{"id":17529,"date":"2026-03-24T14:11:58","date_gmt":"2026-03-24T13:11:58","guid":{"rendered":"https:\/\/www.jmlib.be\/site\/?page_id=17529"},"modified":"2026-03-24T14:11:59","modified_gmt":"2026-03-24T13:11:59","slug":"inscription-stage-art-et-cuisine-a-la-louviere","status":"publish","type":"page","link":"https:\/\/www.jmlib.be\/site\/inscription-stage-art-et-cuisine-a-la-louviere\/","title":{"rendered":"Inscription stage Art et cuisine \u00e0 La Louvi\u00e8re"},"content":{"rendered":"<div class=\"forminator-ui forminator-custom-form forminator-custom-form-17528 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-17528\" data-uid=\"69e3094b20e53\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-17528\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-17528 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"17528\"\n\t\t\t\t data-color-option=\"theme\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"69e3094b20e53\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div role=\"tablist\" class=\"forminator-pagination-steps\" aria-label=\"Pagination\"><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-17528--page-0\"\n\t\t\t\tclass=\"forminator-pagination forminator-pagination-start\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-17528--page-0-label\"\n\t\t\t\tdata-step=\"0\"\n\t\t\t\tdata-label=\"Termin\u00e9\"\n\t\t\t\tdata-actual-label=\"Page 1\"\n\t\t\t\tdata-name=\"page-break-1\"\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_69e3094b20e53\" id=\"forminator-field-name-2_69e3094b20e53-label\" class=\"forminator-label\">Nom du jeune <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_69e3094b20e53\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69e3094b20e53\" id=\"forminator-field-name-1_69e3094b20e53-label\" class=\"forminator-label\">Pr\u00e9nom du jeune <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_69e3094b20e53\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><div id=\"radio-8\" class=\"forminator-field-radio forminator-col forminator-col-4 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-8-69e3094b20e53-label\"><span id=\"forminator-radiogroup-radio-8-69e3094b20e53-label\" class=\"forminator-label\">Sexe <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-8-label-1\" for=\"forminator-field-radio-8-1-69e3094b20e53\" class=\"forminator-radio forminator-radio-inline\" title=\"M\"><input type=\"radio\" name=\"radio-8\" value=\"one\" id=\"forminator-field-radio-8-1-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-8-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">M<\/span><\/label><label id=\"forminator-field-radio-8-label-2\" for=\"forminator-field-radio-8-2-69e3094b20e53\" class=\"forminator-radio forminator-radio-inline\" title=\"F\"><input type=\"radio\" name=\"radio-8\" value=\"two\" id=\"forminator-field-radio-8-2-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-8-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">F<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_69e3094b20e53\" id=\"forminator-field-date-2-picker_69e3094b20e53-label\" class=\"forminator-label\">Date de naissance du jeune <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"\" id=\"forminator-field-date-2-picker_69e3094b20e53\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"number-1\" class=\"forminator-field-number forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-1_69e3094b20e53\" id=\"forminator-field-number-1_69e3094b20e53-label\" class=\"forminator-label\">Num\u00e9ro national du jeune <span class=\"forminator-required\">*<\/span><\/label><input name=\"number-1\" value=\"\" placeholder=\"000000-000-00\" id=\"forminator-field-number-1_69e3094b20e53\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"1\" data-decimals=\"0\" aria-required=\"true\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-17528__field--select-1_69e3094b20e53\" id=\"forminator-form-17528__field--select-1_69e3094b20e53-label\" class=\"forminator-label\">Personne responsable du jeune - Exer\u00e7ant l&#039;autorit\u00e9 parentale en tant que : <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-17528__field--select-1_69e3094b20e53\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-1\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"S\u00e9lectionnez\" data-search=\"false\" data-search-placeholder=\"S\u00e9lectionnez\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-17528__field--select-1_69e3094b20e53-label\"><option value=\"\"  >S\u00e9lectionnez<\/option><option value=\"one\"  data-calculation=\"0\">P\u00e8re<\/option><option value=\"two\"  data-calculation=\"0\">M\u00e8re<\/option><option value=\"Tuteur-Tutrice\"  data-calculation=\"0\">Tuteur\/Tutrice<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_69e3094b20e53\" id=\"forminator-field-name-3_69e3094b20e53-label\" class=\"forminator-label\">Nom du responsable <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"\" id=\"forminator-field-name-3_69e3094b20e53\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><div id=\"name-4\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-4_69e3094b20e53\" id=\"forminator-field-name-4_69e3094b20e53-label\" class=\"forminator-label\">Pr\u00e9nom du responsable <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-4\" value=\"\" placeholder=\"\" id=\"forminator-field-name-4_69e3094b20e53\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69e3094b20e53\" id=\"forminator-field-date-1-picker_69e3094b20e53-label\" class=\"forminator-label\">Date de naissance du responsable <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"\" id=\"forminator-field-date-1-picker_69e3094b20e53\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"number-2\" class=\"forminator-field-number forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-2_69e3094b20e53\" id=\"forminator-field-number-2_69e3094b20e53-label\" class=\"forminator-label\">Num\u00e9ro national du responsable <span class=\"forminator-required\">*<\/span><\/label><input name=\"number-2\" value=\"\" placeholder=\"000000-000-00\" id=\"forminator-field-number-2_69e3094b20e53\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"1\" data-decimals=\"0\" aria-required=\"true\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-2\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-2-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-street_address_69e3094b20e53\" id=\"forminator-field-address-2-street_address_69e3094b20e53-label\" class=\"forminator-label\">Rue<\/label><input type=\"text\" name=\"address-2-street_address\" placeholder=\"\" id=\"forminator-field-address-2-street_address_69e3094b20e53\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-2-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-address_line_69e3094b20e53\" id=\"forminator-field-address-2-address_line_69e3094b20e53-label\" class=\"forminator-label\">Appartement, suite, etc.<\/label><input type=\"text\" name=\"address-2-address_line\" placeholder=\"\" id=\"forminator-field-address-2-address_line_69e3094b20e53\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-2-city\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-city_69e3094b20e53\" id=\"forminator-field-address-2-city_69e3094b20e53-label\" class=\"forminator-label\">Ville<\/label><input type=\"text\" name=\"address-2-city\" placeholder=\"\" id=\"forminator-field-address-2-city_69e3094b20e53\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-2-zip\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-zip_69e3094b20e53\" id=\"forminator-field-address-2-zip_69e3094b20e53-label\" class=\"forminator-label\">Code postal<\/label><input type=\"text\" name=\"address-2-zip\" placeholder=\"\" id=\"forminator-field-address-2-zip_69e3094b20e53\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><div id=\"address-2-country\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-17528__field--address-2-country_69e3094b20e53\" id=\"forminator-field-17528__field--address-2-country_69e3094b20e53-label\" class=\"forminator-label\">Pays<\/label><select name=\"address-2-country\" id=\"forminator-field-17528__field--address-2-country_69e3094b20e53\" class=\"forminator-select2\" data-search=\"true\" data-placeholder=\"S\u00e9lectionner un pays\" autocomplete=\"country-name country\" data-default-value=\"\"><option value=\"\" data-country-code=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" data-country-code=\"AF\" >Afghanistan<\/option><option value=\"Afrique du Sud\" data-country-code=\"ZA\" >Afrique du Sud<\/option><option value=\"Albanie\" data-country-code=\"AL\" >Albanie<\/option><option value=\"Alg\u00e9rie\" data-country-code=\"DZ\" >Alg\u00e9rie<\/option><option value=\"Allemagne\" data-country-code=\"DE\" >Allemagne<\/option><option value=\"Andorre\" data-country-code=\"AD\" >Andorre<\/option><option value=\"Angola\" data-country-code=\"AO\" >Angola<\/option><option value=\"Anguilla\" data-country-code=\"AI\" >Anguilla<\/option><option value=\"Antarctique\" data-country-code=\"AQ\" >Antarctique<\/option><option value=\"Antigua-et-Barbuda\" data-country-code=\"AG\" >Antigua-et-Barbuda<\/option><option value=\"Antilles N\u00e9erlandaises\" data-country-code=\"AN\" >Antilles N\u00e9erlandaises<\/option><option value=\"Apatrides\" data-country-code=\"XX\" >Apatrides<\/option><option value=\"Arabie Saoudite\" data-country-code=\"SA\" >Arabie Saoudite<\/option><option value=\"Argentine\" data-country-code=\"AR\" >Argentine<\/option><option value=\"Arm\u00e9nie\" data-country-code=\"AM\" >Arm\u00e9nie<\/option><option value=\"Aruba\" data-country-code=\"AW\" >Aruba<\/option><option value=\"Australie\" data-country-code=\"AU\" >Australie<\/option><option value=\"Autriche\" data-country-code=\"AT\" >Autriche<\/option><option value=\"Azerba\u00efdjan\" data-country-code=\"AZ\" >Azerba\u00efdjan<\/option><option value=\"Bahamas\" data-country-code=\"BS\" >Bahamas<\/option><option value=\"Bahre\u00efn\" data-country-code=\"BH\" >Bahre\u00efn<\/option><option value=\"Bangladesh\" data-country-code=\"BD\" >Bangladesh<\/option><option value=\"Belgique\" data-country-code=\"BE\" >Belgique<\/option><option value=\"Bermudes\" data-country-code=\"BM\" >Bermudes<\/option><option value=\"Bhoutan\" data-country-code=\"BT\" >Bhoutan<\/option><option value=\"Bi\u00e9lorussie\" data-country-code=\"BY\" >Bi\u00e9lorussie<\/option><option value=\"Bolivie\" data-country-code=\"BO\" >Bolivie<\/option><option value=\"Bosnie-Herz\u00e9govine\" data-country-code=\"BA\" >Bosnie-Herz\u00e9govine<\/option><option value=\"Botswana\" data-country-code=\"BW\" >Botswana<\/option><option value=\"Brunei\" data-country-code=\"BN\" >Brunei<\/option><option value=\"Br\u00e9sil\" data-country-code=\"BR\" >Br\u00e9sil<\/option><option value=\"Bulgarie\" data-country-code=\"BG\" >Bulgarie<\/option><option value=\"Burkina Faso\" data-country-code=\"BF\" >Burkina Faso<\/option><option value=\"Burundi\" data-country-code=\"BI\" >Burundi<\/option><option value=\"B\u00e9lize\" data-country-code=\"BZ\" >B\u00e9lize<\/option><option value=\"B\u00e9nin\" data-country-code=\"BJ\" >B\u00e9nin<\/option><option value=\"Cambodge\" data-country-code=\"KH\" >Cambodge<\/option><option value=\"Cameroun\" data-country-code=\"CM\" >Cameroun<\/option><option value=\"Canada\" data-country-code=\"CA\" >Canada<\/option><option value=\"Cap Vert\" data-country-code=\"CV\" >Cap Vert<\/option><option value=\"Chili\" data-country-code=\"CL\" >Chili<\/option><option value=\"Chine, R\u00e9publique populaire de\" data-country-code=\"CN\" >Chine, R\u00e9publique populaire de<\/option><option value=\"Chypre\" data-country-code=\"CY\" >Chypre<\/option><option value=\"Cit\u00e9 du Vatican\" data-country-code=\"VA\" >Cit\u00e9 du Vatican<\/option><option value=\"Colombie\" data-country-code=\"CO\" >Colombie<\/option><option value=\"Comores\" data-country-code=\"KM\" >Comores<\/option><option value=\"Congo, R\u00e9publique du\" data-country-code=\"CG\" >Congo, R\u00e9publique du<\/option><option value=\"Congo, R\u00e9publique d\u00e9mocratique du\" data-country-code=\"CD\" >Congo, R\u00e9publique d\u00e9mocratique du<\/option><option value=\"Cor\u00e9e, R\u00e9publique