{"id":306,"date":"2021-01-28T16:26:48","date_gmt":"2021-01-28T16:26:48","guid":{"rendered":"https:\/\/lionssickkids.ca\/?page_id=306"},"modified":"2024-02-10T16:16:05","modified_gmt":"2024-02-10T16:16:05","slug":"application-form","status":"publish","type":"page","link":"https:\/\/lionssickkids.ca\/fr\/application-form\/","title":{"rendered":"Demande d&rsquo;assistance"},"content":{"rendered":"<p><div class=\"fusion-bg-parallax\" data-bg-align=\"center center\" data-direction=\"up\" data-mute=\"false\" data-opacity=\"100\" data-velocity=\"-0.3\" data-mobile-enabled=\"false\" data-break_parents=\"0\" data-bg-image=\"http:\/\/lionssickkids.ca\/wp-content\/uploads\/2020\/04\/Our-Partners-Header-09.png\" data-bg-repeat=\"false\" ><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container has-pattern-background has-mask-background fusion-parallax-up hundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:0px;--awb-padding-right:0px;--awb-padding-bottom:0px;--awb-padding-left:0px;--awb-margin-top:0px;--awb-margin-bottom:30px;--awb-background-image:url(&quot;http:\/\/lionssickkids.ca\/wp-content\/uploads\/2020\/04\/Our-Partners-Header-09.png&quot;);--awb-background-size:cover;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-padding-top:120px;--awb-padding-bottom:80px;--awb-bg-color:rgba(0,22,137,0.52);--awb-bg-color-hover:rgba(0,22,137,0.52);--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\" data-scroll-devices=\"small-visibility,medium-visibility,large-visibility\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-1 fusion-sep-none fusion-title-center fusion-title-text fusion-title-size-one\" style=\"--awb-text-color:#ffffff;--awb-margin-top-small:0px;--awb-margin-right-small:0px;--awb-margin-bottom-small:15px;--awb-margin-left-small:0px;\"><h1 class=\"fusion-title-heading title-heading-center fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:43;line-height:1;\">Demande d&rsquo;assistance<\/h1><\/div><div class=\"fusion-separator\" style=\"align-self: center;margin-left: auto;margin-right: auto;margin-top:10px;margin-bottom:10px;width:100%;max-width:40px;\"><div class=\"fusion-separator-border sep-single sep-solid\" style=\"--awb-height:20px;--awb-amount:20px;--awb-sep-color:#ff5555;border-color:#ff5555;border-top-width:4px;\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-margin-bottom:30px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-stretch fusion-flex-content-wrap\" style=\"max-width:1248px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form fusion-form-builder fusion-form-form-wrapper fusion-form-360\" style=\"--awb-tooltip-text-color:#ffffff;--awb-tooltip-background-color:#333333;--awb-field-margin-bottom:5px;--awb-form-focus-border-color:#f46258;--awb-form-focus-border-hover-color:rgba(244,98,88,0.5);\" data-form-id=\"360\" data-config=\"{&quot;form_id&quot;:360,&quot;form_post_id&quot;:360,&quot;post_id&quot;:306,&quot;form_type&quot;:&quot;ajax&quot;,&quot;confirmation_type&quot;:&quot;message&quot;,&quot;redirect_url&quot;:&quot;&quot;,&quot;redirect_timeout&quot;:&quot;0&quot;,&quot;field_labels&quot;:{&quot;referrer_first_name&quot;:&quot;Pr\\u00e9nom&quot;,&quot;referrer_last_name&quot;:&quot;Nom de famille&quot;,&quot;referrer_phone_number&quot;:&quot;T\\u00e9l\\u00e9phone&quot;,&quot;referrer_email&quot;:&quot;Email&quot;,&quot;referrer_occupation&quot;:&quot;Occupation&quot;,&quot;referrer-reason&quot;:&quot;Pourquoi, selon vous, cette famille a-t-elle besoin d&#039;une aide financi\\u00e8re?&quot;,&quot;Child_first_name&quot;:&quot;Pr\\u00e9nom&quot;,&quot;Child_last_name&quot;:&quot;Nom de famille&quot;,&quot;Child_Street&quot;:&quot;Addresse&quot;,&quot;Child_City&quot;:&quot;Ville&quot;,&quot;province&quot;:&quot;Province&quot;,&quot;Child_Postal_Code&quot;:&quot;Code Postal&quot;,&quot;Child_DOB&quot;:&quot; Date de naissance&quot;,&quot;Sex&quot;:&quot;Sexe&quot;,&quot;Illness&quot;:&quot;Maladie&quot;,&quot;Mother_first_name&quot;:&quot;Pr\\u00e9nom&quot;,&quot;Mother_last_name&quot;:&quot; Nom de famille&quot;,&quot;Mother_phone_number&quot;:&quot;Num\\u00e9ro de t\\u00e9l\\u00e9phone principal:&quot;,&quot;Father_first_name&quot;:&quot;Pr\\u00e9nom&quot;,&quot;Father_last_name&quot;:&quot; Nom de famille&quot;,&quot;Father_phone_number&quot;:&quot;Num\\u00e9ro de t\\u00e9l\\u00e9phone principal:&quot;,&quot;langue_de_correspondance_preferee&quot;:&quot;Langue de correspondance pr\\u00e9f\\u00e9r\\u00e9e&quot;,&quot;email_address&quot;:&quot;Courriel&quot;,&quot;Social_assistance&quot;:&quot; Le client b\\u00e9n\\u00e9ficie-t-il de l&#039;aide sociale ? (Si oui, contactez l&#039;agent)&quot;,&quot;Why_do_you_need_support&quot;:&quot;En tant que famille, pourquoi avez-vous besoin de l&#039;aide financi\\u00e8re du Fond pour enfants malades ?