{"id":3685,"date":"2025-12-08T22:42:12","date_gmt":"2025-12-09T03:42:12","guid":{"rendered":"https:\/\/lafermedandre.ca\/registration\/summer-camp-registration\/"},"modified":"2026-05-11T10:07:07","modified_gmt":"2026-05-11T14:07:07","slug":"summer-camp-registration","status":"publish","type":"page","link":"https:\/\/lafermedandre.ca\/en\/registration\/summer-camp-registration\/","title":{"rendered":"Summer camp registration"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3685\" class=\"elementor elementor-3685 elementor-3528\" data-elementor-post-type=\"page\">\n\t\t\t\t<div data-dce-background-image-url=\"https:\/\/lafermedandre.ca\/wp-content\/uploads\/2024\/11\/inscription-ferme-dandre.webp\" data-dce-background-overlay-image-url=\"https:\/\/lafermedandre.ca\/wp-content\/uploads\/2024\/11\/filtre-accueil-scaled.webp\" class=\"elementor-element elementor-element-cb9a8a9 e-con-full e-flex e-con e-parent\" data-id=\"cb9a8a9\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-bc7c315 e-con-full e-flex e-con e-child\" data-id=\"bc7c315\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3acb209 elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"3acb209\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;zoomIn&quot;,&quot;_animation_delay&quot;:100}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Summer camp registration<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-8cd8935 e-con-full e-flex e-con e-parent\" data-id=\"8cd8935\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-627c4bd e-con-full e-flex e-con e-child\" data-id=\"627c4bd\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-42c6d95 elementor-widget elementor-widget-heading\" data-id=\"42c6d95\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">Summer Camp \u2013 2026 Season<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3738782 elementor-widget elementor-widget-text-editor\" data-id=\"3738782\" data-element_type=\"widget\" data-e-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>La Ferme d&#8217;Andr\u00e9 is a summer camp where kids can emancipate themselves with confidence and safety. During their stay, campers will experience unforgettable moments while developing their social skills and imagination in a stimulating environment that emphasizes freedom, autonomy and initiative. <\/p>\n<p>Children are masters of their schedule! They are the ones who choose the activities and workshops that interest them on a daily basis. There is no dedicated group.   Each child is invited to participate, to make new acquaintances, to discover new things and to surpass themselves while having fun.<\/p>\n<p>The campers have the chance to feed, brush and have fun with the animals, ride horses in the merry-go-round, collect eggs in the hen house, go hiking, jump and climb in La Grange \u00e0 Tarzan, pet and feed the rabbits, sing in the evening around the bondfire while eating marshmallows. In a nutshell, children play outside and enjoy nature rain or shine! <\/p>\n\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-d5b86c5 elementor-widget elementor-widget-text-editor\" data-id=\"d5b86c5\" data-element_type=\"widget\" data-e-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>The male gender is used in this document simply to lighten the text and make it easier to read it.<\/p>\n\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-40dacbd elementor-widget elementor-widget-spacer\" data-id=\"40dacbd\" data-element_type=\"widget\" data-e-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<div class=\"elementor-element elementor-element-1a7e46a elementor-widget elementor-widget-heading\" data-id=\"1a7e46a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h5 class=\"elementor-heading-title elementor-size-default\">Length of Stay (5 days and 5 nights)<\/h5>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6293801 elementor-widget elementor-widget-text-editor\" data-id=\"6293801\" data-element_type=\"widget\" data-e-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><strong>Arrival:<\/strong> Sunday between 2:30 p.m. and 4 p.m.<br \/><strong>Departure:<\/strong> Following Friday between 3 p.m. and 4 p.m.<br \/><strong>Show:<\/strong> 4:30 p.m.<\/p>\n<p>The return home policy applies to all campers, including those who book a stay of two (2) consecutive weeks or more.<\/p>\n\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-22ad8d1 elementor-widget elementor-widget-spacer\" data-id=\"22ad8d1\" data-element_type=\"widget\" data-e-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<div class=\"elementor-element elementor-element-42f3efb elementor-widget elementor-widget-heading\" data-id=\"42f3efb\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h5 class=\"elementor-heading-title elementor-size-default\">Package Pricing<\/h5>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-c8c1c91 uael-header-sticky-no uael-border-yes elementor-widget elementor-widget-uael-table\" data-id=\"c8c1c91\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"uael-table.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div itemscope class=\"uael-table-wrapper\" itemtype=\"http:\/\/schema.org\/Table\">\n\t\t<table id=\"uael-table-id-c8c1c91\" class=\"uael-text-break uael-column-rules uael-table\" data-sort-table=\"no\" data-show-entry=\"no\" data-searchable=\"no\" data-responsive=\"no\">\n\t\t\t\t<thead>\n\t\t\t\t\t\t\t\t\t\t<tr class=\"uael-table-row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<th data-sort=\"0\" class=\"sort-this elementor-repeater-item-8deac76 uael-table-col uael-table-head-cell-text\" scope=\"col\">\n\t\t\t\t\t\t\t<span class=\"sort-style\">\n\t\t\t\t\t\t\t<span class=\"uael-table__text\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"uael-table__text-inner\">Cost<\/span>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t<\/th>\n\t\t\t\t\t\t\t\t\t\t\t\t<th data-sort=\"1\" class=\"sort-this elementor-repeater-item-ea1ac12 uael-table-col uael-table-head-cell-text\" scope=\"col\">\n\t\t\t\t\t\t\t<span class=\"sort-style\">\n\t\t\t\t\t\t\t<span class=\"uael-table__text\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"uael-table__text-inner\">GST<\/span>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t<\/th>\n\t\t\t\t\t\t\t\t\t\t\t\t<th data-sort=\"2\" class=\"sort-this elementor-repeater-item-0d2966d uael-table-col uael-table-head-cell-text\" scope=\"col\">\n\t\t\t\t\t\t\t<span class=\"sort-style\">\n\t\t\t\t\t\t\t<span class=\"uael-table__text\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"uael-table__text-inner\">QST<\/span>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t<\/th>\n\t\t\t\t\t\t\t\t\t\t\t\t<th data-sort=\"3\" class=\"sort-this elementor-repeater-item-e175177 uael-table-col uael-table-head-cell-text\" scope=\"col\">\n\t\t\t\t\t\t\t<span class=\"sort-style\">\n\t\t\t\t\t\t\t<span class=\"uael-table__text\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"uael-table__text-inner\">Total<\/span>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t<\/th>\n\t\t\t\t\t\t\t\t<\/thead>\n\t\t\t\t<tbody>\n\t\t\t<!-- ROWS -->\n\t\t\t\t\t\t\t\t\t\t<tr data-entry=\"1\" class=\"uael-table-row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<td class=\"uael-table-col uael-table-body-cell-text elementor-repeater-item-d905ac4\" data-title=\"Cost\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"uael-table__text\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"uael-table__text-inner\">$&nbsp;835<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<td class=\"uael-table-col uael-table-body-cell-text elementor-repeater-item-6110429\" data-title=\"GST\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"uael-table__text\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"uael-table__text-inner\">$&nbsp;41,75<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<td class=\"uael-table-col uael-table-body-cell-text elementor-repeater-item-83a0067\" data-title=\"QST\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"uael-table__text\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"uael-table__text-inner\">$&nbsp;83,29<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<td class=\"uael-table-col uael-table-body-cell-text elementor-repeater-item-3edcd67\" data-title=\"Total\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"uael-table__text\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"uael-table__text-inner\">$&nbsp;960,04<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t\t\t\t<\/tbody>\n\t<\/table>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6d75e4c elementor-widget elementor-widget-spacer\" data-id=\"6d75e4c\" data-element_type=\"widget\" data-e-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<div class=\"elementor-element elementor-element-d7fbba4 elementor-widget elementor-widget-heading\" data-id=\"d7fbba4\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h5 class=\"elementor-heading-title elementor-size-default\">Discount<\/h5>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-ce04781 elementor-widget elementor-widget-text-editor\" data-id=\"ce04781\" data-element_type=\"widget\" data-e-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>Enjoy a $50 discount for registering a second child from the same family. A $75 discount will be granted for the registration of a third child and beyond. <\/p>\n<p>Enjoy a $50 discount for registering your child for a second week or more.<\/p>\n<p><strong>Only one discount is granted per child.<\/strong><\/p>\n<p>Earn a $75 referral bonus for signing up one or more friends who never stayed at the farm camp before. <strong>A bonus will be given for each family referred.