de\" data-country-code=\"KR\" >Cor\u00e9e, R\u00e9publique de<\/option><option value=\"Cor\u00e9e, R\u00e9publique d\u00e9mocratique populaire de\" data-country-code=\"KP\" >Cor\u00e9e, R\u00e9publique d\u00e9mocratique populaire de<\/option><option value=\"Costa Rica\" data-country-code=\"CR\" >Costa Rica<\/option><option value=\"Croatie\" data-country-code=\"HR\" >Croatie<\/option><option value=\"Cuba\" data-country-code=\"CU\" >Cuba<\/option><option value=\"Cura\u00e7ao\" data-country-code=\"CW\" >Cura\u00e7ao<\/option><option value=\"C\u00f4te d\u2019Ivoire\" data-country-code=\"CI\" >C\u00f4te d\u2019Ivoire<\/option><option value=\"Danemark\" data-country-code=\"DK\" >Danemark<\/option><option value=\"Djibouti\" data-country-code=\"DJ\" >Djibouti<\/option><option value=\"Dominique\" data-country-code=\"DM\" >Dominique<\/option><option value=\"Espagne\" data-country-code=\"ES\" >Espagne<\/option><option value=\"Estonie\" data-country-code=\"EE\" >Estonie<\/option><option value=\"Fidji\" data-country-code=\"FJ\" >Fidji<\/option><option value=\"Finlande\" data-country-code=\"FI\" >Finlande<\/option><option value=\"France\" data-country-code=\"FR\" >France<\/option><option value=\"France, M\u00e9tropolitaine\" data-country-code=\"FX\" >France, M\u00e9tropolitaine<\/option><option value=\"Gabon\" data-country-code=\"GA\" >Gabon<\/option><option value=\"Gambie\" data-country-code=\"GM\" >Gambie<\/option><option value=\"Ghana\" data-country-code=\"GH\" >Ghana<\/option><option value=\"Gibraltar\" data-country-code=\"GI\" >Gibraltar<\/option><option value=\"Grenade\" data-country-code=\"GD\" >Grenade<\/option><option value=\"Groenland\" data-country-code=\"GL\" >Groenland<\/option><option value=\"Gr\u00e8ce\" data-country-code=\"GR\" >Gr\u00e8ce<\/option><option value=\"Guadeloupe\" data-country-code=\"GP\" >Guadeloupe<\/option><option value=\"Guam\" data-country-code=\"GU\" >Guam<\/option><option value=\"Guat\u00e9mala\" data-country-code=\"GT\" >Guat\u00e9mala<\/option><option value=\"Guernesey\" data-country-code=\"GG\" >Guernesey<\/option><option value=\"Guin\u00e9e\" data-country-code=\"GN\" >Guin\u00e9e<\/option><option value=\"Guin\u00e9e \u00c9quatoriale\" data-country-code=\"GQ\" >Guin\u00e9e \u00c9quatoriale<\/option><option value=\"Guin\u00e9e-Bissau\" data-country-code=\"GW\" >Guin\u00e9e-Bissau<\/option><option value=\"Guyane\" data-country-code=\"GY\" >Guyane<\/option><option value=\"Guyane fran\u00e7aise\" data-country-code=\"GF\" >Guyane fran\u00e7aise<\/option><option value=\"G\u00e9orgie\" data-country-code=\"GE\" >G\u00e9orgie<\/option><option value=\"G\u00e9orgie du Sud et Sandwich du Sud\" data-country-code=\"GS\" >G\u00e9orgie du Sud et Sandwich du Sud<\/option><option value=\"Ha\u00efti\" data-country-code=\"HT\" >Ha\u00efti<\/option><option value=\"Honduras\" data-country-code=\"HN\" >Honduras<\/option><option value=\"Hong Kong\" data-country-code=\"HK\" >Hong Kong<\/option><option value=\"Hongrie\" data-country-code=\"HU\" >Hongrie<\/option><option value=\"Inde\" data-country-code=\"IN\" >Inde<\/option><option value=\"Indon\u00e9sie\" data-country-code=\"ID\" >Indon\u00e9sie<\/option><option value=\"Iran\" data-country-code=\"IR\" >Iran<\/option><option value=\"Iraq\" data-country-code=\"IQ\" >Iraq<\/option><option value=\"Irlande\" data-country-code=\"IE\" >Irlande<\/option><option value=\"Islande\" data-country-code=\"IS\" >Islande<\/option><option value=\"Israel\" data-country-code=\"IL\" >Israel<\/option><option value=\"Italie\" data-country-code=\"IT\" >Italie<\/option><option value=\"Jama\u00efque\" data-country-code=\"JM\" >Jama\u00efque<\/option><option value=\"Japon\" data-country-code=\"JP\" >Japon<\/option><option value=\"Jersey\" data-country-code=\"JE\" >Jersey<\/option><option value=\"Jordanie\" data-country-code=\"JO\" >Jordanie<\/option><option value=\"Kazakhstan\" data-country-code=\"KZ\" >Kazakhstan<\/option><option value=\"Kenya\" data-country-code=\"KE\" >Kenya<\/option><option value=\"Kirghizistan\" data-country-code=\"KG\" >Kirghizistan<\/option><option value=\"Kiribati\" data-country-code=\"KI\" >Kiribati<\/option><option value=\"Kosovo\" data-country-code=\"XK\" >Kosovo<\/option><option value=\"Kowe\u00eft\" data-country-code=\"KW\" >Kowe\u00eft<\/option><option value=\"La Barbade\" data-country-code=\"BB\" >La Barbade<\/option><option value=\"Lesotho\" data-country-code=\"LS\" >Lesotho<\/option><option value=\"Lettonie\" data-country-code=\"LV\" >Lettonie<\/option><option value=\"Liban\" data-country-code=\"LB\" >Liban<\/option><option value=\"Libye\" data-country-code=\"LY\" >Libye<\/option><option value=\"Lib\u00e9ria\" data-country-code=\"LR\" >Lib\u00e9ria<\/option><option value=\"Liechtenstein\" data-country-code=\"LI\" >Liechtenstein<\/option><option value=\"Lithuanie\" data-country-code=\"LT\" >Lithuanie<\/option><option value=\"Luxembourg\" data-country-code=\"LU\" >Luxembourg<\/option><option value=\"Macao\" data-country-code=\"MO\" >Macao<\/option><option value=\"Mac\u00e9doine du Nord\" data-country-code=\"MK\" >Mac\u00e9doine du Nord<\/option><option value=\"Madagascar\" data-country-code=\"MG\" >Madagascar<\/option><option value=\"Malaisie\" data-country-code=\"MY\" >Malaisie<\/option><option value=\"Malawi\" data-country-code=\"MW\" >Malawi<\/option><option value=\"Maldives\" data-country-code=\"MV\" >Maldives<\/option><option value=\"Mali\" data-country-code=\"ML\" >Mali<\/option><option value=\"Malte\" data-country-code=\"MT\" >Malte<\/option><option value=\"Maroc\" data-country-code=\"MA\" >Maroc<\/option><option value=\"Martinique\" data-country-code=\"MQ\" >Martinique<\/option><option value=\"Mauritanie\" data-country-code=\"MR\" >Mauritanie<\/option><option value=\"Mayotte\" data-country-code=\"YT\" >Mayotte<\/option><option value=\"Mexique\" data-country-code=\"MX\" >Mexique<\/option><option value=\"Micron\u00e9sie\" data-country-code=\"FM\" >Micron\u00e9sie<\/option><option value=\"Moldavie\" data-country-code=\"MD\" >Moldavie<\/option><option value=\"Monaco\" data-country-code=\"MC\" >Monaco<\/option><option value=\"Mongolie\" data-country-code=\"MN\" >Mongolie<\/option><option value=\"Montserrat\" data-country-code=\"MS\" >Montserrat<\/option><option value=\"Mont\u00e9n\u00e9gro\" data-country-code=\"ME\" >Mont\u00e9n\u00e9gro<\/option><option value=\"Mozambique\" data-country-code=\"MZ\" >Mozambique<\/option><option value=\"Myanmar\" data-country-code=\"MM\" >Myanmar<\/option><option value=\"Namibie\" data-country-code=\"NA\" >Namibie<\/option><option value=\"Nauru\" data-country-code=\"NR\" >Nauru<\/option><option value=\"Nicaragua\" data-country-code=\"NI\" >Nicaragua<\/option><option value=\"Niger\" data-country-code=\"NE\" >Niger<\/option><option value=\"Nigeria\" data-country-code=\"NG\" >Nigeria<\/option><option value=\"Niu\u00e9\" data-country-code=\"NU\" >Niu\u00e9<\/option><option value=\"Norv\u00e8ge\" data-country-code=\"NO\" >Norv\u00e8ge<\/option><option value=\"Nouvelle Zelande\" data-country-code=\"NZ\" >Nouvelle Zelande<\/option><option value=\"Nouvelle-Cal\u00e9donie\" data-country-code=\"NC\" >Nouvelle-Cal\u00e9donie<\/option><option value=\"N\u00e9pal\" data-country-code=\"NP\" >N\u00e9pal<\/option><option value=\"Oman\" data-country-code=\"OM\" >Oman<\/option><option value=\"Ouganda\" data-country-code=\"UG\" >Ouganda<\/option><option value=\"Ouzb\u00e9kistan\" data-country-code=\"UZ\" >Ouzb\u00e9kistan<\/option><option value=\"Pakistan\" data-country-code=\"PK\" >Pakistan<\/option><option value=\"Palau\" data-country-code=\"PW\" >Palau<\/option><option value=\"Palestine, \u00c9tat de\" data-country-code=\"PS\" >Palestine, \u00c9tat de<\/option><option value=\"Panama\" data-country-code=\"PA\" >Panama<\/option><option value=\"Papouasie-Nouvelle-Guin\u00e9e\" data-country-code=\"PG\" >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value=\"Paraguay\" data-country-code=\"PY\" >Paraguay<\/option><option value=\"Pays-Bas\" data-country-code=\"NL\" >Pays-Bas<\/option><option value=\"Philippines\" data-country-code=\"PH\" >Philippines<\/option><option value=\"Pologne\" data-country-code=\"PL\" >Pologne<\/option><option value=\"Polyn\u00e9sie Fran\u00e7aise\" data-country-code=\"PF\" >Polyn\u00e9sie Fran\u00e7aise<\/option><option value=\"Porto Rico\" data-country-code=\"PR\" >Porto Rico<\/option><option value=\"Portugal\" data-country-code=\"PT\" >Portugal<\/option><option value=\"P\u00e9rou\" data-country-code=\"PE\" >P\u00e9rou<\/option><option value=\"Qatar\" data-country-code=\"QA\" >Qatar<\/option><option value=\"Roumanie\" data-country-code=\"RO\" >Roumanie<\/option><option value=\"Royaume-Uni\" data-country-code=\"GB\" >Royaume-Uni<\/option><option value=\"Russie\" data-country-code=\"RU\" >Russie<\/option><option value=\"Rwanda\" data-country-code=\"RW\" >Rwanda<\/option><option value=\"R\u00e9publique Centrafricaine\" data-country-code=\"CF\" >R\u00e9publique Centrafricaine<\/option><option value=\"R\u00e9publique Dominicaine\" data-country-code=\"DO\" >R\u00e9publique Dominicaine<\/option><option value=\"R\u00e9publique Tch\u00e8que\" data-country-code=\"CZ\" >R\u00e9publique Tch\u00e8que<\/option><option value=\"R\u00e9publique du Salvador\" data-country-code=\"SV\" >R\u00e9publique du Salvador<\/option><option value=\"R\u00e9publique d\u00e9mocratique populaire du Laos\" data-country-code=\"LA\" >R\u00e9publique d\u00e9mocratique populaire du Laos<\/option><option value=\"Sahara occidental\" data-country-code=\"EH\" >Sahara occidental<\/option><option value=\"Saint Pierre et Miquelon\" data-country-code=\"PM\" >Saint Pierre et Miquelon<\/option><option value=\"Saint-Kitts-et-Nevis\" data-country-code=\"KN\" >Saint-Kitts-et-Nevis<\/option><option value=\"Saint-Marin\" data-country-code=\"SM\" >Saint-Marin<\/option><option value=\"Saint-Martin (Royaume des Pays-Bas)\" data-country-code=\"MF\" >Saint-Martin (Royaume des Pays-Bas)<\/option><option value=\"Saint-Vincent-et-les-Grenadines\" data-country-code=\"VC\" >Saint-Vincent-et-les-Grenadines<\/option><option value=\"Sainte Lucie\" data-country-code=\"LC\" >Sainte Lucie<\/option><option value=\"Sainte-H\u00e9l\u00e8ne\" data-country-code=\"SH\" >Sainte-H\u00e9l\u00e8ne<\/option><option value=\"Samoa\" data-country-code=\"WS\" >Samoa<\/option><option value=\"Samoa am\u00e9ricaines\" data-country-code=\"AS\" >Samoa am\u00e9ricaines<\/option><option value=\"Sao Tom\u00e9-et-Principe\" data-country-code=\"ST\" >Sao Tom\u00e9-et-Principe<\/option><option value=\"Serbie\" data-country-code=\"RS\" >Serbie<\/option><option value=\"Seychelles\" data-country-code=\"SC\" >Seychelles<\/option><option value=\"Sierra Leone\" data-country-code=\"SL\" >Sierra Leone<\/option><option value=\"Singapour\" data-country-code=\"SG\" >Singapour<\/option><option value=\"Slovaquie\" data-country-code=\"SK\" >Slovaquie<\/option><option value=\"Slov\u00e9nie\" data-country-code=\"SI\" >Slov\u00e9nie<\/option><option value=\"Somalie\" data-country-code=\"SO\" >Somalie<\/option><option value=\"Soudan\" data-country-code=\"SD\" >Soudan<\/option><option value=\"Soudan, Sud\" data-country-code=\"SS\" >Soudan, Sud<\/option><option value=\"Sri Lanka\" data-country-code=\"LK\" >Sri Lanka<\/option><option value=\"Suisse\" data-country-code=\"CH\" >Suisse<\/option><option value=\"Suriname\" data-country-code=\"SR\" >Suriname<\/option><option value=\"Su\u00e8de\" data-country-code=\"SE\" >Su\u00e8de<\/option><option value=\"Svalbard et Jan Mayen\" data-country-code=\"SJ\" >Svalbard et Jan Mayen<\/option><option value=\"Swaziland\" data-country-code=\"SZ\" >Swaziland<\/option><option value=\"Syrie\" data-country-code=\"SY\" >Syrie<\/option><option value=\"S\u00e9n\u00e9gal\" data-country-code=\"SN\" >S\u00e9n\u00e9gal<\/option><option value=\"Tadjikistan\" data-country-code=\"TJ\" >Tadjikistan<\/option><option value=\"Taiwan, R\u00e9publique de Chine\" data-country-code=\"TW\" >Taiwan, R\u00e9publique de Chine<\/option><option value=\"Tanzanie\" data-country-code=\"TZ\" >Tanzanie<\/option><option value=\"Tchad\" data-country-code=\"TD\" >Tchad<\/option><option value=\"Terres australes et antarctiques fran\u00e7aises\" data-country-code=\"TF\" >Terres australes et antarctiques