&quot;,&quot;veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_1&quot;:&quot;Veuillez indiquer les \\u00e9l\\u00e9ments pour lesquels vous avez besoin d&#039;aide :&quot;,&quot;veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_2&quot;:&quot;&quot;,&quot;veuillez_telecharger_la_prescription&quot;:&quot;Veuillez t\\u00e9l\\u00e9charger la prescription&quot;,&quot;veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_3&quot;:&quot;&quot;,&quot;veuillez_telecharger_la_prescription_la_lettre_du_medecin&quot;:&quot;Veuillez t\\u00e9l\\u00e9charger la prescription la lettre du m\\u00e9decin&quot;,&quot;veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_4&quot;:&quot;&quot;,&quot;veuillez_preciser&quot;:&quot;Veuillez pr\\u00e9ciser&quot;,&quot;en_cas_d\\u2019acceptation_quelle_serait_la_methode_preferee_pour_recevoir_les_fonds&quot;:&quot;En cas d\\u2019acceptation, quelle serait la m\\u00e9thode pr\\u00e9f\\u00e9r\\u00e9e pour recevoir les fonds ?&quot;,&quot;courriel_pour_le_virement_interac&quot;:&quot;Courriel pour le Virement INTERAC&quot;,&quot;I_understand&quot;:&quot;&quot;},&quot;field_logics&quot;:{&quot;referrer_first_name&quot;:&quot;&quot;,&quot;referrer_last_name&quot;:&quot;&quot;,&quot;referrer_phone_number&quot;:&quot;&quot;,&quot;referrer_email&quot;:&quot;&quot;,&quot;referrer_occupation&quot;:&quot;&quot;,&quot;referrer-reason&quot;:&quot;&quot;,&quot;Child_first_name&quot;:&quot;&quot;,&quot;Child_last_name&quot;:&quot;&quot;,&quot;Child_Street&quot;:&quot;&quot;,&quot;Child_City&quot;:&quot;&quot;,&quot;province&quot;:&quot;&quot;,&quot;Child_Postal_Code&quot;:&quot;&quot;,&quot;Child_DOB&quot;:&quot;&quot;,&quot;Sex&quot;:&quot;&quot;,&quot;Illness&quot;:&quot;&quot;,&quot;Mother_first_name&quot;:&quot;&quot;,&quot;Mother_last_name&quot;:&quot;&quot;,&quot;Mother_phone_number&quot;:&quot;&quot;,&quot;Father_first_name&quot;:&quot;&quot;,&quot;Father_last_name&quot;:&quot;&quot;,&quot;Father_phone_number&quot;:&quot;&quot;,&quot;langue_de_correspondance_preferee&quot;:&quot;&quot;,&quot;email_address&quot;:&quot;&quot;,&quot;Social_assistance&quot;:&quot;&quot;,&quot;Why_do_you_need_support&quot;:&quot;&quot;,&quot;veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_1&quot;:&quot;&quot;,&quot;veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_2&quot;:&quot;&quot;,&quot;veuillez_telecharger_la_prescription&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_2[]\\&quot;,\\&quot;value\\&quot;:\\&quot;M\\u00e9dicaments sur ordonnance (prescription requise)\\&quot;}]&quot;,&quot;veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_3&quot;:&quot;[]&quot;,&quot;veuillez_telecharger_la_prescription_la_lettre_du_medecin&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_3[]\\&quot;,\\&quot;value\\&quot;:\\&quot;\\u00c9quipement m\\u00e9dical (prescription ou lettre du m\\u00e9decin requise)\\&quot;}]&quot;,&quot;veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_4&quot;:&quot;&quot;,&quot;veuillez_preciser&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_4[]\\&quot;,\\&quot;value\\&quot;:\\&quot;Autre\\&quot;}]&quot;,&quot;en_cas_d\\u2019acceptation_quelle_serait_la_methode_preferee_pour_recevoir_les_fonds&quot;:&quot;&quot;,&quot;courriel_pour_le_virement_interac&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;en_cas_d\\u2019acceptation_quelle_serait_la_methode_preferee_pour_recevoir_les_fonds\\&quot;,\\&quot;value\\&quot;:\\&quot;Virement INTERAC\\&quot;}]&quot;,&quot;I_understand&quot;:&quot;&quot;,&quot;notice_1&quot;:&quot;&quot;,&quot;submit_1&quot;:&quot;&quot;},&quot;field_types&quot;:{&quot;referrer_first_name&quot;:&quot;text&quot;,&quot;referrer_last_name&quot;:&quot;text&quot;,&quot;referrer_phone_number&quot;:&quot;phone_number&quot;,&quot;referrer_email&quot;:&quot;email&quot;,&quot;referrer_occupation&quot;:&quot;text&quot;,&quot;referrer-reason&quot;:&quot;text&quot;,&quot;Child_first_name&quot;:&quot;text&quot;,&quot;Child_last_name&quot;:&quot;text&quot;,&quot;Child_Street&quot;:&quot;text&quot;,&quot;Child_City&quot;:&quot;text&quot;,&quot;province&quot;:&quot;select&quot;,&quot;Child_Postal_Code&quot;:&quot;text&quot;,&quot;Child_DOB&quot;:&quot;date&quot;,&quot;Sex&quot;:&quot;text&quot;,&quot;Illness&quot;:&quot;text&quot;,&quot;Mother_first_name&quot;:&quot;text&quot;,&quot;Mother_last_name&quot;:&quot;text&quot;,&quot;Mother_phone_number&quot;:&quot;phone_number&quot;,&quot;Father_first_name&quot;:&quot;text&quot;,&quot;Father_last_name&quot;:&quot;text&quot;,&quot;Father_phone_number&quot;:&quot;phone_number&quot;,&quot;langue_de_correspondance_preferee&quot;:&quot;radio&quot;,&quot;email_address&quot;:&quot;email&quot;,&quot;Social_assistance&quot;:&quot;select&quot;,&quot;Why_do_you_need_support&quot;:&quot;textarea&quot;,&quot;veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_1&quot;:&quot;checkbox&quot;,&quot;veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_2&quot;:&quot;checkbox&quot;,&quot;veuillez_telecharger_la_prescription&quot;:&quot;upload&quot;,&quot;veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_3&quot;:&quot;checkbox&quot;,&quot;veuillez_telecharger_la_prescription_la_lettre_du_medecin&quot;:&quot;upload&quot;,&quot;veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_4&quot;:&quot;checkbox&quot;,&quot;veuillez_preciser&quot;:&quot;text&quot;,&quot;en_cas_d\\u2019acceptation_quelle_serait_la_methode_preferee_pour_recevoir_les_fonds&quot;:&quot;radio&quot;,&quot;courriel_pour_le_virement_interac&quot;:&quot;email&quot;,&quot;I_understand&quot;:&quot;checkbox&quot;,&quot;notice_1&quot;:&quot;notice&quot;,&quot;submit_1&quot;:&quot;submit&quot;},&quot;nonce_method&quot;:&quot;ajax&quot;,&quot;form_views&quot;:&quot;ajax&quot;,&quot;form_views_counting&quot;:&quot;all&quot;}\"><form