{"id":3688,"date":"2021-04-30T18:30:14","date_gmt":"2021-05-01T01:30:14","guid":{"rendered":"https:\/\/terreboreale.com\/?page_id=3688"},"modified":"2021-08-15T16:43:57","modified_gmt":"2021-08-15T23:43:57","slug":"formulaire-inscription","status":"publish","type":"page","link":"https:\/\/terreboreale.com\/fr\/formulaire-inscription\/","title":{"rendered":"Formulaire d&rsquo;inscription"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3688\" class=\"elementor elementor-3688 elementor-3687\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-85c77f0 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"85c77f0\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-6e37568\" data-id=\"6e37568\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-de65f7d elementor-widget elementor-widget-spacer\" data-id=\"de65f7d\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-6f21b5b elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"6f21b5b\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-c510c78\" data-id=\"c510c78\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-765cf82\" data-id=\"765cf82\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-58fddae elementor-widget elementor-widget-text-editor\" data-id=\"58fddae\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Ce formulaire doit \u00eatre rempli par chaque participant.\u00a0<br \/><br \/>Terre Bor\u00e9ale garanti la confidentialit\u00e9 de ces donn\u00e9es. Elles ne seront partag\u00e9es qu&rsquo;avec votre ou vos guides et le personnel de secours.<\/p><p><br \/>Nous vous rappelons que nos conditions de vente sont disponibles <a href=\"https:\/\/terreboreale.com\/fr\/conditions-de-ventes\/\" target=\"_blank\" rel=\"noopener\">ici<\/a>.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e40f754 elementor-widget elementor-widget-spacer\" data-id=\"e40f754\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-021ace3\" data-id=\"021ace3\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-f8366ab elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"f8366ab\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-54e6117\" data-id=\"54e6117\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-a638061\" data-id=\"a638061\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-7708b7d elementor-widget elementor-widget-shortcode\" data-id=\"7708b7d\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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   <h2 class=\"gform_title\">Formulaire d'inscription<\/h2>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>\u00ab\u00a0<span class=\"gfield_required gfield_required_asterisk\">*<\/span>\u00a0\u00bb indique les champs n\u00e9cessaires<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_9' id='gform_9'  action='\/fr\/wp-json\/wp\/v2\/pages\/3688#gf_9' data-formid='9' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_9_78\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_78'>X\/Twitter<\/label><div class='ginput_container'><input name='input_78' id='input_9_78' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_9_78'>Ce champ n\u2019est utilis\u00e9 qu\u2019\u00e0 des fins de validation et devrait rester inchang\u00e9.<\/div><\/div><fieldset id=\"field_9_70\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Je m&#039;inscris pour un s\u00e9jour<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_70'>\n\t\t\t<div class='gchoice gchoice_9_70_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Guid\u00e9'  id='choice_9_70_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_70_0' id='label_9_70_0' class='gform-field-label gform-field-label--type-inline'>Guid\u00e9<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_70_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Auto-guid\u00e9'  id='choice_9_70_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_70_1' id='label_9_70_1' class='gform-field-label gform-field-label--type-inline'>Auto-guid\u00e9<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_70_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Guid\u00e9 et auto-guid\u00e9'  id='choice_9_70_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_70_2' id='label_9_70_2' class='gform-field-label gform-field-label--type-inline'>Guid\u00e9 et auto-guid\u00e9<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_73\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_73'>En quelle ann\u00e9e votre voyage se d\u00e9roule-t-il ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_73' id='input_9_73' type='number' step='any' min='2024' max='2030' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_9_73\" \/><div class='gfield_description instruction ' id='gfield_instruction_9_73'>Veuillez saisir un nombre entre <strong>2024<\/strong> et <strong>2030<\/strong>.<\/div><\/div><\/div><div id=\"field_9_66\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_66'>Nom du s\u00e9jour pour lequel je m&#039;inscris<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_66' id='input_9_66' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Merci de s\u00e9lectionner votre aventure<\/option><option value='Cano\u00eb - Yukon River - Laberge \u00e0 Carmacks' >Cano\u00eb - Yukon River - Laberge \u00e0 Carmacks<\/option><option value='Cano\u00eb - Yukon River - Laberge \u00e0 Dawson City' >Cano\u00eb - Yukon River - Laberge \u00e0 Dawson City<\/option><option value='Cano\u00eb - Rivi\u00e8re Upper Liard' >Cano\u00eb - Rivi\u00e8re Upper Liard<\/option><option value='Trekking - Au coeur des Montagnes C\u00f4ti\u00e8res' >Trekking - Au coeur des Montagnes C\u00f4ti\u00e8res<\/option><option value='Trekking - Sur la route du glacier Donjek' >Trekking - Sur la route du glacier Donjek<\/option><option value='Trekking - Sur les cr\u00eates des Ogilvie Mountains' >Trekking - Sur les