fran\u00e7aises<\/option><option value=\"Territoire britannique de l\u2019oc\u00e9an Indien\" data-country-code=\"IO\" >Territoire britannique de l\u2019oc\u00e9an Indien<\/option><option value=\"Tha\u00eflande\" data-country-code=\"TH\" >Tha\u00eflande<\/option><option value=\"Timor-Oriental\" data-country-code=\"TL\" >Timor-Oriental<\/option><option value=\"Togo\" data-country-code=\"TG\" >Togo<\/option><option value=\"Tokelau\" data-country-code=\"TK\" >Tokelau<\/option><option value=\"Tonga\" data-country-code=\"TO\" >Tonga<\/option><option value=\"Trinit\u00e9 et Tobago\" data-country-code=\"TT\" >Trinit\u00e9 et Tobago<\/option><option value=\"Tunisie\" data-country-code=\"TN\" >Tunisie<\/option><option value=\"Turkm\u00e9nistan\" data-country-code=\"TM\" >Turkm\u00e9nistan<\/option><option value=\"Turquie\" data-country-code=\"TR\" >Turquie<\/option><option value=\"Tuvalu\" data-country-code=\"TV\" >Tuvalu<\/option><option value=\"Ukraine\" data-country-code=\"UA\" >Ukraine<\/option><option value=\"Uruguay\" data-country-code=\"UY\" >Uruguay<\/option><option value=\"Vanuatu\" data-country-code=\"VU\" >Vanuatu<\/option><option value=\"Vietnam\" data-country-code=\"VN\" >Vietnam<\/option><option value=\"V\u00e9n\u00e9zu\u00e9la\" data-country-code=\"VE\" >V\u00e9n\u00e9zu\u00e9la<\/option><option value=\"Yemen\" data-country-code=\"YE\" >Yemen<\/option><option value=\"Zambie\" data-country-code=\"ZM\" >Zambie<\/option><option value=\"Zimbabwe\" data-country-code=\"ZW\" >Zimbabwe<\/option><option value=\"\u00c9gypte\" data-country-code=\"EG\" >\u00c9gypte<\/option><option value=\"\u00c9mirats Arabes Unis\" data-country-code=\"AE\" >\u00c9mirats Arabes Unis<\/option><option value=\"\u00c9quateur\" data-country-code=\"EC\" >\u00c9quateur<\/option><option value=\"\u00c9rythr\u00e9e\" data-country-code=\"ER\" >\u00c9rythr\u00e9e<\/option><option value=\"\u00c9tats-Unis d\u2019Am\u00e9rique (USA)\" data-country-code=\"US\" >\u00c9tats-Unis d\u2019Am\u00e9rique (USA)<\/option><option value=\"\u00c9thiopie\" data-country-code=\"ET\" >\u00c9thiopie<\/option><option value=\"\u00cele Bouvet\" data-country-code=\"BV\" >\u00cele Bouvet<\/option><option value=\"\u00cele Christmas\" data-country-code=\"CX\" >\u00cele Christmas<\/option><option value=\"\u00cele Heard et \u00eele Mcdonald\" data-country-code=\"HM\" >\u00cele Heard et \u00eele Mcdonald<\/option><option value=\"\u00cele Johnston\" data-country-code=\"JT\" >\u00cele Johnston<\/option><option value=\"\u00cele Maurice\" data-country-code=\"MU\" >\u00cele Maurice<\/option><option value=\"\u00cele Norfolk\" data-country-code=\"NF\" >\u00cele Norfolk<\/option><option value=\"\u00cele de la R\u00e9union\" data-country-code=\"RE\" >\u00cele de la R\u00e9union<\/option><option value=\"\u00celes Ca\u00efmans\" data-country-code=\"KY\" >\u00celes Ca\u00efmans<\/option><option value=\"\u00celes Cocos\" data-country-code=\"CC\" >\u00celes Cocos<\/option><option value=\"\u00celes Cook\" data-country-code=\"CK\" >\u00celes Cook<\/option><option value=\"\u00celes Falkland\" data-country-code=\"FK\" >\u00celes Falkland<\/option><option value=\"\u00celes F\u00e9ro\u00e9\" data-country-code=\"FO\" >\u00celes F\u00e9ro\u00e9<\/option><option value=\"\u00celes Mariannes du Nord\" data-country-code=\"MP\" >\u00celes Mariannes du Nord<\/option><option value=\"\u00celes Marshall\" data-country-code=\"MH\" >\u00celes Marshall<\/option><option value=\"\u00celes Pitcairn\" data-country-code=\"PN\" >\u00celes Pitcairn<\/option><option value=\"\u00celes Salomon\" data-country-code=\"SB\" >\u00celes Salomon<\/option><option value=\"\u00celes Turques-et-Ca\u00efques\" data-country-code=\"TC\" >\u00celes Turques-et-Ca\u00efques<\/option><option value=\"\u00celes Vierges am\u00e9ricaines\" data-country-code=\"VI\" >\u00celes Vierges am\u00e9ricaines<\/option><option value=\"\u00celes Vierges britanniques\" data-country-code=\"VG\" >\u00celes Vierges britanniques<\/option><option value=\"\u00celes Wallis et Futuna\" data-country-code=\"WF\" >\u00celes Wallis et Futuna<\/option><option value=\"\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis\" data-country-code=\"UM\" >\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69e3094b20e53\" id=\"forminator-field-phone-1_69e3094b20e53-label\" class=\"forminator-label\">Num\u00e9ro de t\u00e9l\u00e9phone <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_69e3094b20e53\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" data-national_mode=\"enabled\" data-country=\"be\" data-validation=\"standard\" \/><\/div><\/div><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69e3094b20e53\" id=\"forminator-field-email-1_69e3094b20e53-label\" class=\"forminator-label\">Adresse de messagerie <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_69e3094b20e53\" class=\"forminator-input forminator-email--field\" data-required=\"true\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-17528--page-1\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-17528--page-1-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"1\"\n\t\t\t\tdata-label=\"Page 1\"\n\t\t\t\tdata-actual-label=\"Page 2\"\n\t\t\t\tdata-name=\"page-break-3\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-69e3094b20e53-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-69e3094b20e53-label\" class=\"forminator-label\">L\u2019enfant est atteint de:<\/span><label id=\"forminator-field-checkbox-1-1-69e3094b20e53-label\" for=\"forminator-field-checkbox-1-1-69e3094b20e53\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Diab\u00e8te\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-69e3094b20e53\" aria-labelledby=\"forminator-field-checkbox-1-1-69e3094b20e53-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Diab\u00e8te<\/span><\/label><label id=\"forminator-field-checkbox-1-2-69e3094b20e53-label\" for=\"forminator-field-checkbox-1-2-69e3094b20e53\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Asthme\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"two\" id=\"forminator-field-checkbox-1-2-69e3094b20e53\" aria-labelledby=\"forminator-field-checkbox-1-2-69e3094b20e53-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Asthme<\/span><\/label><label id=\"forminator-field-checkbox-1-3-69e3094b20e53-label\" for=\"forminator-field-checkbox-1-3-69e3094b20e53\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Epilepsie\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Epilepsie\" id=\"forminator-field-checkbox-1-3-69e3094b20e53\" aria-labelledby=\"forminator-field-checkbox-1-3-69e3094b20e53-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Epilepsie<\/span><\/label><label id=\"forminator-field-checkbox-1-4-69e3094b20e53-label\" for=\"forminator-field-checkbox-1-4-69e3094b20e53\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Somnambulisme\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"fdd\" id=\"forminator-field-checkbox-1-4-69e3094b20e53\" aria-labelledby=\"forminator-field-checkbox-1-4-69e3094b20e53-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Somnambulisme<\/span><\/label><label id=\"forminator-field-checkbox-1-5-69e3094b20e53-label\" for=\"forminator-field-checkbox-1-5-69e3094b20e53\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Rhumatisme\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"dddd\" id=\"forminator-field-checkbox-1-5-69e3094b20e53\" aria-labelledby=\"forminator-field-checkbox-1-5-69e3094b20e53-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Rhumatisme<\/span><\/label><label id=\"forminator-field-checkbox-1-6-69e3094b20e53-label\" for=\"forminator-field-checkbox-1-6-69e3094b20e53\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Maux de t\u00eate\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Maux-de-t\u00eate\" id=\"forminator-field-checkbox-1-6-69e3094b20e53\" aria-labelledby=\"forminator-field-checkbox-1-6-69e3094b20e53-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Maux de t\u00eate<\/span><\/label><label id=\"forminator-field-checkbox-1-7-69e3094b20e53-label\" for=\"forminator-field-checkbox-1-7-69e3094b20e53\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Saignements de nez\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Saignements-de-nez\" id=\"forminator-field-checkbox-1-7-69e3094b20e53\" aria-labelledby=\"forminator-field-checkbox-1-7-69e3094b20e53-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Saignements de nez<\/span><\/label><label id=\"forminator-field-checkbox-1-8-69e3094b20e53-label\" for=\"forminator-field-checkbox-1-8-69e3094b20e53\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Insomnie\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Insomnie\" id=\"forminator-field-checkbox-1-8-69e3094b20e53\" aria-labelledby=\"forminator-field-checkbox-1-8-69e3094b20e53-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Insomnie<\/span><\/label><label id=\"forminator-field-checkbox-1-9-69e3094b20e53-label\" for=\"forminator-field-checkbox-1-9-69e3094b20e53\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Incontinence\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Incontinence\" id=\"forminator-field-checkbox-1-9-69e3094b20e53\" aria-labelledby=\"forminator-field-checkbox-1-9-69e3094b20e53-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Incontinence<\/span><\/label><label id=\"forminator-field-checkbox-1-10-69e3094b20e53-label\" for=\"forminator-field-checkbox-1-10-69e3094b20e53\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Affection cutan\u00e9e\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Affection-cutan\u00e9e\" id=\"forminator-field-checkbox-1-10-69e3094b20e53\" aria-labelledby=\"forminator-field-checkbox-1-10-69e3094b20e53-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Affection cutan\u00e9e<\/span><\/label><label id=\"forminator-field-checkbox-1-11-69e3094b20e53-label\" for=\"forminator-field-checkbox-1-11-69e3094b20e53\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Affection cardiaque\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Affection-cardiaque\" id=\"forminator-field-checkbox-1-11-69e3094b20e53\" aria-labelledby=\"forminator-field-checkbox-1-11-69e3094b20e53-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Affection cardiaque<\/span><\/label><label id=\"forminator-field-checkbox-1-12-69e3094b20e53-label\" for=\"forminator-field-checkbox-1-12-69e3094b20e53\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Maladie contagieuse\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Maladie-contagieuse\" id=\"forminator-field-checkbox-1-12-69e3094b20e53\" aria-labelledby=\"forminator-field-checkbox-1-12-69e3094b20e53-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Maladie contagieuse<\/span><\/label><label id=\"forminator-field-checkbox-1-13-69e3094b20e53-label\" for=\"forminator-field-checkbox-1-13-69e3094b20e53\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Maux de ventre\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Maux-de-ventre\" id=\"forminator-field-checkbox-1-13-69e3094b20e53\" aria-labelledby=\"forminator-field-checkbox-1-13-69e3094b20e53-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Maux de ventre<\/span><\/label><label id=\"forminator-field-checkbox-1-14-69e3094b20e53-label\" for=\"forminator-field-checkbox-1-14-69e3094b20e53\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Allergies\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Allergies\" id=\"forminator-field-checkbox-1-14-69e3094b20e53\" aria-labelledby=\"forminator-field-checkbox-1-14-69e3094b20e53-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Allergies<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_69e3094b20e53\" id=\"forminator-field-textarea-1_69e3094b20e53-label\" class=\"forminator-label\">Si autres veuillez le pr\u00e9ciser ?<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_69e3094b20e53\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-69e3094b20e53-label\"><span id=\"forminator-radiogroup-radio-1-69e3094b20e53-label\" class=\"forminator-label\">Est-il sensible aux refroidissements ? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-69e3094b20e53\" class=\"forminator-radio\" title=\"oui\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">oui<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-69e3094b20e53\" class=\"forminator-radio\" title=\"non\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">non<\/span><\/label><\/div><\/div><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-2-69e3094b20e53-label\"><span id=\"forminator-radiogroup-radio-2-69e3094b20e53-label\" class=\"forminator-label\">Est-il vite fatigu\u00e9 ? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-69e3094b20e53\" class=\"forminator-radio\" title=\"oui\"><input type=\"radio\" name=\"radio-2\" value=\"one\" id=\"forminator-field-radio-2-1-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">oui<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-69e3094b20e53\" class=\"forminator-radio\" title=\"non\"><input type=\"radio\" name=\"radio-2\" value=\"two\" id=\"forminator-field-radio-2-2-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-3-69e3094b20e53-label\"><span id=\"forminator-radiogroup-radio-3-69e3094b20e53-label\" class=\"forminator-label\">Porte-t-il des lunettes? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-69e3094b20e53\" class=\"forminator-radio\" title=\"oui\"><input type=\"radio\" name=\"radio-3\" value=\"one\" id=\"forminator-field-radio-3-1-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-3-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">oui<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-69e3094b20e53\" class=\"forminator-radio\" title=\"non\"><input type=\"radio\" name=\"radio-3\" value=\"two\" id=\"forminator-field-radio-3-2-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-3-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">non<\/span><\/label><\/div><\/div><div id=\"radio-4\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-4-69e3094b20e53-label\"><span id=\"forminator-radiogroup-radio-4-69e3094b20e53-label\" class=\"forminator-label\">Sait-il rouler \u00e0 v\u00e9lo ? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-69e3094b20e53\" class=\"forminator-radio\" title=\"oui\"><input type=\"radio\" name=\"radio-4\" value=\"one\" id=\"forminator-field-radio-4-1-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-4-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">oui<\/span><\/label><label id=\"forminator-field-radio-4-label-2\" for=\"forminator-field-radio-4-2-69e3094b20e53\" class=\"forminator-radio\" title=\"non\"><input type=\"radio\" name=\"radio-4\" value=\"two\" id=\"forminator-field-radio-4-2-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-4-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-7\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-7-69e3094b20e53-label\"><span id=\"forminator-radiogroup-radio-7-69e3094b20e53-label\" class=\"forminator-label\">Sait-il nager ? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-7-label-1\" for=\"forminator-field-radio-7-1-69e3094b20e53\" class=\"forminator-radio\" title=\"oui\"><input type=\"radio\" name=\"radio-7\" value=\"one\" id=\"forminator-field-radio-7-1-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-7-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">oui<\/span><\/label><label id=\"forminator-field-radio-7-label-2\" for=\"forminator-field-radio-7-2-69e3094b20e53\" class=\"forminator-radio\" title=\"non\"><input type=\"radio\" name=\"radio-7\" value=\"two\" id=\"forminator-field-radio-7-2-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-7-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">non<\/span><\/label><\/div><\/div><div id=\"radio-5\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-5-69e3094b20e53-label\"><span id=\"forminator-radiogroup-radio-5-69e3094b20e53-label\" class=\"forminator-label\">Peut-il participer \u00e0 toutes les activit\u00e9s <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-5-label-1\" for=\"forminator-field-radio-5-1-69e3094b20e53\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-5\" value=\"one\" id=\"forminator-field-radio-5-1-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-5-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-5-label-2\" for=\"forminator-field-radio-5-2-69e3094b20e53\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-5\" value=\"two\" id=\"forminator-field-radio-5-2-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-5-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-3\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><textarea name=\"textarea-3\" placeholder=\"Autre(s):\" id=\"forminator-field-textarea-3_69e3094b20e53\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-5\" class=\"forminator-field-number forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-5_69e3094b20e53\" id=\"forminator-field-number-5_69e3094b20e53-label\" class=\"forminator-label\">Poids du jeune : <span class=\"forminator-required\">*<\/span><\/label><span id=\"forminator-field-number-5_69e3094b20e53-description\" class=\"forminator-description\">Kg<\/span><input name=\"number-5\" value=\"\" placeholder=\"\" id=\"forminator-field-number-5_69e3094b20e53\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"1\" data-decimals=\"0\" aria-required=\"true\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"150\" aria-describedby=\"forminator-field-number-5_69e3094b20e53-description\" \/><\/div><\/div><div id=\"radio-11\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-11-69e3094b20e53-label\"><span id=\"forminator-radiogroup-radio-11-69e3094b20e53-label\" class=\"forminator-label\">Groupe sanguin du jeune : <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-11-label-1\" for=\"forminator-field-radio-11-1-69e3094b20e53\" class=\"forminator-radio forminator-radio-inline\" title=\"A+\"><input type=\"radio\" name=\"radio-11\" value=\"one\" id=\"forminator-field-radio-11-1-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-11-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">A+<\/span><\/label><label id=\"forminator-field-radio-11-label-2\" for=\"forminator-field-radio-11-2-69e3094b20e53\" class=\"forminator-radio forminator-radio-inline\" title=\"A-\"><input type=\"radio\" name=\"radio-11\" value=\"two\" id=\"forminator-field-radio-11-2-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-11-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">A-<\/span><\/label><label id=\"forminator-field-radio-11-label-3\" for=\"forminator-field-radio-11-3-69e3094b20e53\" class=\"forminator-radio forminator-radio-inline\" title=\"B+\"><input type=\"radio\" name=\"radio-11\" value=\"B+\" id=\"forminator-field-radio-11-3-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-11-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">B+<\/span><\/label><label id=\"forminator-field-radio-11-label-4\" for=\"forminator-field-radio-11-4-69e3094b20e53\" class=\"forminator-radio forminator-radio-inline\" title=\"B-\"><input type=\"radio\" name=\"radio-11\" value=\"B-\" id=\"forminator-field-radio-11-4-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-11-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">B-<\/span><\/label><label id=\"forminator-field-radio-11-label-5\" for=\"forminator-field-radio-11-5-69e3094b20e53\" class=\"forminator-radio forminator-radio-inline\" title=\"AB+\"><input type=\"radio\" name=\"radio-11\" value=\"AB+\" id=\"forminator-field-radio-11-5-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-11-label-5\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">AB+<\/span><\/label><label id=\"forminator-field-radio-11-label-6\" for=\"forminator-field-radio-11-6-69e3094b20e53\" class=\"forminator-radio forminator-radio-inline\" title=\"AB-\"><input type=\"radio\" name=\"radio-11\" value=\"AB-\" id=\"forminator-field-radio-11-6-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-11-label-6\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">AB-<\/span><\/label><label id=\"forminator-field-radio-11-label-7\" for=\"forminator-field-radio-11-7-69e3094b20e53\" class=\"forminator-radio forminator-radio-inline\" title=\"O+\"><input type=\"radio\" name=\"radio-11\" value=\"O+\" id=\"forminator-field-radio-11-7-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-11-label-7\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">O+<\/span><\/label><label id=\"forminator-field-radio-11-label-8\" for=\"forminator-field-radio-11-8-69e3094b20e53\" class=\"forminator-radio forminator-radio-inline\" title=\"O-\"><input type=\"radio\" name=\"radio-11\" value=\"O-\" id=\"forminator-field-radio-11-8-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-11-label-8\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">O-<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-6\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-6-69e3094b20e53-label\"><span id=\"forminator-radiogroup-radio-6-69e3094b20e53-label\" class=\"forminator-label\">A-t-il \u00e9t\u00e9 vaccin\u00e9 contre le t\u00e9tanos ? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-6-label-1\" for=\"forminator-field-radio-6-1-69e3094b20e53\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-6\" value=\"one\" id=\"forminator-field-radio-6-1-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-6-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-6-label-2\" for=\"forminator-field-radio-6-2-69e3094b20e53\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-6\" value=\"two\" id=\"forminator-field-radio-6-2-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-6-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-6 \"><div class=\"forminator-field\"><textarea name=\"textarea-2\" placeholder=\"En quelle ann\u00e9es ? \nDate du dernier rappel\" id=\"forminator-field-textarea-2_69e3094b20e53\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-9\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-9-69e3094b20e53-label\"><span id=\"forminator-radiogroup-radio-9-69e3094b20e53-label\" class=\"forminator-label\">Est-il allergique \u00e0 des m\u00e9dicaments? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-9-label-1\" for=\"forminator-field-radio-9-1-69e3094b20e53\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-9\" value=\"one\" id=\"forminator-field-radio-9-1-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-9-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-9-label-2\" for=\"forminator-field-radio-9-2-69e3094b20e53\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-9\" value=\"two\" id=\"forminator-field-radio-9-2-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-9-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"textarea-8\" class=\"forminator-field-textarea forminator-col forminator-col-6 \"><div class=\"forminator-field\"><textarea name=\"textarea-8\" placeholder=\"Si oui lesquels?\" id=\"forminator-field-textarea-8_69e3094b20e53\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-10\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-10-69e3094b20e53-label\"><span id=\"forminator-radiogroup-radio-10-69e3094b20e53-label\" class=\"forminator-label\">Est-il allergique \u00e0 des mati\u00e8res ou aliments ? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-10-label-1\" for=\"forminator-field-radio-10-1-69e3094b20e53\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-10\" value=\"one\" id=\"forminator-field-radio-10-1-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-10-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-10-label-2\" for=\"forminator-field-radio-10-2-69e3094b20e53\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-10\" value=\"two\" id=\"forminator-field-radio-10-2-69e3094b20e53\" aria-labelledby=\"forminator-field-radio-10-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"textarea-9\" class=\"forminator-field-textarea forminator-col forminator-col-6 \"><div class=\"forminator-field\"><textarea name=\"textarea-9\" placeholder=\"Si oui lesquels?