<\/strong><\/p>\n\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-ebc417b elementor-widget elementor-widget-spacer\" data-id=\"ebc417b\" data-element_type=\"widget\" data-e-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<div class=\"elementor-element elementor-element-bc3f6bd elementor-widget elementor-widget-heading\" data-id=\"bc3f6bd\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h5 class=\"elementor-heading-title elementor-size-default\">Payment Policy and Bank Transfer Information<\/h5>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b26540b elementor-widget elementor-widget-text-editor\" data-id=\"b26540b\" data-element_type=\"widget\" data-e-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>A deposit of $250 per child for each week of registration must be paid now to reserve their place. The full balance must be paid before June 1st, 2026. <\/p>\n<p><strong>Email bank transfer:<\/strong> <a href=\"mailto:gestion@lafermedandre.ca\">gestion@lafermedandre.ca<\/a><br \/><strong>Security Question:<\/strong> Farm\u2019s Name<br \/><strong>Answer:<\/strong> Andre1<\/p>\n\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-58ded5a elementor-widget elementor-widget-spacer\" data-id=\"58ded5a\" data-element_type=\"widget\" data-e-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<div class=\"elementor-element elementor-element-f2f20f2 elementor-widget elementor-widget-heading\" data-id=\"f2f20f2\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h5 class=\"elementor-heading-title elementor-size-default\">Cancellation Policy<\/h5>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e56a675 elementor-widget elementor-widget-text-editor\" data-id=\"e56a675\" data-element_type=\"widget\" data-e-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>Before June 1<sup>st,<\/sup> 2026, possibility of refund, except the $250 deposit retained for the opening of the file and the administration and management fees. Non-refundable after June 1<sup>st<\/sup>, 2026. <\/p>\n\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-dd044e8 elementor-widget elementor-widget-spacer\" data-id=\"dd044e8\" data-element_type=\"widget\" data-e-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<div class=\"elementor-element elementor-element-057edd2 elementor-widget elementor-widget-heading\" data-id=\"057edd2\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h5 class=\"elementor-heading-title elementor-size-default\">Registration<\/h5>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-c1786a2 elementor-widget elementor-widget-text-editor\" data-id=\"c1786a2\" data-element_type=\"widget\" data-e-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>Registration can be completed two different ways: by filling out the online form below or the PDF form and sending it to <a href=\"mailto:gestion@lafermedandre.ca\">gestion@lafermedandre.ca<\/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-b05803d elementor-align-left btn-pdf elementor-widget elementor-widget-button\" data-id=\"b05803d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"https:\/\/lafermedandre.ca\/wp-content\/uploads\/2026\/05\/Summer-Camp-Registration-Form-2026-Form-1-2-5-6-sold-out.pdf\" target=\"_blank\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" width=\"32px\" height=\"37px\" viewBox=\"0 0 32 37\"><title>pdf<\/title><g id=\"Page-1\" stroke=\"none\" stroke-width=\"1\" fill=\"none\" fill-rule=\"evenodd\"><g id=\"infos-utiles\" transform=\"translate(-1228, -1084)\" fill=\"#A5C342\" fill-rule=\"nonzero\"><g id=\"Group\" transform=\"translate(1228.4992, 1084)\"><path d=\"M23.3769408,11.0393848 C25.8627375,11.3043458 28.3628296,11.4069081 30.8612442,11.3442344 L30.8555461,11.3342626 L30.8541216,11.3356874 C27.903943,6.87967699 24.0947998,3.05930172 19.6486357,0.0977450536 C19.5831065,2.60917865 19.6856724,5.1219251 19.9534853,7.62070434 C20.1443728,9.267448 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L22.762856,25.2650021 C22.926677,25.3604459 23.1246867,25.373268 23.2984962,25.2991908 C23.4808356,25.2251172 23.6161643,25.0684184 23.6645973,24.8789714 C23.7130303,24.6895098 23.6702954,24.4872334 23.547787,24.3333754 C23.4252768,24.1795284 23.234393,24.0940549 23.0378202,24.1040253 L23.0377895,24.1040034 Z\" id=\"Path\"><\/path><\/g><\/g><\/g><\/svg>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Registration form - Summer Camp 2026<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-da117cd e-con-full e-flex e-con e-parent\" data-id=\"da117cd\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6029f76 elementor-widget-divider--view-line elementor-widget elementor-widget-divider\" data-id=\"6029f76\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"divider.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-divider\">\n\t\t\t<span class=\"elementor-divider-separator\">\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-eda8523 e-con-full e-flex e-con e-parent\" data-id=\"eda8523\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-75b2f62 e-con-full e-flex e-con e-child\" data-id=\"75b2f62\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-63caadf elementor-widget elementor-widget-heading\" data-id=\"63caadf\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">Registration Form<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-33a3cc4 elementor-widget elementor-widget-text-editor\" data-id=\"33a3cc4\" data-element_type=\"widget\" data-e-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><strong>2026 Summer Camp<\/strong><\/p>\n\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-58d05c3 elementor-widget elementor-widget-spacer\" data-id=\"58d05c3\" data-element_type=\"widget\" data-e-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<div class=\"elementor-element elementor-element-503368a uael-gf-check-yes uael-gf-check-default-yes uael-gf-button-right formulaire-inscription uael-gf-ajax-true uael-gf-style-box uael-gf-input-size-sm uael-gf-enable-classes-no uael-gf-btn-size-sm elementor-widget elementor-widget-uael-gf-styler\" data-id=\"503368a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"uael-gf-styler.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"uael-gf-style uael-gf-check-style elementor-clickable\">\n\t<script type=\"text\/javascript\">var 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 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_5' >\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/en\/wp-json\/wp\/v2\/pages\/3685' data-formid='5' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LdyaKEqAAAAAPzviKQFGBD3avC4CkYIwiJxFLCK' data-tabindex='1'><input id=\"input_0ccb4d249aa69678abf7b34cbc036139\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_0ccb4d249aa69678abf7b34cbc036139\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_5_1\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Check the week(s) for which you wish to register your child<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_1'><div class='gchoice gchoice_5_1_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_1.1' type='checkbox'  value='July 12 to July 17 (Closing evening: Beach party)'  id='choice_5_1_1' tabindex='2'  aria-describedby=\"gfield_description_5_1\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_5_1_1' id='label_5_1_1' class='gform-field-label gform-field-label--type-inline'>July 12 to July 17 (Closing evening: Beach party)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_1_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_1.2' type='checkbox'  value='July 26 to July 31 (Closing evening: Campers\u2019 Christmas party)'  id='choice_5_1_2' tabindex='3'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_1_2' id='label_5_1_2' class='gform-field-label gform-field-label--type-inline'>July 26 to July 31 (Closing evening: Campers\u2019 Christmas party)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_1'>Please note that a week may be canceled if the number of registrations is less than 50 campers. We will contact you to\noffer you another choice of dates, if necessary. CLOSED for vacation from July 19 to July 24.<br><br>\n<strong>The following weeks are already fully booked:<\/strong><br>\n\u2022 June 28 to July 3 (Closing evening: Disco Night) <br>\n\u2022 July 5 to July 10 (Closing evening: Halloween party)<br>\n\u2022 August 2 to August 7 (Closing evening: Western party)<br>\n\u2022 August 9 to August 14 (Closing evening: Hollywood evening)<\/div><\/fieldset><div id=\"field_5_3\" 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\"  data-js-reload=\"field_5_3\" ><h3 class=\"gsection_title\">Identification of your child<\/h3><\/div><fieldset id=\"field_5_4\" 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\"  data-js-reload=\"field_5_4\" ><legend class='gfield_label gform-field-label' >New Camper:<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_5_4'>\n\t\t\t<div class='gchoice gchoice_5_4_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Yes'  id='choice_5_4_0' onchange='gformToggleRadioOther( this )'  tabindex='4'  \/>\n\t\t\t\t\t<label for='choice_5_4_0' id='label_5_4_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_4_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='No'  id='choice_5_4_1' onchange='gformToggleRadioOther( this )'  tabindex='5'  \/>\n\t\t\t\t\t<label for='choice_5_4_1' id='label_5_4_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_5\" ><label class='gfield_label gform-field-label' for='input_5_5'>How did you discover La Ferme d\u2019Andr\u00e9?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_5_5' type='text' value='' class='large'   tabindex='6' placeholder='How did you discover La Ferme d\u2019Andr\u00e9? *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_7\" ><label class='gfield_label gform-field-label' for='input_5_7'>First Name<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_5_7' type='text' value='' class='large'   tabindex='7' placeholder='First Name *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_6\" ><label class='gfield_label gform-field-label' for='input_5_6'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_5_6' type='text' value='' class='large'   tabindex='8' placeholder='Last Name *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_8\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_8\" ><label class='gfield_label gform-field-label' for='input_5_8'>Birth Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_8' id='input_5_8' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon' tabindex='9'  placeholder='Birth Date *' aria-describedby=\"input_5_8_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_8_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_8' class='gform_hidden' value='https:\/\/lafermedandre.