Contact form

Please note that fields marked with an asterisk (*) are mandatory.

For an:

(*)Lastame:

(*)Infant lastname:

(*)Firstname:

(*)Infant firstname:

(*)Contact parent full name:

(*)Tel:

(*)E-mail:

(*)Address:

(*)Zip:

(*)City:

(*)Birthdate: (day/month/year)

(*)Mutuelle:

(*)National number

(or equivalent)

(*)Reason for the request:

(*)Request origin (spontaneous, physician, shrink,...):

(*)Request origin (Parents, physician, shrink, school...):

(*)School level:

(*)Education type:

Message:

University of Liège intends to comply with the General Regulations for the Protection of Data (GDPR - European Regulation 2016/679 of April 27 2016) organizing the processing of personal data as well as the relevant Belgian related regulations.
The data collected in this form are registered in the University of Liège's CPLU in order to allow appointments reservation, and if necessary, to complete your administrative file. These data will be kept the time to answer your request. These data will be processed on the basis of this consent.
These data will not be transfered to third parties.
In accordance with the provisions of [cplu@uliege.be or, failing this, the Data Protection Delegate of the ULiège (dpo@uliege.be - the Data Protection Officer, Bât. B9 Cellule « GDPR », Quartier Village 3, Boulevard de Colonster 2, 4000 Liège, Belgium). You also have the right to introduce a complaint to the Data Protection Authority (https://www.autoriteprotectiondonnees.be, contact@apd-gba.be)