\" id=\"forminator-field-textarea-9_69e3094b20e53\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-4\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-4_69e3094b20e53\" id=\"forminator-field-textarea-4_69e3094b20e53-label\" class=\"forminator-label\">Date du dernier test \u00e0 la tuberculose et r\u00e9sultat :<\/label><textarea name=\"textarea-4\" placeholder=\"\" id=\"forminator-field-textarea-4_69e3094b20e53\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-5\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-5_69e3094b20e53\" id=\"forminator-field-textarea-5_69e3094b20e53-label\" class=\"forminator-label\">Autres observations :<\/label><span id=\"forminator-field-textarea-5_69e3094b20e53-description\" class=\"forminator-description\">M\u00e9dicaments \u00e0 prendre (lesquels ? quand ? quantit\u00e9 ?), r\u00e9gime alimentaire, pr\u00e9cautions \u00e0 prendre etc.<\/span><textarea name=\"textarea-5\" placeholder=\"\" id=\"forminator-field-textarea-5_69e3094b20e53\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" aria-describedby=\"forminator-field-textarea-5_69e3094b20e53-description\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-3\" class=\"forminator-field-number forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-3_69e3094b20e53\" id=\"forminator-field-number-3_69e3094b20e53-label\" class=\"forminator-label\">Nombres de fr\u00e8res :<\/label><input name=\"number-3\" value=\"0\" placeholder=\"\" id=\"forminator-field-number-3_69e3094b20e53\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"0\" max=\"150\" \/><\/div><\/div><div id=\"number-4\" class=\"forminator-field-number forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-4_69e3094b20e53\" id=\"forminator-field-number-4_69e3094b20e53-label\" class=\"forminator-label\">Nombres de soeurs:<\/label><input name=\"number-4\" value=\"0\" placeholder=\"\" id=\"forminator-field-number-4_69e3094b20e53\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"0\" max=\"150\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-2\" class=\"forminator-field-checkbox forminator-col forminator-col-6 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-2-69e3094b20e53-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-2-69e3094b20e53-label\" class=\"forminator-label\">L\u2019enfant vit avec: <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-checkbox-2-1-69e3094b20e53-label\" for=\"forminator-field-checkbox-2-1-69e3094b20e53\" class=\"forminator-checkbox\" title=\"ses parents\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"one\" id=\"forminator-field-checkbox-2-1-69e3094b20e53\" aria-labelledby=\"forminator-field-checkbox-2-1-69e3094b20e53-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">ses parents<\/span><\/label><label id=\"forminator-field-checkbox-2-2-69e3094b20e53-label\" for=\"forminator-field-checkbox-2-2-69e3094b20e53\" class=\"forminator-checkbox\" title=\"dans un home\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"two\" id=\"forminator-field-checkbox-2-2-69e3094b20e53\" aria-labelledby=\"forminator-field-checkbox-2-2-69e3094b20e53-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">dans un home<\/span><\/label><label id=\"forminator-field-checkbox-2-3-69e3094b20e53-label\" for=\"forminator-field-checkbox-2-3-69e3094b20e53\" class=\"forminator-checkbox\" title=\"une maison d\u2019accueil\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"une-maison-d\u2019accueil\" id=\"forminator-field-checkbox-2-3-69e3094b20e53\" aria-labelledby=\"forminator-field-checkbox-2-3-69e3094b20e53-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">une maison d\u2019accueil<\/span><\/label><label id=\"forminator-field-checkbox-2-4-69e3094b20e53-label\" for=\"forminator-field-checkbox-2-4-69e3094b20e53\" class=\"forminator-checkbox\" title=\"Autres:\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Autres:\" id=\"forminator-field-checkbox-2-4-69e3094b20e53\" aria-labelledby=\"forminator-field-checkbox-2-4-69e3094b20e53-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Autres:<\/span><\/label><\/div><\/div><div id=\"textarea-6\" class=\"forminator-field-textarea forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-6_69e3094b20e53\" id=\"forminator-field-textarea-6_69e3094b20e53-label\" class=\"forminator-label\">Si autres veuillez le pr\u00e9ciser :<\/label><textarea name=\"textarea-6\" placeholder=\"\" id=\"forminator-field-textarea-6_69e3094b20e53\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-7\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-7_69e3094b20e53\" id=\"forminator-field-textarea-7_69e3094b20e53-label\" class=\"forminator-label\">Caract\u00e9ristiques familiales particuli\u00e8res &amp; autres :<\/label><textarea name=\"textarea-7\" placeholder=\"\" id=\"forminator-field-textarea-7_69e3094b20e53\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-7\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-7_69e3094b20e53\" id=\"forminator-field-name-7_69e3094b20e53-label\" class=\"forminator-label\">M\u00e9decin traitant<\/label><input type=\"text\" name=\"name-7\" value=\"\" placeholder=\"\" id=\"forminator-field-name-7_69e3094b20e53\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"phone-3\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-3_69e3094b20e53\" id=\"forminator-field-phone-3_69e3094b20e53-label\" class=\"forminator-label\">T\u00e9l\u00e9phone du m\u00e9decin<\/label><input type=\"text\" name=\"phone-3\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-3_69e3094b20e53\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" data-national_mode=\"enabled\" data-country=\"be\" data-validation=\"standard\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-3\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-3-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-3-zip_69e3094b20e53\" id=\"forminator-field-address-3-zip_69e3094b20e53-label\" class=\"forminator-label\">Localit\u00e9 du m\u00e9decin<\/label><input type=\"text\" name=\"address-3-zip\" placeholder=\"\" id=\"forminator-field-address-3-zip_69e3094b20e53\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-11\" class=\"forminator-field-textarea forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-11_69e3094b20e53\" id=\"forminator-field-textarea-11_69e3094b20e53-label\" class=\"forminator-label\">Maladie ant\u00e9rieure de l\u2019enfant ou op\u00e9ration subie :<\/label><textarea name=\"textarea-11\" placeholder=\"\" id=\"forminator-field-textarea-11_69e3094b20e53\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><div id=\"textarea-13\" class=\"forminator-field-textarea forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-13_69e3094b20e53\" id=\"forminator-field-textarea-13_69e3094b20e53-label\" class=\"forminator-label\">Informations essentielles concernant votre enfant<\/label><textarea name=\"textarea-13\" placeholder=\"Afin de garantir un encadrement optimal et s\u00e9curis\u00e9, merci de nous informer de tout \u00e9l\u00e9ment m\u00e9dical, comportemental ou besoin sp\u00e9cifique concernant votre enfant. Ces informations resteront strictement confidentielles et ne serviront qu\u2019\u00e0 assurer son accompagnement dans les meilleures conditions au sein de nos activit\u00e9s.\" id=\"forminator-field-textarea-13_69e3094b20e53\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-17528--page-2\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-17528--page-2-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"2\"\n\t\t\t\tdata-label=\"Page 2\"\n\t\t\t\tdata-actual-label=\"Page 3\"\n\t\t\t\tdata-name=\"page-break-2\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"name-5\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-5_69e3094b20e53\" id=\"forminator-field-name-5_69e3094b20e53-label\" class=\"forminator-label\">Nom (personne pouvant reprendre le jeune)<\/label><span id=\"forminator-field-name-5_69e3094b20e53-description\" class=\"forminator-description\">Autre personne pouvant reprendre le jeune<\/span><input type=\"text\" name=\"name-5\" value=\"\" placeholder=\"\" id=\"forminator-field-name-5_69e3094b20e53\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" aria-describedby=\"forminator-field-name-5_69e3094b20e53-description\" \/><\/div><\/div><div id=\"name-6\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-6_69e3094b20e53\" id=\"forminator-field-name-6_69e3094b20e53-label\" class=\"forminator-label\">Pr\u00e9nom<\/label><span id=\"forminator-field-name-6_69e3094b20e53-description\" class=\"forminator-description\">Autre personne pouvant reprendre le jeune<\/span><input type=\"text\" name=\"name-6\" value=\"\" placeholder=\"\" id=\"forminator-field-name-6_69e3094b20e53\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" aria-describedby=\"forminator-field-name-6_69e3094b20e53-description\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_69e3094b20e53\" id=\"forminator-field-phone-2_69e3094b20e53-label\" class=\"forminator-label\">GSM<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-2_69e3094b20e53\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" data-national_mode=\"enabled\" data-country=\"be\" data-validation=\"standard\" \/><\/div><\/div><div id=\"email-2\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-2_69e3094b20e53\" id=\"forminator-field-email-2_69e3094b20e53-label\" class=\"forminator-label\">Adresse de messagerie<\/label><span id=\"forminator-field-email-2_69e3094b20e53-description\" class=\"forminator-description\">Autre personne pouvant reprendre le jeune<\/span><input type=\"email\" name=\"email-2\" value=\"\" placeholder=\"\" id=\"forminator-field-email-2_69e3094b20e53\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" aria-describedby=\"forminator-field-email-2_69e3094b20e53-description\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_69e3094b20e53\" id=\"forminator-field-address-1-street_address_69e3094b20e53-label\" class=\"forminator-label\">Rue<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_69e3094b20e53\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-address_line_69e3094b20e53\" id=\"forminator-field-address-1-address_line_69e3094b20e53-label\" class=\"forminator-label\">Appartement, suite, etc.<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_69e3094b20e53\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-1-city\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-city_69e3094b20e53\" id=\"forminator-field-address-1-city_69e3094b20e53-label\" class=\"forminator-label\">Ville<\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"\" id=\"forminator-field-address-1-city_69e3094b20e53\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_69e3094b20e53\" id=\"forminator-field-address-1-zip_69e3094b20e53-label\" class=\"forminator-label\">Code postal<\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"\" id=\"forminator-field-address-1-zip_69e3094b20e53\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><div id=\"address-1-country\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-17528__field--address-1-country_69e3094b20e53\" id=\"forminator-field-17528__field--address-1-country_69e3094b20e53-label\" class=\"forminator-label\">Pays<\/label><select name=\"address-1-country\" id=\"forminator-field-17528__field--address-1-country_69e3094b20e53\" class=\"forminator-select2\" data-search=\"true\" data-placeholder=\"S\u00e9lectionner un pays\" autocomplete=\"country-name country\" data-default-value=\"\"><option value=\"\" data-country-code=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" data-country-code=\"AF\" >Afghanistan<\/option><option value=\"Afrique du Sud\" data-country-code=\"ZA\" >Afrique du Sud<\/option><option value=\"Albanie\" data-country-code=\"AL\" >Albanie<\/option><option value=\"Alg\u00e9rie\" data-country-code=\"DZ\" >Alg\u00e9rie<\/option><option value=\"Allemagne\" data-country-code=\"DE\" >Allemagne<\/option><option value=\"Andorre\" data-country-code=\"AD\" >Andorre<\/option><option value=\"Angola\" data-country-code=\"AO\" >Angola<\/option><option value=\"Anguilla\" data-country-code=\"AI\" >Anguilla<\/option><option value=\"Antarctique\" data-country-code=\"AQ\" >Antarctique<\/option><option value=\"Antigua-et-Barbuda\" data-country-code=\"AG\" >Antigua-et-Barbuda<\/option><option value=\"Antilles N\u00e9erlandaises\" data-country-code=\"AN\" >Antilles N\u00e9erlandaises<\/option><option value=\"Apatrides\" data-country-code=\"XX\" >Apatrides<\/option><option value=\"Arabie Saoudite\" data-country-code=\"SA\" >Arabie Saoudite<\/option><option