cr\u00eates des Ogilvie Mountains<\/option><option value='Trekking - Sur la piste des bisons' >Trekking - Sur la piste des bisons<\/option><option value='Trekking - \u00c0 la d\u00e9couverte de la Dempster' >Trekking - \u00c0 la d\u00e9couverte de la Dempster<\/option><option value='Trekking - Seuls dans les Hess Mountains' >Trekking - Seuls dans les Hess Mountains<\/option><option value='Trekking - Couleurs de Kluane' >Trekking - Couleurs de Kluane<\/option><option value='Trekking - \u00c0 la d\u00e9couverte du sud du Yukon' >Trekking - \u00c0 la d\u00e9couverte du sud du Yukon<\/option><option value='\u00c9t\u00e9 - Sur mesure' >\u00c9t\u00e9 - Sur mesure<\/option><option value='Hiver - Au del\u00e0 du cercle' >Hiver - Au del\u00e0 du cercle<\/option><option value='Hiver - Escapade hivernale au Yukon' >Hiver - Escapade hivernale au Yukon<\/option><option value='Hiver - Sur mesure' >Hiver - Sur mesure<\/option><\/select><\/div><\/div><div id=\"field_9_19\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Informations personnelles<\/h3><\/div><fieldset id=\"field_9_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_9_1'>\n                            \n                            <span id='input_9_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_9_1_3' value=''   aria-required='true'   placeholder='Pr\u00e9nom'  \/>\n                                                    <label for='input_9_1_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_9_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_9_1_6' value=''   aria-required='true'   placeholder='Nom'  \/>\n                                                    <label for='input_9_1_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_9_62\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_62'>T\u00e9l\u00e9phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_9_62' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_57\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_57'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_57' id='input_9_57' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_9_3\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_9_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_9_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_9_3_1' value=''    aria-required='true'    \/>\n                                        <label for='input_9_3_1' id='input_9_3_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_9_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_9_3_3' value=''    aria-required='true'    \/>\n                                    <label for='input_9_3_3' id='input_9_3_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_9_3_4_container' >\n                                        <input type='text' name='input_3.4' id='input_9_3_4' value=''      aria-required='true'    \/>\n                                        <label for='input_9_3_4' id='input_9_3_4_label' class='gform-field-label gform-field-label--type-sub '>\u00c9tat\/Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_9_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_9_3_5' value=''    aria-required='true'    \/>\n                                    <label for='input_9_3_5' id='input_9_3_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_9_3_6_container' >\n                                        <select name='input_3.6' id='input_9_3_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Afrique du Sud' >Afrique du Sud<\/option><option value='Albanie' >Albanie<\/option><option value='Alg\u00e9rie' >Alg\u00e9rie<\/option><option value='Allemagne' >Allemagne<\/option><option value='Andorre' >Andorre<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctique' >Antarctique<\/option><option value='Antigua-et-Barbuda' >Antigua-et-Barbuda<\/option><option value='Arabie Saoudite' >Arabie Saoudite<\/option><option value='Argentine' >Argentine<\/option><option value='Arm\u00e9nie' >Arm\u00e9nie<\/option><option value='Aruba' >Aruba<\/option><option value='Australie' >Australie<\/option><option value='Autriche' >Autriche<\/option><option value='Azerba\u00efdjan' >Azerba\u00efdjan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahre\u00efn' >Bahre\u00efn<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Belarus' >Belarus<\/option><option value='Belgique' >Belgique<\/option><option value='Belize' >Belize<\/option><option value='Bermudes' >Bermudes<\/option><option value='Bhoutan' >Bhoutan<\/option><option value='Bolivie' >Bolivie<\/option><option value='Bonaire, Saint-Eustache et Saba' >Bonaire, Saint-Eustache et Saba<\/option><option value='Bosnie-Herz\u00e9govine' >Bosnie-Herz\u00e9govine<\/option><option value='Botswana' >Botswana<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Br\u00e9sil' >Br\u00e9sil<\/option><option value='Bulgarie' >Bulgarie<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9nin' >B\u00e9nin<\/option><option value='Cambodge' >Cambodge<\/option><option value='Cameroun' >Cameroun<\/option><option value='Canada' >Canada<\/option><option value='Cap-Vert' >Cap-Vert<\/option><option value='Chili' >Chili<\/option><option value='Chine' >Chine<\/option><option value='Chypre' >Chypre<\/option><option value='Colombie' >Colombie<\/option><option value='Comores' >Comores<\/option><option value='Congo' >Congo<\/option><option value='Cor\u00e9e (R\u00e9publique de)' >Cor\u00e9e (R\u00e9publique de)<\/option><option value='Cor\u00e9e (R\u00e9publique populaire d\u00e9mocratique de)' >Cor\u00e9e (R\u00e9publique populaire d\u00e9mocratique de)<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatie' >Croatie<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='C\u00f4te d\u2019Ivoire' >C\u00f4te d\u2019Ivoire<\/option><option value='Danemark' >Danemark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominique' >Dominique<\/option><option