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_9\" ><label class='gfield_label gform-field-label' for='input_5_9'>Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_5_9' type='text' value='' class='large'   tabindex='10' placeholder='Age *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_11\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_11\" ><label class='gfield_label gform-field-label' for='input_5_11'>Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_11' id='input_5_11' class='large gfield_select' tabindex='11'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Gender *<\/option><option value='Female' >Female<\/option><option value='Male' >Male<\/option><option value='Nonbinary' >Nonbinary<\/option><\/select><\/div><\/div><fieldset id=\"field_5_113\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full condition-enfance gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_113\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Mother Tongue<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_113'><div class='gchoice gchoice_5_113_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.1' type='checkbox'  value='French'  id='choice_5_113_1' tabindex='12'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_113_1' id='label_5_113_1' class='gform-field-label gform-field-label--type-inline'>French<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_113_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.2' type='checkbox'  value='English'  id='choice_5_113_2' tabindex='13'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_113_2' id='label_5_113_2' class='gform-field-label gform-field-label--type-inline'>English<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_50\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_50\" ><label class='gfield_label gform-field-label' for='input_5_50'>Picture of your child<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='62914560' \/><input name='input_50' id='input_5_50' type='file' class='large' aria-describedby=\"gfield_upload_rules_5_50\" onchange='javascript:gformValidateFileSize( this, 62914560 );' tabindex='14' \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_50'>Max. file size: 60 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_5_50'><\/div><\/div><\/div><div id=\"field_5_12\" 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\"  data-js-reload=\"field_5_12\" ><h3 class=\"gsection_title\">Health information about your child<\/h3><\/div><div id=\"field_5_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_13\" ><label class='gfield_label gform-field-label' for='input_5_13'>Medicare Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_5_13' type='text' value='' class='large'   tabindex='15' placeholder='Medicare Number *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_14\" ><label class='gfield_label gform-field-label' for='input_5_14'>Expiry date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_5_14' type='text' value='' class='large'   tabindex='16' placeholder='Expiry date (yy\/mm) *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_15\" ><label class='gfield_label gform-field-label' for='input_5_15'>Date of last anti-tetanus vaccine<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_5_15' type='text' value='' class='large'   tabindex='17' placeholder='Date of last anti-tetanus vaccine (yyyy-mm-dd) *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_16\" ><label class='gfield_label gform-field-label' for='input_5_16'>Usual time of your child&#039;s bedtime<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_5_16' type='text' value='' class='large'   tabindex='18' placeholder='Usual time of your child&#039;s bedtime *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_17\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_17\" ><label class='gfield_label gform-field-label' for='input_5_17'>Does your child wet his bed?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_17' id='input_5_17' class='large gfield_select' tabindex='19'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Does your child wet his bed? *<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_5_18\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_18\" ><label class='gfield_label gform-field-label' for='input_5_18'>Does your child know how to swim?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_18' id='input_5_18' class='large gfield_select' tabindex='20'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Does your child know how to swim? *<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><fieldset id=\"field_5_48\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full condition-enfance field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_48\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Does your child have any of these conditions?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_48'><div class='gchoice gchoice_5_48_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.1' type='checkbox'  value='ADD'  id='choice_5_48_1' tabindex='21'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_1' id='label_5_48_1' class='gform-field-label gform-field-label--type-inline'>ADD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.2' type='checkbox'  value='ADHD'  id='choice_5_48_2' tabindex='22'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_2' id='label_5_48_2' class='gform-field-label gform-field-label--type-inline'>ADHD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.3' type='checkbox'  value='Anxiety'  id='choice_5_48_3' tabindex='23'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_3' id='label_5_48_3' class='gform-field-label gform-field-label--type-inline'>Anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.4' type='checkbox'  value='Asthma'  id='choice_5_48_4' tabindex='24'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_4' id='label_5_48_4' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.5' type='checkbox'  value='Attachment disorder'  id='choice_5_48_5' tabindex='25'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_5' id='label_5_48_5' class='gform-field-label gform-field-label--type-inline'>Attachment disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.6' type='checkbox'  value='Autistic Spectrum Disorder'  id='choice_5_48_6' tabindex='26'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_6' id='label_5_48_6' class='gform-field-label gform-field-label--type-inline'>Autistic Spectrum Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.7' type='checkbox'  value='Diabetes'  id='choice_5_48_7' tabindex='27'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_7' id='label_5_48_7' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.8' type='checkbox'  value='Dyslexia'  id='choice_5_48_8' tabindex='28'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_8' id='label_5_48_8' class='gform-field-label gform-field-label--type-inline'>Dyslexia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.9' type='checkbox'  value='Dysphasia'  id='choice_5_48_9' tabindex='29'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_9' id='label_5_48_9' class='gform-field-label gform-field-label--type-inline'>Dysphasia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.11' type='checkbox'  value='Epilepsy'  id='choice_5_48_11' tabindex='30'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_11' id='label_5_48_11' class='gform-field-label gform-field-label--type-inline'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.12' type='checkbox'  value='Gilles de la Tourette syndrome'  id='choice_5_48_12' tabindex='31'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_12' id='label_5_48_12' class='gform-field-label gform-field-label--type-inline'>Gilles de la Tourette syndrome<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.13' type='checkbox'  value='Hearing disorder'  id='choice_5_48_13' tabindex='32'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_13' id='label_5_48_13' class='gform-field-label gform-field-label--type-inline'>Hearing disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.14' type='checkbox'  value='Hyperactivity'  id='choice_5_48_14' tabindex='33'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_14' id='label_5_48_14' class='gform-field-label gform-field-label--type-inline'>Hyperactivity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.15' type='checkbox'  value='Impulsivity'  id='choice_5_48_15' tabindex='34'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_15' id='label_5_48_15' class='gform-field-label gform-field-label--type-inline'>Impulsivity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.16' type='checkbox'  value='Language disorder'  id='choice_5_48_16' tabindex='35'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_16' id='label_5_48_16' class='gform-field-label gform-field-label--type-inline'>Language disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.17' type='checkbox'  value='Migraine'  id='choice_5_48_17' tabindex='36'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_17' id='label_5_48_17' class='gform-field-label gform-field-label--type-inline'>Migraine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.18' type='checkbox'  value='Motricity problem'  id='choice_5_48_18' tabindex='37'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_18' id='label_5_48_18' class='gform-field-label gform-field-label--type-inline'>Motricity problem<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.19' type='checkbox'  value='Scoliosis'  id='choice_5_48_19' tabindex='38'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_19' id='label_5_48_19' class='gform-field-label gform-field-label--type-inline'>Scoliosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.21' type='checkbox'  value='Sensory hypersensitivity'  id='choice_5_48_21' tabindex='39'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_21' id='label_5_48_21' class='gform-field-label gform-field-label--type-inline'>Sensory hypersensitivity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.22' type='checkbox'  value='Swimmer\u2019s otitis'  id='choice_5_48_22' tabindex='40'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_22' id='label_5_48_22' class='gform-field-label gform-field-label--type-inline'>Swimmer\u2019s otitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.23' type='checkbox'  value='Vegan'  id='choice_5_48_23' tabindex='41'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_23' id='label_5_48_23' class='gform-field-label gform-field-label--type-inline'>Vegan<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.24' type='checkbox'  value='Vegetarian'  id='choice_5_48_24' tabindex='42'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_24' id='label_5_48_24' class='gform-field-label gform-field-label--type-inline'>Vegetarian<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.25' type='checkbox'  value='Visual problem'  id='choice_5_48_25' tabindex='43'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_25' id='label_5_48_25' class='gform-field-label gform-field-label--type-inline'>Visual problem<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_48_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.26' type='checkbox'  value='Wearing a dental appliance'  id='choice_5_48_26' tabindex='44'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_48_26' id='label_5_48_26' class='gform-field-label gform-field-label--type-inline'>Wearing a dental appliance<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_49\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_49\" ><label class='gfield_label gform-field-label' for='input_5_49'>Please specify and add any important information<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_5_49' type='text' value='' class='large'   tabindex='45' placeholder='Please specify and add any important information'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_51\" ><legend class='gfield_label gform-field-label' >Does your child need special accompaniment?