value=\"Argentine\" data-country-code=\"AR\" >Argentine<\/option><option value=\"Arm\u00e9nie\" data-country-code=\"AM\" >Arm\u00e9nie<\/option><option value=\"Aruba\" data-country-code=\"AW\" >Aruba<\/option><option value=\"Australie\" data-country-code=\"AU\" >Australie<\/option><option value=\"Autriche\" data-country-code=\"AT\" >Autriche<\/option><option value=\"Azerba\u00efdjan\" data-country-code=\"AZ\" >Azerba\u00efdjan<\/option><option value=\"Bahamas\" data-country-code=\"BS\" >Bahamas<\/option><option value=\"Bahre\u00efn\" data-country-code=\"BH\" >Bahre\u00efn<\/option><option value=\"Bangladesh\" data-country-code=\"BD\" >Bangladesh<\/option><option value=\"Belgique\" data-country-code=\"BE\" >Belgique<\/option><option value=\"Bermudes\" data-country-code=\"BM\" >Bermudes<\/option><option value=\"Bhoutan\" data-country-code=\"BT\" >Bhoutan<\/option><option value=\"Bi\u00e9lorussie\" data-country-code=\"BY\" >Bi\u00e9lorussie<\/option><option value=\"Bolivie\" data-country-code=\"BO\" >Bolivie<\/option><option value=\"Bosnie-Herz\u00e9govine\" data-country-code=\"BA\" >Bosnie-Herz\u00e9govine<\/option><option value=\"Botswana\" data-country-code=\"BW\" >Botswana<\/option><option value=\"Brunei\" data-country-code=\"BN\" >Brunei<\/option><option value=\"Br\u00e9sil\" data-country-code=\"BR\" >Br\u00e9sil<\/option><option value=\"Bulgarie\" data-country-code=\"BG\" >Bulgarie<\/option><option value=\"Burkina Faso\" data-country-code=\"BF\" >Burkina Faso<\/option><option value=\"Burundi\" data-country-code=\"BI\" >Burundi<\/option><option value=\"B\u00e9lize\" data-country-code=\"BZ\" >B\u00e9lize<\/option><option value=\"B\u00e9nin\" data-country-code=\"BJ\" >B\u00e9nin<\/option><option value=\"Cambodge\" data-country-code=\"KH\" >Cambodge<\/option><option value=\"Cameroun\" data-country-code=\"CM\" >Cameroun<\/option><option value=\"Canada\" data-country-code=\"CA\" >Canada<\/option><option value=\"Cap Vert\" data-country-code=\"CV\" >Cap Vert<\/option><option value=\"Chili\" data-country-code=\"CL\" >Chili<\/option><option value=\"Chine, R\u00e9publique populaire de\" data-country-code=\"CN\" >Chine, R\u00e9publique populaire de<\/option><option value=\"Chypre\" data-country-code=\"CY\" >Chypre<\/option><option value=\"Cit\u00e9 du Vatican\" data-country-code=\"VA\" >Cit\u00e9 du Vatican<\/option><option value=\"Colombie\" data-country-code=\"CO\" >Colombie<\/option><option value=\"Comores\" data-country-code=\"KM\" >Comores<\/option><option value=\"Congo, R\u00e9publique du\" data-country-code=\"CG\" >Congo, R\u00e9publique du<\/option><option value=\"Congo, R\u00e9publique d\u00e9mocratique du\" data-country-code=\"CD\" >Congo, R\u00e9publique d\u00e9mocratique du<\/option><option value=\"Cor\u00e9e, R\u00e9publique de\" data-country-code=\"KR\" >Cor\u00e9e, R\u00e9publique de<\/option><option value=\"Cor\u00e9e, R\u00e9publique d\u00e9mocratique populaire de\" data-country-code=\"KP\" >Cor\u00e9e, R\u00e9publique d\u00e9mocratique populaire de<\/option><option value=\"Costa Rica\" data-country-code=\"CR\" >Costa Rica<\/option><option value=\"Croatie\" data-country-code=\"HR\" >Croatie<\/option><option value=\"Cuba\" data-country-code=\"CU\" >Cuba<\/option><option value=\"Cura\u00e7ao\" data-country-code=\"CW\" >Cura\u00e7ao<\/option><option value=\"C\u00f4te d\u2019Ivoire\" data-country-code=\"CI\" >C\u00f4te d\u2019Ivoire<\/option><option value=\"Danemark\" data-country-code=\"DK\" >Danemark<\/option><option value=\"Djibouti\" data-country-code=\"DJ\" >Djibouti<\/option><option value=\"Dominique\" data-country-code=\"DM\" >Dominique<\/option><option value=\"Espagne\" data-country-code=\"ES\" >Espagne<\/option><option value=\"Estonie\" data-country-code=\"EE\" >Estonie<\/option><option value=\"Fidji\" data-country-code=\"FJ\" >Fidji<\/option><option value=\"Finlande\" data-country-code=\"FI\" >Finlande<\/option><option value=\"France\" data-country-code=\"FR\" >France<\/option><option value=\"France, M\u00e9tropolitaine\" data-country-code=\"FX\" >France, M\u00e9tropolitaine<\/option><option value=\"Gabon\" data-country-code=\"GA\" >Gabon<\/option><option value=\"Gambie\" data-country-code=\"GM\" >Gambie<\/option><option value=\"Ghana\" data-country-code=\"GH\" >Ghana<\/option><option value=\"Gibraltar\" data-country-code=\"GI\" >Gibraltar<\/option><option value=\"Grenade\" data-country-code=\"GD\" >Grenade<\/option><option value=\"Groenland\" data-country-code=\"GL\" >Groenland<\/option><option value=\"Gr\u00e8ce\" data-country-code=\"GR\" >Gr\u00e8ce<\/option><option value=\"Guadeloupe\" data-country-code=\"GP\" >Guadeloupe<\/option><option value=\"Guam\" data-country-code=\"GU\" >Guam<\/option><option value=\"Guat\u00e9mala\" data-country-code=\"GT\" >Guat\u00e9mala<\/option><option value=\"Guernesey\" data-country-code=\"GG\" >Guernesey<\/option><option value=\"Guin\u00e9e\" data-country-code=\"GN\" >Guin\u00e9e<\/option><option value=\"Guin\u00e9e \u00c9quatoriale\" data-country-code=\"GQ\" >Guin\u00e9e \u00c9quatoriale<\/option><option value=\"Guin\u00e9e-Bissau\" data-country-code=\"GW\" >Guin\u00e9e-Bissau<\/option><option value=\"Guyane\" data-country-code=\"GY\" >Guyane<\/option><option value=\"Guyane fran\u00e7aise\" data-country-code=\"GF\" >Guyane fran\u00e7aise<\/option><option value=\"G\u00e9orgie\" data-country-code=\"GE\" >G\u00e9orgie<\/option><option value=\"G\u00e9orgie du Sud et Sandwich du Sud\" data-country-code=\"GS\" >G\u00e9orgie du Sud et Sandwich du Sud<\/option><option value=\"Ha\u00efti\" data-country-code=\"HT\" >Ha\u00efti<\/option><option value=\"Honduras\" data-country-code=\"HN\" >Honduras<\/option><option value=\"Hong Kong\" data-country-code=\"HK\" >Hong Kong<\/option><option value=\"Hongrie\" data-country-code=\"HU\" >Hongrie<\/option><option value=\"Inde\" data-country-code=\"IN\" >Inde<\/option><option value=\"Indon\u00e9sie\" data-country-code=\"ID\" >Indon\u00e9sie<\/option><option value=\"Iran\" data-country-code=\"IR\" >Iran<\/option><option value=\"Iraq\" data-country-code=\"IQ\" >Iraq<\/option><option value=\"Irlande\" data-country-code=\"IE\" >Irlande<\/option><option value=\"Islande\" data-country-code=\"IS\" >Islande<\/option><option value=\"Israel\" data-country-code=\"IL\" >Israel<\/option><option value=\"Italie\" data-country-code=\"IT\" >Italie<\/option><option value=\"Jama\u00efque\" data-country-code=\"JM\" >Jama\u00efque<\/option><option value=\"Japon\" data-country-code=\"JP\" >Japon<\/option><option value=\"Jersey\" data-country-code=\"JE\" >Jersey<\/option><option value=\"Jordanie\" data-country-code=\"JO\" >Jordanie<\/option><option value=\"Kazakhstan\" data-country-code=\"KZ\" >Kazakhstan<\/option><option value=\"Kenya\" data-country-code=\"KE\" >Kenya<\/option><option value=\"Kirghizistan\" data-country-code=\"KG\" >Kirghizistan<\/option><option value=\"Kiribati\" data-country-code=\"KI\" >Kiribati<\/option><option value=\"Kosovo\" data-country-code=\"XK\" >Kosovo<\/option><option value=\"Kowe\u00eft\" data-country-code=\"KW\" >Kowe\u00eft<\/option><option value=\"La Barbade\" data-country-code=\"BB\" >La Barbade<\/option><option value=\"Lesotho\" data-country-code=\"LS\" >Lesotho<\/option><option value=\"Lettonie\" data-country-code=\"LV\" >Lettonie<\/option><option value=\"Liban\" data-country-code=\"LB\" >Liban<\/option><option value=\"Libye\" data-country-code=\"LY\" >Libye<\/option><option value=\"Lib\u00e9ria\" data-country-code=\"LR\" >Lib\u00e9ria<\/option><option value=\"Liechtenstein\" data-country-code=\"LI\" >Liechtenstein<\/option><option value=\"Lithuanie\" data-country-code=\"LT\" >Lithuanie<\/option><option value=\"Luxembourg\" data-country-code=\"LU\" >Luxembourg<\/option><option value=\"Macao\" data-country-code=\"MO\" >Macao<\/option><option value=\"Mac\u00e9doine du Nord\" data-country-code=\"MK\" >Mac\u00e9doine du Nord<\/option><option value=\"Madagascar\" data-country-code=\"MG\" >Madagascar<\/option><option value=\"Malaisie\" data-country-code=\"MY\" >Malaisie<\/option><option value=\"Malawi\" data-country-code=\"MW\" >Malawi<\/option><option value=\"Maldives\" data-country-code=\"MV\" >Maldives<\/option><option value=\"Mali\" data-country-code=\"ML\" >Mali<\/option><option value=\"Malte\" data-country-code=\"MT\" >Malte<\/option><option value=\"Maroc\" data-country-code=\"MA\" >Maroc<\/option><option value=\"Martinique\" data-country-code=\"MQ\" >Martinique<\/option><option value=\"Mauritanie\" data-country-code=\"MR\" >Mauritanie<\/option><option value=\"Mayotte\" data-country-code=\"YT\" >Mayotte<\/option><option value=\"Mexique\" data-country-code=\"MX\" >Mexique<\/option><option value=\"Micron\u00e9sie\" data-country-code=\"FM\" >Micron\u00e9sie<\/option><option value=\"Moldavie\" data-country-code=\"MD\" >Moldavie<\/option><option value=\"Monaco\" data-country-code=\"MC\" >Monaco<\/option><option value=\"Mongolie\" data-country-code=\"MN\" >Mongolie<\/option><option value=\"Montserrat\" data-country-code=\"MS\" >Montserrat<\/option><option value=\"Mont\u00e9n\u00e9gro\" data-country-code=\"ME\" >Mont\u00e9n\u00e9gro<\/option><option value=\"Mozambique\" data-country-code=\"MZ\" >Mozambique<\/option><option value=\"Myanmar\" data-country-code=\"MM\" >Myanmar<\/option><option value=\"Namibie\" data-country-code=\"NA\" >Namibie<\/option><option value=\"Nauru\" data-country-code=\"NR\" >Nauru<\/option><option value=\"Nicaragua\" data-country-code=\"NI\" >Nicaragua<\/option><option value=\"Niger\" data-country-code=\"NE\" >Niger<\/option><option value=\"Nigeria\" data-country-code=\"NG\" >Nigeria<\/option><option value=\"Niu\u00e9\" data-country-code=\"NU\" >Niu\u00e9<\/option><option value=\"Norv\u00e8ge\" data-country-code=\"NO\" >Norv\u00e8ge<\/option><option value=\"Nouvelle Zelande\" data-country-code=\"NZ\" >Nouvelle Zelande<\/option><option value=\"Nouvelle-Cal\u00e9donie\" data-country-code=\"NC\" >Nouvelle-Cal\u00e9donie<\/option><option value=\"N\u00e9pal\" data-country-code=\"NP\" >N\u00e9pal<\/option><option value=\"Oman\" data-country-code=\"OM\" >Oman<\/option><option value=\"Ouganda\" data-country-code=\"UG\" >Ouganda<\/option><option value=\"Ouzb\u00e9kistan\" data-country-code=\"UZ\" >Ouzb\u00e9kistan<\/option><option value=\"Pakistan\" data-country-code=\"PK\" >Pakistan<\/option><option value=\"Palau\" data-country-code=\"PW\" >Palau<\/option><option value=\"Palestine, \u00c9tat de\" data-country-code=\"PS\" >Palestine, \u00c9tat de<\/option><option value=\"Panama\" data-country-code=\"PA\" >Panama<\/option><option value=\"Papouasie-Nouvelle-Guin\u00e9e\" data-country-code=\"PG\" >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value=\"Paraguay\" data-country-code=\"PY\" >Paraguay<\/option><option value=\"Pays-Bas\" data-country-code=\"NL\" >Pays-Bas<\/option><option value=\"Philippines\" data-country-code=\"PH\" >Philippines<\/option><option value=\"Pologne\" data-country-code=\"PL\" >Pologne<\/option><option value=\"Polyn\u00e9sie Fran\u00e7aise\" data-country-code=\"PF\" >Polyn\u00e9sie Fran\u00e7aise<\/option><option value=\"Porto Rico\" data-country-code=\"PR\" >Porto Rico<\/option><option value=\"Portugal\" data-country-code=\"PT\" >Portugal<\/option><option value=\"P\u00e9rou\" data-country-code=\"PE\" >P\u00e9rou<\/option><option value=\"Qatar\" data-country-code=\"QA\" >Qatar<\/option><option value=\"Roumanie\" data-country-code=\"RO\" >Roumanie<\/option><option value=\"Royaume-Uni\" data-country-code=\"GB\" >Royaume-Uni<\/option><option value=\"Russie\" data-country-code=\"RU\" >Russie<\/option><option value=\"Rwanda\" data-country-code=\"RW\" >Rwanda<\/option><option value=\"R\u00e9publique Centrafricaine\" data-country-code=\"CF\" >R\u00e9publique Centrafricaine<\/option><option value=\"R\u00e9publique Dominicaine\" data-country-code=\"DO\" >R\u00e9publique Dominicaine<\/option><option value=\"R\u00e9publique Tch\u00e8que\" data-country-code=\"CZ\" >R\u00e9publique Tch\u00e8que<\/option><option value=\"R\u00e9publique du Salvador\" data-country-code=\"SV\" >R\u00e9publique du Salvador<\/option><option value=\"R\u00e9publique d\u00e9mocratique populaire du Laos\" data-country-code=\"LA\" >R\u00e9publique d\u00e9mocratique populaire du Laos<\/option><option