value='Espagne' >Espagne<\/option><option value='Estonie' >Estonie<\/option><option value='Eswatini' >Eswatini<\/option><option value='Fidji' >Fidji<\/option><option value='Finlande' >Finlande<\/option><option value='France' >France<\/option><option value='F\u00e9d\u00e9ration Russe' >F\u00e9d\u00e9ration Russe<\/option><option value='Gabon' >Gabon<\/option><option value='Gambie' >Gambie<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Grenade' >Grenade<\/option><option value='Groenland' >Groenland<\/option><option value='Gr\u00e8ce' >Gr\u00e8ce<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guin\u00e9e' >Guin\u00e9e<\/option><option value='Guin\u00e9e \u00e9quatoriale' >Guin\u00e9e \u00e9quatoriale<\/option><option value='Guin\u00e9e-Bissau' >Guin\u00e9e-Bissau<\/option><option value='Guyane' >Guyane<\/option><option value='Guyane' >Guyane<\/option><option value='G\u00e9orgie' >G\u00e9orgie<\/option><option value='G\u00e9orgie du Sud et \u00celes Sandwich du Sud' >G\u00e9orgie du Sud et \u00celes Sandwich du Sud<\/option><option value='Ha\u00efti' >Ha\u00efti<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hongrie' >Hongrie<\/option><option value='Inde' >Inde<\/option><option value='Indon\u00e9sie' >Indon\u00e9sie<\/option><option value='Irak' >Irak<\/option><option value='Iran' >Iran<\/option><option value='Irlande' >Irlande<\/option><option value='Islande' >Islande<\/option><option value='Isra\u00ebl' >Isra\u00ebl<\/option><option value='Italie' >Italie<\/option><option value='Jama\u00efque' >Jama\u00efque<\/option><option value='Japon' >Japon<\/option><option value='Jersey' >Jersey<\/option><option value='Jordanie' >Jordanie<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kirghizistan' >Kirghizistan<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kowe\u00eft' >Kowe\u00eft<\/option><option value='La Barbade' >La Barbade<\/option><option value='La R\u00e9union' >La R\u00e9union<\/option><option value='Lesotho' >Lesotho<\/option><option value='Lettonie' >Lettonie<\/option><option value='Liban' >Liban<\/option><option value='Liberia' >Liberia<\/option><option value='Libye' >Libye<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituanie' >Lituanie<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Mac\u00e9doine du Nord' >Mac\u00e9doine du Nord<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malaisie' >Malaisie<\/option><option value='Malawi' >Malawi<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malte' >Malte<\/option><option value='Maroc' >Maroc<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritanie' >Mauritanie<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexique' >Mexique<\/option><option value='Micron\u00e9sie' >Micron\u00e9sie<\/option><option value='Moldavie' >Moldavie<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolie' >Mongolie<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mont\u00e9n\u00e9gro' >Mont\u00e9n\u00e9gro<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibie' >Namibie<\/option><option value='Nauru' >Nauru<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nig\u00e9ria' >Nig\u00e9ria<\/option><option value='Niu\u00e9' >Niu\u00e9<\/option><option value='Norv\u00e8ge' >Norv\u00e8ge<\/option><option value='Nouvelle-Cal\u00e9donie' >Nouvelle-Cal\u00e9donie<\/option><option value='Nouvelle-Z\u00e9lande' >Nouvelle-Z\u00e9lande<\/option><option value='N\u00e9pal' >N\u00e9pal<\/option><option value='Oman' >Oman<\/option><option value='Ouganda' >Ouganda<\/option><option value='Ouzb\u00e9kistan' >Ouzb\u00e9kistan<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Panama' >Panama<\/option><option value='Papouasie-Nouvelle-Guin\u00e9e' >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value='Paraguay' >Paraguay<\/option><option value='Pays-Bas' >Pays-Bas<\/option><option value='Philippines' >Philippines<\/option><option value='Pologne' >Pologne<\/option><option value='Polyn\u00e9sie fran\u00e7aise' >Polyn\u00e9sie fran\u00e7aise<\/option><option value='Porto Rico' >Porto Rico<\/option><option value='Portugal' >Portugal<\/option><option value='P\u00e9rou' >P\u00e9rou<\/option><option value='Qatar' >Qatar<\/option><option value='Roumanie' >Roumanie<\/option><option value='Royaume-Uni' >Royaume-Uni<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9publique Dominicaine' >R\u00e9publique Dominicaine<\/option><option value='R\u00e9publique Tch\u00e8que' >R\u00e9publique Tch\u00e8que<\/option><option value='R\u00e9publique arabe syrienne' >R\u00e9publique arabe syrienne<\/option><option value='R\u00e9publique centrafricaine' >R\u00e9publique centrafricaine<\/option><option value='R\u00e9publique d\u00e9mocratique du Congo' >R\u00e9publique d\u00e9mocratique du Congo<\/option><option value='R\u00e9publique d\u00e9mocratique populaire du Laos' >R\u00e9publique d\u00e9mocratique populaire du Laos<\/option><option value='Sahara occidental' >Sahara occidental<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre et Miquelon' >Saint Pierre et Miquelon<\/option><option value='Saint-Christophe-et-Nevis' >Saint-Christophe-et-Nevis<\/option><option value='Saint-Marin' >Saint-Marin<\/option><option value='Saint-Si\u00e8ge' >Saint-Si\u00e8ge<\/option><option value='Saint-Vincent-et-les Grenadines' >Saint-Vincent-et-les Grenadines<\/option><option value='Sainte-H\u00e9l\u00e8ne, Ascension et Tristan da Cunha' >Sainte-H\u00e9l\u00e8ne, Ascension et Tristan da Cunha<\/option><option value='Sainte-Lucie' >Sainte-Lucie<\/option><option value='Salvador' >Salvador<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa am\u00e9ricaines' >Samoa am\u00e9ricaines<\/option><option value='Sao Tom\u00e9 et Principe' >Sao Tom\u00e9 et Principe<\/option><option