action=\"https:\/\/lionssickkids.ca\/fr\/application-form\/\" method=\"post\" class=\"fusion-form fusion-form-360\" enctype=\"multipart\/form-data\"><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:calc( 100% + 20px ) !important;max-width:calc( 100% + 20px ) !important;margin-left: calc(-20px \/ 2 );margin-right: calc(-20px \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:20px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\" data-scroll-devices=\"small-visibility,medium-visibility,large-visibility\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-2 fusion-title-text fusion-title-size-three\" style=\"--awb-margin-bottom:0px;--awb-margin-top-small:0px;--awb-margin-right-small:0px;--awb-margin-bottom-small:15px;--awb-margin-left-small:0px;--awb-sep-color:#f4594e;\"><div class=\"title-sep-container title-sep-container-left fusion-no-large-visibility fusion-no-medium-visibility fusion-no-small-visibility\"><div class=\"title-sep sep-single sep-solid\" style=\"border-color:#f4594e;\"><\/div><\/div><span class=\"awb-title-spacer fusion-no-large-visibility fusion-no-medium-visibility fusion-no-small-visibility\"><\/span><h3 class=\"fusion-title-heading title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:25;line-height:1.3;\">R\u00e9f\u00e9r\u00e9 par:<\/h3><span class=\"awb-title-spacer\"><\/span><div class=\"title-sep-container title-sep-container-right\"><div class=\"title-sep sep-single sep-solid\" style=\"border-color:#f4594e;\"><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-alert alert notice alert-warning fusion-alert-left awb-alert-native-link-color\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"awb-icon-cog\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">Doit \u00eatre un professionnel de la sant\u00e9.<\/span><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div class=\"fusion-form-label-wrapper\"><label for=\"referrer_first_name\">Pr\u00e9nom <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"referrer_first_name\" id=\"referrer_first_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div class=\"fusion-form-label-wrapper\"><label for=\"referrer_last_name\">Nom de famille <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"referrer_last_name\" id=\"referrer_last_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-6 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div class=\"fusion-form-label-wrapper\"><label for=\"referrer_phone_number\">T\u00e9l\u00e9phone <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"awb-form-icon fa-phone fas\"><\/i><input type=\"tel\" autocomplete=\"off\" name=\"referrer_phone_number\" id=\"referrer_phone_number\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-7 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-email-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div class=\"fusion-form-label-wrapper\"><label for=\"referrer_email\">Email <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"awb-form-icon fa-envelope fas\"><\/i><input type=\"email\" autocomplete=\"off\" name=\"referrer_email\" id=\"referrer_email\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-8 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div class=\"fusion-form-label-wrapper\"><label for=\"referrer_occupation\">Occupation <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"referrer_occupation\" id=\"referrer_occupation\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-9 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div class=\"fusion-form-label-wrapper\"><label for=\"referrer-reason\">Pourquoi, selon vous, cette famille a-t-elle besoin d&#039;une aide financi\u00e8re? <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"referrer-reason\" id=\"referrer-reason\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-10 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:20px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-3 fusion-title-text fusion-title-size-three\" style=\"--awb-margin-bottom:0px;--awb-margin-top-small:0px;--awb-margin-right-small:0px;--awb-margin-bottom-small:15px;--awb-margin-left-small:0px;--awb-sep-color:#f4594e;\"><div class=\"title-sep-container title-sep-container-left