                            d                        M                                                                               $&d 'd If   P    Q    A  kd  $$If   l 4  <*C*                
t  C*6                4 
l ae f4  $If   T  kd9  $$If   l 4 0 <*                  %                
t  C*6                            4 
l ae f4 2      f  h  |  ~                                   
    ϸsYsϸ?s  3j  h( hE CJ OJ QJ U^J mH	sH	3j  h( hE CJ OJ QJ U^J mH	sH	.j    h= CJ OJ QJ U^J mH nH sH	u 3j  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 -j    h( hE CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  h( hE CJ OJ QJ ^J  $h( hE CJ OJ QJ ^J mHsH            L                            [            O                        F                                         	  $$If   a$ 	!V $If   A  kd^  $$If   l 4  g<* (                
t  C*6n              4 
l ae f4   $&d If   P    T  kd{  $$If   l 4=0 <*                                  
t  C*6                            4 
l ae f4     L  P  R  f  h  j  n  p                                  >  ˴횴˴h˴N                      3j   h( hE CJ OJ QJ U^J mH	sH	3j  h( hE CJ OJ QJ U^J mH	sH	.j    h= CJ OJ QJ U^J mH nH sH	u 3j8  h( hE CJ OJ QJ U^J mH	sH	-j    h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 h( hE CJ OJ QJ ^J  $h( hE CJ OJ QJ ^J mH	sH	                                  v            g                                                                                                                                                     $&d If   P    	  $$If   a$  $If   z  kd  $$If   l 4=\ F~"<*                  a                 8
                                 
t  C*6                                                    4 
l ae f4 >  @  \  ^  `  t  v                                ݱݚmUC                         "h( hE 5CJ OJ QJ \^J  .j    h= CJ OJ QJ U^J mH nH sH	u 3j  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 -j    h( hE CJ OJ QJ U^J mH	sH	+j  h= h= CJ OJ QJ U^J +j  h= h= CJ OJ QJ U^J h( hE CJ OJ QJ ^J  %j    h( hE CJ OJ QJ U^J                                       K            8            8                                      V $&d If   P    A  kd  $$If   l 4  <* C*                
t  C*6                4 
l ae f4 	!V $If   g  kdu  $$If   l 4=F <*                                                   
t  C*6                                        4 
l ae f4                         
               (   *   ,   0   2   B   D   X   ζΣΣsζ΍`ΣFζ`Σ                     3j;  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 3j  h( hE CJ OJ QJ U^J mH	sH	*h( hE 5CJ OJ QJ \^J mH	sH	 $h( hE CJ OJ QJ ^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3jO  h( hE CJ OJ QJ U^J mH	sH	 X   Z   \   `   b   r   t                        &!  (!  F!  H!  X!  Z!  n!  ζΣΐvζΣ`Q?Q?Qΐ                      "h( hE 5CJ OJ QJ \^J  h( hE CJ OJ QJ ^J  *h( hE 5CJ OJ QJ \^J mH	sH	 3j#   h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 $h( hE CJ OJ QJ ^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3j  h( hE CJ OJ QJ U^J mH	sH	          (!  <!  F!                          {            {            {                                                                                                                                                                           V ( ( $If   g  kd   $$If   l 4KF ~"<*                                                   
t  C*6                                        4 
l ae f4   $&d If   P     F!  H!  X!  !  !                                      /                                  T  kd!  $$If   l 4=0 d<* k                 &                
t  C*6                            4 
l ae f4   $&d If   P      $If   g  kd!  $$If   l 4 F ~"<*                                                   
t  C*6                                        4 
l ae f4 n!  p!  r!  |!  ~!  !  !  !  "  3#  4#  6#  Y#  ζΣo[J5                                          (h( hE CJ OJ QJ ^J aJ mHsH  h( hE CJ OJ QJ ^J aJ  &h( hE 5CJ OJ QJ \^J aJ  *h( hE 5@CJ OJ QJ \^J aJ  h( h!y CJ OJ QJ ^J  h( hE CJ OJ QJ ^J  $h( hE CJ OJ QJ ^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3j!  h( hE CJ OJ QJ U^J mH	sH	 !  "  "  3#  4#  5#                                      W            O                                                                                    $If    P  kd"  $$If   l 4 <*C*                	 
t  
      C*6                4 
l ae f4p
        $$If   a$gd* A  kdf"  $$If   l 4  <*C*                
t  C*6                4 
l ae f4
   ( $If    5#  6#  Y#  Z#  [#  p#                                      B            <                                             $If    c  kd#  $$If   l 40 `<*g                            	 
t  
      C*6                            4 
l ae f4p
        ( $If   gdE  < ( $If   gdE A  kdC#  $$If   l 4P  <*C*                
t  C*6                4 
l ae f4 Y#  [#  p#  q#  {#  |#   $  
$  $  $  ,$  .$  B$  D$  F$  ƳƁƳkQk4Q                              9j$  h( hE 5CJ OJ QJ U\^J mH	sH	3j    h( hE 5CJ OJ QJ U\^J mH	sH	*h( hE 5CJ OJ QJ \^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sH	u 3j<$  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 -j    h( hE CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  &h( hE 5CJ OJ QJ \^J aJ p#  $  ,$  T$  V$  $  $                                      m            g                                                                                                                              $If   z  kd(%  $$If   l 4)\ ~"<*                                                                    
t  C*6                                                    4 
l ae f4	  $$If   a$   $&d If   P     F$  P$  R$  T$  V$  $  $  $  $  $  $  $  $  $  $   %  %  %  %  ˵|b|J||0|J|  3j&  h( hE CJ OJ QJ U^J mH	sH	.j    h= CJ OJ QJ U^J mH nH sH	u 3j%  h( hE CJ OJ QJ U^J mH	sH	-j    h( hE CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  $h( hE CJ OJ QJ ^J mH	sH	 *h( hE 5CJ OJ QJ \^J mH	sH	 3j    h( hE 5CJ OJ QJ U\^J mH	sH	4j    h= 5CJ OJ QJ U\^J mH nH sH	u$  $  $  %  z%  &                                                                                                                                                                                                                                                               	  $$If   a$   $&d If   P      $If   T  kd'&  $$If   l 4 0 &<* -                                 
t  C*6                            4 
l ae f4 %  %  z%  ~%  %  %  %  %  %  %  %  %  %  %  %  %  %  %  %  %  %  %   &  &  &  &  M&  ˴횴˴h˴N                      3j'  h( hE CJ OJ QJ U^J mH	sH	3j~'  h( hE CJ OJ QJ U^J mH	sH	.j    h= CJ OJ QJ U^J mH nH sH	u 3j
'  h( hE CJ OJ QJ U^J mH	sH	-j    h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 h( hE CJ OJ QJ ^J  $h( hE CJ OJ QJ ^J mH	sH	&  &  &  &  &              w            6            w                                                A  kd)  $$If   l 4  <* C*                
t  C*6                4 
l ae f4  !V  $If   z  kd\(  $$If   l 4 \ `~"<*                                                                    
t  C*6                                                    4 
l ae f4 M&  N&  \&  ]&  ^&  _&  h&  i&  w&  x&  y&  &  &  &  &  &  &  &  &  &  &  &  %'  &'  4'  5'  6'  7'  G'  ٿٰٖ|ٰbHٰ3js+  h= h= CJ OJ QJ U^J mH	sH	3j*  h= h= CJ OJ QJ U^J mH	sH	3j,*  h= h= CJ OJ QJ U^J mH	sH	3jY)  h= h= CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  3j(  h= h= CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  -j    h( hE CJ OJ QJ U^J mH	sH	 &  &  '  '  '    6                          m            ^            ^            ^                                                                                                 $&d If   P    A  kd,  $$If   l 4  <* C*                
t  C*6                4 
l ae f4  !V  ( $If   A  kd+  $$If   l 4  <* C*                
t  C*6                4 
l ae f4 G'  H'  V'  W'  X'  h'  i'  w'  x'  y'  '  '  '  '   (     
        $  ٿٖlRP8ll        .j    h= CJ OJ QJ U^J mH nH sH	u U3j.-  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 -j    h( hE CJ OJ QJ U^J mH	sH	3j[,  h= h= CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  3j+  h= h= CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  -j    h( hE CJ OJ QJ U^J mH	sH	           F O R M T E X T             S i g n a t a i r e   a u t o r i s   N o m   ( e n   m a j u s c u l e s )  T i t r e   o u   p o s t e   o f f i c i e l   A d r e s s e         F O R M T E X T                                                           R u e                                                                                                                                                                             V i l l e                                                                                                       P r o v i n c e                                                                       C o d e   p o s t a l   T  l  p h o n e  (      F O R M T E X T             )        F O R M T E X T            D a t e  J      F O R M T E X T                      M      F O R M T E X T                    A        F O R M T E X T            D  c l a r a t i o n   d u   m  d e c i n   t r a i t a n t  P a g e   2  P o l i c e   n      F O R M T E X T              1 .       N o m   d u   p a t i e n t     F O R M T E X T            2 .      g e     F O R M T E X T            3 .       D i a g n o s t i c   d e   l  a f f e c t i o n   a c t u e l l e     F O R M T E X T                         a )     P r i n c i p a l     F O R M T E X T                         b )     S e c o n d a i r e   ( l e   c a s    c h  a n t )     F O R M T E X T             4 .       D a t e   d e s   e x a m e n s  J      F O R M T E X T                    M      F O R M T E X T                    A      F O R M T E X T            J      F O R M T E X T                    M      F O R M T E X T                    A      F O R M T E X T            J      F O R M T E X T                    M      F O R M T E X T                    A      F O R M T E X T            J      F O R M T E X T                    M      F O R M T E X T                    A      F O R M T E X T            5 .          v o t r e   c o n n a i s s a n c e  :               a )     Q u e l l e   e s t   l a   d a t e   d e   l  a c c i d e n t   o u   d e   l  a p p a r i t i o n   d e s   s y m p t  m e s ?  J      F O R M T E X T                        M      F O R M T E X T                      A        F O R M T E X T                        b )     L e   p a t i e n t   a - t - i l   d  j    p r  s e n t    u n e   a f f e c t i o n   d e   c e t t e   n a t u r e ?                F O R M C H E C K B O X         O u i                F O R M C H E C K B O X         N o n                         D a n s   l ' a f f i r m a t i v e ,   d o n n e z   l a   d a t e   e t   p r  c i s e z .     F O R M T E X T                F O R M T E X T             6 .       