<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_5_51'>\n\t\t\t<div class='gchoice gchoice_5_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Yes'  id='choice_5_51_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_51\" tabindex='46'  \/>\n\t\t\t\t\t<label for='choice_5_51_0' id='label_5_51_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='No'  id='choice_5_51_1' onchange='gformToggleRadioOther( this )'  tabindex='47'  \/>\n\t\t\t\t\t<label for='choice_5_51_1' id='label_5_51_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_51'>If so, please contact us as soon as possible so that we can assess his situation and our capacity to accommodate him adequately.<\/div><\/fieldset><div id=\"field_5_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\"  data-js-reload=\"field_5_19\" ><h3 class=\"gsection_title\">Does your child suffer from any of these allergies\/intolerances?<\/h3><\/div><fieldset id=\"field_5_20\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergies-intolerances field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_20\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >CAT<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_20'><div class='gchoice gchoice_5_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='Allergy'  id='choice_5_20_1' tabindex='48'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_1' id='label_5_20_1' class='gform-field-label gform-field-label--type-inline'>Allergy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='Intolerance'  id='choice_5_20_2' tabindex='49'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_2' id='label_5_20_2' class='gform-field-label gform-field-label--type-inline'>Intolerance<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergie-reaction field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_21\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Severity of reactions<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_21'><div class='gchoice gchoice_5_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Mild'  id='choice_5_21_1' tabindex='50'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_21_1' id='label_5_21_1' class='gform-field-label gform-field-label--type-inline'>Mild<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='Moderate'  id='choice_5_21_2' tabindex='51'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_21_2' id='label_5_21_2' class='gform-field-label gform-field-label--type-inline'>Moderate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_21_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.3' type='checkbox'  value='Severe'  id='choice_5_21_3' tabindex='52'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_21_3' id='label_5_21_3' class='gform-field-label gform-field-label--type-inline'>Severe<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_22\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergies-intolerances field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_22\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >CITRUS<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_22'><div class='gchoice gchoice_5_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='Allergy'  id='choice_5_22_1' tabindex='53'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_22_1' id='label_5_22_1' class='gform-field-label gform-field-label--type-inline'>Allergy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value='Intolerance'  id='choice_5_22_2' tabindex='54'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_22_2' id='label_5_22_2' class='gform-field-label gform-field-label--type-inline'>Intolerance<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergie-reaction field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_23\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Severity of reactions<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_23'><div class='gchoice gchoice_5_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Mild'  id='choice_5_23_1' tabindex='55'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_23_1' id='label_5_23_1' class='gform-field-label gform-field-label--type-inline'>Mild<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='Moderate'  id='choice_5_23_2' tabindex='56'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_23_2' id='label_5_23_2' class='gform-field-label gform-field-label--type-inline'>Moderate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_23_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.3' type='checkbox'  value='Severe'  id='choice_5_23_3' tabindex='57'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_23_3' id='label_5_23_3' class='gform-field-label gform-field-label--type-inline'>Severe<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_26\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergies-intolerances field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_26\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >DOG<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_26'><div class='gchoice gchoice_5_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='Allergy'  id='choice_5_26_1' tabindex='58'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_26_1' id='label_5_26_1' class='gform-field-label gform-field-label--type-inline'>Allergy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='Intolerance'  id='choice_5_26_2' tabindex='59'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_26_2' id='label_5_26_2' class='gform-field-label gform-field-label--type-inline'>Intolerance<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_35\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergie-reaction field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_35\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Severity of reactions<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_35'><div class='gchoice gchoice_5_35_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.1' type='checkbox'  value='Mild'  id='choice_5_35_1' tabindex='60'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_35_1' id='label_5_35_1' class='gform-field-label gform-field-label--type-inline'>Mild<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_35_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.2' type='checkbox'  value='Moderate'  id='choice_5_35_2' tabindex='61'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_35_2' id='label_5_35_2' class='gform-field-label gform-field-label--type-inline'>Moderate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_35_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.3' type='checkbox'  value='Severe'  id='choice_5_35_3' tabindex='62'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_35_3' id='label_5_35_3' class='gform-field-label gform-field-label--type-inline'>Severe<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_25\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergies-intolerances field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_25\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >EGGS<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_25'><div class='gchoice gchoice_5_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='Allergy'  id='choice_5_25_1' tabindex='63'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_1' id='label_5_25_1' class='gform-field-label gform-field-label--type-inline'>Allergy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='Intolerance'  id='choice_5_25_2' tabindex='64'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_2' id='label_5_25_2' class='gform-field-label gform-field-label--type-inline'>Intolerance<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_36\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergie-reaction field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_36\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Severity of reactions<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_36'><div class='gchoice gchoice_5_36_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.1' type='checkbox'  value='Mild'  id='choice_5_36_1' tabindex='65'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_36_1' id='label_5_36_1' class='gform-field-label gform-field-label--type-inline'>Mild<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_36_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.2' type='checkbox'  value='Moderate'  id='choice_5_36_2' tabindex='66'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_36_2' id='label_5_36_2' class='gform-field-label gform-field-label--type-inline'>Moderate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_36_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.3' type='checkbox'  value='Severe'  id='choice_5_36_3' tabindex='67'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_36_3' id='label_5_36_3' class='gform-field-label gform-field-label--type-inline'>Severe<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergies-intolerances field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_24\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >GLUTEN<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_24'><div class='gchoice gchoice_5_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Allergy'  id='choice_5_24_1' tabindex='68'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_1' id='label_5_24_1' class='gform-field-label gform-field-label--type-inline'>Allergy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='Intolerance'  id='choice_5_24_2' tabindex='69'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_2' id='label_5_24_2' class='gform-field-label gform-field-label--type-inline'>Intolerance<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_39\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergie-reaction field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_39\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Severity of reactions<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_39'><div class='gchoice