fusion-no-large-visibility fusion-no-medium-visibility fusion-no-small-visibility\"><div class=\"title-sep sep-single sep-solid\" style=\"border-color:#f4594e;\"><\/div><\/div><span class=\"awb-title-spacer fusion-no-large-visibility fusion-no-medium-visibility fusion-no-small-visibility\"><\/span><h3 class=\"fusion-title-heading title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:25;line-height:1.3;\">Information sur l\u2019enfant :<\/h3><span class=\"awb-title-spacer\"><\/span><div class=\"title-sep-container title-sep-container-right\"><div class=\"title-sep sep-single sep-solid\" style=\"border-color:#f4594e;\"><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-11 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div class=\"fusion-form-label-wrapper\"><label for=\"Child_first_name\">Pr\u00e9nom <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"Child_first_name\" id=\"Child_first_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-12 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div class=\"fusion-form-label-wrapper\"><label for=\"Child_last_name\">Nom de famille <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"Child_last_name\" id=\"Child_last_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-13 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div class=\"fusion-form-label-wrapper\"><label for=\"Child_Street\">Addresse <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"Child_Street\" id=\"Child_Street\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-14 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div class=\"fusion-form-label-wrapper\"><label for=\"Child_City\">Ville <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"Child_City\" id=\"Child_City\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-15 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-select-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><label for=\"province\">Province <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><div class=\"fusion-select-wrapper\"><select autocomplete=\"off\" tabindex=\"\" id=\"province\" name=\"province\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"><option value=\"\" disabled selected>- Province -<\/option><option value=\"Alberta\" >Alberta<\/option><option value=\"British Columbia\" >Colombie-Britannique<\/option><option value=\"Prince Edward Island\" >\u00cele du Prince-\u00c9douard<\/option><option value=\"Manitoba\" >Manitoba<\/option><option value=\"New Brunswick\" >Nouveau-Brunswick<\/option><option value=\"Nova Scotia\" >Nouvelle-\u00c9cosse<\/option><option value=\"Nunavut\" >Nunavut<\/option><option value=\"Ontario\" >Ontario<\/option><option value=\"Quebec\" >Qu\u00e9bec<\/option><option value=\"Saskatchewan\" >Saskatchewan<\/option><option value=\"Newfoundland and Labrador\" >Terre-Neuve-et-Labrador<\/option><option value=\"Northwest Territories\" >Territoires du Nord-Ouest<\/option><option value=\"Yukon\" >Yukon<\/option><\/select><div class=\"select-arrow\"><svg width=\"12\" height=\"8\" viewBox=\"0 0 12 8\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"> <path d=\"M1.5 1.75L6 6.25L10.5 1.75\" stroke=\"#6D6D6D\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/> <\/svg><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-16 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div class=\"fusion-form-label-wrapper\"><label for=\"Child_Postal_Code\">Code Postal <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"Child_Postal_Code\" id=\"Child_Postal_Code\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-17 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><label for=\"Child_DOB\"> Date de naissance <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><input autocomplete=\"off\" type=\"date\" data-first-day=\"1\"  data-format=\"\" tabindex=\"\" id=\"Child_DOB\" name=\"Child_DOB\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\"autocomplete=\"no\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-18 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div class=\"fusion-form-label-wrapper\"><label for=\"Sex\">Sexe <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"Sex\" id=\"Sex\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-19 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div class=\"fusion-form-label-wrapper\"><label for=\"Illness\">Maladie <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"Illness\" id=\"Illness\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-20 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:20px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-4 fusion-title-text fusion-title-size-three\" style=\"--awb-margin-bottom:0px;--awb-margin-top-small:0px;--awb-margin-right-small:0px;--awb-margin-bottom-small:15px;--awb-margin-left-small:0px;--awb-sep-color:#f4594e;\"><div class=\"title-sep-container title-sep-container-left fusion-no-large-visibility fusion-no-medium-visibility