{"id":10894,"date":"2024-06-28T15:03:21","date_gmt":"2024-06-28T13:03:21","guid":{"rendered":"https:\/\/dev.konsept.ch\/aivd\/?page_id=10894"},"modified":"2024-09-20T11:15:55","modified_gmt":"2024-09-20T09:15:55","slug":"demande-dallocations-speciales-aminh","status":"publish","type":"page","link":"https:\/\/dev.konsept.ch\/aivd\/demande-dallocations-speciales-aminh\/","title":{"rendered":"Demande d&rsquo;allocations sp\u00e9ciales AMINH"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"10894\" class=\"elementor elementor-10894\" data-elementor-settings=\"{&quot;element_pack_global_tooltip_width&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;element_pack_global_tooltip_width_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;element_pack_global_tooltip_width_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;element_pack_global_tooltip_padding&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;element_pack_global_tooltip_padding_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;element_pack_global_tooltip_padding_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;element_pack_global_tooltip_border_radius&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;element_pack_global_tooltip_border_radius_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;element_pack_global_tooltip_border_radius_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true}}\">\n\t\t\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-b3f6b4d elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"b3f6b4d\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-ba19559\" data-id=\"ba19559\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-e2675d1 elementor-widget elementor-widget-spacer\" data-id=\"e2675d1\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.15.0 - 20-08-2023 *\/\n.elementor-column .elementor-spacer-inner{height:var(--spacer-size)}.e-con{--container-widget-width:100%}.e-con-inner>.elementor-widget-spacer,.e-con>.elementor-widget-spacer{width:var(--container-widget-width,var(--spacer-size));--align-self:var(--container-widget-align-self,initial);--flex-shrink:0}.e-con-inner>.elementor-widget-spacer>.elementor-widget-container,.e-con-inner>.elementor-widget-spacer>.elementor-widget-container>.elementor-spacer,.e-con>.elementor-widget-spacer>.elementor-widget-container,.e-con>.elementor-widget-spacer>.elementor-widget-container>.elementor-spacer{height:100%}.e-con-inner>.elementor-widget-spacer>.elementor-widget-container>.elementor-spacer>.elementor-spacer-inner,.e-con>.elementor-widget-spacer>.elementor-widget-container>.elementor-spacer>.elementor-spacer-inner{height:var(--container-widget-height,var(--spacer-size))}<\/style>\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<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-2a902b6 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"2a902b6\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-465d070\" data-id=\"465d070\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-29d198d elementor-widget elementor-widget-shortcode\" data-id=\"29d198d\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-shortcode\"><script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/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_15' style='display:none'><div id='gf_15' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Formulaire de demande d'allocations sp\u00e9ciales (AMINH)<\/h2>\n                            <p class='gform_description'>Allocation sp\u00e9ciale en faveur des familles s'occupant d'un\u00b7e mineur\u00b7e handicap\u00e9\u00b7e \u00e0 domicile<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_15'  action='\/aivd\/wp-json\/wp\/v2\/pages\/10894#gf_15' data-formid='15' novalidate>\n        <div id='gf_progressbar_wrapper_15' class='gf_progressbar_wrapper'>\n        \t<p class=\"gf_progressbar_title\">\u00c9tape <span class='gf_step_current_page'>1<\/span> sur <span class='gf_step_page_count'>8<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_12' style='width:12%;'><span>12%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_15_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><div id='gform_fields_15' class='gform_fields top_label form_sublabel_above description_below'><div id=\"field_15_7\"  class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_7\"><h3 class=\"gsection_title\">1. Identit\u00e9 de l&#039;enfant<\/h3><\/div><div id=\"field_15_34\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_34\"><label class='gfield_label gform-field-label' for='input_15_34' >Num\u00e9ro AVS<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_15_34' type='text' value='' class='large'    placeholder='756.____.____.__' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_1\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_1\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >1.1 Nom et pr\u00e9nom(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_15_1'>\n                            \n                            <span id='input_15_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_15_1_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                    <input type='text' name='input_1.3' id='input_15_1_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            <span id='input_15_1_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_15_1_4' class='gform-field-label gform-field-label--type-sub '>2\u00e8me pr\u00e9nom<\/label>\n                                                    <input type='text' name='input_1.4' id='input_15_1_4' value=''   aria-required='false'    autocomplete=\"additional-name\" \/>\n                                                <\/span>\n                            <span id='input_15_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_15_1_6' class='gform-field-label gform-field-label--type-sub '>Nom de famille<\/label>\n                                                            <input type='text' name='input_1.6' id='input_15_1_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_15_18\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_18\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >1.2 Date de naissance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div id='input_15_18' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_15_18_2_container'>\n                                            <label for='input_15_18_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number'  name='input_18[]' id='input_15_18_2' value=''   aria-required='true'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_15_18_1_container'>\n                                        <label for='input_15_18_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                        <input type='number'  name='input_18[]' id='input_15_18_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_15_18_3_container'>\n                                            <label for='input_15_18_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number'  name='input_18[]' id='input_15_18_3' value=''   aria-required='true'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><div id=\"field_15_19\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_19\"><label class='gfield_label gform-field-label' for='input_15_19' >1.3 Lieu de naissance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_15_19' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_20\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_20\"><legend class='gfield_label gform-field-label'  >1.4 Sexe<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_15_20'>\n\t\t\t<div class='gchoice gchoice_15_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='F'  id='choice_15_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_20_0' id='label_15_20_0' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='M'  id='choice_15_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_20_1' id='label_15_20_1' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_20_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Autre'  id='choice_15_20_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_20_2' id='label_15_20_2' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_21\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_21\"><label class='gfield_label gform-field-label' for='input_15_21' >1.5 Lieu d&#039;origine ou nationalit\u00e9<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_15_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_27\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_27\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >1.6 Date du d\u00e9but du s\u00e9jour dans le canton de Vaud<\/legend><div id='input_15_27' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_15_27_2_container'>\n                                            <label for='input_15_27_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number'  name='input_27[]' id='input_15_27_2' value=''   aria-required='false'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_15_27_1_container'>\n                                        <label for='input_15_27_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                        <input type='number'  name='input_27[]' id='input_15_27_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_15_27_3_container'>\n                                            <label for='input_15_27_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number'  name='input_27[]' id='input_15_27_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><fieldset