gchoice_5_39_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.1' type='checkbox'  value='Mild'  id='choice_5_39_1' tabindex='70'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_39_1' id='label_5_39_1' class='gform-field-label gform-field-label--type-inline'>Mild<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_39_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.2' type='checkbox'  value='Moderate'  id='choice_5_39_2' tabindex='71'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_39_2' id='label_5_39_2' class='gform-field-label gform-field-label--type-inline'>Moderate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_39_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.3' type='checkbox'  value='Severe'  id='choice_5_39_3' tabindex='72'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_39_3' id='label_5_39_3' class='gform-field-label gform-field-label--type-inline'>Severe<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_27\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergies-intolerances field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_27\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >HAY<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_27'><div class='gchoice gchoice_5_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='Allergy'  id='choice_5_27_1' tabindex='73'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_27_1' id='label_5_27_1' class='gform-field-label gform-field-label--type-inline'>Allergy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='Intolerance'  id='choice_5_27_2' tabindex='74'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_27_2' id='label_5_27_2' class='gform-field-label gform-field-label--type-inline'>Intolerance<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_38\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergie-reaction field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_38\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Severity of reactions<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_38'><div class='gchoice gchoice_5_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='Mild'  id='choice_5_38_1' tabindex='75'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_1' id='label_5_38_1' class='gform-field-label gform-field-label--type-inline'>Mild<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_38_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.2' type='checkbox'  value='Moderate'  id='choice_5_38_2' tabindex='76'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_2' id='label_5_38_2' class='gform-field-label gform-field-label--type-inline'>Moderate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_38_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.3' type='checkbox'  value='Severe'  id='choice_5_38_3' tabindex='77'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_3' id='label_5_38_3' class='gform-field-label gform-field-label--type-inline'>Severe<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_28\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergies-intolerances field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_28\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >INSECT BITES<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_28'><div class='gchoice gchoice_5_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value='Allergy'  id='choice_5_28_1' tabindex='78'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_28_1' id='label_5_28_1' class='gform-field-label gform-field-label--type-inline'>Allergy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_28_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.2' type='checkbox'  value='Intolerance'  id='choice_5_28_2' tabindex='79'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_28_2' id='label_5_28_2' class='gform-field-label gform-field-label--type-inline'>Intolerance<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_37\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergie-reaction field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_37\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Severity of reactions<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_37'><div class='gchoice gchoice_5_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='Mild'  id='choice_5_37_1' tabindex='80'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_1' id='label_5_37_1' class='gform-field-label gform-field-label--type-inline'>Mild<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.2' type='checkbox'  value='Moderate'  id='choice_5_37_2' tabindex='81'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_2' id='label_5_37_2' class='gform-field-label gform-field-label--type-inline'>Moderate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.3' type='checkbox'  value='Severe'  id='choice_5_37_3' tabindex='82'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_3' id='label_5_37_3' class='gform-field-label gform-field-label--type-inline'>Severe<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_29\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergies-intolerances field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_29\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >LACTOSE<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_29'><div class='gchoice gchoice_5_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Allergy'  id='choice_5_29_1' tabindex='83'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_29_1' id='label_5_29_1' class='gform-field-label gform-field-label--type-inline'>Allergy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='Intolerance'  id='choice_5_29_2' tabindex='84'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_29_2' id='label_5_29_2' class='gform-field-label gform-field-label--type-inline'>Intolerance<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_42\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergie-reaction field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_42\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Severity of reactions<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_42'><div class='gchoice gchoice_5_42_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.1' type='checkbox'  value='Mild'  id='choice_5_42_1' tabindex='85'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_42_1' id='label_5_42_1' class='gform-field-label gform-field-label--type-inline'>Mild<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_42_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.2' type='checkbox'  value='Moderate'  id='choice_5_42_2' tabindex='86'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_42_2' id='label_5_42_2' class='gform-field-label gform-field-label--type-inline'>Moderate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_42_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.3' type='checkbox'  value='Severe'  id='choice_5_42_3' tabindex='87'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_42_3' id='label_5_42_3' class='gform-field-label gform-field-label--type-inline'>Severe<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_30\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergies-intolerances field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_30\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >MEDECINES<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_30'><div class='gchoice gchoice_5_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='Allergy'  id='choice_5_30_1' tabindex='88'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_30_1' id='label_5_30_1' class='gform-field-label gform-field-label--type-inline'>Allergy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='Intolerance'  id='choice_5_30_2' tabindex='89'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_30_2' id='label_5_30_2' class='gform-field-label gform-field-label--type-inline'>Intolerance<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_41\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergie-reaction field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_41\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Severity of reactions<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_41'><div class='gchoice gchoice_5_41_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.1' type='checkbox'  value='Mild'  id='choice_5_41_1' tabindex='90'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_41_1' id='label_5_41_1' class='gform-field-label gform-field-label--type-inline'>Mild<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_41_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.2' type='checkbox'  value='Moderate'  id='choice_5_41_2' tabindex='91'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_41_2' id='label_5_41_2' class='gform-field-label gform-field-label--type-inline'>Moderate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_41_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.3' type='checkbox'  value='Severe'  id='choice_5_41_3' tabindex='92'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_41_3' id='label_5_41_3' class='gform-field-label gform-field-label--type-inline'>Severe<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_31\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergies-intolerances field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_31\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >PEANUTS \/ NUTS \/ PACAN<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_31'><div class='gchoice gchoice_5_31_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.1' type='checkbox'  value='Allergy'  id='choice_5_31_1' tabindex='93'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_31_1' id='label_5_31_1' class='gform-field-label gform-field-label--type-inline'>Allergy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_31_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.2' type='checkbox'  value='Intolerance'  id='choice_5_31_2' tabindex='94'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_31_2' id='label_5_31_2' class='gform-field-label gform-field-label--type-inline'>Intolerance<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_40\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergie-reaction field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_40\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Severity of reactions<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_40'><div class='gchoice gchoice_5_40_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.1' type='checkbox'  value='Mild'  id='choice_5_40_1' tabindex='95'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_40_1' id='label_5_40_1' class='gform-field-label