value='Serbie' >Serbie<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapour' >Singapour<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovaquie' >Slovaquie<\/option><option value='Slov\u00e9nie' >Slov\u00e9nie<\/option><option value='Somalie' >Somalie<\/option><option value='Soudan' >Soudan<\/option><option value='Soudan du Sud' >Soudan du Sud<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Suisse' >Suisse<\/option><option value='Suriname' >Suriname<\/option><option value='Su\u00e8de' >Su\u00e8de<\/option><option value='S\u00e9n\u00e9gal' >S\u00e9n\u00e9gal<\/option><option value='Tadjikistan' >Tadjikistan<\/option><option value='Tanzanie (R\u00e9publique-Unie de)' >Tanzanie (R\u00e9publique-Unie de)<\/option><option value='Ta\u00efwan' >Ta\u00efwan<\/option><option value='Tchad' >Tchad<\/option><option value='Terres Australes Fran\u00e7aises' >Terres Australes Fran\u00e7aises<\/option><option value='Territoire britannique de l\u2019oc\u00e9an Indien' >Territoire britannique de l\u2019oc\u00e9an Indien<\/option><option value='Tha\u00eflande' >Tha\u00eflande<\/option><option value='Timor oriental' >Timor oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinit\u00e9 et Tobago' >Trinit\u00e9 et Tobago<\/option><option value='Tunisie' >Tunisie<\/option><option value='Turkm\u00e9nistan' >Turkm\u00e9nistan<\/option><option value='Turquie' >Turquie<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Ukraine' >Ukraine<\/option><option value='Uruguay' >Uruguay<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis et Futuna' >Wallis et Futuna<\/option><option value='Y\u00e9men' >Y\u00e9men<\/option><option value='Zambie' >Zambie<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c9gypte' >\u00c9gypte<\/option><option value='\u00c9mirats arabes unis' >\u00c9mirats arabes unis<\/option><option value='\u00c9quateur' >\u00c9quateur<\/option><option value='\u00c9rythr\u00e9e' >\u00c9rythr\u00e9e<\/option><option value='\u00c9tat palestinien' >\u00c9tat palestinien<\/option><option value='\u00c9tats-Unis' >\u00c9tats-Unis<\/option><option value='\u00c9thiopie' >\u00c9thiopie<\/option><option value='\u00cele Bouvet' >\u00cele Bouvet<\/option><option value='\u00cele Christmas' >\u00cele Christmas<\/option><option value='\u00cele Maurice' >\u00cele Maurice<\/option><option value='\u00cele Norfolk' >\u00cele Norfolk<\/option><option value='\u00cele de Man' >\u00cele de Man<\/option><option value='\u00celes Cayman' >\u00celes Cayman<\/option><option value='\u00celes Cocos' >\u00celes Cocos<\/option><option value='\u00celes Cook' >\u00celes Cook<\/option><option value='\u00celes Falkland' >\u00celes Falkland<\/option><option value='\u00celes F\u00e9ro\u00e9' >\u00celes F\u00e9ro\u00e9<\/option><option value='\u00celes Heard et McDonald' >\u00celes Heard et McDonald<\/option><option value='\u00celes Mariannes du Nord' >\u00celes Mariannes du Nord<\/option><option value='\u00celes Marshall' >\u00celes Marshall<\/option><option value='\u00celes Pitcairn' >\u00celes Pitcairn<\/option><option value='\u00celes Salomon' >\u00celes Salomon<\/option><option value='\u00celes Turques et Ca\u00efques' >\u00celes Turques et Ca\u00efques<\/option><option value='\u00celes Vierges am\u00e9ricaines' >\u00celes Vierges am\u00e9ricaines<\/option><option value='\u00celes Vierges britanniques' >\u00celes Vierges britanniques<\/option><option value='\u00celes de Svalbard et Jan Mayen' >\u00celes de Svalbard et Jan Mayen<\/option><option value='\u00celes mineures am\u00e9ricaines' >\u00celes mineures am\u00e9ricaines<\/option><option value='\u00celes \u00c5land' >\u00celes \u00c5land<\/option><\/select>\n                                        <label for='input_9_3_6' id='input_9_3_6_label' class='gform-field-label gform-field-label--type-sub '>Pays<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_9_72\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Quelle(s) langue(s) parlez-vous ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_72'><div class='gchoice gchoice_9_72_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.1' type='checkbox'  value='Fran\u00e7ais'  id='choice_9_72_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_72_1' id='label_9_72_1' class='gform-field-label gform-field-label--type-inline'>Fran\u00e7ais<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_72_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.2' type='checkbox'  value='Anglais'  id='choice_9_72_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_72_2' id='label_9_72_2' class='gform-field-label gform-field-label--type-inline'>Anglais<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_72_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.3' type='checkbox'  value='Autre'  id='choice_9_72_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_72_3' id='label_9_72_3' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_4\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-five-twelfths gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date de naissance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_9_4' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_9_4_2_container'>\n                                            <input type='number' maxlength='2' name='input_4[]' id='input_9_4_2' value=''   aria-required='true'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                            <label for='input_9_4_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Jour<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_9_4_1_container'>\n                                        <input type='number' maxlength='2' name='input_4[]' id='input_9_4_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_9_4_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Mois<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_9_4_3_container'>\n                                        <input type='number' maxlength='4' name='input_4[]' id='input_9_4_3' value=''   aria-required='true'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                        <label for='input_9_4_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Ann\u00e9e<\/label>\n                                   <\/div>\n                                <\/div><\/fieldset><fieldset id=\"field_9_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sexe<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_5'>\n\t\t\t<div class='gchoice gchoice_9_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Femme'  id='choice_9_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_5_0' id='label_9_5_0' class='gform-field-label gform-field-label--type-inline'>Femme<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Homme'  id='choice_9_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_5_1' id='label_9_5_1' class='gform-field-label gform-field-label--type-inline'>Homme<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Votre sexe et votre genre sont-ils diff\u00e9rents ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_9'>\n\t\t\t<div class='gchoice gchoice_9_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Oui'  id='choice_9_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_9_0' id='label_9_9_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Non'  id='choice_9_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_9_1' id='label_9_9_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_7'>Merci d&#039;indiquer comment vous vous indentifiez<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_9_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_11\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_11'>Poids (kg)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_11' id='input_9_11' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_9_74\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_74'>Taille (cm)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_74' id='input_9_74' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_9_12\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_12'>Pointure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_12' id='input_9_12' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_9_12\" \/><\/div><div class='gfield_description' id='gfield_description_9_12'>US 6 \u00e0 US 13<\/div><\/div><div id=\"field_9_75\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_75'>Taille de pantalon<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_9_75' type='text' value='' class='large'  aria-describedby=\"gfield_description_9_75\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_9_75'>XS \u00e0 3XL<\/div><\/div><div id=\"field_9_76\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_76'>Taille de veste (en duvet)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_9_76' type='text' value='' class='large'  aria-describedby=\"gfield_description_9_76\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_9_76'>XS \u00e0 3XL<\/div><\/div><div id=\"field_9_77\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_77'>Taille de sous veste (en duvet)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_9_77' type='text' value='' class='large'  aria-describedby=\"gfield_description_9_77\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_9_77'>XS \u00e0 2XL<\/div><\/div><div id=\"field_9_55\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Informations m\u00e9dicales<\/h3><\/div><fieldset id=\"field_9_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous des allergies ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_24'>\n\t\t\t<div class='gchoice gchoice_9_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Oui'  id='choice_9_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_24_0' id='label_9_24_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Non'  id='choice_9_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_24_1' id='label_9_24_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_39\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Merci de lister les d\u00e9tails de votre\/vos allergie(s) ci-dessous<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Allergie<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Symptome(s)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">S\u00e9v\u00e9rit\u00e9<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Traitement ?<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_39_cell1 gform-grid-col' data-label='Allergie'><input aria-invalid='false' aria-required=\"true\"  aria-label='Allergie, Ligne 1' data-aria-label-template='Allergie, Ligne {0}' type='text' name='input_39[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_39_cell2 gform-grid-col' data-label='Symptome(s)'><input aria-invalid='false' aria-required=\"true\"  aria-label='Symptome(s), Ligne 1' data-aria-label-template='Symptome(s), Ligne {0}' type='text' name='input_39[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_39_cell3 gform-grid-col' data-label='S\u00e9v\u00e9rit\u00e9'><input aria-invalid='false' aria-required=\"true\"  aria-label='S\u00e9v\u00e9rit\u00e9, Ligne 1' data-aria-label-template='S\u00e9v\u00e9rit\u00e9, Ligne {0}' type='text' name='input_39[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_39_cell4 gform-grid-col' data-label='Traitement ?'