fusion-no-small-visibility\"><div class=\"title-sep sep-single sep-solid\" style=\"border-color:#f4594e;\"><\/div><\/div><span class=\"awb-title-spacer fusion-no-large-visibility fusion-no-medium-visibility fusion-no-small-visibility\"><\/span><h3 class=\"fusion-title-heading title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:25;line-height:1.3;\">Information sur la m\u00e8re<\/h3><span class=\"awb-title-spacer\"><\/span><div class=\"title-sep-container title-sep-container-right\"><div class=\"title-sep sep-single sep-solid\" style=\"border-color:#f4594e;\"><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-21 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div class=\"fusion-form-label-wrapper\"><label for=\"Mother_first_name\">Pr\u00e9nom<\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"Mother_first_name\" id=\"Mother_first_name\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-22 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div class=\"fusion-form-label-wrapper\"><label for=\"Mother_last_name\"> Nom de famille<\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"Mother_last_name\" id=\"Mother_last_name\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-23 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div class=\"fusion-form-label-wrapper\"><label for=\"Mother_phone_number\">Num\u00e9ro de t\u00e9l\u00e9phone principal:<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"awb-form-icon fa-phone-square-alt fas\"><\/i><input type=\"tel\" autocomplete=\"off\" name=\"Mother_phone_number\" id=\"Mother_phone_number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-24 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:20px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-5 fusion-title-text fusion-title-size-three\" style=\"--awb-margin-bottom:0px;--awb-margin-top-small:0px;--awb-margin-right-small:0px;--awb-margin-bottom-small:15px;--awb-margin-left-small:0px;--awb-sep-color:#f4594e;\"><div class=\"title-sep-container title-sep-container-left fusion-no-large-visibility fusion-no-medium-visibility fusion-no-small-visibility\"><div class=\"title-sep sep-single sep-solid\" style=\"border-color:#f4594e;\"><\/div><\/div><span class=\"awb-title-spacer fusion-no-large-visibility fusion-no-medium-visibility fusion-no-small-visibility\"><\/span><h3 class=\"fusion-title-heading title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:25;line-height:1.3;\">Information sur le p\u00e8re<\/h3><span class=\"awb-title-spacer\"><\/span><div class=\"title-sep-container title-sep-container-right\"><div class=\"title-sep sep-single sep-solid\" style=\"border-color:#f4594e;\"><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-25 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div class=\"fusion-form-label-wrapper\"><label for=\"Father_first_name\">Pr\u00e9nom<\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"Father_first_name\" id=\"Father_first_name\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-26 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div class=\"fusion-form-label-wrapper\"><label for=\"Father_last_name\"> Nom de famille<\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"Father_last_name\" id=\"Father_last_name\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-27 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div class=\"fusion-form-label-wrapper\"><label for=\"Father_phone_number\">Num\u00e9ro de t\u00e9l\u00e9phone principal:<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"awb-form-icon fa-phone-square-alt fas\"><\/i><input type=\"tel\" autocomplete=\"off\" name=\"Father_phone_number\" id=\"Father_phone_number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-28 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:20px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-6 fusion-title-text fusion-title-size-three\" style=\"--awb-margin-bottom:0px;--awb-margin-top-small:0px;--awb-margin-right-small:0px;--awb-margin-bottom-small:15px;--awb-margin-left-small:0px;--awb-sep-color:#f4594e;\"><div class=\"title-sep-container title-sep-container-left fusion-no-large-visibility fusion-no-medium-visibility fusion-no-small-visibility\"><div class=\"title-sep sep-single sep-solid\" style=\"border-color:#f4594e;\"><\/div><\/div><span class=\"awb-title-spacer fusion-no-large-visibility fusion-no-medium-visibility fusion-no-small-visibility\"><\/span><h3 class=\"fusion-title-heading title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:25;line-height:1.3;\">Information additionnelle<\/h3><span class=\"awb-title-spacer\"><\/span><div class=\"title-sep-container title-sep-container-right\"><div class=\"title-sep sep-single sep-solid\" style=\"border-color:#f4594e;\"><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-29 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><fieldset><legend class=\"fusion-form-label-wrapper\"><span class=\"label\">Langue