id=\"field_15_4\"  class=\"gfield gfield--type-address gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_4\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >1.7 Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip ginput_container_address gform-grid-row' id='input_15_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_15_4_1_container' >\n                                        <label for='input_15_4_1' id='input_15_4_1_label' class='gform-field-label gform-field-label--type-sub '>Rue et n\u00b0<\/label>\n                                        <input type='text' name='input_4.1' id='input_15_4_1' value=''    aria-required='true'   autocomplete=\"address-line1\" \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_15_4_3_container' >\n                                    <label for='input_15_4_3' id='input_15_4_3_label' class='gform-field-label gform-field-label--type-sub '>Code postal (NPA)<\/label>\n                                    <input type='text' name='input_4.3' id='input_15_4_3' value=''    aria-required='true'   autocomplete=\"address-level2\" \/>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_4.4' id='input_15_4_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_15_4_5_container' >\n                                    <label for='input_15_4_5' id='input_15_4_5_label' class='gform-field-label gform-field-label--type-sub '>Localit\u00e9<\/label>\n                                    <input type='text' name='input_4.5' id='input_15_4_5' value=''    aria-required='true'   autocomplete=\"postal-code\" \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_15_4_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_15_28\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_28\"><legend class='gfield_label gform-field-label'  >1.8 Existe-t-il une curatelle?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_15_28'>La curatelle est une mesure de protection, volontaire ou impos\u00e9e par l'\u00c9tat, en faveur d'une personne majeure ou mineure qui a besoin d'aide.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_15_28'>\n\t\t\t<div class='gchoice gchoice_15_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Oui'  id='choice_15_28_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_15_28\"   \/>\n\t\t\t\t\t<label for='choice_15_28_0' id='label_15_28_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Non'  id='choice_15_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_28_1' id='label_15_28_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_15_29\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_29\"><legend class='gfield_label gform-field-label'  >1.8 Existe-t-il une tutelle?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_15_29'>Par tutelle, on entend l'assistance l\u00e9gale en faveur d'une personne mineure.\nL'autorit\u00e9 de protection institue une tutelle notamment lorsque l'enfant n'est pas soumis-e \u00e0 l'autorit\u00e9 parentale. La tutrice ou le tuteur peut \u00eatre un-e membre de la famille ou un tiers.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_15_29'>\n\t\t\t<div class='gchoice gchoice_15_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Oui'  id='choice_15_29_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_15_29\"   \/>\n\t\t\t\t\t<label for='choice_15_29_0' id='label_15_29_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Non'  id='choice_15_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_29_1' id='label_15_29_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_30\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_30\"><label class='gfield_label gform-field-label' for='input_15_30' >1.8.1 Nom du tuteur ou curateur<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_15_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_31\"  class=\"gfield gfield--type-address gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_31\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >1.8.1 Adresse<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip ginput_container_address gform-grid-row' id='input_15_31' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_15_31_1_container' >\n                                        <label for='input_15_31_1' id='input_15_31_1_label' class='gform-field-label gform-field-label--type-sub '>Rue et n\u00b0<\/label>\n                                        <input type='text' name='input_31.1' id='input_15_31_1' value=''    aria-required='false'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_15_31_3_container' >\n                                    <label for='input_15_31_3' id='input_15_31_3_label' class='gform-field-label gform-field-label--type-sub '>Code postal (NPA)<\/label>\n                                    <input type='text' name='input_31.3' id='input_15_31_3' value=''    aria-required='false'    \/>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_31.4' id='input_15_31_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_15_31_5_container' >\n                                    <label for='input_15_31_5' id='input_15_31_5_label' class='gform-field-label gform-field-label--type-sub '>Localit\u00e9<\/label>\n                                    <input type='text' name='input_31.5' id='input_15_31_5' value=''    aria-required='false'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_31.6' id='input_15_31_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_15_32\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_32\"><label class='gfield_label gform-field-label' for='input_15_32' >1.8.1 Si\u00e8ge de l&#039;autorit\u00e9 tut\u00e9laire<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_15_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_15_162' class='gform_next_button gform-theme-button button' value='Suivant'  onclick='jQuery(\"#gform_target_page_number_15\").val(\"2\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_15\").val(\"2\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_15_2' class='gform_page' data-js='page-field-id-162' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_15_2' class='gform_fields top_label form_sublabel_above description_below'><div id=\"field_15_10\"  class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_10\"><h3 class=\"gsection_title\">2. Identit\u00e9 des parents<\/h3><\/div><div id=\"field_15_38\"  class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_38\"><h3 class=\"gsection_title\">2.1 Parent ayant droit<\/h3><\/div><div id=\"field_15_151\"  class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_151\"><label class='gfield_label gform-field-label' for='input_15_151' >Civilit\u00e9<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_151' id='input_15_151' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>--Veillez s\u00e9l\u00e9ctionner--<\/option><option value='Mme' >Mme<\/option><option value='M.' >M.<\/option><option value='Autre' >Autre<\/option><\/select><\/div><\/div><div id=\"field_15_181\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_181\"><label class='gfield_label gform-field-label' for='input_15_181' >Num\u00e9ro AVS<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_181' id='input_15_181' type='text' value='' class='large'    placeholder='756.____.____.__' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_35\"  class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_35\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >2.1.1 Nom et pr\u00e9nom(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_15_35'>\n                            \n                            <span id='input_15_35_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_15_35_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom(s)<\/label>\n                                                    <input type='text' name='input_35.3' id='input_15_35_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_15_35_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_15_35_6' class='gform-field-label gform-field-label--type-sub '>Nom de famille<\/label>\n                                                            <input type='text' name='input_35.6' id='input_15_35_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_15_36\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_36\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >2.1.2 Date de naissance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div id='input_15_36' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_15_36_2_container'>\n                                            <label for='input_15_36_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number'  name='input_36[]' id='input_15_36_2' value=''   aria-required='true'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_15_36_1_container'>\n                                        <label for='input_15_36_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                        <input type='number'  name='input_36[]' id='input_15_36_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_15_36_3_container'>\n                                            <label for='input_15_36_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number'  name='input_36[]' id='input_15_36_3' value=''   aria-required='true'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><div id=\"field_15_37\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_37\"><label class='gfield_label gform-field-label' for='input_15_37' >2.1.2 Lieu de naissance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_15_37' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_15_89\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_89\"><label class='gfield_label gform-field-label' for='input_15_89' >2.1.3 Etat civil<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_89' id='input_15_89' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>--Veuillez s\u00e9lectionner--<\/option><option value='Mari\u00e9\u00b7e \/ Partenariat enregistr\u00e9' >Mari\u00e9\u00b7e \/ Partenariat enregistr\u00e9<\/option><option value='En concubinage' >En concubinage<\/option><option value='S\u00e9par\u00e9\u00b7e' >S\u00e9par\u00e9\u00b7e<\/option><option value='Divorc\u00e9\u00b7e \/ Partenariat dissout judiciairement' >Divorc\u00e9\u00b7e \/ Partenariat dissout judiciairement<\/option><option value='Veuf\u00b7ve \/ Partenariat dissout par d\u00e9c\u00e8s' >Veuf\u00b7ve \/ Partenariat dissout par d\u00e9c\u00e8s<\/option><option value='C\u00e9libataire' >C\u00e9libataire<\/option><\/select><\/div><\/div><div id=\"field_15_41\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_41\"><label class='gfield_label gform-field-label' for='input_15_41' >Qui exerce l&#039;autorit\u00e9 parentale?