N o m   d e   l  h  p i t a l ,   s  i l   y   a   l i e u     F O R M T E X T                         D a t e   d  a d m i s s i o n  J      F O R M T E X T                    M      F O R M T E X T                    A      F O R M T E X T           H e u r e     F O R M T E X T                         D a t e   d e   s o r t i e  J      F O R M T E X T                    M      F O R M T E X T                    A      F O R M T E X T           H e u r e     F O R M T E X T             7 .       N a t u r e   d e   l  o p  r a t i o n ,   s  i l   y   a   l i e u     F O R M T E X T                F O R M T E X T             8 .       N o m   d u   m  d e c i n   q u i   v o u s   a   a d r e s s    l e   p a t i e n t     F O R M T E X T             9 .       E n v o i   d u   p a t i e n t   c h e z   u n   s p  c i a l i s t e                                  F O R M C H E C K B O X       O u i              F O R M C H E C K B O X       N o n               D a n s   l ' a f f i r m a t i v e ,   p r  c i s e z .     F O R M T E X T                F O R M T E X T             1 0 .     E n v o i   d u   p a t i e n t   c h e z   u n   p h y s i o t h  r a p e u t e            F O R M C H E C K B O X       O u i              F O R M C H E C K B O X       N o n  D a n s   l ' a f f i r m a t i v e ,   d o n n e z   l a   d a t e .  J      F O R M T E X T                    M      F O R M T E X T                    A      F O R M T E X T                          D u r  e   e t   f r  q u e n c e   d u   t r a i t e m e n t     F O R M T E X T               N o m   d u   m  d e c i n   ( e n   m a j u s c u l e s )     F O R M T E X T            S i g n a t u r e    A d r e s s e         F O R M T E X T                                                         R u e                                                                                                                                                                           V i l l e                                                                                                       P r o v i n c e                                                                       C o d e   p o s t a l   T  l  p h o n e  (      F O R M T E X T             )        F O R M T E X T            D a t e  J      F O R M T E X T                    M      F O R M T E X T                    A      F O R M T E X T               I l   i n c o m b e   a u   p a t i e n t   d e   f a i r e   r e m p l i r   c e   f o r m u l a i r e ,   l e s   f r a i s    t a n t      s a   c h a r g e .                        P A G E            P r e u v e   d u   s i n i s t r e      a c c i d e n t s   d u   s p o r t   ( 2 0 1 2 . 0 8 )                                                                                                                                 $  &  (  2  4  6  8  ^  `      ΐ  А                В  Ғ    ζΣ~l~l~ΣRζΣC~~                    h( hE CJ OJ QJ ^J  3j/  h( hE CJ OJ QJ U^J mH	sH	"h( hE 5CJ OJ QJ \^J  h( hE CJ OJ QJ ^J  *h( hE 5CJ OJ QJ \^J mH	sH	 $h( hE CJ OJ QJ ^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3j-  h( hE CJ OJ QJ U^J mH	sH	 6  8  `                                                                                                                                                                                                                                                                    V ( ( $If   g  kd.  $$If   l 4)F L|<* S                 0                                 
t  C*6                                        4 
l ae f4     ΐ                                          /                                  T  kd/  $$If   l 4 0 d<* k                 &                
t  C*6                            4 
l ae f4   $&d If   P      $If   g  kd.  $$If   l 4 F L|<* S                 0                                 
t  C*6                                        4 
l ae f4       ̒  $  .                                                                                                                                                                                                                                        $&d If   P    	  $$If   a$   V  $&d If   P      $If   A  kd/  $$If   l 4  <* C*                
t  C*6                4 
l ae f4   $If                             "  $  .  2  4  H  J  L  P  R  d  f  z  ζΧΧ{ζΕlΧRζlΧ                                        3j21  h( hE CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  3j0  h( hE CJ OJ QJ U^J mH	sH	"h( hE 5CJ OJ QJ \^J  h( hE CJ OJ QJ ^J  .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3jR0  h( hE CJ OJ QJ U^J mH	sH	 z  |  ~                               "  ζΧΘ~ζΧl[A                                         3j    h( hE 5CJ OJ QJ U\^J mH	sH	 h( hE OJ QJ ^J mHsH "h( hE 5CJ OJ QJ \^J  3j2  h( hE CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  h( hE CJ OJ QJ ^J  .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3j1  h( hE CJ OJ QJ U^J mH	sH	            H              }            r            l            ]                                                                                                                $&d If   P     $If     $( $If   a$  ( $If   z  kd2  $$If   l 4 \ D~"<*                  v                 :                                 
t  C*6                                                    4 
l ae f4 "  6  8  :  D  F  H  J  L  t  v        ͳo`Io/I                         3j94  h( hE CJ OJ QJ U^J mH	sH	-j    h( hE CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  $h( hE CJ OJ QJ ^J mH	sH	 *h( hE 5CJ OJ QJ \^J mH	sH	 4j    h= 5CJ OJ QJ U\^J mH nH sH	u 3j    h( hE 5CJ OJ QJ U\^J mH	sH	9j3  h( hE 5CJ OJ QJ U\^J mH	sH	*h( hE 5CJ OJ QJ \^J mH	sH	H  J  L  t      Ҕ  u            j            d            U            L            U                                                          	  $$If   a$   $&d If   P      $If    
 ! $If      kd3  $$If   l 4h\ ")                
                                            	 
t  
      C*6  i                                                 4 
l ae f4p
                       Ĕ  Ɣ  Δ  Д  Ԕ  $  &  :  <  >  H  J  v  x                    ѾѾѾѾhѾѾNѾѾ  3j6  h( hE CJ OJ QJ U^J mH	sH	3j5  h( hE CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  3j4  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mHsH $h( hE CJ OJ QJ ^J mH	sH	 -j    h( hE CJ OJ QJ U^J mH	sH	.j    h= CJ OJ QJ U^J mH nH sH	uҔ  Ԕ  $  L                          p                                                                                                                                                                                        $&d If   P      $If   z  kd5  $$If   l 4\ Q%)                                                                    
t  C*6  i                                                 4 
l ae f4 L  N  v                                              @                                                          T  kd6  $$If   l 4=0 )                  $                
t  C*6  i                         4 
l ae f4   $&d If   P      ( $If   T  kd6  $$If   l 4h0 )                  O                
t  C*6  i                         4 
l ae f4             B  F  H  \  ^  `  d  f  v  x                  ζΣΣgζ΁ΣMζ΁Σ                                   3j8  h( hE CJ OJ QJ U^J mH	sH	3j38  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 h( hE CJ OJ QJ ^J  $h( hE CJ OJ QJ ^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3j\7  h( hE CJ OJ QJ U^J mH	sH	     B  ̖  Ζ  X  Z      p                                                                                                                                                                                                                                                                $&d If   P      $If   T  kd7  $$If   l 4=0 
) 
                                 
t  C*6  i                         4 
l ae f4 	      Ȗ  ʖ  Җ  Ԗ                         "  2  4  H  J  L  T  V  ζΣΐvζΣΐ\ζΣΐBζ   3j:  h( hE CJ OJ QJ U^J mH	sH	3j:  h( hE CJ OJ QJ U^J mH	sH	3j9  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 $h( hE CJ OJ QJ ^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3j9  h( hE CJ OJ QJ U^J mH	sH	 V  ^  `  t  v  x  |  ~                    ԗ  ֗  ؗ                 é֑w֑]֑C3jY<  h( hE CJ OJ QJ U^J mH	sH	3j;  h( hE CJ OJ QJ U^J mH	sH	3jm;  h( hE CJ OJ QJ U^J mH	sH	.j    h= CJ OJ QJ U^J mH nH sH	u 3j:  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 -j    h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	    
      0  2  4  8  :  J  L  `  b  d  l  n  p  r  F  J  L  `  b  d  h  j  ~      ѾѫѾѫwѾhѫNѾѫ       3j>  h( hE CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  3jE=  h( hE CJ OJ QJ U^J mH	sH	3j<  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 $h( hE CJ OJ QJ ^J mH	sH	 -j    h( hE CJ OJ QJ U^J mH	sH	.j    h= CJ OJ QJ U^J mH nH sH	up  r    9            3                                                                              $If     kd=  $$If   l 4hִ t\!~")                                   =                                                   n                                   U                
t  C*6  i                                                                                                     4 
l ae f4     F  ؙ  ڙ  ܚ                                      S                                                                                                     T  kd#@  $$If   l 4 0 ^ e                 &                
t  C*6                          4 
l ae f4   $&d If   P      ( $If   A  kd|>  $$If   l 4h ) )                
t  C*6  i             4 
l ae f4               ș  ʙ  ̙  ԙ  ֙  ؙ  ڙ  v  x            ̚  ζΣΐvζΣggMgg                                             3j@  h= h= CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  3j?  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 $h( hE CJ OJ QJ ^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3jE?  h( hE CJ OJ QJ U^J mH	sH	 ̚  Κ  К  T  V  j  l  n  x  z  ~                      
          J  οάzάά`zάάFzά      3j|C  h( hE CJ OJ QJ U^J mH	sH	3jB  h( hE CJ OJ QJ U^J mH	sH	.j    h= CJ OJ QJ U^J mH nH sH	u 3jA  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 h( hE CJ OJ QJ ^J  -j    h( hE CJ OJ QJ U^J mH	sH	3jA  h= h= CJ OJ QJ U^J mH	sH	 ܚ  ޚ  T  |  ~                                        U                                                                                                         T  kdAB  $$If   l 4=0 )                                  
t  C*6  i                         4 
l ae f4   $&d If   P      $If   A  kdxA  $$If   l 4   &                
t  C*6              4 
l ae f4           J  Ԝ                                        U            M                        D                         	  $$If   a$  ( $If   T  kdC  $$If   l 4h0 
) 
                 N                
t  C*6  i                         4 