><input aria-invalid='false' aria-required=\"true\"  aria-label='Traitement ?, Ligne 1' data-aria-label-template='Traitement ?, Ligne {0}' type='text' name='input_39[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Ajouter une autre ligne' onclick='gformAddListItem(this, 0)'>Ajouter<\/button>   <button type='button'  class='delete_list_item' aria-label='Supprimer la ligne 1' data-aria-label-template='Supprimer la ligne {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Retirer<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Terre Bor\u00e9ale \u00e9quipe ses guides d&#039;\u00e9pipens (0.3mg \u00e9pin\u00e9phrine) pour les cas de r\u00e9actions anaphylactiques. Pour une s\u00e9curit\u00e9 accrue sur le terrain, nous demandons \u00e0 nos clients sujets \u00e0 des r\u00e9actions allergiques s\u00e9v\u00e8res d&#039;apporter leur propre \u00e9pipen pour leur s\u00e9jour avec Terre Bor\u00e9ale au Yukon.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_38'>\n\t\t\t<div class='gchoice gchoice_9_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Je vais apporter mon propre \u00e9pipen'  id='choice_9_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_38_0' id='label_9_38_0' class='gform-field-label gform-field-label--type-inline'>Je vais apporter mon propre \u00e9pipen<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Mes r\u00e9actions allergiques ne requi\u00e8rent pas l&#039;utilisation d&#039;un \u00e9pipen'  id='choice_9_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_38_1' id='label_9_38_1' class='gform-field-label gform-field-label--type-inline'>Mes r\u00e9actions allergiques ne requi\u00e8rent pas l'utilisation d'un \u00e9pipen<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Prenez-vous des m\u00e9dicaments ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_36'>\n\t\t\t<div class='gchoice gchoice_9_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Oui'  id='choice_9_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_36_0' id='label_9_36_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Non'  id='choice_9_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_36_1' id='label_9_36_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_40\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Pour chaque m\u00e9dicament, merci de pr\u00e9ciser :  le nom, la raison, la posologie, les effets secondaires<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Nom du m\u00e9dicaments<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Raison pour la prise du m\u00e9dicament<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Posologie<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Effets secondaires<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_40_cell1 gform-grid-col' data-label='Nom du m\u00e9dicaments'><input aria-invalid='false'   aria-label='Nom du m\u00e9dicaments, Ligne 1' data-aria-label-template='Nom du m\u00e9dicaments, Ligne {0}' type='text' name='input_40[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_40_cell2 gform-grid-col' data-label='Raison pour la prise du m\u00e9dicament'><input aria-invalid='false'   aria-label='Raison pour la prise du m\u00e9dicament, Ligne 1' data-aria-label-template='Raison pour la prise du m\u00e9dicament, Ligne {0}' type='text' name='input_40[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_40_cell3 gform-grid-col' data-label='Posologie'><input aria-invalid='false'   aria-label='Posologie, Ligne 1' data-aria-label-template='Posologie, Ligne {0}' type='text' name='input_40[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_40_cell4 gform-grid-col' data-label='Effets secondaires'><input aria-invalid='false'   aria-label='Effets secondaires, Ligne 1' data-aria-label-template='Effets secondaires, Ligne {0}' type='text' name='input_40[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Ajouter une autre ligne' onclick='gformAddListItem(this, 0)'>Ajouter<\/button>   <button type='button'  class='delete_list_item' aria-label='Supprimer la ligne 1' data-aria-label-template='Supprimer la ligne {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Retirer<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00cates-vous asthmatique ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_42'>\n\t\t\t<div class='gchoice gchoice_9_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Oui'  id='choice_9_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_42_0' id='label_9_42_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Non'  id='choice_9_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_42_1' id='label_9_42_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_43\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Pour plus de s\u00e9curit\u00e9, nous demandons \u00e0 nos clients asthmatiques de s&#039;\u00e9quiper d&#039;un ou deux  inhalateurs (Ventolin, bleu) pour leur s\u00e9jour avec Terre Bor\u00e9ale. Merci de v\u00e9rifier que la date de p\u00e9remption va au-del\u00e0 de la fin de votre s\u00e9jour au Yukon.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_43.1' id='input_9_43_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_43_1' >je prendrais un ou deux inhalateurs pour mon voyage avec Terre Bor\u00e9ale.<\/label><input type='hidden' name='input_43.2' value='je prendrais un ou deux inhalateurs pour mon voyage avec Terre Bor\u00e9ale.' class='gform_hidden' \/><input type='hidden' name='input_43.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_9_45\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_45'>Avez-vous d&#039;autres conditions m\u00e9dicales ? (pression sanguine \u00e9lev\u00e9e, probl\u00e8me au coeur, diab\u00e8te, grossesse, probl\u00e8mes physiques, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_45' id='input_9_45' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_9_50\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_50'>Avez-vous des restrictions alimentaires ?