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_15_41'>Pri\u00e8re de joindre l\u2019extrait du jugement actuel \u00e0 la derni\u00e8re \u00e9tape de ce formulaire<\/div><div class='ginput_container ginput_container_text'><input name='input_41' id='input_15_41' type='text' value='' class='large'  aria-describedby=\"gfield_description_15_41\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_15_43\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_43\"><label class='gfield_label gform-field-label' for='input_15_43' >2.1.4 Lieu d&#039;origine ou nationalit\u00e9<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_15_43' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_45\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_45\"><legend class='gfield_label gform-field-label'  >2.1.5 Pour les personnes de nationalit\u00e9 \u00e9trang\u00e8re, type de permis<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_15_45'>\n\t\t\t<div class='gchoice gchoice_15_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='A'  id='choice_15_45_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_45_0' id='label_15_45_0' class='gform-field-label gform-field-label--type-inline'>A<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='B'  id='choice_15_45_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_45_1' id='label_15_45_1' class='gform-field-label gform-field-label--type-inline'>B<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_45_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='C'  id='choice_15_45_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_45_2' id='label_15_45_2' class='gform-field-label gform-field-label--type-inline'>C<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_15_47\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_47\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >2.1.6 Date du d\u00e9but du s\u00e9jour dans le canton de Vaud<\/legend><div id='input_15_47' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_15_47_2_container'>\n                                            <label for='input_15_47_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number'  name='input_47[]' id='input_15_47_2' value=''   aria-required='false'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_15_47_1_container'>\n                                        <label for='input_15_47_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                        <input type='number'  name='input_47[]' id='input_15_47_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_15_47_3_container'>\n                                            <label for='input_15_47_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number'  name='input_47[]' id='input_15_47_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><div id=\"field_15_24\"  class=\"gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_24\"><label class='gfield_label gform-field-label' for='input_15_24' >2.1.7 Num\u00e9ro de t\u00e9l\u00e9phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_15_24'>Format international: +41 ...<\/div><div class='ginput_container ginput_container_phone'><input name='input_24' id='input_15_24' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_15_24\"  \/><\/div><\/div><fieldset id=\"field_15_189\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_189\"><legend class='gfield_label gform-field-label'  >2.1.8 Vivez-vous au m\u00eame domicile que votre enfant?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_15_189'>\n\t\t\t<div class='gchoice gchoice_15_189_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_189' type='radio' value='Oui'  id='choice_15_189_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_189_0' id='label_15_189_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_189_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_189' type='radio' value='Non'  id='choice_15_189_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_189_1' id='label_15_189_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_15_48\"  class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_48\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Adresse actuelle<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip ginput_container_address gform-grid-row' id='input_15_48' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_15_48_1_container' >\n                                        <label for='input_15_48_1' id='input_15_48_1_label' class='gform-field-label gform-field-label--type-sub '>Rue et n\u00b0<\/label>\n                                        <input type='text' name='input_48.1' id='input_15_48_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_15_48_3_container' >\n                                    <label for='input_15_48_3' id='input_15_48_3_label' class='gform-field-label gform-field-label--type-sub '>Code postal (NPA)<\/label>\n                                    <input type='text' name='input_48.3' id='input_15_48_3' value=''    aria-required='true'    \/>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_48.4' id='input_15_48_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_15_48_5_container' >\n                                    <label for='input_15_48_5' id='input_15_48_5_label' class='gform-field-label gform-field-label--type-sub '>Localit\u00e9<\/label>\n                                    <input type='text' name='input_48.5' id='input_15_48_5' value=''    aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_48.6' id='input_15_48_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_15_2\"  class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_2\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >2.1.9 Adresse e-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_15_2_container'>\n                                <span id='input_15_2_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_15_2' class='gform-field-label gform-field-label--type-sub '>Adresse E-mail<\/label>\n                                    <input class='' type='email' name='input_2' id='input_15_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <span id='input_15_2_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_15_2_2' class='gform-field-label gform-field-label--type-sub '>Confirmer l'adresse e-mail<\/label>\n                                    <input class='' type='email' name='input_2_2' id='input_15_2_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_15_8\"  class=\"gfield gfield--type-section gsection field_sublabel_above gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_8\"><h3 class=\"gsection_title\">2.2 Parent 2<\/h3><div class='gsection_description' id='gfield_description_15_8'>Ou 2\u00e8me parent vivant en m\u00e9nage commun avec l\u2019enfant<\/div><\/div><div id=\"field_15_152\"  class=\"gfield gfield--type-select gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_152\"><label class='gfield_label gform-field-label' for='input_15_152' >Civilit\u00e9<\/label><div class='ginput_container ginput_container_select'><select name='input_152' id='input_15_152' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>--S\u00e9l\u00e9ctionnez--<\/option><option value='Mme' >Mme<\/option><option value='M.' >M.<\/option><option value='Autre' >Autre<\/option><\/select><\/div><\/div><div id=\"field_15_182\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_182\"><label class='gfield_label gform-field-label' for='input_15_182' >Num\u00e9ro AVS<\/label><div class='ginput_container ginput_container_text'><input name='input_182' id='input_15_182' type='text' value='' class='large'    placeholder='756.____.____.