l ae f4   $&d If   P      $If   A  kdC  $$If   l 4= 8) '                
t  C*6?i             4 
l ae f4 J  N  P  d  f  h  l  n  ~                  Ĝ  Ɯ  Ȝ  М  Ҝ  Ԝ        ˱ڙڙeڙR                                   $h( hE CJ OJ QJ ^J mH	sH	 3j1E  h( hE CJ OJ QJ U^J mH	sH	3jD  h( hE CJ OJ QJ U^J mH	sH	.j    h= CJ OJ QJ U^J mH nH sH	u 3jSD  h( hE CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  -j    h( hE CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J           
  4  8  :  N  P  R  V  X  h  j  ~                ζΣΣgζ΁ΣMζ΁Σ                                   3jG  h( hE CJ OJ QJ U^J mH	sH	3jF  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 h( hE CJ OJ QJ ^J  $h( hE CJ OJ QJ ^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3jE  h( hE CJ OJ QJ U^J mH	sH	     
  4    ʝ                v            n                        e                                                                                                                        	  $$If   a$  ( $If   z  kdF  $$If   l 4 \ 1F[ 8                                  o                                 
t  C*6                                                  4 
l ae f4   $&d If   P                 ʝ  ̝              H  J  ^  `  b  l  n  r  t    ζΣ΁gζ΁΁Mζ΁΁                                   3jH  h( hE CJ OJ QJ U^J mH	sH	3jG  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 h( hE CJ OJ QJ ^J  $h( hE CJ OJ QJ ^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3jxG  h( hE CJ OJ QJ U^J mH	sH	     H  p              }            j                                                                                                                                                                            (  $&d If   P      ( $If   z  kdXH  $$If   l 4 \ 1F[ 8                                  o                                 
t  C*6                                                  4 
l ae f4 p  r         (                          [            U                                                                                                           $If   A  kd.J  $$If   l 4=  <* )                
t  C*6'              4 
l ae f4   $&d If   P    T  kdWI  $$If   l 4h0 )                  O                
t  C*6  i                         4 
l ae f4                        $  &  *            Ο  П        D  F  Z  ζΣΣzζΣΔ`ΔΔFΔΣ      3jK  h= h= CJ OJ QJ U^J mH	sH	3jiK  h= h= CJ OJ QJ U^J mH	sH	3jJ  h( hE CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  $h( hE CJ OJ QJ ^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3jI  h( hE CJ OJ QJ U^J mH	sH	 (  *      D  l                          b            \            M                                                                                $&d If   P      $If   A  kdQL  $$If   l 4h <* C*                
t  C*6                4 
l ae f4  ( $If   T  kdJ  $$If   l 4h0 <*                  =                
t  C*6                            4 
l ae f4 Z  \  ^  h  j  n  p                        0  2  N  P  R    ζΣΣζΣzz`zzFz                     3jN  h= h= CJ OJ QJ U^J mH	sH	3jUN  h= h= CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  3jM  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3jL  h( hE CJ OJ QJ U^J mH	sH	 l  n      \    .                          [            S            H                                                                $( $If   a$  ( $If   A  kdM  $$If   l 4=  <* )                
t  C*6'              4 
l ae f4   $&d If   P    T  kdM  $$If   l 4=0 M
<* T
                                 
t  C*6                            4 
l ae f4           ¡  ơ  ȡ  ء  ڡ              
       "  *  ,  .  0        é֑w֑]֑N                      h( hE CJ OJ QJ ^J  3j%P  h( hE CJ OJ QJ U^J mH	sH	3jO  h( hE CJ OJ QJ U^J mH	sH	.j    h= CJ OJ QJ U^J mH nH sH	u 3j=O  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 -j    h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	.  0                                              /                             T  kdtQ  $$If   l 4=0 <*                                  
t  C*6                            4 
l ae f4   $&d If   P      $If   g  kdP  $$If   l 4hF "<*                                   g                
t  C*6                                        4 
l ae f4                             *  ,  @  B  V  ζΣΣgζΣQ>Σ                              $h( hE CJ OJ QJ ^J mHsH *h( hE 5CJ OJ QJ \^J mH	sH	 3jNR  h( hE CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  $h( hE CJ
 OJ QJ ^J mH	sH	 $h( hE CJ OJ QJ ^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3j
Q  h( hE CJ OJ QJ U^J mH	sH	         (  *                                                                                                                                                                                                                                                                                             	  $$If   a$   $&d If   P    
  V $If   A  kdQ  $$If   l 4  <* C*              
t  C*6                4 
l ae f4 *  ,  @  h                          p                                                                                                                                                                                        $&d If   P      $If   z  kdR  $$If   l 4@\ M
Co<* T
                                  ,                                 
t  C*6                                                    4 
l ae f4 V  X  Z  d  f  j  &  >  @  T  V  X  ^  `  h  j  l                ζΣ΅kζ΅Y΅?ζY       3jT  h( hE CJ OJ QJ U^J mH	sH	"h( hE 5CJ OJ QJ \^J  3jT  h( hE CJ OJ QJ U^J mH	sH	h( hE CJ OJ QJ ^J  h( hE CJ OJ QJ ^J  $h( hE CJ OJ QJ ^J mH	sH	 .j    h= CJ OJ QJ U^J mH nH sH	u -j    h( hE CJ OJ QJ U^J mH	sH	3jMS  h( hE CJ OJ QJ U^J mH	sH	 h  j  $  &  :                              d                        Q            H                                                  	  $$If   a$   V $&d If   P    A  kd0T  $$If   l 4  <*C*                
t  C*6                4 
l ae f4  $If   T  kdS  $$If   l 4)0 <*                  &                
t  C*6                            4 
l ae f4                 Х  ҥ                       "  $  &  (  ,  .  é֑w֑]֑L                        h( hE OJ QJ ^J mH	sH	 3jWV  h( hE CJ OJ QJ U^J mH	sH	3jU  h( hE CJ OJ QJ U^J mH	sH	.j    h= CJ OJ QJ U^J mH nH sH	u 3joU  h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	 -j    h( hE CJ OJ QJ U^J mH	sH	$h( hE CJ OJ QJ ^J mH	sH	  &  (  *  ,              v            p            /                                  A  kdJW  $$If   l 4  <*C*              
t  C*6                4 
l ae f4  $If   z  kdV  $$If   l 4h\ -"<* 4                 S                 U                 g                
t  C*6                                                    4 
l ae f4   $&d If   P     ,  .  Ԧ  ֦  ئ  ڦ  ܦ  ަ                                                                                                                                                                                                                                                                                                                                        h]h   &`#$      x             $ @& a$gdgx<    $ a$ .  Ԧ                                     l  t  z  |  ~        ù{                                                                                                                hx2 CJ OJ QJ  h.- CJ OJ QJ  hK CJ OJ QJ  hx2 CJ OJ QJ  hx2 0J CJ OJ QJ  hx2  
hx2 0J  j    hx2 0J UhqO  j    hqO Uh( hgx< CJ OJ QJ ^J  "h( hE 5CJ OJ QJ \^J  h( hE 6OJ QJ ]^J         ~                                                                                                                                                                                                                                                                                                                                                                                                            x   $ $d N    a$gdgx<      h]h 
 &,  &#$ 5 0P / =!"&#h$%   MDp   FX  #=?iE5U JFIF  ` `  bExif  MM *                  b       j(       1       r2       i              '    'Adobe Photoshop CS4 Macintosh 2012:01:26 11:59:32               ʠ       5                          &(             .      ,       H      H    JFIF   H H   Adobe_CM  Adobe d     			
  * "   
?          	
         	
 3 !1AQa"q2B#$Rb34rC%Scs5&DTdE£t6UeuF'Vfv7GWgw 5 !1AQaq"2B#R3$brCScs4%&5DTdEU6teuFVfv'7GWgw   ? U}i ì;g!T@c?2kegE_~gc!}mz.%$$I)) m]-]c c5T #峧RqK\eO?[/^_6YW}Gu^foQsj\wis=:,q/ څXb[x{ME8>G[SX]3`?|vN?F};ob<,szgK.}r,O  ]f v~کh?]~lXF{I K %=.=2}chM77mKҺ?Xkzu= 4}v0|uAf.(ϱSO;^ EU_:슱	}nlǷZJ{ St,0qIk*peLpUْC H* Gf,ǇQdtE_lqwoH I<_@gDڭ=;{nqmAĔ?T?gIː0S:Kǁ.oucw9z_2}^ o߳i3g%JRK?X:WKuJF职0v6fNkvj_@,ηEBkT8V/N6 Y%=K 8*߰SO㱸ֽW竣 Z.ܬf6k]=2Ku;INK0=>zfnVWSm9wZzw'`tFFFGSb`1ef.ݹ*seޮT	,[MVٍsr >Vm/cD >}\3OcY ^flO^C?ŷJӚε&w6vw~ M# dFX_X+_Y1r-佹bŮc_K?c-uoINI׺=72GK\=ǳu/wek~ϩvbܜlM%[cWT/\s#KA2ݴ{wMO
 ;'uXkkǳY>l} C%:YA[QǳZ8cm g\'Rse5`MV@.l;v>Egbp d/G?^z% ~me}BZ8;{~WIN/K =o_]7f=;!sO_1Bq"{.!ª{r6MZ("a+s㵌ky]=FH2{]0;%<,?}gxƸYo.xf/ u5[{mU <>S{};}e+aԺWͥ4v-	zO,%<noN[y4 *]K96|'
q\WW׾?D7zn[f=Ĕ_VN~;;NMgY/}>n}  7D~gաeهШuk.,
{fY Ar;;Tγl1h6qm[*F}YOc.ӭt1z.&쿫Ceه#_cK_ʿIz) Qkv3zoZeEqm_~3_˪O3:}&Oul|z.ױՏ[qߍ6w>?	WמkcLǱn6]ϳ!{w\a[ur v jn7MkчV9O|Pﲧ:}:6zUu:n>gSj}bX6k[˪ǺE̳K;\_GAǭuz}w3'N7\n{kiwo{gVoK7us3,<c]Uy)ujQue~A>MhȾϳӇ[赖/ۨ1%=g^ދl|;_cWX8f2?쥖} uMf@oMR0a][]kpo۵BS?XzOzqqʢqk/uxs SuOz𶤧Nzo_JRax2_wkr u8}Xzd[u'pٵ kIOt#]ͳu'V54X~7={KѺNu`R|Zg̓{c Ig)$)zOZ~~CnMĺ*{S{l + egVm.q 4i$/:՛U!}@]-6N5:L=?9B_3wւI)q:Ucv\֏a:m.Ƣv =]~S 0 ^1ί,6ʬoگE C _F8Xuh~M6TۀX^VvKwz{)$?R+z`ˊzEYO>.w?AYU c'u,պEBMs7oz 
IO?ŮNvWX}}av;-xunj/{l=V
}[ h}I72Yo[ƫ5]mmiۻMu	$̜8xRBo C7}+ŬcZ#Z.is]vغS;el:][*SSkk\*sk='~bpq+§jMխ j:I)@Photoshop 3.0 8BIM%                     8BIM      `     `    8BIM&               ?  8BIM        8BIM        8BIM     	         8BIM'     
        8BIM     H /ff  lff       /ff         2    Z         5    -        8BIM     p                8BIM       8BIM         8BIM0     8BIM-         8BIM          @  @    8BIM         8BIM    K              5       s a n s   t i t r e 1                                    5                                            null      boundsObjc         Rct1       Top long        Leftlong        Btomlong   5    Rghtlong      slicesVlLs   Objc        slice      sliceIDlong       groupIDlong       originenum   ESliceOrigin   autoGenerated    Typeenum   
ESliceType    Img    boundsObjc         Rct1       Top long        Leftlong        Btomlong   5    Rghtlong      urlTEXT         nullTEXT         MsgeTEXT        altTagTEXT        cellTextIsHTMLbool   cellTextTEXT        	horzAlignenum   ESliceHorzAlign   default   	vertAlignenum   ESliceVertAlign   default   bgColorTypeenum   ESliceBGColorType    None   	topOutsetlong       
leftOutsetlong       bottomOutsetlong       rightOutsetlong     8BIM(        ?      8BIM      8BIM        8BIM    H         *    N  ,   JFIF   H H   Adobe_CM  Adobe d     			
  * "   
?          	