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_50' id='input_9_50' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_9_18\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Information sur le contact d&#039;urgence<\/h3><\/div><fieldset id=\"field_9_14\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nom du contact d&#039;urgence<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_9_14'>\n                            \n                            <span id='input_9_14_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_14.3' id='input_9_14_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_9_14_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_9_14_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_14.6' id='input_9_14_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_9_14_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_9_71\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_71'>Relation avec votre contact d&#039;urgence<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_9_71' type='text' value='' class='large'    placeholder='Parent, ami.e, etc.?' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_63\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_63'>Num\u00e9ro de t\u00e9l\u00e9phone du contact d&#039;urgence<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_9_63' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_16\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_16'>Adresse email du contact d&#039;urgence<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_16' id='input_9_16' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_9_65\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_65'>Pays de r\u00e9sidence du contact d&#039;urgence<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_65' id='input_9_65' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select><\/div><\/div><div id=\"field_9_20\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Assurance<\/h3><div class='gsection_description' id='gfield_description_9_20'>Comme indiqu\u00e9 dans nos conditions de ventes, nous conseillons fortement \u00e0 nos clients de souscrire \u00e0 une assurance annulation et une assurance \u00e9vacuation m\u00e9dicale. <\/div><\/div><fieldset id=\"field_9_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Assurance annulation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_21'>\n\t\t\t<div class='gchoice gchoice_9_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Oui, j&#039;ai souscrit \u00e0 une assurance annulation'  id='choice_9_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_21_0' id='label_9_21_0' class='gform-field-label gform-field-label--type-inline'>Oui, j'ai souscrit \u00e0 une assurance annulation<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Je n&#039;ai pas encore d&#039;assurance annulation mais je compte y souscrire avant mon d\u00e9part avec Terre Bor\u00e9ale'  id='choice_9_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_21_1' id='label_9_21_1' class='gform-field-label gform-field-label--type-inline'>Je n'ai pas encore d'assurance annulation mais je compte y souscrire avant mon d\u00e9part avec Terre Bor\u00e9ale<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_21_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Je ne souhaite pas souscrire \u00e0 une assurance annulation et comprend que si je dois annuler mon s\u00e9jour moins de 30 jours avant le d\u00e9part je n&#039;obtiendrai aucun remboursement de la part de Terre Bor\u00e9ale'  id='choice_9_21_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_21_2' id='label_9_21_2' class='gform-field-label gform-field-label--type-inline'>Je ne souhaite pas souscrire \u00e0 une assurance annulation et comprend que si je dois annuler mon s\u00e9jour moins de 30 jours avant le d\u00e9part je n'obtiendrai aucun remboursement de la part de Terre Bor\u00e9ale<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Assurance rapatriement, frais m\u00e9dicaux, frais de recherche et secours<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_22'>\n\t\t\t<div class='gchoice gchoice_9_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Oui, j&#039;ai souscrit \u00e0 une assurance rapatriement, frais m\u00e9dicaux, frais de recherche et secours'  id='choice_9_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_22_0' id='label_9_22_0' class='gform-field-label gform-field-label--type-inline'>Oui, j'ai souscrit \u00e0 une assurance rapatriement, frais m\u00e9dicaux, frais de recherche et secours<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Je n&#039;ai pas encore cette assurance mais je compte y souscrire avant mon d\u00e9part avec Terre Bor\u00e9ale'  id='choice_9_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_22_1' id='label_9_22_1' class='gform-field-label gform-field-label--type-inline'>Je n'ai pas encore cette assurance mais je compte y souscrire avant mon d\u00e9part avec Terre Bor\u00e9ale<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_22_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Je ne souhaite pas souscrire \u00e0 une assurance rapatriement, frais m\u00e9dicaux, frais de recherche et secours et je suis conscient que si je dois \u00eatre \u00e9vacu\u00e9, les frais d&#039;\u00e9vacuation seront totalement \u00e0 ma charge.'  id='choice_9_22_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_22_2' id='label_9_22_2' class='gform-field-label gform-field-label--type-inline'>Je ne souhaite pas souscrire \u00e0 une assurance rapatriement, frais m\u00e9dicaux, frais de recherche et secours et je suis conscient que si je dois \u00eatre \u00e9vacu\u00e9, les frais d'\u00e9vacuation seront totalement \u00e0 ma charge.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_23\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_23'>Information sur votre assurance rapatriement, frais m\u00e9dicaux, frais de recherche et secours<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_23' id='input_9_23' class='textarea small'  aria-describedby=\"gfield_description_9_23\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_9_23'>Merci de nous indiquer le nom de votre assureur, votre num\u00e9ro de police d'assurance et le num\u00e9ro d'urgence 24\/7.