__'  aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_49\"  class=\"gfield gfield--type-name gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_49\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >2.2.1 Nom et pr\u00e9nom(s)<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_15_49'>\n                            \n                            <span id='input_15_49_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_15_49_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom(s)<\/label>\n                                                    <input type='text' name='input_49.3' id='input_15_49_3' value=''   aria-required='false'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            \n                            <span id='input_15_49_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_15_49_6' class='gform-field-label gform-field-label--type-sub '>Nom de famille<\/label>\n                                                            <input type='text' name='input_49.6' id='input_15_49_6' value=''   aria-required='false'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_15_50\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_50\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >2.2.2 Date de naissance<\/legend><div id='input_15_50' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_15_50_2_container'>\n                                            <label for='input_15_50_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number'  name='input_50[]' id='input_15_50_2' value=''   aria-required='false'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_15_50_1_container'>\n                                        <label for='input_15_50_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                        <input type='number'  name='input_50[]' id='input_15_50_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_15_50_3_container'>\n                                            <label for='input_15_50_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number'  name='input_50[]' id='input_15_50_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><div id=\"field_15_51\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_51\"><label class='gfield_label gform-field-label' for='input_15_51' >2.2.2 Lieu de naissance<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_15_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_15_88\"  class=\"gfield gfield--type-select gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_88\"><label class='gfield_label gform-field-label' for='input_15_88' >2.2.3 Etat civil<\/label><div class='ginput_container ginput_container_select'><select name='input_88' id='input_15_88' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>--Veuillez s\u00e9lectionner--<\/option><option value='Mari\u00e9\u00b7e \/ Partenariat enregistr\u00e9' >Mari\u00e9\u00b7e \/ Partenariat enregistr\u00e9<\/option><option value='En concubinage' >En concubinage<\/option><option value='S\u00e9par\u00e9\u00b7e' >S\u00e9par\u00e9\u00b7e<\/option><option value='Divorc\u00e9\u00b7e \/ Partenariat dissout judiciairement' >Divorc\u00e9\u00b7e \/ Partenariat dissout judiciairement<\/option><option value='Veuf\u00b7ve \/ Partenariat dissout par d\u00e9c\u00e8s' >Veuf\u00b7ve \/ Partenariat dissout par d\u00e9c\u00e8s<\/option><option value='C\u00e9libataire' >C\u00e9libataire<\/option><\/select><\/div><\/div><div id=\"field_15_53\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_53\"><label class='gfield_label gform-field-label' for='input_15_53' >Qui exerce l&#039;autorit\u00e9 parentale?<\/label><div class='gfield_description' id='gfield_description_15_53'>Pri\u00e8re de joindre l\u2019extrait du jugement actuel \u00e0 la derni\u00e8re \u00e9tape de ce formulaire<\/div><div class='ginput_container ginput_container_text'><input name='input_53' id='input_15_53' type='text' value='' class='large'  aria-describedby=\"gfield_description_15_53\"    aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_15_55\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_55\"><label class='gfield_label gform-field-label' for='input_15_55' >2.2.4 Lieu d&#039;origine ou nationalit\u00e9<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_15_55' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_56\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_56\"><legend class='gfield_label gform-field-label'  >2.2.4  Pour les personnes de nationalit\u00e9 \u00e9trang\u00e8re, type de permis<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_15_56'>\n\t\t\t<div class='gchoice gchoice_15_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='A'  id='choice_15_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_56_0' id='label_15_56_0' class='gform-field-label gform-field-label--type-inline'>A<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='B'  id='choice_15_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_56_1' id='label_15_56_1' class='gform-field-label gform-field-label--type-inline'>B<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_56_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='C'  id='choice_15_56_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_56_2' id='label_15_56_2' class='gform-field-label gform-field-label--type-inline'>C<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_15_57\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_57\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >2.1.5 Date du d\u00e9but du s\u00e9jour dans le canton de Vaud<\/legend><div id='input_15_57' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_15_57_2_container'>\n                                            <label for='input_15_57_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number'  name='input_57[]' id='input_15_57_2' value=''   aria-required='false'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_15_57_1_container'>\n                                        <label for='input_15_57_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                        <input type='number'  name='input_57[]' id='input_15_57_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_15_57_3_container'>\n                                            <label for='input_15_57_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number'  name='input_57[]' id='input_15_57_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><fieldset id=\"field_15_190\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_190\"><legend class='gfield_label gform-field-label'  >2.1.6 Vivez-vous au m\u00eame domicile que votre enfant?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_15_190'>\n\t\t\t<div class='gchoice gchoice_15_190_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_190' type='radio' value='Oui'  id='choice_15_190_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_190_0' id='label_15_190_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_190_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_190' type='radio' value='Non'  id='choice_15_190_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_190_1' id='label_15_190_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_15_58\"  class=\"gfield gfield--type-address gfield--width-full field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_58\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Adresse actuelle<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip ginput_container_address gform-grid-row' id='input_15_58' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_15_58_1_container' >\n                                        <label for='input_15_58_1' id='input_15_58_1_label' class='gform-field-label gform-field-label--type-sub '>Rue et n\u00b0<\/label>\n                                        <input type='text' name='input_58.1' id='input_15_58_1' value=''    aria-required='false'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_15_58_3_container' >\n                                    <label for='input_15_58_3' id='input_15_58_3_label' class='gform-field-label gform-field-label--type-sub '>Code postal (NPA)<\/label>\n                                    <input type='text' name='input_58.3' id='input_15_58_3' value=''    aria-required='false'    \/>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_58.4' id='input_15_58_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_15_58_5_container' >\n                                    <label for='input_15_58_5' id='input_15_58_5_label' class='gform-field-label gform-field-label--type-sub '>Localit\u00e9<\/label>\n                                    <input type='text' name='input_58.5' id='input_15_58_5' value=''    aria-required='false'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_58.6' id='input_15_58_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_15_59\"  class=\"gfield gfield--type-email gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_59\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >2.2.7 Adresse e-mail<\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_15_59_container'>\n                                <span id='input_15_59_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_15_59' class='gform-field-label gform-field-label--type-sub '>Adresse E-mail<\/label>\n                                    <input class='' type='email' name='input_59' id='input_15_59' value=''     aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <span id='input_15_59_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_15_59_2' class='gform-field-label gform-field-label--type-sub '>Confirmer l'adresse e-mail<\/label>\n                                    <input class='' type='email' name='input_59_2' id='input_15_59_2' value=''     aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_15_163' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Pr\u00e9c\u00e9dent'  onclick='jQuery(\"#gform_target_page_number_15\").val(\"1\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_15\").val(\"1\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_15_163' class='gform_next_button gform-theme-button button' value='Suivant'  