         	
 3 !1AQa"q2B#$Rb34rC%Scs5&DTdE£t6UeuF'Vfv7GWgw 5 !1AQaq"2B#R3$brCScs4%&5DTdEU6teuFVfv'7GWgw   ? U}i ì;g!T@c?2kegE_~gc!}mz.%$$I)) m]-]c c5T #峧RqK\eO?[/^_6YW}Gu^foQsj\wis=:,q/ څXb[x{ME8>G[SX]3`?|vN?F};ob<,szgK.}r,O  ]f v~کh?]~lXF{I K %=.=2}chM77mKҺ?Xkzu= 4}v0|uAf.(ϱSO;^ EU_:슱	}nlǷZJ{ St,0qIk*peLpUْC H* Gf,ǇQdtE_lqwoH I<_@gDڭ=;{nqmAĔ?T?gIː0S:Kǁ.oucw9z_2}^ o߳i3g%JRK?X:WKuJF职0v6fNkvj_@,ηEBkT8V/N6 Y%=K 8*߰SO㱸ֽW竣 Z.ܬf6k]=2Ku;INK0=>zfnVWSm9wZzw'`tFFFGSb`1ef.ݹ*seޮT	,[MVٍsr >Vm/cD >}\3OcY ^flO^C?ŷJӚε&w6vw~ M# dFX_X+_Y1r-佹bŮc_K?c-uoINI׺=72GK\=ǳu/wek~ϩvbܜlM%[cWT/\s#KA2ݴ{wMO
 ;'uXkkǳY>l} C%:YA[QǳZ8cm g\'Rse5`MV@.l;v>Egbp d/G?^z% ~me}BZ8;{~WIN/K =o_]7f=;!sO_1Bq"{.!ª{r6MZ("a+s㵌ky]=FH2{]0;%<,?}gxƸYo.xf/ u5[{mU <>S{};}e+aԺWͥ4v-	zO,%<noN[y4 *]K96|'
q\WW׾?D7zn[f=Ĕ_VN~;;NMgY/}>n}  7D~gաeهШuk.,
{fY Ar;;Tγl1h6qm[*F}YOc.ӭt1z.&쿫Ceه#_cK_ʿIz) Qkv3zoZeEqm_~3_˪O3:}&Oul|z.ױՏ[qߍ6w>?	WמkcLǱn6]ϳ!{w\a[ur v jn7MkчV9O|Pﲧ:}:6zUu:n>gSj}bX6k[˪ǺE̳K;\_GAǭuz}w3'N7\n{kiwo{gVoK7us3,<c]Uy)ujQue~A>MhȾϳӇ[赖/ۨ1%=g^ދl|;_cWX8f2?쥖} uMf@oMR0a][]kpo۵BS?XzOzqqʢqk/uxs SuOz𶤧Nzo_JRax2_wkr u8}Xzd[u'pٵ kIOt#]ͳu'V54X~7={KѺNu`R|Zg̓{c Ig)$)zOZ~~CnMĺ*{S{l + egVm.q 4i$/:՛U!}@]-6N5:L=?9B_3wւI)q:Ucv\֏a:m.Ƣv =]~S 0 ^1ί,6ʬoگE C _F8Xuh~M6TۀX^VvKwz{)$?R+z`ˊzEYO>.w?AYU c'u,պEBMs7oz 
IO?ŮNvWX}}av;-xunj/{l=V
}[ h}I72Yo[ƫ5]mmiۻMu	$̜8xRBo C7}+ŬcZ#Z.is]vغS;el:][*SSkk\*sk='~bpq+§jMխ j:I)8BIM!     U       A d o b e   P h o t o s h o p    A d o b e   P h o t o s h o p   C S 4    8BIM          http://ns.adobe.com/xap/1.0/ <?xpacket begin="﻿" id="W5M0MpCehiHzreSzNTczkc9d"?> <x:xmpmeta xmlns:x="adobe:ns:meta/" x:xmptk="Adobe XMP Core 4.2.2-c063 53.352624, 2008/07/30-18:05:41        "> <rdf:RDF xmlns:rdf="http://www.w3.org/1999/02/22-rdf-syntax-ns#"> <rdf:Description rdf:about="" xmlns:xmp="http://ns.adobe.com/xap/1.0/" xmlns:dc="http://purl.org/dc/elements/1.1/" xmlns:photoshop="http://ns.adobe.com/photoshop/1.0/" xmlns:xmpMM="http://ns.adobe.com/xap/1.0/mm/" xmlns:stEvt="http://ns.adobe.com/xap/1.0/sType/ResourceEvent#" xmlns:tiff="http://ns.adobe.com/tiff/1.0/" xmlns:exif="http://ns.adobe.com/exif/1.0/" xmp:CreatorTool="Adobe Photoshop CS4 Macintosh" xmp:CreateDate="2012-01-26T11:58:57-05:00" xmp:ModifyDate="2012-01-26T11:59:32-05:00" xmp:MetadataDate="2012-01-26T11:59:32-05:00" dc:format="image/jpeg" photoshop:ColorMode="3" xmpMM:InstanceID="xmp.iid:02801174072068118DBBF945EEA929BB" xmpMM:DocumentID="xmp.did:01801174072068118DBBF945EEA929BB" xmpMM:OriginalDocumentID="xmp.did:01801174072068118DBBF945EEA929BB" tiff:Orientation="1" tiff:XResolution="960000/10000" tiff:YResolution="960000/10000" tiff:ResolutionUnit="2" tiff:NativeDigest="256,257,258,259,262,274,277,284,530,531,282,283,296,301,318,319,529,532,306,270,271,272,305,315,33432;7B95C5196E25E32430D1C4D4EE9A279F" exif:PixelXDimension="202" exif:PixelYDimension="53" exif:ColorSpace="65535" exif:NativeDigest="36864,40960,40961,37121,37122,40962,40963,37510,40964,36867,36868,33434,33437,34850,34852,34855,34856,37377,37378,37379,37380,37381,37382,37383,37384,37385,37386,37396,41483,41484,41486,41487,41488,41492,41493,41495,41728,41729,41730,41985,41986,41987,41988,41989,41990,41991,41992,41993,41994,41995,41996,42016,0,2,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,20,22,23,24,25,26,27,28,30;1ADF286DF2CD99B2142446EBBB3527F4"> <xmpMM:History> <rdf:Seq> <rdf:li stEvt:action="created" stEvt:instanceID="xmp.iid:01801174072068118DBBF945EEA929BB" stEvt:when="2012-01-26T11:59:32-05:00" stEvt:softwareAgent="Adobe Photoshop CS4 Macintosh"/> <rdf:li stEvt:action="saved" stEvt:instanceID="xmp.iid:02801174072068118DBBF945EEA929BB" stEvt:when="2012-01-26T11:59:32-05:00" stEvt:softwareAgent="Adobe Photoshop CS4 Macintosh" stEvt:changed="/"/> </rdf:Seq> </xmpMM:History> </rdf:Description> </rdf:RDF> </x:xmpmeta>                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 <?xpacket end="w"?> Adobe d@       5                 	
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z=9 ^ozl gnnٙ=%4Jq瞊GUIb#^$ä |ܶ ;k+7mÓx+xǅ5_}68g: ;BxU	u`|&$s?t^ۙϘ[{l>oU'P݁wP\rĴYa9`7UN.o>7F[:˿(ߦ9[͒Ǎדaw.\>Bk=׺*]Kh.;O{/g0XχyS/k}ӖJ܉6=
VTDOP;HOV{{^ 3\eMol;ps;~;7)_U^?!M6|}TQNTZ}vn ߽]ʯݙXp{qAY)hk:s<q33'-Xo-c 0_LͯY-ӛlSvFַ\_UJݫOUoe,&xG}׺ߺ[=}ܿ˗wuV>ܹ*gRS[],6By1-B'#STe^m_'χ ͗Vjvnb|
|_[pKa˃Ðɏjr`<???2~oźuoG^Q+f7&A]VF) ܛWn$3L=׺K7n;ӠCucwNqBOQMum%]X/iieIHXt2?vw}vk˻6d#}lR}wofi<^HڢWZW(Ou |w>3`mQwG `k"w>lFT҆z:-N׺ߺ__ aOsQ2[Ɨzn^nNM,2vVbdo{wu Dtf>EQE]ux"VwCwd85۝{GuY}OqkG^|x\Yح;')57-^;E8_-%F=#J^ou +ɺ_5?'O뾶t_nۧ6Zjϸ6>m6%[V)7^~4 )> Ͷvŧ8f7N鏳p=~Xmtq,)X9<щ=tI. n	|in MFb=񛩾Jw~?e;S*!KH"j<{UOEӇONo-;wO>`u6:?zqQb;}]%٘p41䖆xLZT'6OdS<|Yؿ%o#OiGYٹMɴܝ1lUF5^vV^>
%O׵*=ޟ!~CfFުߴ"65Yys=qVI#NJTW?^ss / ?9xnOܛۥ;oz|emq%hROk^mmnJ08vJŠCCF*y:FSI%y#ON׺u9𵽯r>SVTͩƇnwjkEN'daMTp\ߺ[-Qk6g]GʾnF}Õo`n^JY6=\KI 5E9Xh{?wVM]x. z+[1nd7Kh&+I	sRFdS{&3|0yl;G$U2j,tR,U:JWR>׺c5/-_,>=o w/U~ݸ}}(fokV6iTQKIT2XX׺ Ak w&^6Vl[qaG)s#v*
* S#<^Wχ=J|Teuf7SIv-,[iZ:l6GHSTƍ?u?O|n:n$8)zg}o,ۧx>TLJ~j{W :I^S^u6ߘJ?TǘRbvcy=O]E=EeDZݽ׺ 0;pwF 2%Mv7~۽-*,Pܙiu/UЩ`{" {[ߨc~TJMۮmuk19:H#h%aln}׺ߺZ!*3 6ߔUv Ǟ7M'I7ݩ[Kuf1SU?iz?R$TIY{tr% ; 4zD 2<OKu6gd|p띵6 wf8l}Cb9'\~\u5D6V?:m~|؟A+=Խ)וzcmS!5[-Ssia'5EOha?u:x_̣N ̏`OY'ۇ{yu>cdo|r6X3С-4( Ռ|f_Ws 2  Vs}޿v.&Vm>Cr͑VذnYFWd%E(SK /m?G>Fo)1?6:owkg食oPibmLNiQ0^uOg<ngWoۗ%">,:duF鮽4E]]5y
_rd2&5`̹8}׺>sݛoa.δ'?* NkR2o֝e[1`ShXQӟu#h 8MLzUwƿoTdo=הm{[?1+e~PH:uj^ _a 7]w2sC FuOZPw[rmmUR,,mj&'oGA%=]+9l{7]҃zu?j+RWS<s_rqOg3IO_@*}׺ f}ۗ|.%TˀMԽŊwMǗm&B-R eN"u^J6&_1*f-윕|jG}uw?ŷ6{1N
ΌYwE8b7GlFnQNL>:H"
y {uPuXtYl鍏۫zIVڴ	0At)i&yyj&i*jeyi{G %'k|bmįܝ=IyVy*2	ۘk7V䪼8;#6${Vw_%G[KyҬ9ݩq5*M{}18yk}@7׺4s0$g/_󆝙 ڝiKn[N}uL? _q=)޴4}~Sɿ}5<U&AFFçgB["G%eEdG2t6 2_||\EqdmYi(;-ɴUtCUM)!j=X4>hu?p_eG^z#M6Vhl:Tp=׺! 	It=wۊd|gZO_e]=:'^)JI
>׺ ,T.~6wi&Vrl˔C_=۶QHei*؂3{_&w?^~ۘ6g`cmZ`6gǢSmnܧՎo,}Vɮ%PA-===}׺RvaIgXhbCI0Bc
4w-^[/>a2_̯ܷ/;g`mŶwvfgz6_6U+r:2৑Qw~[W-a0n4~a4xn-2mWM'G[!*?4G?l?9q?[lM ˻|A.GӲ7]m`n<$[kE3ջ&U+h^ݜeտrozmtɌws;J/=3bL{cM:hJ\S%vF(){: g;?vzc/=Olb.qa&t㋪ߨm|V̔5֣{ _tݽ4_4xV܃g֘7K~\ʪqTRI ^wÏv|Ku|;z{6?Svv'][K1|l=V><=%Uh
,Q)I+=ݟ]?m`p9tg(`jFE.[壬*mБ+T2_'?ųWK3ؽF1{_fs:&lI;mǵ)*9p!^d_=;Ko4Mҝ-R+-AڲUSk*qM fUfr'ߺCuߺ^׽u~{ߺ^׽u~{ߺ^׽uѵ7 Z?ߺZo5 ſ?W? eW￈yϽ ί&^ߟ~Yol/ o-? <Og=^?7~׺_~{ߺ^׽u~{ߺ^׽u~{ߺ^׽u                                                                                                                                                                                                                                                                            n $$If   F !v h#v #v:V F t
t  *65 5al p                ytqO  $$If   q !v h#v &#v:V l 4
t  0                                      C*6   5 &5/      /      4    ae f4v   D                                                                     T e x t 4 2                            $$If   e !v h#v #v	#v'#v
:V l 4	 
t  
      C*6  , 5 5	5'5
/      /     4    ae f4p
      t   D                                                                 2    T e x t 2                           v   D                                                                     T e x t 4 3                           v   D                                                                     T e x t 4 4                           v   D                                                                     T e x t 4 5                            $$If   e !v h#v 	#v#v#v:V l 4K
t  C*6  , 5 	555/     4    ae f4v   D                                                                 2    T e x t 4 6                           k $$If   e !v h#v X#v:V l 4=
t  C*6  , 5 X54    ae f4t   D                                                                 2    T e x t 7                           k $$If   e !v h#v #v:V l 4=
t  C*6  , 5 54    ae f4t   D                                                                 d    T e x t 8                           k $$If   e !v h#v #v7%:V l 4=
t  C*6  , 5 57%4    ae f4t   D                                                                      T e x t 9                           q $$If   e !v h#v >#v&:V l 4n
t  C*6  , ,5 >5&4    ae f4] $$If   e !v h#v C*:V l 4 
t  C*6  , 5 C*4    ae f4j   D                                                                 2                               v   D                                                                     T e x t 5 0                            $$If   e !v h#v #v#v8#vJ:V l 4=