gform-field-label--type-inline'>Mild<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_40_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.2' type='checkbox'  value='Moderate'  id='choice_5_40_2' tabindex='96'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_40_2' id='label_5_40_2' class='gform-field-label gform-field-label--type-inline'>Moderate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_40_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.3' type='checkbox'  value='Severe'  id='choice_5_40_3' tabindex='97'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_40_3' id='label_5_40_3' class='gform-field-label gform-field-label--type-inline'>Severe<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_32\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergies-intolerances field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_32\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >SEEFOOD<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_32'><div class='gchoice gchoice_5_32_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.1' type='checkbox'  value='Allergy'  id='choice_5_32_1' tabindex='98'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_32_1' id='label_5_32_1' class='gform-field-label gform-field-label--type-inline'>Allergy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_32_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.2' type='checkbox'  value='Intolerance'  id='choice_5_32_2' tabindex='99'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_32_2' id='label_5_32_2' class='gform-field-label gform-field-label--type-inline'>Intolerance<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_45\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergie-reaction field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_45\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Severity of reactions<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_45'><div class='gchoice gchoice_5_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='Mild'  id='choice_5_45_1' tabindex='100'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_45_1' id='label_5_45_1' class='gform-field-label gform-field-label--type-inline'>Mild<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_45_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.2' type='checkbox'  value='Moderate'  id='choice_5_45_2' tabindex='101'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_45_2' id='label_5_45_2' class='gform-field-label gform-field-label--type-inline'>Moderate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_45_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.3' type='checkbox'  value='Severe'  id='choice_5_45_3' tabindex='102'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_45_3' id='label_5_45_3' class='gform-field-label gform-field-label--type-inline'>Severe<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_33\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergies-intolerances field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_33\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >SEASONAL<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_33'><div class='gchoice gchoice_5_33_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.1' type='checkbox'  value='Allergy'  id='choice_5_33_1' tabindex='103'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_1' id='label_5_33_1' class='gform-field-label gform-field-label--type-inline'>Allergy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_33_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.2' type='checkbox'  value='Intolerance'  id='choice_5_33_2' tabindex='104'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_2' id='label_5_33_2' class='gform-field-label gform-field-label--type-inline'>Intolerance<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_44\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergie-reaction field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_44\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Severity of reactions<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_44'><div class='gchoice gchoice_5_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='Mild'  id='choice_5_44_1' tabindex='105'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_44_1' id='label_5_44_1' class='gform-field-label gform-field-label--type-inline'>Mild<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_44_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.2' type='checkbox'  value='Moderate'  id='choice_5_44_2' tabindex='106'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_44_2' id='label_5_44_2' class='gform-field-label gform-field-label--type-inline'>Moderate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_44_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.3' type='checkbox'  value='Severe'  id='choice_5_44_3' tabindex='107'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_44_3' id='label_5_44_3' class='gform-field-label gform-field-label--type-inline'>Severe<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_34\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergies-intolerances field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_34\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >SESAME<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_34'><div class='gchoice gchoice_5_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='Allergy'  id='choice_5_34_1' tabindex='108'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_34_1' id='label_5_34_1' class='gform-field-label gform-field-label--type-inline'>Allergy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_34_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.2' type='checkbox'  value='Intolerance'  id='choice_5_34_2' tabindex='109'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_34_2' id='label_5_34_2' class='gform-field-label gform-field-label--type-inline'>Intolerance<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_43\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half allergie-reaction field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_43\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Severity of reactions<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_43'><div class='gchoice gchoice_5_43_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.1' type='checkbox'  value='Mild'  id='choice_5_43_1' tabindex='110'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_43_1' id='label_5_43_1' class='gform-field-label gform-field-label--type-inline'>Mild<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_43_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.2' type='checkbox'  value='Moderate'  id='choice_5_43_2' tabindex='111'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_43_2' id='label_5_43_2' class='gform-field-label gform-field-label--type-inline'>Moderate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_43_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.3' type='checkbox'  value='Severe'  id='choice_5_43_3' tabindex='112'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_43_3' id='label_5_43_3' class='gform-field-label gform-field-label--type-inline'>Severe<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_46\" ><label class='gfield_label gform-field-label' for='input_5_46'>Other allergies and important information<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_5_46' type='text' value='' class='large'   tabindex='113' placeholder='Other allergies and important information'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_47\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_47\" ><label class='gfield_label gform-field-label' for='input_5_47'>Does your child need an Auto-injector?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_47' id='input_5_47' class='large gfield_select' tabindex='114'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Does your child need an Auto-injector?<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_5_52\" 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\"  data-js-reload=\"field_5_52\" ><h3 class=\"gsection_title\">Parent # 1\u2019s Identification<\/h3><\/div><div id=\"field_5_53\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_53\" ><label class='gfield_label gform-field-label' for='input_5_53'>Frist Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_5_53' type='text' value='' class='large'   tabindex='115' placeholder='Frist Name *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_54\" ><label class='gfield_label gform-field-label' for='input_5_54'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_5_54' type='text' value='' class='large'   tabindex='116' placeholder='Last Name *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_55\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_55\" ><label class='gfield_label gform-field-label' for='input_5_55'>Adress<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_5_55' type='text' value='' class='large'   tabindex='117' placeholder='Adress *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_56\" ><label class='gfield_label gform-field-label' for='input_5_56'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_5_56' type='text' value='' class='large'   tabindex='118' placeholder='City *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_57\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_57\" ><label class='gfield_label gform-field-label' for='input_5_57'>Province<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_5_57' type='text' value='' class='large'   tabindex='119' placeholder='Province *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_58\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_58\" ><label class='gfield_label gform-field-label' for='input_5_58'>Postal Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_5_58' type='text' value='' class='large'   tabindex='120' placeholder='Postal Code *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_59\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_59\" ><label class='gfield_label gform-field-label' for='input_5_59'>Telephone Home<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_5_59' type='text' value='' class='large'   tabindex='121' placeholder='Telephone Home *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_61\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_61\" ><label class='gfield_label gform-field-label' for='input_5_61'>Telephone Home<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_5_61' type='text' value='' class='large'   