onclick='jQuery(\"#gform_target_page_number_15\").val(\"3\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_15\").val(\"3\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_15_3' class='gform_page' data-js='page-field-id-163' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_15_3' class='gform_fields top_label form_sublabel_above description_below'><div id=\"field_15_60\"  class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_60\"><h3 class=\"gsection_title\">3. Identit\u00e9 des fr\u00e8res et soeurs<\/h3><\/div><div id=\"field_15_67\"  class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_67\"><label class='gfield_label gform-field-label' for='input_15_67' >3.1 Nombre d&#039;enfant vivant au m\u00eame domicile:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_67' id='input_15_67' type='number' step='any' min='0' max='6' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_15_67\" \/><div class='gfield_description instruction ' id='gfield_instruction_15_67'>Veuillez saisir un nombre entre <strong>0<\/strong> et <strong>6<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_15_62\"  class=\"gfield gfield--type-name gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_62\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Enfant 1<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_15_62'>\n                            \n                            <span id='input_15_62_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_15_62_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9noms<\/label>\n                                                    <input type='text' name='input_62.3' id='input_15_62_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_15_62_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_15_62_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                            <input type='text' name='input_62.6' id='input_15_62_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_15_63\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_63\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Enfant 1 - Date de naissance<\/legend><div id='input_15_63' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_15_63_2_container'>\n                                            <label for='input_15_63_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number'  name='input_63[]' id='input_15_63_2' value=''   aria-required='false'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_15_63_1_container'>\n                                        <label for='input_15_63_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                        <input type='number'  name='input_63[]' id='input_15_63_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_15_63_3_container'>\n                                            <label for='input_15_63_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number'  name='input_63[]' id='input_15_63_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><div id=\"field_15_199\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_199\"><label class='gfield_label gform-field-label' for='input_15_199' >Enfant 1 - Num\u00e9ro AVS<\/label><div class='ginput_container ginput_container_text'><input name='input_199' id='input_15_199' type='text' value='' class='large'    placeholder='756.____.____.__'  aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_195\"  class=\"gfield gfield--type-name gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_195\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Enfant 2<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_15_195'>\n                            \n                            <span id='input_15_195_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_15_195_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9noms<\/label>\n                                                    <input type='text' name='input_195.3' id='input_15_195_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_15_195_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_15_195_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                            <input type='text' name='input_195.6' id='input_15_195_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_15_69\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_69\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Enfant 2 - Date de naissance<\/legend><div id='input_15_69' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_15_69_2_container'>\n                                            <label for='input_15_69_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number'  name='input_69[]' id='input_15_69_2' value=''   aria-required='false'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_15_69_1_container'>\n                                        <label for='input_15_69_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                        <input type='number'  name='input_69[]' id='input_15_69_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_15_69_3_container'>\n                                            <label for='input_15_69_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number'  name='input_69[]' id='input_15_69_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><div id=\"field_15_200\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_200\"><label class='gfield_label gform-field-label' for='input_15_200' >Enfant 2 - Num\u00e9ro AVS<\/label><div class='ginput_container ginput_container_text'><input name='input_200' id='input_15_200' type='text' value='' class='large'    placeholder='756.____.____.__'  aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_70\"  class=\"gfield gfield--type-name gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_70\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Enfant 3<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_15_70'>\n                            \n                            <span id='input_15_70_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_15_70_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9noms<\/label>\n                                                    <input type='text' name='input_70.3' id='input_15_70_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_15_70_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_15_70_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                            <input type='text' name='input_70.6' id='input_15_70_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_15_71\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_71\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Enfant 3 - Date de naissance<\/legend><div id='input_15_71' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_15_71_2_container'>\n                                            <label for='input_15_71_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number'  name='input_71[]' id='input_15_71_2' value=''   aria-required='false'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_15_71_1_container'>\n                                        <label for='input_15_71_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                        <input type='number'  name='input_71[]' id='input_15_71_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_15_71_3_container'>\n                                            <label for='input_15_71_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number'  name='input_71[]' id='input_15_71_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><div id=\"field_15_201\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_201\"><label class='gfield_label gform-field-label' for='input_15_201' >Enfant 3 - Num\u00e9ro AVS<\/label><div class='ginput_container ginput_container_text'><input name='input_201' id='input_15_201' type='text' value='' class='large'    placeholder='756.____.____.__'  aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_172\"  class=\"gfield gfield--type-name gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_172\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Enfant 4<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_15_172'>\n                            \n                            <span id='input_15_172_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_15_172_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9noms<\/label>\n                                                    <input type='text' name='input_172.3' id='input_15_172_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_15_172_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_15_172_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                            <input type='text' name='input_172.6' id='input_15_172_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_15_178\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_178\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Enfant 4 - Date de naissance<\/legend><div id='input_15_178' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_15_178_2_container'>\n                                            <label for='input_15_178_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number'  name='input_178[]' id='input_15_178_2' value=''   aria-required='false'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_15_178_1_container'>\n                                        <label for='input_15_178_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                        <input type='number'  name='input_178[]' id='input_15_178_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_15_178_3_container'>\n                                            <label for='input_15_178_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number'  name='input_178[]' id='input_15_178_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><div id=\"field_15_202\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_202\"><label class='gfield_label gform-field-label' for='input_15_202' >Enfant 4 - Num\u00e9ro AVS<\/label><div class='ginput_container ginput_container_text'><input name='input_202' id='input_15_202' type='text' value='' class='large'    placeholder='756.