t  C*6  , 5 5585J4    ae f4j   D                                                                                                t   D                                                                     T e x t 4                           j   D                                                                                                t   D                                                                     T e x t 3                           t   D                                                                     T e x t 4                           j   D                                                                                                 $$If   e !v h#v #v#v2#v:V l 4=
t  C*6  , 5 55254    ae f4v   D                                                                 P    T e x t 1 2                           k $$If   e !v h#v #v":V l 4=
t  C*6  , 5 5"4    ae f4t   D                                                               e     C h e c k 1                         t   D                                                               e     C h e c k 2                         t   D                                                               e     C h e c k 9                         ] $$If   e !v h#v C*:V l 4=
t  C*6  , 5 C*4    ae f4j   D                                                                                                t   D                                                                     T e x t 4                           j   D                                                                                                t   D                                                                     T e x t 3                           t   D                                                                     T e x t 4                           j   D                                                                                                 $$If   e !v h#v #v#v5#v:V l 4 
t  C*6  , 5 55552  2   2 29 2 2  4    ae f4v   D                                                                 K    T e x t 1 5                           k $$If   e !v h#v 	#v :V l 4
t  C*6  , 5 	5 4    ae f4v   D                                                                 F    T e x t 1 6                           k $$If   e !v h#v #v:V l 4=
t  C*6  , 5 54    ae f4v   D                                                                 n    T e x t 1 7                           b $$If   !v h#v (:V l 4 
t  C*6n  , 5 (4    ae f4v   D                                                                 F    T e x t 1 3                           k $$If   e !v h#v #v:V l 4=
t  C*6  , 5 54    ae f4v   D                                                                      T e x t 1 4                           k $$If   e !v h#v #v%:V l 4 
t  C*6  , 5 5%4    ae f4] $$If   e !v h#v C*:V l 4 
t  C*6  , 5 C*4    ae f4v   D                                                                 <    T e x t 1 9                           k $$If   e !v h#v #v:V l 4=
t  C*6  , 5 54    ae f4v   D                                                                 n    T e x t 2 0                           b $$If   !v h#v (:V l 4 
t  C*6n  , 5 (4    ae f4v   D                                                                 2    T e x t 2 1                           t   D                                                                     T e x t 3                           t   D                                                                     T e x t 4                           j   D                                                                                                 $$If   e !v h#v #va#v8
#v:V l 4=
t  C*6  , 5 5a58
54    ae f4v   D                                                               e     C h e c k 1 0                         v   D                                                               e     C h e c k 1 1                         v   D                                                                     T e x t 3 6                           y $$If   e !v h#v #v#v:V l 4=
t  C*6  , 5 554    ae f4] $$If   e !v h#v C*:V l 4 
t  C*6  , 5 C*4    ae f4v   D                                                                     T e x t 2 2                           v   D                                                                 
    T e x t 2 3                           t   D                                                                     T e x t 3                           t   D                                                                     T e x t 4                           j   D                                                                                                y $$If   e !v h#v #v#v:V l 4K
t  C*6  , 5 554    ae f4y $$If   e !v h#v #v#v:V l 4 
t  C*6  , 5 554    ae f4v   D                                                                      T e x t 2 4                           k $$If   e !v h#v k#v&:V l 4=
t  C*6  , 5 k5&4    ae f4] $$If   e !v h#v C*:V l 4 
t  C*6  , 5 C*4    ae f4| $$If   e !v h#v C*:V l 4	 
t  
      C*6  , 5 C*4    ae f4p
      ] $$If   e !v h#v C*:V l 4P 
t  C*6  , 5 C*4    ae f4 $$If   e !v h#v g#v:V l 4	 
t  
      C*6  , 5 g5/      4    ae f4p
      v   D                                                                 7    T e x t 2 5                           v   D                                                                     T e x t 3 7                            $$If   e !v h#v #v#v#v:V l 4)
t  C*6  , 5 5554    ae f4v   D                                                                 U    T e x t 2 7                           k $$If   e !v h#v -#v:V l 4 
t  C*6  , 5 -54    ae f4v   D                                                                 #    T e x t 2 8                           t   D                                                                     T e x t 3                           t   D                                                                     T e x t 4                           j   D                                                                                                 $$If   e !v h#v #v#v#v:V l 4 
t  C*6  , 5 5554    ae f4t   D                                                               e     C h e c k 1                         t   D                                                               e     C h e c k 2                         ] $$If   e !v h#v C*:V l 4 
t  C*6  , 5 C*4    ae f4t   D                                                               e     C h e c k 1                         t   D                                                               e     C h e c k 2                         ] $$If   e !v h#v C*:V l 4 
t  C*6  , 5 C*4    ae f4t   D                                                               e     C h e c k 1                         t   D                                                               e     C h e c k 2                         t   D                                                               e     C h e c k 9                         ] $$If   e !v h#v C*:V l 4 
t  C*6  , 5 C*4    ae f4v   D                                                                 (    T e x t 2 9                           v   D                                                                 (    T e x t 3 0                           y $$If   e !v h#v S#v0#v:V l 4)
t  C*6  , 5 S5054    ae f4y $$If   e !v h#v S#v0#v:V l 4 
t  C*6  , 5 S5054    ae f4v   D                                                                      T e x t 3 1                           k $$If   e !v h#v k#v&:V l 4 
t  C*6  , 5 k5&4    ae f4] $$If   e !v h#v C*:V l 4 
t  C*6  , 5 C*4    ae f4j   D                                                                                                v   D                                                                 
    T e x t 2 3                           t   D                                                                     T e x t 3                           t   D                                                                     T e x t 4                           j   D                                                                                                 $$If   e !v h#v #vv#v:#v:V l 4 
t  C*6  , 5 5v5:54    ae f4v   D                                                                     T e x t 3 7                            $$If   e !v h#v #v
#v#v:V l 4h	 
t  
      C*6i , 5 5
55/      4    ae f4p