tabindex='122' placeholder='Telephone Home'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_60\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_60\" ><label class='gfield_label gform-field-label' for='input_5_60'>Cell Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_5_60' type='text' value='' class='large'   tabindex='123' placeholder='Cell Phone'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_62\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_62\" ><label class='gfield_label gform-field-label' for='input_5_62'>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_62' id='input_5_62' type='email' value='' class='large' tabindex='124'  placeholder='Email *' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_63\" 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\"  data-js-reload=\"field_5_63\" ><h3 class=\"gsection_title\">Parent # 2\u2019s Identification<\/h3><\/div><div id=\"field_5_64\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_64\" ><label class='gfield_label gform-field-label' for='input_5_64'>Frist Name<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_5_64' type='text' value='' class='large'   tabindex='125' placeholder='Frist Name'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_65\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_65\" ><label class='gfield_label gform-field-label' for='input_5_65'>Last Name<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_5_65' type='text' value='' class='large'   tabindex='126' placeholder='Last Name'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_66\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_66\" ><label class='gfield_label gform-field-label' for='input_5_66'>Adress<\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_5_66' type='text' value='' class='large'   tabindex='127' placeholder='Adress'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_67\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_67\" ><label class='gfield_label gform-field-label' for='input_5_67'>City<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_5_67' type='text' value='' class='large'   tabindex='128' placeholder='City'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_68\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_68\" ><label class='gfield_label gform-field-label' for='input_5_68'>Province<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_5_68' type='text' value='' class='large'   tabindex='129' placeholder='Province'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_69\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_69\" ><label class='gfield_label gform-field-label' for='input_5_69'>Postal Code<\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_5_69' type='text' value='' class='large'   tabindex='130' placeholder='Postal Code'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_70\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_70\" ><label class='gfield_label gform-field-label' for='input_5_70'>Telephone Home<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_5_70' type='text' value='' class='large'   tabindex='131' placeholder='Telephone Home'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_72\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_72\" ><label class='gfield_label gform-field-label' for='input_5_72'>Telephone Work<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_5_72' type='text' value='' class='large'   tabindex='132' placeholder='Telephone Work'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_71\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_71\" ><label class='gfield_label gform-field-label' for='input_5_71'>Cell Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_5_71' type='text' value='' class='large'   tabindex='133' placeholder='Cell Phone'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_73\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_73\" ><label class='gfield_label gform-field-label' for='input_5_73'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_73' id='input_5_73' type='email' value='' class='large' tabindex='134'  placeholder='Email'  aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_74\" 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\"  data-js-reload=\"field_5_74\" ><h3 class=\"gsection_title\">RL-24 Summary Information \u2013 Childcare expenses<\/h3><\/div><div id=\"field_5_75\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_75\" ><label class='gfield_label gform-field-label' for='input_5_75'>Tax receipt in the name of<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_75' id='input_5_75' class='large gfield_select' tabindex='135'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Tax receipt in the name of *<\/option><option value='Parent 1' >Parent 1<\/option><option value='Parent 2' >Parent 2<\/option><\/select><\/div><\/div><div id=\"field_5_76\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_76\" ><label class='gfield_label gform-field-label' for='input_5_76'>Social insurance number<\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_5_76' type='text' value='' class='large'   tabindex='136' placeholder='Social insurance number *'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_77\" 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\"  data-js-reload=\"field_5_77\" ><h3 class=\"gsection_title\">1st contact in case of an emergency<\/h3><\/div><div id=\"field_5_78\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_78\" ><label class='gfield_label gform-field-label' for='input_5_78'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_5_78' type='text' value='' class='large'   tabindex='137' placeholder='First Name *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_79\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_79\" ><label class='gfield_label gform-field-label' for='input_5_79'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_5_79' type='text' value='' class='large'   tabindex='138' placeholder='Last Name *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_80\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_80\" ><label class='gfield_label gform-field-label' for='input_5_80'>Telephone Home<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_5_80' type='text' value='' class='large'   tabindex='139' placeholder='Telephone Home *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_81\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_81\" ><label class='gfield_label gform-field-label' for='input_5_81'>Cell Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_5_81' type='text' value='' class='large'   tabindex='140' placeholder='Cell Phone'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_82\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_82\" ><label class='gfield_label gform-field-label' for='input_5_82'>Relationship to the child<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_5_82' type='text' value='' class='large'   tabindex='141' placeholder='Relationship to the child *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_83\" 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\"  data-js-reload=\"field_5_83\" ><h3 class=\"gsection_title\">2nd contact in case of an emergency<\/h3><\/div><div id=\"field_5_84\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_84\" ><label class='gfield_label gform-field-label' for='input_5_84'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_5_84' type='text' value='' class='large'   tabindex='142' placeholder='First Name *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_85\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_85\" ><label class='gfield_label gform-field-label' for='input_5_85'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_5_85' type='text' value='' class='large'   tabindex='143' placeholder='Last Name *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_86\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_86\" ><label class='gfield_label gform-field-label' for='input_5_86'>Telephone Home<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_5_86' type='text' value='' class='large'   tabindex='144' placeholder='Telephone Home *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_87\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_87\" ><label class='gfield_label gform-field-label' for='input_5_87'>Cell Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_5_87' type='text' value='' class='large'   tabindex='145' placeholder='Cell Phone'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_88\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_88\" ><label class='gfield_label gform-field-label' for='input_5_88'>Relationship to the child<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_5_88' type='text' value='' class='large'   tabindex='146' placeholder='Relationship to the child *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_89\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_89\" ><p>La Ferme d\u2019Andr\u00e9 2.0 reserves the right to send the child home in the event that the child disrupts activities or interferes with his safety or that of others. You or an authorized person will have a maximum of 24 hours to pick up your child.<\/p><\/div><div id=\"field_5_90\" 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\"  data-js-reload=\"field_5_90\" ><h3 class=\"gsection_title\">Parent&#039;s \/ Guardian&#039;s Authorization<\/h3><\/div><div id=\"field_5_91\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_91\" ><p>In signing this, I authorize the management of La Ferme d\u2019Andr\u00e9 2.0 to administer the medication mentioned below and any over-the-counter medications as required (e.g. Tylenol, Advil, Benadryl, Reactine) during my child's stay and to provide all necessary first aid.<\/p>\n<p>If management deems it necessary, I authorize them to transport my child by ambulance or any other transportation, at my own expense, to a hospital or community health facility. In addition, if it is impossible to reach us, I authorize the physician to provide my child with all the medical care required by his condition, including the practice of surgery, injections, anesthesia and hospitalization.