de correspondance pr\u00e9f\u00e9r\u00e9e <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/legend><div class=\"fusion-form-radio option-inline\"><input data-empty-notice=\"Veuillez s\u00e9lectionner votre langue de correspondance pr\u00e9f\u00e9r\u00e9e\" tabindex=\"\" id=\"radio-langue_de_correspondance_preferee-1-0\" type=\"radio\" value=\"French\" name=\"langue_de_correspondance_preferee\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-langue_de_correspondance_preferee-1-0\">Fran\u00e7ais<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input data-empty-notice=\"Veuillez s\u00e9lectionner votre langue de correspondance pr\u00e9f\u00e9r\u00e9e\" tabindex=\"\" id=\"radio-langue_de_correspondance_preferee-1-1\" type=\"radio\" value=\"English\" name=\"langue_de_correspondance_preferee\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-langue_de_correspondance_preferee-1-1\">Anglais<\/label><\/div><\/fieldset><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-30 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-email-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div class=\"fusion-form-label-wrapper\"><label for=\"email_address\">Courriel <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"awb-form-icon fa-envelope fas\"><\/i><input type=\"email\" autocomplete=\"off\" name=\"email_address\" id=\"email_address\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-31 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-select-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><label for=\"Social_assistance\"> Le client b\u00e9n\u00e9ficie-t-il de l&#039;aide sociale ? (Si oui, contactez l&#039;agent) <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><div class=\"fusion-select-wrapper\"><select autocomplete=\"off\" tabindex=\"\" id=\"Social_assistance\" name=\"Social_assistance\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"><option value=\"Oui\" >Oui<\/option><option value=\"Non\" >Non<\/option><\/select><div class=\"select-arrow\"><svg width=\"12\" height=\"8\" viewBox=\"0 0 12 8\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"> <path d=\"M1.5 1.75L6 6.25L10.5 1.75\" stroke=\"#6D6D6D\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/> <\/svg><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-32 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><label for=\"Why_do_you_need_support\">En tant que famille, pourquoi avez-vous besoin de l&#039;aide financi\u00e8re du Fond pour enfants malades ? <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><textarea cols=\"40\" autocomplete=\"off\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"Why_do_you_need_support\" name=\"Why_do_you_need_support\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"><\/textarea><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-33 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><fieldset><legend class=\"fusion-form-label-wrapper\"><span class=\"label\">Veuillez indiquer les \u00e9l\u00e9ments pour lesquels vous avez besoin d&#039;aide :<\/span><\/legend><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_1-1-0\" type=\"checkbox\" value=\"Voyage\" name=\"veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_1[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_1-1-0\">Voyage<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><fieldset><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_2-2-0\" type=\"checkbox\" value=\"M\u00e9dicaments sur ordonnance (prescription requise)\" name=\"veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_2[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_2-2-0\">M\u00e9dicaments sur ordonnance (prescription requise)<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-upload-field fusion-form-label-above fusion-form-field-hidden\" style=\"--awb-preview-thumb-width:115px;\" data-form-id=\"360\" data-form-element-name=\"upload_1\"><label for=\"veuillez_telecharger_la_prescription\">Veuillez t\u00e9l\u00e9charger la prescription <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><div class=\"fusion-form-input-with-icon\"><i class=\" fa-upload fas\"><\/i><div class=\"fusion-form-upload-field-container\"><input type=\"file\" id=\"veuillez_telecharger_la_prescription\" name=\"veuillez_telecharger_la_prescription\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Click or drag a file to this area to upload. *\" data-size=\"2\" data-single-add-remove=\"no\" data-min-upload-files=\"0\" data-max-upload-files=\"0\" data-uploads-preview=\"filenames\"\/><div class=\"fusion-form-upload-field\"  data-holds-private-data=\"false\"><span class=\"awb-upload-placeholder\" data-default=\"Click or drag a file to this area to upload.\">Click or drag a file to this area to upload.