      j   D                                                                 K                               v   D                                                                     T e x t 3 3                            $$If   e !v h#v #v#v#v:V l 4
t  C*6i , 5 5554    ae f4v   D                                                                 K    T e x t 3 2                           k $$If   e !v h#v #vO:V l 4h
t  C*6i , 5 5O4    ae f4j   D                                                                 d                               k $$If   e !v h#v #v$:V l 4=
t  C*6i , 5 5$4    ae f4j   D                                                                 d                               k $$If   e !v h#v 
#v:V l 4=
t  C*6i , 5 
54    ae f4v   D                                                                     T e x t 4 7                           v   D                                                                     T e x t 4 8                           v   D                                                                     T e x t 4 9                           v   D                                                                     T e x t 4 7                           v   D                                                                     T e x t 4 8                           v   D                                                                     T e x t 4 9                           v   D                                                                     T e x t 4 7                           v   D                                                                     T e x t 4 8                           v   D                                                                     T e x t 4 9                           v   D                                                                     T e x t 4 7                           v   D                                                                     T e x t 4 8                           v   D                                                                     T e x t 4 9                            $$If   e !v h#v #v#v=#v#v#vn#v #vU:V l 4h
t  C*6i , 5 55=555n5 5U4    ae f4] $$If   e !v h#v ):V l 4h
t  C*6i , 5 )4    ae f4j   D                                                                                                t   D                                                                     T e x t 4                           j   D                                                                                                k $$If   e !v h#v e#v&:V l 4 
t  C*6, 5 e5&4    ae f4t   D                                                               e     C h e c k 5                         t   D                                                               e     C h e c k 6                         ] $$If   e !v h#v &:V l 4 
t  C*6, 5 &4    ae f4j   D                                                                 K                               k $$If   e !v h#v #v:V l 4=
t  C*6i , 5 54    ae f4j   D                                                                 n                               b $$If   !v h#v ':V l 4=
t  C*6?i , 5 '4    ae f4j   D                                                                 K                               k $$If   e !v h#v 
#vN:V l 4h
t  C*6i , 5 
5N4    ae f4j   D                                                                                                t   D                                                                     T e x t 4                           j   D                                                                                                v   D                                                                     T e x t 3 9                            $$If   e !v h#v 8#v#vo#v:V l 4 
t  C*6, 5 855o54    ae f4j   D                                                                                                t   D                                                                     T e x t 4                           j   D                                                                                                v   D                                                                     T e x t 4 0                            $$If   e !v h#v 8#v#vo#v:V l 4 
t  C*6, 5 855o54    ae f4v   D                                                                 P    T e x t 4 1                           k $$If   e !v h#v #vO:V l 4h
t  C*6i , 5 5O4    ae f4j   D                                                                 n                               b $$If   !v h#v ):V l 4=
t  C*6'  , 5 )4    ae f4j   D                                                                 K                               k $$If   e !v h#v #v=:V l 4h
t  C*6  , 5 5=4    ae f4t   D                                                               e     C h e c k 5                         t   D                                                               e     C h e c k 6                         ] $$If   e !v h#v C*:V l 4h
t  C*6  , 5 C*4    ae f4j   D                                                                 K                               k $$If   e !v h#v T
#v:V l 4=
t  C*6  , 5 T
54    ae f4j   D                                                                 n                               b $$If   !v h#v ):V l 4=
t  C*6'  , 5 )4    ae f4t   D                                                               e     C h e c k 5                         t   D                                                               e     C h e c k 6                         t   D                                                                     T e x t 3                           t   D                                                                     T e x t 4                           j   D                                                                                                y $$If   e !v h#v #v#vg:V l 4h
t  C*6  , 5 55g4    ae f4j   D                                                                 K                               k $$If   e !v h#v #v:V l 4=
t  C*6  , 5 54    ae f4k $$If   e !v h#v C*:V l 4 
t  C*6  , 5 C*/      4    ae f4v   D                                                                 (    T e x t 3 5                            $$If   e !v h#v T
#v#v,#v:V l 4@
t  C*6  , 5 T
55,54    ae f4v   D                                                                      T e x t 3 1                           k $$If   e !v h#v #v&:V l 4)
t  C*6  , 5 5&4    ae f4] $$If   e !v h#v C*:V l 4 
t  C*6  , 5 C*4    ae f4j   D                                                                                                v   D                                                                 
    T e x t 2 3                           t   D                                                                     T e x t 3                           t   D                                                                     T e x t 4                           j   D                                                                                                 $$If   e !v h#v 4#vS#vU#vg:V l 4h
t  C*6  , 5 45S5U5g4    ae f4k $$If   e !v h#v C*:V l 4 
t  C*6  , 5 C*/      4    ae f4                                                                         ^                                            6  6  6  6  6  6  6  6  6  v  v  v  v  v  v  v  v  v  6  6  6  6  6  6  8  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6     6  6     6  6  6  6  6  6  6  6     6  6  6  6  6  6  6  6  6  6  6  6  h  H  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6  6    6  2                     0  @  P  `  p                   2  (         0  @  P  `  p                      0  @  P  `  p                      0  @  P  `  p                      0  @  P  `  p                      0  @  P  `  p                      0  @  P  `  p      8  X        V  ~     _HmHnHsHtH    H  ` H          N o r m a l      5$ 7$ 8$ 9D H$  _HmHsHtH	H @  H          T i t r e   1     $@&  5CJ OJ QJ mH	sH	 H @  H          T i t r e   2     $@& 5CJ  OJ QJ mH	sH	 ^ @  ^          T i t r e   3     $< &d @&P      5CJ OJ QJ mH	sH	 J @  J          T i t r e   4     $@& 5CJ OJ QJ \mH	sH	F @  F          T i t r e   5     $@& 5OJ QJ \mH	sH	P @  P          T i t r e   6     $$@&a$ 5CJ OJ QJ \mH	sH	R @  R          T i t r e   7     $( ( @& 5CJ OJ QJ \mH	sH	    : A` :          P o l i c e   p a r   d  f a u t     Z i@ Z          T a b l e a u   N o r m a l     :V   4   4 