____.____.__'  aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_177\"  class=\"gfield gfield--type-name gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_177\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Enfant 5<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_15_177'>\n                            \n                            <span id='input_15_177_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_15_177_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9noms<\/label>\n                                                    <input type='text' name='input_177.3' id='input_15_177_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_15_177_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_15_177_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                            <input type='text' name='input_177.6' id='input_15_177_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_15_173\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_173\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Enfant 5 - Date de naissance<\/legend><div id='input_15_173' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_15_173_2_container'>\n                                            <label for='input_15_173_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number'  name='input_173[]' id='input_15_173_2' value=''   aria-required='false'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_15_173_1_container'>\n                                        <label for='input_15_173_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                        <input type='number'  name='input_173[]' id='input_15_173_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_15_173_3_container'>\n                                            <label for='input_15_173_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number'  name='input_173[]' id='input_15_173_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><div id=\"field_15_203\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_203\"><label class='gfield_label gform-field-label' for='input_15_203' >Enfant 5 - Num\u00e9ro AVS<\/label><div class='ginput_container ginput_container_text'><input name='input_203' id='input_15_203' type='text' value='' class='large'    placeholder='756.____.____.__'  aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_175\"  class=\"gfield gfield--type-name gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_175\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Enfant 6<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_15_175'>\n                            \n                            <span id='input_15_175_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_15_175_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9noms<\/label>\n                                                    <input type='text' name='input_175.3' id='input_15_175_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_15_175_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_15_175_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                            <input type='text' name='input_175.6' id='input_15_175_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_15_174\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_174\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Enfant 6 - Date de naissance<\/legend><div id='input_15_174' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_15_174_2_container'>\n                                            <label for='input_15_174_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number'  name='input_174[]' id='input_15_174_2' value=''   aria-required='false'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_15_174_1_container'>\n                                        <label for='input_15_174_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                        <input type='number'  name='input_174[]' id='input_15_174_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_15_174_3_container'>\n                                            <label for='input_15_174_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number'  name='input_174[]' id='input_15_174_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><div id=\"field_15_204\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_204\"><label class='gfield_label gform-field-label' for='input_15_204' >Enfant 6 - Num\u00e9ro AVS<\/label><div class='ginput_container ginput_container_text'><input name='input_204' id='input_15_204' type='text' value='' class='large'    placeholder='756.____.____.__'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_15_74\"  class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_74\"><label class='gfield_label gform-field-label' for='input_15_74' >3.2 Nombre d&#039;enfant vivant \u00e0 un autre domicile:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_74' id='input_15_74' type='number' step='any' min='0' max='4' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_15_74\" \/><div class='gfield_description instruction ' id='gfield_instruction_15_74'>Veuillez saisir un nombre entre <strong>0<\/strong> et <strong>4<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_15_75\"  class=\"gfield gfield--type-name gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_75\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Enfant 1<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_15_75'>\n                            \n                            <span id='input_15_75_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_15_75_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9noms<\/label>\n                                                    <input type='text' name='input_75.3' id='input_15_75_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_15_75_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_15_75_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                            <input type='text' name='input_75.6' id='input_15_75_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_15_76\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_76\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Enfant 1 - Date de naissance<\/legend><div id='input_15_76' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_15_76_2_container'>\n                                            <label for='input_15_76_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number'  name='input_76[]' id='input_15_76_2' value=''   aria-required='false'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_15_76_1_container'>\n                                        <label for='input_15_76_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                        <input type='number'  name='input_76[]' id='input_15_76_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_15_76_3_container'>\n                                            <label for='input_15_76_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number'  name='input_76[]' id='input_15_76_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><div id=\"field_15_205\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_205\"><label class='gfield_label gform-field-label' for='input_15_205' >Enfant 1 - Num\u00e9ro AVS<\/label><div class='ginput_container ginput_container_text'><input name='input_205' id='input_15_205' type='text' value='' class='large'    placeholder='756.____.____.__'  aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_79\"  class=\"gfield gfield--type-name gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_79\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Enfant 2<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_15_79'>\n                            \n                            <span id='input_15_79_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_15_79_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9noms<\/label>\n                                                    <input type='text' name='input_79.3' id='input_15_79_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_15_79_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_15_79_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                            <input type='text' name='input_79.6' id='input_15_79_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_15_80\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_80\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Enfant 2 - Date de naissance<\/legend><div id='input_15_80' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_15_80_2_container'>\n                                            <label for='input_15_80_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number'  name='input_80[]' id='input_15_80_2' value=''   aria-required='false'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_15_80_1_container'>\n                                        <label for='input_15_80_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                        <input type='number'  name='input_80[]' id='input_15_80_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_15_80_3_container'>\n                                            <label for='input_15_80_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number'  name='input_80[]' id='input_15_80_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><div id=\"field_15_206\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_206\"><label class='gfield_label gform-field-label' for='input_15_206' >Enfant 2 - Num\u00e9ro AVS<\/label><div class='ginput_container ginput_container_text'><input name='input_206' id='input_15_206' type='text' value='' class='large'    placeholder='756.