value=\"Sahara occidental\" data-country-code=\"EH\" >Sahara occidental<\/option><option value=\"Saint Pierre et Miquelon\" data-country-code=\"PM\" >Saint Pierre et Miquelon<\/option><option value=\"Saint-Kitts-et-Nevis\" data-country-code=\"KN\" >Saint-Kitts-et-Nevis<\/option><option value=\"Saint-Marin\" data-country-code=\"SM\" >Saint-Marin<\/option><option value=\"Saint-Martin (Royaume des Pays-Bas)\" data-country-code=\"MF\" >Saint-Martin (Royaume des Pays-Bas)<\/option><option value=\"Saint-Vincent-et-les-Grenadines\" data-country-code=\"VC\" >Saint-Vincent-et-les-Grenadines<\/option><option value=\"Sainte Lucie\" data-country-code=\"LC\" >Sainte Lucie<\/option><option value=\"Sainte-H\u00e9l\u00e8ne\" data-country-code=\"SH\" >Sainte-H\u00e9l\u00e8ne<\/option><option value=\"Samoa\" data-country-code=\"WS\" >Samoa<\/option><option value=\"Samoa am\u00e9ricaines\" data-country-code=\"AS\" >Samoa am\u00e9ricaines<\/option><option value=\"Sao Tom\u00e9-et-Principe\" data-country-code=\"ST\" >Sao Tom\u00e9-et-Principe<\/option><option value=\"Serbie\" data-country-code=\"RS\" >Serbie<\/option><option value=\"Seychelles\" data-country-code=\"SC\" >Seychelles<\/option><option value=\"Sierra Leone\" data-country-code=\"SL\" >Sierra Leone<\/option><option value=\"Singapour\" data-country-code=\"SG\" >Singapour<\/option><option value=\"Slovaquie\" data-country-code=\"SK\" >Slovaquie<\/option><option value=\"Slov\u00e9nie\" data-country-code=\"SI\" >Slov\u00e9nie<\/option><option value=\"Somalie\" data-country-code=\"SO\" >Somalie<\/option><option value=\"Soudan\" data-country-code=\"SD\" >Soudan<\/option><option value=\"Soudan, Sud\" data-country-code=\"SS\" >Soudan, Sud<\/option><option value=\"Sri Lanka\" data-country-code=\"LK\" >Sri Lanka<\/option><option value=\"Suisse\" data-country-code=\"CH\" >Suisse<\/option><option value=\"Suriname\" data-country-code=\"SR\" >Suriname<\/option><option value=\"Su\u00e8de\" data-country-code=\"SE\" >Su\u00e8de<\/option><option value=\"Svalbard et Jan Mayen\" data-country-code=\"SJ\" >Svalbard et Jan Mayen<\/option><option value=\"Swaziland\" data-country-code=\"SZ\" >Swaziland<\/option><option value=\"Syrie\" data-country-code=\"SY\" >Syrie<\/option><option value=\"S\u00e9n\u00e9gal\" data-country-code=\"SN\" >S\u00e9n\u00e9gal<\/option><option value=\"Tadjikistan\" data-country-code=\"TJ\" >Tadjikistan<\/option><option value=\"Taiwan, R\u00e9publique de Chine\" data-country-code=\"TW\" >Taiwan, R\u00e9publique de Chine<\/option><option value=\"Tanzanie\" data-country-code=\"TZ\" >Tanzanie<\/option><option value=\"Tchad\" data-country-code=\"TD\" >Tchad<\/option><option value=\"Terres australes et antarctiques fran\u00e7aises\" data-country-code=\"TF\" >Terres australes et antarctiques fran\u00e7aises<\/option><option value=\"Territoire britannique de l\u2019oc\u00e9an Indien\" data-country-code=\"IO\" >Territoire britannique de l\u2019oc\u00e9an Indien<\/option><option value=\"Tha\u00eflande\" data-country-code=\"TH\" >Tha\u00eflande<\/option><option value=\"Timor-Oriental\" data-country-code=\"TL\" >Timor-Oriental<\/option><option value=\"Togo\" data-country-code=\"TG\" >Togo<\/option><option value=\"Tokelau\" data-country-code=\"TK\" >Tokelau<\/option><option value=\"Tonga\" data-country-code=\"TO\" >Tonga<\/option><option value=\"Trinit\u00e9 et Tobago\" data-country-code=\"TT\" >Trinit\u00e9 et Tobago<\/option><option value=\"Tunisie\" data-country-code=\"TN\" >Tunisie<\/option><option value=\"Turkm\u00e9nistan\" data-country-code=\"TM\" >Turkm\u00e9nistan<\/option><option value=\"Turquie\" data-country-code=\"TR\" >Turquie<\/option><option value=\"Tuvalu\" data-country-code=\"TV\" >Tuvalu<\/option><option value=\"Ukraine\" data-country-code=\"UA\" >Ukraine<\/option><option value=\"Uruguay\" data-country-code=\"UY\" >Uruguay<\/option><option value=\"Vanuatu\" data-country-code=\"VU\" >Vanuatu<\/option><option value=\"Vietnam\" data-country-code=\"VN\" >Vietnam<\/option><option value=\"V\u00e9n\u00e9zu\u00e9la\" data-country-code=\"VE\" >V\u00e9n\u00e9zu\u00e9la<\/option><option value=\"Yemen\" data-country-code=\"YE\" >Yemen<\/option><option value=\"Zambie\" data-country-code=\"ZM\" >Zambie<\/option><option value=\"Zimbabwe\" data-country-code=\"ZW\" >Zimbabwe<\/option><option value=\"\u00c9gypte\" data-country-code=\"EG\" >\u00c9gypte<\/option><option value=\"\u00c9mirats Arabes Unis\" data-country-code=\"AE\" >\u00c9mirats Arabes Unis<\/option><option value=\"\u00c9quateur\" data-country-code=\"EC\" >\u00c9quateur<\/option><option value=\"\u00c9rythr\u00e9e\" data-country-code=\"ER\" >\u00c9rythr\u00e9e<\/option><option value=\"\u00c9tats-Unis d\u2019Am\u00e9rique (USA)\" data-country-code=\"US\" >\u00c9tats-Unis d\u2019Am\u00e9rique (USA)<\/option><option value=\"\u00c9thiopie\" data-country-code=\"ET\" >\u00c9thiopie<\/option><option value=\"\u00cele Bouvet\" data-country-code=\"BV\" >\u00cele Bouvet<\/option><option value=\"\u00cele Christmas\" data-country-code=\"CX\" >\u00cele Christmas<\/option><option value=\"\u00cele Heard et \u00eele Mcdonald\" data-country-code=\"HM\" >\u00cele Heard et \u00eele Mcdonald<\/option><option value=\"\u00cele Johnston\" data-country-code=\"JT\" >\u00cele Johnston<\/option><option value=\"\u00cele Maurice\" data-country-code=\"MU\" >\u00cele Maurice<\/option><option value=\"\u00cele Norfolk\" data-country-code=\"NF\" >\u00cele Norfolk<\/option><option value=\"\u00cele de la R\u00e9union\" data-country-code=\"RE\" >\u00cele de la R\u00e9union<\/option><option value=\"\u00celes Ca\u00efmans\" data-country-code=\"KY\" >\u00celes Ca\u00efmans<\/option><option value=\"\u00celes Cocos\" data-country-code=\"CC\" >\u00celes Cocos<\/option><option value=\"\u00celes Cook\" data-country-code=\"CK\" >\u00celes Cook<\/option><option value=\"\u00celes Falkland\" data-country-code=\"FK\" >\u00celes Falkland<\/option><option value=\"\u00celes F\u00e9ro\u00e9\" data-country-code=\"FO\" >\u00celes F\u00e9ro\u00e9<\/option><option value=\"\u00celes Mariannes du Nord\" data-country-code=\"MP\" >\u00celes Mariannes du Nord<\/option><option value=\"\u00celes Marshall\" data-country-code=\"MH\" >\u00celes Marshall<\/option><option value=\"\u00celes Pitcairn\" data-country-code=\"PN\" >\u00celes Pitcairn<\/option><option value=\"\u00celes Salomon\" data-country-code=\"SB\" >\u00celes Salomon<\/option><option value=\"\u00celes Turques-et-Ca\u00efques\" data-country-code=\"TC\" >\u00celes Turques-et-Ca\u00efques<\/option><option value=\"\u00celes Vierges am\u00e9ricaines\" data-country-code=\"VI\" >\u00celes Vierges am\u00e9ricaines<\/option><option value=\"\u00celes Vierges britanniques\" data-country-code=\"VG\" >\u00celes Vierges britanniques<\/option><option value=\"\u00celes Wallis et Futuna\" data-country-code=\"WF\" >\u00celes Wallis et Futuna<\/option><option value=\"\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis\" data-country-code=\"UM\" >\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-17528--page-3\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-17528--page-3-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"3\"\n\t\t\t\tdata-label=\"Page 3\"\n\t\t\t\tdata-actual-label=\"Page 4\"\n\t\t\t\tdata-name=\"\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"select-6\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-17528__field--select-6_69e3094b20e53\" id=\"forminator-form-17528__field--select-6_69e3094b20e53-label\" class=\"forminator-label\">Etes vous membre de la ML ? <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-17528__field--select-6_69e3094b20e53\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-6\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"S\u00e9lectionner\" data-search=\"false\" data-search-placeholder=\"S\u00e9lectionner\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-17528__field--select-6_69e3094b20e53-label\"><option value=\"\"  >S\u00e9lectionner<\/option><option value=\"one\"  data-calculation=\"0\">Mutplus.be<\/option><option value=\"two\"  data-calculation=\"0\">ML Hainaut-Namur<\/option><option value=\"ML-Li\u00e8ge-Luxembourg\"  data-calculation=\"0\">ML Li\u00e8ge-Luxembourg<\/option><option value=\"Non-membre-de-la-ML\"  data-calculation=\"0\">Non-membre de la ML<\/option><\/select><\/div><\/div><div id=\"select-7\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-17528__field--select-7_69e3094b20e53\" id=\"forminator-form-17528__field--select-7_69e3094b20e53-label\" class=\"forminator-label\">Autorisez-vous la ML \u00e0 vous contacter ? <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-17528__field--select-7_69e3094b20e53\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-7\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"S\u00e9lectionner\" data-search=\"false\" data-search-placeholder=\"S\u00e9lectionner\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-17528__field--select-7_69e3094b20e53-label\"><option value=\"\"  >S\u00e9lectionner<\/option><option value=\"one\"  data-calculation=\"0\">Oui<\/option><option value=\"two\"  data-calculation=\"0\">Non<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-8\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-17528__field--select-8_69e3094b20e53\" id=\"forminator-form-17528__field--select-8_69e3094b20e53-label\" class=\"forminator-label\">Voulez-vous \u00eatre tenus inform\u00e9s des activit\u00e9s des JML ? <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-17528__field--select-8_69e3094b20e53\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-8\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"S\u00e9lectionner\" data-search=\"false\" data-search-placeholder=\"S\u00e9lectionner\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-17528__field--select-8_69e3094b20e53-label\"><option value=\"\"  >S\u00e9lectionner<\/option><option value=\"one\"  data-calculation=\"0\">Oui<\/option><option value=\"two\"  data-calculation=\"0\">Non<\/option><\/select><\/div><\/div><div id=\"select-9\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-17528__field--select-9_69e3094b20e53\" id=\"forminator-form-17528__field--select-9_69e3094b20e53-label\" class=\"forminator-label\">Comment avez-vous connu cette activit\u00e9 ? <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-17528__field--select-9_69e3094b20e53\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-9\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"S\u00e9lectionner\" data-search=\"false\" data-search-placeholder=\"S\u00e9lectionner\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-17528__field--select-9_69e3094b20e53-label\"><option value=\"\"  >S\u00e9lectionner<\/option><option value=\"one\"  data-calculation=\"0\">R\u00e9seaux sociaux<\/option><option value=\"two\"  data-calculation=\"0\">Bouche \u00e0 oreille<\/option><option value=\"OJ.be\"  data-calculation=\"0\">OJ.be<\/option><option value=\"P\u00e9riodique-de-la-ML\"  data-calculation=\"0\">P\u00e9riodique de la ML<\/option><option value=\"Newsletter\"  data-calculation=\"0\">Newsletter<\/option><option value=\"IMPACT\"  data-calculation=\"0\">IMPACT<\/option><option value=\"ONE\"  data-calculation=\"0\">ONE<\/option><option value=\"Flyers\"  data-calculation=\"0\">Flyers<\/option><option value=\"Recherche-internet\"  data-calculation=\"0\">Recherche internet<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-5\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-17528__field--select-5_69e3094b20e53\" id=\"forminator-form-17528__field--select-5_69e3094b20e53-label\" class=\"forminator-label\">Autorise le responsable \u00e0 prendre les mesures d\u2019urgence d\u2019ordre m\u00e9dical ou chirurgical que n\u00e9cessiterait l\u2019\u00e9tat de mon enfant suite \u00e0 une maladie ou \u00e0 un accident survenu pendant les activit\u00e9s, dans le cas o\u00f9 le tuteur l\u00e9gal ou les tuteurs l\u00e9gaux seraient injoignables. <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-17528__field--select-5_69e3094b20e53\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-5\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"S\u00e9lectionner\" data-search=\"false\" data-search-placeholder=\"S\u00e9lectionner\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-17528__field--select-5_69e3094b20e53-label\"><option value=\"\"  >S\u00e9lectionner<\/option><option value=\"one\"  data-calculation=\"0\">J\u2019autorise<\/option><option value=\"two\"  data-calculation=\"0\">Je n'autorise pas<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-12\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-12_69e3094b20e53\" id=\"forminator-field-textarea-12_69e3094b20e53-label\" class=\"forminator-label\">ATTENTION, si un ou des m\u00e9dicament(s) doi(vent)t \u00eatre donn\u00e9(s) \u00e0 l\u2019enfant lors de l\u2019une de nos activit\u00e9s, une copie de la prescription m\u00e9dicale DOIT \u00eatre fournie pr\u00e9alablement \u00e0 notre \u00e9quipe.