<\/div><\/div><div id=\"field_9_67\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Si vous souhaitez obtenir plus d'informations sur les assurances annulation et \u00e9vacuation, nous vous invitons \u00e0 contacter Karin \u00e0 <a>Uniglobe Specialty Travel<\/a> \u00e0 karin@uniglobespecialtytravel.com ou +1 867 668 3300 depuis le Canada.\nDepuis la France\/Europe, nous vous invitons \u00e0 contacter Chapka pour leurs assurances <a href=\"http:\/\/www.chapkadirect.fr\/index.php?action=produit&amp;id=784&amp;app=cd_boreale\" target=\"_blank\" rel=\"noopener\">annulation<\/a> et <a href=\"http:\/\/www.chapkadirect.fr\/index.php?action=produit&amp;id=481&amp;app=cd_boreale\" target=\"_blank\" rel=\"noopener\">rapatriement<\/a>. <\/div><div id=\"field_9_47\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Divers<\/h3><\/div><fieldset id=\"field_9_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Que buvez-vous le matin ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_51'>\n\t\t\t<div class='gchoice gchoice_9_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Caf\u00e9 noir'  id='choice_9_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_51_0' id='label_9_51_0' class='gform-field-label gform-field-label--type-inline'>Caf\u00e9 noir<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Caf\u00e9 au lait'  id='choice_9_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_51_1' id='label_9_51_1' class='gform-field-label gform-field-label--type-inline'>Caf\u00e9 au lait<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_51_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Th\u00e9\/tisane'  id='choice_9_51_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_51_2' id='label_9_51_2' class='gform-field-label gform-field-label--type-inline'>Th\u00e9\/tisane<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_51_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Th\u00e9\/tisane avec lait'  id='choice_9_51_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_51_3' id='label_9_51_3' class='gform-field-label gform-field-label--type-inline'>Th\u00e9\/tisane avec lait<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_51_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Chocolat chaud'  id='choice_9_51_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_51_4' id='label_9_51_4' class='gform-field-label gform-field-label--type-inline'>Chocolat chaud<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_51_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Eau'  id='choice_9_51_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_51_5' id='label_9_51_5' class='gform-field-label gform-field-label--type-inline'>Eau<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_46\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Pendant votre s\u00e9jour, Terre Bor\u00e9ale pourrait prendre des photos qui pourrait \u00eatre utilis\u00e9es plus tard pour de la promotion sur www.terreboreale.com, des brochures, etc. Autorisez-vous Terre Bor\u00e9ale \u00e0 utiliser votre image ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_46'>\n\t\t\t<div class='gchoice gchoice_9_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Oui'  id='choice_9_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_46_0' id='label_9_46_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Non'  id='choice_9_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_46_1' id='label_9_46_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_53\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consentement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_53.1' id='input_9_53_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_53_1' >J'atteste que les informations fournies dans ce formulaire sont, \u00e0 ma connaissance, compl\u00e8tes et correctes et que je suis enti\u00e8rement responsable de mon bien-\u00eatre et de ma forme physique durant mon voyage avec Terre Bor\u00e9ale.<\/label><input type='hidden' name='input_53.2' value='J&#039;atteste que les informations fournies dans ce formulaire sont, \u00e0 ma connaissance, compl\u00e8tes et correctes et que je suis enti\u00e8rement responsable de mon bien-\u00eatre et de ma forme physique durant mon voyage avec Terre Bor\u00e9ale.' class='gform_hidden' \/><input type='hidden' name='input_53.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_9_56\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_56.1' id='input_9_56_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_56_1' >Je m'engage \u00e0 pr\u00e9venir Terre Bor\u00e9ale si des changements au niveau de ma sant\u00e9 se pr\u00e9sentaient entre l'envoi de ce formulaire et le d\u00e9but de mon s\u00e9jour avec Terre Bor\u00e9ale.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_56.2' value='Je m&#039;engage \u00e0 pr\u00e9venir Terre Bor\u00e9ale si des changements au niveau de ma sant\u00e9 se pr\u00e9sentaient entre l&#039;envoi de ce formulaire et le d\u00e9but de mon s\u00e9jour avec Terre Bor\u00e9ale.' class='gform_hidden' \/><input type='hidden' name='input_56.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_9_54\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_54.1' id='input_9_54_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_54_1' >J'ai lu les conditions de ventes de Terre Bor\u00e9ale<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_54.2' value='J&#039;ai lu les conditions de ventes de Terre Bor\u00e9ale' class='gform_hidden' \/><input type='hidden' name='input_54.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_9' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' 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