____.____.__'  aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_81\"  class=\"gfield gfield--type-name gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_81\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Enfant 3<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_15_81'>\n                            \n                            <span id='input_15_81_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_15_81_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9noms<\/label>\n                                                    <input type='text' name='input_81.3' id='input_15_81_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_15_81_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_15_81_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                            <input type='text' name='input_81.6' id='input_15_81_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_15_82\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_82\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Enfant 3 - Date de naissance<\/legend><div id='input_15_82' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_15_82_2_container'>\n                                            <label for='input_15_82_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number'  name='input_82[]' id='input_15_82_2' value=''   aria-required='false'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_15_82_1_container'>\n                                        <label for='input_15_82_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                        <input type='number'  name='input_82[]' id='input_15_82_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_15_82_3_container'>\n                                            <label for='input_15_82_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number'  name='input_82[]' id='input_15_82_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><div id=\"field_15_207\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_207\"><label class='gfield_label gform-field-label' for='input_15_207' >Enfant 3 - Num\u00e9ro AVS<\/label><div class='ginput_container ginput_container_text'><input name='input_207' id='input_15_207' type='text' value='' class='large'    placeholder='756.____.____.__'  aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_179\"  class=\"gfield gfield--type-name gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_179\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Enfant 4<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_15_179'>\n                            \n                            <span id='input_15_179_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_15_179_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9noms<\/label>\n                                                    <input type='text' name='input_179.3' id='input_15_179_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_15_179_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_15_179_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                            <input type='text' name='input_179.6' id='input_15_179_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_15_180\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_180\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Enfant 4 - Date de naissance<\/legend><div id='input_15_180' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_15_180_2_container'>\n                                            <label for='input_15_180_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number'  name='input_180[]' id='input_15_180_2' value=''   aria-required='false'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_15_180_1_container'>\n                                        <label for='input_15_180_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                        <input type='number'  name='input_180[]' id='input_15_180_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_15_180_3_container'>\n                                            <label for='input_15_180_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number'  name='input_180[]' id='input_15_180_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><div id=\"field_15_208\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_208\"><label class='gfield_label gform-field-label' for='input_15_208' >Enfant 4 - Num\u00e9ro AVS<\/label><div class='ginput_container ginput_container_text'><input name='input_208' id='input_15_208' type='text' value='' class='large'    placeholder='756.____.____.__'  aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_85\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_85\"><legend class='gfield_label gform-field-label'  >3.3 Votre concubin a-t-il des enfants qui ne vous sont pas communs, qui ont entre 18 et 25 ans, et sont \u00e9conomiquement d\u00e9pendants de lui (jeune en formation)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_15_85'>\n\t\t\t<div class='gchoice gchoice_15_85_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='Oui'  id='choice_15_85_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_85_0' id='label_15_85_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_85_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='Non'  id='choice_15_85_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_85_1' id='label_15_85_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_3\"  class=\"gfield gfield--type-textarea field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_3\"><label class='gfield_label gform-field-label' for='input_15_3' >Merci d&#039;indiquer le nom, le(s) pr\u00e9nom(s) et la date de naissance de chaque enfant<\/label><div class='ginput_container ginput_container_textarea'><div id=\"wp-input_15_3-wrap\" class=\"wp-core-ui wp-editor-wrap tmce-active\"><link rel='stylesheet' id='dashicons-css' href='https:\/\/dev.konsept.ch\/aivd\/wp-includes\/css\/dashicons.min.css?ver=7.0' media='all' \/>\n<link rel='stylesheet' id='editor-buttons-css' href='https:\/\/dev.konsept.ch\/aivd\/wp-includes\/css\/editor.min.css?ver=7.0' media='all' \/>\n<div id=\"wp-input_15_3-editor-container\" class=\"wp-editor-container\"><textarea class=\"medium wp-editor-area\" style=\"height: 180px\" autocomplete=\"off\" cols=\"40\" name=\"input_3\" id=\"input_15_3\"><\/textarea><\/div>\n<\/div>\n\n<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_15_164' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Pr\u00e9c\u00e9dent'  onclick='jQuery(\"#gform_target_page_number_15\").val(\"2\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_15\").val(\"2\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_15_164' class='gform_next_button gform-theme-button button' value='Suivant'  onclick='jQuery(\"#gform_target_page_number_15\").val(\"4\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_15\").val(\"4\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_15_4' class='gform_page' data-js='page-field-id-164' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_15_4' class='gform_fields top_label form_sublabel_above description_below'><div id=\"field_15_90\"  class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_90\"><h3 class=\"gsection_title\">4. Scolarit\u00e9 de l&#039;enfant<\/h3><\/div><fieldset id=\"field_15_98\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_98\"><legend class='gfield_label gform-field-label'  >4.1 Votre enfant est-il scolaris\u00e9?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_15_98'>\n\t\t\t<div class='gchoice gchoice_15_98_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='Oui'  id='choice_15_98_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_98_0' id='label_15_98_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_98_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='Non'  id='choice_15_98_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_98_1' id='label_15_98_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_94\"  class=\"gfield gfield--type-textarea gfield--width-half gfield_contains_required field_sublabel_above gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_94\"><label class='gfield_label gform-field-label' for='input_15_94' >Coordonn\u00e9es de l&#039;\u00e9cole suivie actuellement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_94' id='input_15_94' class='textarea medium'  aria-describedby=\"gfield_description_15_94\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_15_94'>Pri\u00e8re de nous jointe la d\u00e9cision DGEO en cas de scolarit\u00e9 sp\u00e9cialis\u00e9e \u00e0 la derni\u00e8re \u00e9tape de ce formulaire<\/div><\/div><fieldset id=\"field_15_95\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_95\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Depuis quand?