<\/label><textarea name=\"textarea-12\" placeholder=\"Autres remarques :\" id=\"forminator-field-textarea-12_69e3094b20e53\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-17528__field--select-2_69e3094b20e53\" id=\"forminator-form-17528__field--select-2_69e3094b20e53-label\" class=\"forminator-label\">Autorise l&#039;A.S.B.L. \u00ab Jeunes Mutualistes Lib\u00e9raux \u00bb \u00e0 utiliser mon image ou celle des mineurs dont je suis repr\u00e9sentant l\u00e9gal, dans le but de promouvoir ses activit\u00e9s, que ce soit sous la forme de photos, vid\u00e9os, affiches, d\u00e9pliants, \u00e9ditions papier, ou toute autre forme de communication, et ce, sans aucune indemnit\u00e9 et sans limite dans le temps. Je d\u00e9clare avoir 18 ans ou plus et avoir la capacit\u00e9 de compl\u00e9ter ce formulaire en mon propre nom. J&#039;ai lu et compris toutes les significations de cette renonciation. <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-17528__field--select-2_69e3094b20e53\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-2\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"S\u00e9lectionner\" data-search=\"false\" data-search-placeholder=\"S\u00e9lectionner\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-17528__field--select-2_69e3094b20e53-label\"><option value=\"\"  >S\u00e9lectionner<\/option><option value=\"one\"  data-calculation=\"0\">J\u2019autorise<\/option><option value=\"two\"  data-calculation=\"0\">Je n'autorise pas<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-3\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-17528__field--select-3_69e3094b20e53\" id=\"forminator-form-17528__field--select-3_69e3094b20e53-label\" class=\"forminator-label\">Autorisation de sortie parentale pour mineur, \u00e0 quitter les locaux de la ML ou JML seul <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-17528__field--select-3_69e3094b20e53\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-3\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"S\u00e9lectionner\" data-search=\"false\" data-search-placeholder=\"S\u00e9lectionner\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-17528__field--select-3_69e3094b20e53-label\"><option value=\"\"  >S\u00e9lectionner<\/option><option value=\"one\"  data-calculation=\"0\">J\u2019autorise<\/option><option value=\"two\"  data-calculation=\"0\">Je n'autorise pas<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-4\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-17528__field--select-4_69e3094b20e53\" id=\"forminator-form-17528__field--select-4_69e3094b20e53-label\" class=\"forminator-label\">Autorisation de sortie parentale pour mineur, \u00e0 quitter les locaux de la ML ou JML en compagnie la personne \u00e0 contacter en cas d\u2019urgence ou de l\u2019autre personne pouvant reprendre le jeune. <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-17528__field--select-4_69e3094b20e53\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-4\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"S\u00e9lectionner\" data-search=\"false\" data-search-placeholder=\"S\u00e9lectionner\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-17528__field--select-4_69e3094b20e53-label\"><option value=\"\"  >S\u00e9lectionner<\/option><option value=\"one\"  data-calculation=\"0\">J\u2019autorise<\/option><option value=\"two\"  data-calculation=\"0\">Je n'autorise pas<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-10\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-10_69e3094b20e53\" id=\"forminator-field-textarea-10_69e3094b20e53-label\" class=\"forminator-label\">Personne \u00e0 contacter en cas d\u2019urgence<\/label><span id=\"forminator-field-textarea-10_69e3094b20e53-description\" class=\"forminator-description\">Si la personne est identique au responsable l\u00e9gal du jeune, ne rien indiquer.<\/span><textarea name=\"textarea-10\" placeholder=\"(possibilit\u00e9 de venir rechercher l\u2019enfant dans l\u2019heure en cas de sympt\u00f4me) \nNom : \u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\nPr\u00e9nom : \u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\nT\u00e9l :\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\nGSM: \u2026\u2026\u2026..\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\nAdresse :\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\n\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\nE-Mail \u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026...\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\" id=\"forminator-field-textarea-10_69e3094b20e53\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" aria-describedby=\"forminator-field-textarea-10_69e3094b20e53-description\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"consent-2\" class=\"forminator-field-consent forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-consent-2_69e3094b20e53\" id=\"forminator-field-consent-2_69e3094b20e53-label\" class=\"forminator-label\">RGPD <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-checkbox__wrapper\"><label id=\"forminator-field-consent-2_69e3094b20e53__label\" class=\"forminator-checkbox forminator-consent\"><input type=\"checkbox\" name=\"consent-2\" id=\"forminator-field-consent-2_69e3094b20e53\" value=\"checked\" aria-labelledby=\"forminator-field-consent-2_69e3094b20e53-label\" aria-describedby=\"forminator-field-consent-2_69e3094b20e53__description\" data-required=\"true\" aria-required=\"true\" \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><\/label><div id=\"forminator-field-consent-2_69e3094b20e53__description\" class=\"forminator-checkbox__label forminator-consent__label\"><p>J'accepte la&nbsp; <a rel=\"noopener\" target=\"_blank\" href=\"https:\/\/www.jmlib.be\/site\/rgpd\/\">politique de confidentialit\u00e9<\/a> des JML asbl.<\/p><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"consent-1\" class=\"forminator-field-consent forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-consent-1_69e3094b20e53\" id=\"forminator-field-consent-1_69e3094b20e53-label\" class=\"forminator-label\">Consentement <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-checkbox__wrapper\"><label id=\"forminator-field-consent-1_69e3094b20e53__label\" class=\"forminator-checkbox forminator-consent\"><input type=\"checkbox\" name=\"consent-1\" id=\"forminator-field-consent-1_69e3094b20e53\" value=\"checked\" aria-labelledby=\"forminator-field-consent-1_69e3094b20e53-label\" aria-describedby=\"forminator-field-consent-1_69e3094b20e53__description\" data-required=\"true\" aria-required=\"true\" \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><\/label><div id=\"forminator-field-consent-1_69e3094b20e53__description\" class=\"forminator-checkbox__label forminator-consent__label\"><p>En envoyant ce formulaire \u00e9lectronique :&nbsp;<\/p>\n<ul>\n<li>J\u2019atteste \u00eatre conscient des conditions propos\u00e9es par les JML.<\/li>\n<li>Je m\u2019engage \u00e0 ne pas amener mon enfant sur les lieux en cas de sympt\u00f4mes (fi\u00e8vre, toux, difficult\u00e9 respiratoire\u2026).<\/li>\n<li>Je m\u2019engage \u00e0 venir rechercher mon enfant IMMEDIATEMENT en cas de sympt\u00f4mes, suite \u00e0 l\u2019appel de l\u2019encadrant.<\/li>\n<\/ul>\n<p>&nbsp;<\/p><\/div><\/div><\/div><\/div><\/div><\/div><button class=\"forminator-button forminator-pagination-submit\" style=\"display: none;\" disabled>Envoyer et valider l&#039;inscription<\/button><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"114e2ac4a1\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/site\/wp-json\/wp\/v2\/pages\/17529\" \/><input type=\"hidden\" name=\"form_id\" value=\"17528\"><input type=\"hidden\" name=\"page_id\" value=\"17529\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/www.jmlib.be\/site\/inscription-stage-art-et-cuisine-a-la-louviere\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form>\n\n\n\n<p><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"template-fullwidth-no-title.php","meta":{"jetpack_post_was_ever_published":false,"footnotes":""},"class_list":["post-17529","page","type-page","status-publish","hentry"],"jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/P93my9-4yJ","jetpack-related-posts":[{"id":17517,"url":"https:\/\/www.jmlib.be\/site\/inscription-stage-cirque-a-la-louviere\/","url_meta":{"origin":17529,"position":0},"title":"Inscription stage cirque \u00e0 La Louvi\u00e8re","author":"jmlib","date":"24 mars 2026","format":false,"excerpt":"","rel":"","context":"Article similaire","block_context":{"text":"Article similaire","link":""},"img":{"alt_text":"","src":"","width":0,"height":0},"classes":[]},{"id":17397,"url":"https:\/\/www.jmlib.be\/site\/inscription-stage-aventure\/","url_meta":{"origin":17529,"position":1},"title":"Inscription stage aventure","author":"jmlib","date":"2 f\u00e9vrier 2026","format":false,"excerpt":"","rel":"","context":"Article similaire","block_context":{"text":"Article similaire","link":""},"img":{"alt_text":"","src":"","width":0,"height":0},"classes":[]},{"id":17221,"url":"https:\/\/www.jmlib.be\/site\/stage-couture-arlon-inscription\/","url_meta":{"origin":17529,"position":2},"title":"Stage couture Arlon &#8211; Inscription","author":"jmlib","date":"28 novembre 2025","format":false,"excerpt":"","rel":"","context":"Article similaire","block_context":{"text":"Article similaire","link":""},"img":{"alt_text":"","src":"","width":0,"height":0},"classes":[]},{"id":17262,"url":"https:\/\/www.jmlib.be\/site\/inscription-stage-harry-potter\/","url_meta":{"origin":17529,"position":3},"title":"Inscription stage Harry Potter","author":"jmlib","date":"11 d\u00e9cembre 2025","format":false,"excerpt":"","rel":"","context":"Article similaire","block_context":{"text":"Article similaire","link":""},"img":{"alt_text":"","src":"","width":0,"height":0},"classes":[]},{"id":17630,"url":"https:\/\/www.jmlib.be\/site\/inscription-stage-ete-tournai\/","url_meta":{"origin":17529,"position":4},"title":"inscription stage \u00e9t\u00e9 Tournai","author":"jmlib","date":"15 avril 2026","format":false,"excerpt":"","rel":"","context":"Article similaire","block_context":{"text":"Article similaire","link":""},"img":{"alt_text":"","src":"","width":0,"height":0},"classes":[]},{"id":17213,"url":"https:\/\/www.jmlib.be\/site\/artrecup-inscription\/","url_meta":{"origin":17529,"position":5},"title":"Art&amp;R\u00e9cup &#8211; Inscription","author":"jmlib","date":"28 novembre 2025","format":false,"excerpt":"","rel":"","context":"Article similaire","block_context":{"text":"Article similaire","link":""},"img":{"alt_text":"","src":"","width":0,"height":0},"classes":[]}],"jetpack_likes_enabled":true,"_links":{"self":[{"href":"https:\/\/www.jmlib.be\/site\/wp-json\/wp\/v2\/pages\/17529","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.jmlib.be\/site\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.jmlib.be\/site\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.jmlib.be\/site\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.jmlib.be\/site\/wp-json\/wp\/v2\/comments?post=17529"}],"version-history":[{"count":1,"href":"https:\/\/www.jmlib.be\/site\/wp-json\/wp\/v2\/pages\/17529\/revisions"}],"predecessor-version":[{"id":17530,"href":"https:\/\/www.jmlib.be\/site\/wp-json\/wp\/v2\/pages\/17529\/revisions\/17530"}],"wp:attachment":[{"href":"https:\/\/www.jmlib.be\/site\/wp-json\/wp\/v2\/media?parent=17529"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}