<\/p><\/div><div id=\"field_5_92\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_92\" ><label class='gfield_label gform-field-label' for='input_5_92'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_92' id='input_5_92_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_5_92_Container' class='gfield_signature_container ginput_container' style='height:180px; width:1600px; ' ><canvas id='input_5_92' width='1600' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/lafermedandre.ca\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_5_92_toolbar' style='margin:5px 0;position:relative;height:20px;width:1600px;max-width:100%;'><img id = 'input_5_92_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_5_92_data' name='input_5_92_data' value=''><\/div><\/div><div id=\"field_5_96\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_5_96\" ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_5_96'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_96' id='input_5_96' type='text' value='24\/05\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='147'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_96_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_96_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_96' class='gform_hidden' value='https:\/\/lafermedandre.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_93\" 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\"  data-js-reload=\"field_5_93\" ><h3 class=\"gsection_title\">Photo Authorization<\/h3><\/div><div id=\"field_5_97\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_97\" ><p>La Ferme d'Andr\u00e9 2.0 regularly uses photos and videos where campers appear during their stay, for promotional purposes and on their Facebook page.<\/p><\/div><fieldset id=\"field_5_98\" 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\"  data-js-reload=\"field_5_98\" ><legend class='gfield_label gform-field-label' >I authorize La Ferme d&#039;Andr\u00e9 2.0 to use these photos and videos<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_5_98'>\n\t\t\t<div class='gchoice gchoice_5_98_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='Yes'  id='choice_5_98_0' onchange='gformToggleRadioOther( this )'  tabindex='148'  \/>\n\t\t\t\t\t<label for='choice_5_98_0' id='label_5_98_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_98_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='No'  id='choice_5_98_1' onchange='gformToggleRadioOther( this )'  tabindex='149'  \/>\n\t\t\t\t\t<label for='choice_5_98_1' id='label_5_98_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_99\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_99\" ><label class='gfield_label gform-field-label' for='input_5_99'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_99' id='input_5_99_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_5_99_Container' class='gfield_signature_container ginput_container' style='height:180px; width:1600px; ' ><canvas id='input_5_99' width='1600' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/lafermedandre.ca\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_5_99_toolbar' style='margin:5px 0;position:relative;height:20px;width:1600px;max-width:100%;'><img id = 'input_5_99_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_5_99_data' name='input_5_99_data' value=''><\/div><\/div><div id=\"field_5_100\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_5_100\" ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_5_100'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_100' id='input_5_100' type='text' value='24\/05\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='150'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_100_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_100_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_100' class='gform_hidden' value='https:\/\/lafermedandre.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_101\" 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\"  data-js-reload=\"field_5_101\" ><h3 class=\"gsection_title\">Bill 25 - Protection of personal information<\/h3><\/div><div id=\"field_5_102\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_102\" ><p>Ensuring your peace of mind is our commitment!<\/p>\n\n<p>The protection of the personal information you entrust to us is a priority. For you, because they are part of your private life. For us, because they allow us to better identify you.<\/p>\n<p>It is in this spirit that we are complying with the new requirements of legislation modernizing privacy legislation.<\/p>\n<p>For the sake of transparency and kindness, we inform you that by doing business with us, you agree that we collect, use and communicate, including to our third parties, the personal information that is necessary to: know who you are; develop and maintain a relationship with you; comply with the law.<\/p><\/div><div id=\"field_5_103\" 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\"  data-js-reload=\"field_5_103\" ><h3 class=\"gsection_title\">Medication to take during the stay<\/h3><\/div><div id=\"field_5_105\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_5_105\" ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_5_105'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_105' id='input_5_105' type='text' value='24\/05\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='151'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_105_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_105_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_105' class='gform_hidden' value='https:\/\/lafermedandre.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_106\" class=\"gfield gfield--type-repeater_start gfield--input-type-repeater_start gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_106\" ><label class='gfield_label gform-field-label' for='input_5_106'>Medication<\/label><div class='ginput_container ginput_container_text'> <div class=\"wpforms-field-repeater-start\">\r\n\t\t\t<input type=\"hidden\" class=\"repeater-field-header-data hidden\" value=\"&lt;div class=&quot;repeater-field-header&quot;&gt;\r\n\t\t\t\t&lt;div class=&quot;repeater-field-header-title&quot;&gt;Medication &lt;span class=&quot;repeater-field-header-count&quot;&gt;1&lt;\/span&gt;&lt;\/div&gt;\r\n\t\t\t\t&lt;div class=&quot;repeater-field-header-acctions&quot;&gt;\r\n\t\t\t\t\t&lt;ul&gt;\r\n\t\t\t\t\t\t&lt;li&gt;&lt;i class=&quot;repeater-icon icon-down-open repeater-field-header-acctions-toogle&quot; aria-hidden=&quot;true&quot;&gt;&lt;\/i&gt;&lt;\/li&gt;\r\n\t\t\t\t\t\t&lt;li&gt;&lt;i class=&quot;repeater-icon icon-cancel-1 repeater-field-header-acctions-remove&quot; aria-hidden=&quot;true&quot;&gt;&lt;\/i&gt;&lt;\/li&gt;\r\n\t\t\t\t\t&lt;\/ul&gt;\r\n\t\t\t\t&lt;\/div&gt;\r\n\t\t\t&lt;\/div&gt;\" \/>\r\n\t\t<\/div> <\/div><\/div><div id=\"field_5_107\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_107\" ><label class='gfield_label gform-field-label' for='input_5_107'>Name of Medication<\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_5_107' type='text' value='' class='large'   tabindex='152' placeholder='Name of Medication'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_108\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_108\" ><label class='gfield_label gform-field-label' for='input_5_108'>Reason<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_108' id='input_5_108' class='textarea small' tabindex='153'   placeholder='Reason'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_112\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full allergie-reaction field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_112\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Frequency<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_112'><div class='gchoice gchoice_5_112_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.1' type='checkbox'  value='Regular'  id='choice_5_112_1' tabindex='154'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_112_1' id='label_5_112_1' class='gform-field-label gform-field-label--type-inline'>Regular<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_112_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.2' type='checkbox'  value='As needed'  id='choice_5_112_2' tabindex='155'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_112_2' id='label_5_112_2' class='gform-field-label gform-field-label--type-inline'>As needed<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_110\" class=\"gfield gfield--type-repeater_end gfield--input-type-repeater_end gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_110\" ><label class='gfield_label gform-field-label' for='input_5_110'><\/label><div class='ginput_container'><div data-initial_rows_map_check=\"\" class=\"repeater-field-warp-item-data\" data-initial_rows=\"1\" data-limit=\"5\" data-initial_rows_map=\"input_5_\" data-map_id=\"field_5_110\">\r\n\t\t\t<div class=\"repeater-field-warp-item\">\r\n\t\t\t<\/div>\r\n\t\t\t<div class=\"repeater-field-footer\"><a href=\"#\"\" class=\"gf-repeater-field-button-add\" >Add more<\/a><\/div>\r\n\t\t\t<input data-initial_rows_map_check='' data-initial_rows_map='input_5_' data-map_id='field_5_110' name='input_110' id='input_5_110' type='hidden' value='' class='large gf-field-repeater-data hidden' tabindex='156'   aria-invalid=\"false\" \/>\r\n\t\t\t<input type=\"hidden\" class=\"gf-field-repeater-data-html hidden\" \/>\r\n\t\t<\/div><\/div><\/div><div id=\"field_5_111\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_111\" ><p>All medications to be taken \"regularly\" must be delivered in the alveolar distribution system (Dispill system) prepared by the pharmacist, which you can obtain free of charge on request, by contacting your pharmacist in advance. This is the safest mode since the child's name and time are written on each dose. Drugs \"as needed\" should be in their original container with the prescription label.<\/p>\n<p>The parents are responsible to inform La Ferme d\u2019Andr\u00e9 2.0 of any new medical information when your child arrives at La Ferme d\u2019Andr\u00e9 2.0, we will validate this information with you.<\/p><\/div><div id=\"field_5_114\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_114\" ><label class='gfield_label gform-field-label' for='input_5_114'>Phone<\/label><div class='ginput_container'><input name='input_114' id='input_5_114' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_5_114'>This field is for validation purposes and should be left unchanged.<\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' value='Send' tabindex='157' \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_5' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_5' id='gform_theme_5' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_5' id='gform_style_settings_5' value='' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_5' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='5' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_5' 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