<\/span><div class=\"awb-uploads-preview\"><div class=\"awb-preview-thumbs\"><\/div><\/div><\/div><div ><a class=\"fusion-button button-flat button-medium button-default fusion-button-default button-1 fusion-button-default-span fusion-button-default-type fusion-form-upload-field-button\" style=\"--button-border-radius-top-left:0px;--button-border-radius-top-right:0px;--button-border-radius-bottom-right:0px;--button-border-radius-bottom-left:0px;\" target=\"_self\" href=\"javascript:void();\"><span class=\"fusion-button-text awb-button__text awb-button__text--default\">Choose File<\/span><\/a><\/div><\/div><\/div><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><fieldset><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_3-3-0\" type=\"checkbox\" value=\"\u00c9quipement m\u00e9dical (prescription ou lettre du m\u00e9decin requise)\" name=\"veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_3[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_3-3-0\">\u00c9quipement m\u00e9dical (prescription ou lettre du m\u00e9decin requise)<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-upload-field fusion-form-label-above fusion-form-field-hidden\" style=\"--awb-preview-thumb-width:115px;\" data-form-id=\"360\" data-form-element-name=\"upload_2\"><label for=\"veuillez_telecharger_la_prescription_la_lettre_du_medecin\">Veuillez t\u00e9l\u00e9charger la prescription la lettre du m\u00e9decin <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><div class=\"fusion-form-input-with-icon\"><i class=\" fa-upload fas\"><\/i><div class=\"fusion-form-upload-field-container\"><input type=\"file\" id=\"veuillez_telecharger_la_prescription_la_lettre_du_medecin\" name=\"veuillez_telecharger_la_prescription_la_lettre_du_medecin\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Click or drag a file to this area to upload. *\" data-size=\"2\" data-single-add-remove=\"no\" data-min-upload-files=\"0\" data-max-upload-files=\"0\" data-uploads-preview=\"filenames\"\/><div class=\"fusion-form-upload-field\"  data-holds-private-data=\"false\"><span class=\"awb-upload-placeholder\" data-default=\"Click or drag a file to this area to upload.\">Click or drag a file to this area to upload.<\/span><div class=\"awb-uploads-preview\"><div class=\"awb-preview-thumbs\"><\/div><\/div><\/div><div ><a class=\"fusion-button button-flat button-medium button-default fusion-button-default button-2 fusion-button-default-span fusion-button-default-type fusion-form-upload-field-button\" style=\"--button-border-radius-top-left:0px;--button-border-radius-top-right:0px;--button-border-radius-bottom-right:0px;--button-border-radius-bottom-left:0px;\" target=\"_self\" href=\"javascript:void();\"><span class=\"fusion-button-text awb-button__text awb-button__text--default\">Choose File<\/span><\/a><\/div><\/div><\/div><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><fieldset><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_4-4-0\" type=\"checkbox\" value=\"Autre\" name=\"veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_4[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-veuillez_indiquer_les_elements_pour_lesquels_vous_avez_besoin_daide_4-4-0\">Autre<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"360\" data-form-element-name=\"text_16\"><div class=\"fusion-form-label-wrapper\"><label for=\"veuillez_preciser\">Veuillez pr\u00e9ciser <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"veuillez_preciser\" id=\"veuillez_preciser\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-34 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><fieldset><legend class=\"fusion-form-label-wrapper\"><span class=\"label\">En cas d\u2019acceptation, quelle serait la m\u00e9thode pr\u00e9f\u00e9r\u00e9e pour recevoir les fonds ? <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/legend><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-en_cas_d\u2019acceptation_quelle_serait_la_methode_preferee_pour_recevoir_les_fonds-2-0\" type=\"radio\" value=\"Cheque\" name=\"en_cas_d\u2019acceptation_quelle_serait_la_methode_preferee_pour_recevoir_les_fonds\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-en_cas_d\u2019acceptation_quelle_serait_la_methode_preferee_pour_recevoir_les_fonds-2-0\">Cheque<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-en_cas_d\u2019acceptation_quelle_serait_la_methode_preferee_pour_recevoir_les_fonds-2-1\" type=\"radio\" value=\"INTERAC e-Transfer\" name=\"en_cas_d\u2019acceptation_quelle_serait_la_methode_preferee_pour_recevoir_les_fonds\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-en_cas_d\u2019acceptation_quelle_serait_la_methode_preferee_pour_recevoir_les_fonds-2-1\">Virement INTERAC<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-en_cas_d\u2019acceptation_quelle_serait_la_methode_preferee_pour_recevoir_les_fonds-2-2\" type=\"radio\" value=\"Unknown\" name=\"en_cas_d\u2019acceptation_quelle_serait_la_methode_preferee_pour_recevoir_les_fonds\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-en_cas_d\u2019acceptation_quelle_serait_la_methode_preferee_pour_recevoir_les_fonds-2-2\">Inconnue<\/label><\/div><\/fieldset><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-35 