l a      2 k  2           A u c u n e   l i s t e         6 @  6           E n - t  t e      !   @  @ @           P i e d   d e   p a g e      !   4 )@ 4           N u m  r o   d e   p a g e     B "@  B          L  g e n d e      5CJ  OJ QJ mH	sH	 L B@ 2L           C o r p s   d e   t e x t e      CJ OJ QJ mH	sH	d C@ Bd           R e t r a i t   c o r p s   d e   t e x t e   
  h^h CJ OJ QJ mH	sH	j Y@ Rj   gx<    E x p l o r a t e u r   d e   d o c u m e n t s     -D M
          OJ QJ ^J x @ cx   K    G r i l l e   d u   t a b l e a u   7 :V 0                                   b O rb    K   	 P E   t i t l e 1     $d  5$7$8$9D H$a$ 5CJ OJ QJ mH	sH	 f O f    K   	 P E   t i t l e 2   &  $d8  < P 5$7$8$9D H$a$ 5CJ OJ QJ aJ  ^ O ^    K    P E   a d d r e s s 2     $d8  5$7$8$9D H$a$ CJ OJ QJ tHPK     !         [Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V<a(7IR{pgL=r85v&uQ뉑8CX=$␴?6NJCFB.ʹ'.+YT^e55 ð_g -;Ylݎ|6^N`?[   PK     ! ֧   6     _rels/.relsj0}Q%v/C/} (h"O
= C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/Seе   PK     ! ky         theme/theme/themeManager.xmlM
 @}w7c(Ebˮ CAǠҟ7՛KY,e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+&
8   PK     ! T       theme/theme/theme1.xmlYOoE#F{oc'vGuرhF[xw;jf7q7P%PEWz'^ڳyoެ/_3t@<i{5M¶wkؿ!p`DzW6}2^W	\m/R*]_Z>,cy$gc.bAn̖kեC	A0vs<>6r=*%@&ٖ6دk. ~8$
6./lS_//"JFV! zn^3 ੵ,_wr%8/[k.$eVi2[Psjcs7fWKՆ7dgȘJj|j(KD- dXiJ؇2x$(
:'vɗsKZj{Zb&^>{?=уG]8	˻^|ɟ>D<Ϫ~j ̜?_|+!D7!18fZNFl;I(q
=9S̲8vt
xur1xEu5$	IA.N&)f^݈8f2((}B*C.X;u0ɐjmڦ1eZ3ۉm-r"+00~Hƫxp\%rcVu*#Sq= !a"e՞-%ƪL.R(_%:漌iv@}OCbU|Cp0ݷ)q}2ܢcҬ@ULC5@W4;fj8?|
Tބӫg"qzr7$%G[r~KS򌅁,bm3v1el\fp}X̕4A6{ASLt(Q%\rl_٫fS_B,sHvx`Wr~(BshUr)
64Cebs)bMjBUkp:6GyZL3E2rQ$)9G񄨕v$5˳:Y+x%vYRnNöj.7=.Yo|%lٟ̦gl厹MPW6s;<
liGY	Dk/7!@Ί5(
Z2_]Zѱ_3*E 
шMR*uahG.9gMW~#fpv4;!6o%JۍsgwŴ9R.+<+΀FS*BiDpT߅PT/ȁa.jHP8T$Z2wzvvY,d*dL#r@Ps>=A6hן=Qr9LV638h&T-;ƬFtExZƚxY(wHH>vu[xA@U_iG08E[LZm6:9Oc֖&gv1^<`gvbm2{Eai_dLbd_.$z~30%M1T=0} o5   PK     ! ѐ     '   theme/theme/_rels/themeManager.xml.relsM
0wooӺ&݈Э56?$Q,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{ P8g/]QAsم(#L[    PK-      !                       [Content_Types].xmlPK-      ! ֧   6               0  _rels/.relsPK-      ! ky                     theme/theme/themeManager.xmlPK-      ! T                   theme/theme/theme1.xmlPK-      ! ѐ     '             	  theme/theme/_rels/themeManager.xml.relsPK      ]  
    <?xml version="1.0" encoding="UTF-8" standalone="yes"?>
<a:clrMap xmlns:a="http://schemas.openxmlformats.org/drawingml/2006/main" bg1="lt1" tx1="dk1" bg2="lt2" tx2="dk2" accent1="accent1" accent2="accent2" accent3="accent3" accent4="accent4" accent5="accent5" accent6="accent6" hlink="hlink" folHlink="folHlink"/>                        	                  M   M   M   P      
      d        \            X    2    >    X   n!  Y#  F$  %  M&  G'  $    z  "        V      ̚  J        Z      V    .                             #   %   &   )   *   +   ,   0   2   4   6   8   9   <   ?   A   C   E   G   T   X   Y   [   ]   `   b   c   d   g   h   k   l   n   q   s   u   w   z   |             v        n    N      l  0           F!  !  5#  p#  $  &  &  6        H  Ҕ  L    p    ܚ        p  (  l  .    *  h    ,                     !   "   $   '   (   -   .   /   1   3   5   7   :   ;   =   >   @   B   D   F   U   V   W   Z   \   ^   _   a   e   f   i   j   m   o   p   r   t   v   x   y   {   }   ~                  	      !  -  0  9  E  J                    0  <  B  :  F  L  Y  e  k                          	  	  	  	  )	  .	  I	  U	  [	  	  	  	  	  	  	  ,
  8
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        C  O  U  X  d  j                      
    )  5  ;  ^  j  m  v                       +  1                                 b  n  t  &  2  8  I  U  [                    
      "  .  3            
    %  X  h  z                    9  E  K  :  F  J  P  \  b  k  w  z                          (  4  9  d  p  v                          %  1  6  ;  G  J  S  _  b  k  w  |                                      w                      )  9  |                               )  5  :  B  N  T  n  z  }                                R  ^  d                 	      P  `  j  z                        $  H  T  Z  r  ~    q  }                              FFtFtFtFtFtFF4F4FTFTFtFtFFtFtFFG$G$G$FtFtFFtFtFFF4FF4F4FF4FTFtFtFG$G$FF4F4FtFtFF4F4FF4F4FtFtFG$G$G$G$G$G$G$FTFTF4F4FtFtFtFFF4F4F4FtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFG$G$F4F4FtFtFtFFFtFtFFFFFtG$G$F4F4G$G$FtFtFF4FtF4F4FtFtFtF      P   !   l                          ,   R $   #=?iE5U X     7     @                       
   b   (    	                    
              
      
   Z        B  C   D   E   F                         @    # "       ?                       
   
   
  S @   A   "             s s q _ f r _ n o i r _ W o r d   # "     ` ?                     B    
        S              	   ?              =     
         t         +     .   u     )    T e x t 4 2  T e x t 2  T e x t 4 3  T e x t 4 4  T e x t 4 5  T e x t 4 6  T e x t 7  T e x t 8  T e x t 9  T e x t 5 0  T e x t 1 5  T e x t 1 6  T e x t 1 7  T e x t 1 9  T e x t 2 0  T e x t 2 1  C h e c k 1 0  C h e c k 1 1  T e x t 3 6  T e x t 2 2  T e x t 2 3  T e x t 2 4  T e x t 2 5  T e x t 3 7  T e x t 2 7  T e x t 2 8  C h e c k 9  T e x t 2 9  T e x t 3 0  T e x t 3 1  T e x t 3 3  T e x t 3 2  T e x t 4 7  T e x t 4 8  T e x t 4 9  C h e c k 5  C h e c k 6  T e x t 3 9  T e x t 4 0  T e x t 4 1  T e x t 3 5     
  "  :        1  Z    D  Y      *             c  '  J            :  )  e      &    *  C      I                                	   
                                                                      !   "   #   $   %   &   '   (         1  K        C  l    V  k      <      2      u  9  \            L  :  w      7    :  U    	  [        X   [           u  x                  	    !  1  9  K              0  C  :  M  Y  l                  	  	  	  /	  I	  \	  ,
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    "  4          9  L  :  K  P  c  k  {                  (  :  d  w                  %  7  ;  K  S  c  k  }                        	  w            |              	    !  )  ;  B  U  n  ~                	      R  e      	                  %  H  [  r    q                    E  G  H  J  K  M  N  P  Q  Y                                                                                                                                                                                                                                                    =   _     B              	    !  1  9  K  M                   0  C  %  :  M  N  Y  l  n                  	  	  	  /	  I	  \	  )
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    "  4  6            9  L  .  :  K  P  c  k  {                       (  :  <  d  w  y                    %  7  ;  K  S  c  k  }                        	  (  u  w                 A  |                	    !  )  ;  B  U  W  n  ~                	      R  e        	                      %  H  [  \  r    e  q                      E  G  H  J  K  M  N  P  Q                                                                                                                                                                                                                                                                                               	      $  %  <  A  E  G  H  J  K  M  N  P  Q                                   oZ"54 G ',fJ [S+` {`<RM G^Ю aHPs O KC[b `hm :cS ? `v`k x`;0e                          ^`o(    .                         ^`  .                        ^L ^^^`L  .                         .
 .
^.
`  .                         ^`  .                        L ^`L  .                          ^`  .                        n n^n`  .                        >L >^>`L  .                          ^`o(    .                         ^`  .                        bL b^b`L  .                         2
 2
^2
`  .                         ^`  .                        L ^`L  .                          ^`  .                        r r^r`  .                        BL B^B`L  .                          ^`o(    .                        t t^t`  .                        DL D^D`L  .                         