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-email-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"360\" data-form-element-name=\"email_3\"><div class=\"fusion-form-label-wrapper\"><label for=\"courriel_pour_le_virement_interac\">Courriel pour le Virement INTERAC <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"awb-form-icon fa-envelope fas\"><\/i><input type=\"email\" autocomplete=\"off\" name=\"courriel_pour_le_virement_interac\" id=\"courriel_pour_le_virement_interac\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-36 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:10px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\" data-scroll-devices=\"small-visibility,medium-visibility,large-visibility\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-1 fusion-text-no-margin\" style=\"--awb-margin-bottom:0px;\"><p>En soumettant cette demande, le FOND comprend que vous demandez de l'aide et vous nous accordez \u00e9galement la permission de parler au m\u00e9decin de l'enfant, au travailleur social, \u00e0 l'intervenant ou \u00e0 toute autre partie concern\u00e9e pour d\u00e9terminer le niveau de l'assistance requise.<\/p>\n<\/div>\n<div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><fieldset><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-i_understand-5-0\" type=\"checkbox\" value=\"Je comprends et donne ma permission\" name=\"I_understand[]\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"checkbox-i_understand-5-0\">Je comprends et donne ma permission<\/label><\/div><\/fieldset><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-37 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"form-submission-notices data-notice_1\" id=\"fusion-notices-1\" data-instance=\"1\"><div class=\"fusion-alert alert success alert-success fusion-alert-center fusion-form-response fusion-form-response-success awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"awb-icon-check-circle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">Thank you for your message. It has been sent.<\/span><\/div><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><\/div><div class=\"fusion-alert alert error alert-danger fusion-alert-center fusion-form-response fusion-form-response-error awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"awb-icon-exclamation-triangle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">There was an error trying to send your message. Please try again later.<\/span><\/div><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><\/div><\/div><div class=\"fusion-form-field fusion-form-submit-field fusion-form-label-above\" style=\"\" data-form-id=\"360\"><div ><button type=\"submit\" class=\"fusion-button button-flat fusion-button-default-size button-default fusion-button-default button-3 fusion-button-span-yes  button-default form-form-submit\" data-form-number=\"360\" tabindex=\"\"><span class=\"fusion-button-text awb-button__text awb-button__text--default\">Soumettre<\/span><\/button><\/div><\/div><\/div><\/div><\/div><\/div><input type=\"hidden\" name=\"fusion_privacy_expiration_interval\" value=\"48\"><input type=\"hidden\" name=\"privacy_expiration_action\" value=\"anonymize\"><\/form><\/div><\/div><\/div><\/div><\/div><\/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":"100-width.php","meta":{"give_campaign_id":0,"_price":"","_stock":"","_tribe_ticket_header":"","_tribe_default_ticket_provider":"","_tribe_ticket_capacity":"0","_ticket_start_date":"","_ticket_end_date":"","_tribe_ticket_show_description":"","_tribe_ticket_show_not_going":false,"_tribe_ticket_use_global_stock":"","_tribe_ticket_global_stock_level":"","_global_stock_mode":"","_global_stock_cap":"","_tribe_rsvp_for_event":"","_tribe_ticket_going_count":"","_tribe_ticket_not_going_count":"","_tribe_tickets_list":"[]","_tribe_ticket_has_attendee_info_fields":false,"footnotes":"","_tec_slr_enabled":"","_tec_slr_layout":""},"class_list":["post-306","page","type-page","status-publish","hentry"],"campaignId":"","ticketed":false,"_links":{"self":[{"href":"https:\/\/lionssickkids.ca\/fr\/wp-json\/wp\/v2\/pages\/306","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/lionssickkids.ca\/fr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/lionssickkids.ca\/fr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/lionssickkids.ca\/fr\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/lionssickkids.ca\/fr\/wp-json\/wp\/v2\/comments?post=306"}],"version-history":[{"count":12,"href":"https:\/\/lionssickkids.ca\/fr\/wp-json\/wp\/v2\/pages\/306\/revisions"}],"predecessor-version":[{"id":514,"href":"https:\/\/lionssickkids.ca\/fr\/wp-json\/wp\/v2\/pages\/306\/revisions\/514"}],"wp:attachment":[{"href":"https:\/\/lionssickkids.ca\/fr\/wp-json\/wp\/v2\/media?parent=306"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}