 
^
`  .                         ^`  .                        L ^`L  .                          ^`  .                        T T^T`  .                        $L $^$`L  .                          ^`o(    .                         ^`  .                        pL p^p`L  .                         @ @^@`  .                         ^`  .                        L ^`L  .                          ^`  .                         ^`  .                        PL P^P`L  .                          ^`o(    .                         ^`  .                        pL p^p`L  .                         @ @^@`  .                         ^`  .                        L ^`L  .                          ^`  .                         ^`  .                        PL P^P`L  .                          ^`o(    .                         ^`  .                        pL p^p`L  .                         @ @^@`  .                         ^`  .                        L ^`L  .                          ^`  .                         ^`  .                        PL P^P`L  .                          ^`o(    .                         ^`  .                        pL p^p`L  .                         @ @^@`  .                         ^`  .                        L ^`L  .                          ^`  .                         ^`  .                        PL P^P`L  .                          ^`o(    .                         ^`  .                        pL p^p`L  .                         @ @^@`  .                         ^`  .                        L ^`L  .                          ^`  .                         ^`  .                        PL P^P`L  .                          ^`o(    .                         ^`  .                        pL p^p`L  .                         @ @^@`  .                         ^`  .                        L ^`L  .                          ^`  .                         ^`  .                        PL P^P`L  .                          ^`o(    .                         ^`  .                        pL p^p`L  .                         @ @^@`  .                         ^`  .                        L ^`L  .                          ^`  .                         ^`  .                        PL P^P`L  . 	                         ^`o(    .                         ^`  .                        pL p^p`L  .                         @ @^@`  .                         ^`  .                        L ^`L  .                          ^`  .                         ^`  .                        PL P^P`L  .                          ^`o(    .                         ^`  .                        pL p^p`L  .                         @ @^@`  .                         ^`  .                        L ^`L  .                          ^`  .                         ^`  .                        PL P^P`L  .    x            [S+            KC[            aH            O            `            ? `v            {`<            :c            G            G '            oZ"                                            	 	 	 	 	 	 	 	 h&j 	 	 	 	 	 	 	 	 VH 	 	 	 	 	 	 	 	  	 	 	 	 	 	 	 	 	  	 	 	 	 	 	 	 	 	  	 	 	 	 	 	 	 	 	  	 	 	 	 	 	 	 	 	  	 	 	 	 	 	 	 	 	  	 	 	 	 	 	 	 	 	  	 	 	 	 	 	 	 	 	  	 	 	 	 	 	 	 	 	  	 	 	 	 	 	 	 	 	                   I E j u*- .- gx< lH VO oSs Pw !y = " y b K x2 9 qO * * ? K ?  ( (     E  G         @                                              	  
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Accidents du sport            Titre                   (      P      X      x            Expires       ContentType            2015-12-18T00:00:00Z          SSQ Document                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            	   
                                                                      !   "   #   $   %   &   '   (   )   *   +   ,   -   .   /   0   1   2   3   4   5   6   7   8   9   :   ;   <   =   >   ?   @   A   B   C   D   E   F   G   H   I   J   K   L   M   N   O   P   Q   R   S   T   U   V   W   X   Y   Z   [   \   ]   ^   _   `   a   b   c   d   e   f   g   h   i   j   k   l   m   n   o   p   q   r   s   t   u   v   w   x   y   z   {   |   }   ~                                                                                                                                                                                                                                                                                                                                                                                                                 	  
                                .     !  "  #  $  %  &  '  *  +  ,  -  R o o t   E n t r y                                                 	           F            `+#)  @	      D a t a                                                         
                                        W      1 T a b l e                                                                                                 [      W o r d D o c u m e n t                                                                                        Z      S u m m a r y I n f o r m a t i o n                           (                                               D o c u m e n t S u m m a r y I n f o r m a t i o n           8                                                 M s o D a t a S t o r e                                           
                       #`#            5 2  W       W P M   G V      = =                 2                         #pp#            I t e m                                                         
 	                                               P r o p e r t i e s                                                                                       
      C U  F  G  F N U G 4 S K D  1  C 4 P A = =                 2                              #pp#            I t e m                                                         
                                                  P r o p e r t i e s                                                                                      O        S    N  T    T F 1  R  C    = =                 2                         #`#            I t e m                                                         
                                                  P r o p e r t i e s                                                                                      S      <?xml version="1.0" encoding="utf-8"?><ct:contentTypeSchema ct:_="" ma:_="" ma:contentTypeName="SSQ Document" ma:contentTypeID="0x0101008F435AD56CB24AD292B25928FDF0015F00F45CF5FDF581AD4B84017AE0E532084E" ma:contentTypeVersion="0" ma:contentTypeDescription="Defines SSQ's default document properties" ma:contentTypeScope="" ma:versionID="036a5a903b7de122852b5ac4b8a723a0" xmlns:ct="http://schemas.microsoft.com/office/2006/metadata/contentType" xmlns:ma="http://schemas.microsoft.com/office/2006/metadata/properties/metaAttributes">
<xsd:schema targetNamespace="http://schemas.microsoft.com/office/2006/metadata/properties" ma:root="true" ma:fieldsID="4e300ea2801f516b4b533e5899a0ac76" ns1:_="" xmlns:xsd="http://www.w3.org/2001/XMLSchema" xmlns:p="http://schemas.microsoft.com/office/2006/metadata/properties" xmlns:ns1="http://schemas.microsoft.com/sharepoint/v3">
<xsd:import namespace="http://schemas.microsoft.com/sharepoint/v3"/>
<xsd:element name="properties">
<xsd:complexType>
<xsd:sequence>
<xsd:element name="documentManagement">
<xsd:complexType>
<xsd:all>
<xsd:element ref="ns1:Expires"/>
</xsd:all>
</xsd:complexType>
</xsd:element>
</xsd:sequence>
</xsd:complexType>
</xsd:element>
</xsd:schema>
<xsd:schema targetNamespace="http://schemas.microsoft.com/sharepoint/v3" elementFormDefault="qualified" xmlns:xsd="http://www.w3.org/2001/XMLSchema" xmlns:dms="http://schemas.microsoft.com/office/2006/documentManagement/types">
<xsd:import namespace="http://schemas.microsoft.com/office/2006/documentManagement/types"/>
<xsd:element name="Expires" ma:index="9" ma:displayName="Expiration Date" ma:format="DateOnly" ma:internalName="Expires">
<xsd:simpleType>
<xsd:restriction base="dms:DateTime"/>
</xsd:simpleType>
</xsd:element>
</xsd:schema>
<xsd:schema targetNamespace="http://schemas.openxmlformats.org/package/2006/metadata/core-properties" elementFormDefault="qualified" attributeFormDefault="unqualified" blockDefault="#all" xmlns="http://schemas.openxmlformats.org/package/2006/metadata/core-properties" xmlns:xsd="http://www.w3.org/2001/XMLSchema" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:dc="http://purl.org/dc/elements/1.1/" xmlns:dcterms="http://purl.org/dc/terms/" xmlns:odoc="http://schemas.microsoft.com/office/internal/2005/internalDocumentation">
<xsd:import namespace="http://purl.org/dc/elements/1.1/" schemaLocation="http://dublincore.org/schemas/xmls/qdc/2003/04/02/dc.xsd"/>
<xsd:import namespace="http://purl.org/dc/terms/" schemaLocation="http://dublincore.org/schemas/xmls/qdc/2003/04/02/dcterms.xsd"/>
<xsd:element name="coreProperties" type="CT_coreProperties"/>
<xsd:complexType name="CT_coreProperties">
<xsd:all>
<xsd:element ref="dc:creator" minOccurs="0" maxOccurs="1"/>
<xsd:element ref="dcterms:created" minOccurs="0" maxOccurs="1"/>
<xsd:element ref="dc:identifier" minOccurs="0" maxOccurs="1"/>
<xsd:element name="contentType" minOccurs="0" maxOccurs="1" type="xsd:string" ma:index="0" ma:displayName="Content Type" ma:readOnly="true"/>
<xsd:element ref="dc:title" maxOccurs="1" ma:index="7" ma:displayName="Title"/>
<xsd:element ref="dc:subject" minOccurs="0" maxOccurs="1"/>
<xsd:element ref="dc:description" minOccurs="0" maxOccurs="1" ma:index="8" ma:displayName="Description"/>
<xsd:element name="keywords" minOccurs="0" maxOccurs="1" type="xsd:string"/>
<xsd:element ref="dc:language" minOccurs="0" maxOccurs="1"/>
<xsd:element name="category" minOccurs="0" maxOccurs="1" type="xsd:string"/>
<xsd:element name="version" minOccurs="0" maxOccurs="1" type="xsd:string"/>
<xsd:element name="revision" minOccurs="0" maxOccurs="1" type="xsd:string">
<xsd:annotation>
<xsd:documentation>
                        This value indicates the number of saves or revisions. The application is responsible for updating this value after each revision.
                    </xsd:documentation>
</xsd:annotation>
</xsd:element>
<xsd:element name="lastModifiedBy" minOccurs="0" maxOccurs="1" type="xsd:string"/>
<xsd:element ref="dcterms:modified" minOccurs="0" maxOccurs="1"/>
<xsd:element name="lastPrinted" minOccurs="0" maxOccurs="1" type="xsd:dateTime"/>
<xsd:element name="contentStatus" minOccurs="0" maxOccurs="1" type="xsd:string"/>
</xsd:all>
</xsd:complexType>
</xsd:schema>
</ct:contentTypeSchema>                                                                                                                                                                                                                                                                                                                          	   
                                                          !   "   $   <?xml version="1.0" encoding="UTF-8" standalone="no"?>
<ds:datastoreItem ds:itemID="{9316C87D-30C8-45AA-8F32-3C06574D78BF}" xmlns:ds="http://schemas.openxmlformats.org/officeDocument/2006/customXml"><ds:schemaRefs><ds:schemaRef ds:uri="http://schemas.microsoft.com/office/2006/metadata/contentType"/><ds:schemaRef ds:uri="http://schemas.microsoft.com/office/2006/metadata/properties/metaAttributes"/><ds:schemaRef ds:uri="http://www.w3.org/2001/XMLSchema"/><ds:schemaRef ds:uri="http://schemas.microsoft.com/office/2006/metadata/properties"/><ds:schemaRef ds:uri="http://schemas.microsoft.com/sharepoint/v3"/><ds:schemaRef ds:uri="http://schemas.microsoft.com/office/2006/documentManagement/types"/><ds:schemaRef ds:uri="http://schemas.openxmlformats.org/package/2006/metadata/core-properties"/><ds:schemaRef ds:uri="http://purl.org/dc/elements/1.1/"/><ds:schemaRef ds:uri="http://purl.org/dc/terms/"/><ds:schemaRef ds:uri="http://schemas.microsoft.com/office/internal/2005/internalDocumentation"/></ds:schemaRefs></ds:datastoreItem>                                                      <?mso-contentType?><FormTemplates xmlns="http://schemas.microsoft.com/sharepoint/v3/contenttype/forms"><Display>DocumentLibraryForm</Display><Edit>DocumentLibraryForm</Edit><New>DocumentLibraryForm</New></FormTemplates>                                     <?xml version="1.0" encoding="UTF-8" standalone="no"?>
<ds:datastoreItem ds:itemID="{FCC54E09-0569-4135-9E48-A0F56F909E3C}" xmlns:ds="http://schemas.openxmlformats.org/officeDocument/2006/customXml"><ds:schemaRefs><ds:schemaRef ds:uri="http://schemas.microsoft.com/sharepoint/v3/contenttype/forms"/></ds:schemaRefs></ds:datastoreItem>                                                 <?xml version="1.0" encoding="utf-8"?><LongProperties xmlns="http://schemas.microsoft.com/office/2006/metadata/longProperties"/><?xml version="1.0" encoding="UTF-8" standalone="no"?>
<ds:datastoreItem ds:itemID="{D2A6348B-7913-4A4E-B94C-56F44610AA8B}" xmlns:ds="http://schemas.openxmlformats.org/officeDocument/2006/customXml"><ds:schemaRefs><ds:schemaRef ds:uri="http://schemas.microsoft.com/office/2006/metadata/longProperties"/></ds:schemaRefs></ds:datastoreItem>                                              
  	           F    Document Microsoft Word 97-2003 
   MSWordDoc    Word.Document.8 9q                                                                                                                                                                                                                           C o m p O b j                                                                                            #   r                                                                                                                                                                                                                                                                                                                                                                   