<\/legend><div id='input_15_95' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_15_95_2_container'>\n                                            <label for='input_15_95_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number'  name='input_95[]' id='input_15_95_2' value=''   aria-required='false'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_15_95_1_container'>\n                                        <label for='input_15_95_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                        <input type='number'  name='input_95[]' id='input_15_95_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_15_95_3_container'>\n                                            <label for='input_15_95_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number'  name='input_95[]' id='input_15_95_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><div id=\"field_15_96\"  class=\"gfield gfield--type-number gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_96\"><label class='gfield_label gform-field-label' for='input_15_96' >Nombre de jours par semaine<\/label><div class='ginput_container ginput_container_number'><input name='input_96' id='input_15_96' type='number' step='any' min='0' max='7' value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_15_96\" \/><div class='gfield_description instruction ' id='gfield_instruction_15_96'>Veuillez saisir un nombre entre <strong>0<\/strong> et <strong>7<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_15_97\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_above gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_97\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Merci de pr\u00e9ciser<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_15_97'><div class='gchoice gchoice_15_97_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_97.1' type='checkbox'  value='En internat'  id='choice_15_97_1'   aria-describedby=\"gfield_description_15_97\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_15_97_1' id='label_15_97_1' class='gform-field-label gform-field-label--type-inline'>En internat<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_97_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_97.2' type='checkbox'  value='En externat'  id='choice_15_97_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_97_2' id='label_15_97_2' class='gform-field-label gform-field-label--type-inline'>En externat<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_15_97'>Pri\u00e8re de nous joindre la d\u00e9cision DGEO \u00e0 la derni\u00e8re \u00e9tape de ce formulaire<\/div><\/fieldset><fieldset id=\"field_15_213\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_above gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_213\"><legend class='gfield_label gform-field-label'  >4.2 Votre enfant passe-t-il des nuits en UAT (Unit\u00e9 d\u2019accueil temporaire) ?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_15_213'>\n\t\t\t<div class='gchoice gchoice_15_213_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_213' type='radio' value='Oui'  id='choice_15_213_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_15_213\"   \/>\n\t\t\t\t\t<label for='choice_15_213_0' id='label_15_213_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_213_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_213' type='radio' value='Non'  id='choice_15_213_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_213_1' id='label_15_213_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_15_213'>Pri\u00e8re de nous joindre la d\u00e9cision UAT \u00e0 la derni\u00e8re \u00e9tape de ce formulaire<\/div><\/fieldset><div id=\"field_15_99\"  class=\"gfield gfield--type-number gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_99\"><label class='gfield_label gform-field-label' for='input_15_99' >4.3 Nombre de nuits par semaine pass\u00e9es \u00e0 domicile<\/label><div class='ginput_container ginput_container_number'><input name='input_99' id='input_15_99' type='number' step='any' min='0' max='7' value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_15_99\" \/><div class='gfield_description instruction ' id='gfield_instruction_15_99'>Veuillez saisir un nombre entre <strong>0<\/strong> et <strong>7<\/strong>.<\/div><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_15_165' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Pr\u00e9c\u00e9dent'  onclick='jQuery(\"#gform_target_page_number_15\").val(\"3\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_15\").val(\"3\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_15_165' class='gform_next_button gform-theme-button button' value='Suivant'  onclick='jQuery(\"#gform_target_page_number_15\").val(\"5\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_15\").val(\"5\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_15_5' class='gform_page' data-js='page-field-id-165' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_15_5' class='gform_fields top_label form_sublabel_above description_below'><div id=\"field_15_110\"  class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_110\"><h3 class=\"gsection_title\">5. Institutions accordant des services ou des prestations en esp\u00e8ces<\/h3><\/div><fieldset id=\"field_15_112\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_112\"><legend class='gfield_label gform-field-label'  >5.1 L\u2019enfant est-il connu de l&#039;allocation pour impotent ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_15_112'>\n\t\t\t<div class='gchoice gchoice_15_112_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='Oui'  id='choice_15_112_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_112_0' id='label_15_112_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_112_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='Non'  id='choice_15_112_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_112_1' id='label_15_112_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_15_113\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_113\"><legend class='gfield_label gform-field-label'  >5.2 Pro Infirmis intervient-il ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_15_113'>\n\t\t\t<div class='gchoice gchoice_15_113_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_113' type='radio' value='Oui'  id='choice_15_113_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_113_0' id='label_15_113_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_113_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_113' type='radio' value='Non'  id='choice_15_113_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_113_1' id='label_15_113_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_170\"  class=\"gfield gfield--type-textarea gfield--width-half field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_170\"><label class='gfield_label gform-field-label' for='input_15_170' >Si vous estimez que votre enfant est impotent, il est indispensable de d\u00e9poser, en son nom, une demande directement aupr\u00e8s de l\u2019AI \u00e0 l\u2019Avenue du G\u00e9n\u00e9ral-Guisan 8 \u00e0 1800 Vevey et de nous en informer par \u00e9crit.<\/label><div class='gfield_description' id='gfield_description_15_170'>Vous pouvez d\u00e9poser votre demande en remplissant le formulaire <a href=\"https:\/\/www.ahv-iv.ch\/p\/001.005.f\" target=\"_blank\">&laquo;001.005 Demande de prestations AI pour mineurs: Allocation pour impotent AI&raquo;<\/a><\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_170' id='input_15_170' class='textarea large'  aria-describedby=\"gfield_description_15_170\"  placeholder='Vos remarques'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_15_171\"  class=\"gfield gfield--type-textarea gfield--width-half field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_171\"><label class='gfield_label gform-field-label' for='input_15_171' >Pr\u00e9ciser le nom et le num\u00e9ro de t\u00e9l\u00e9phone de l\u2019assistant social<\/label><div class='gfield_description' id='gfield_description_15_171'>Pri\u00e8re de joindre la procuration \u00e0 la derni\u00e8re \u00e9tape de ce formulaire<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_171' id='input_15_171' class='textarea large'  aria-describedby=\"gfield_description_15_171\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_15_115\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_115\"><label class='gfield_label gform-field-label' for='input_15_115' >5.3 Autres institutions<\/label><div class='gfield_description' id='gfield_description_15_115'>Nom et adresse<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_115' id='input_15_115' class='textarea large'  aria-describedby=\"gfield_description_15_115\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_15_166' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Pr\u00e9c\u00e9dent'  onclick='jQuery(\"#gform_target_page_number_15\").val(\"4\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_15\").val(\"4\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_15_166' class='gform_next_button gform-theme-button button' value='Suivant'  onclick='jQuery(\"#gform_target_page_number_15\").val(\"6\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_15\").val(\"6\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_15_6' class='gform_page' data-js='page-field-id-166' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_15_6' class='gform_fields top_label form_sublabel_above description_below'><div id=\"field_15_116\"  class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_116\"><h3 class=\"gsection_title\">6. Activit\u00e9 des parents<\/h3><\/div><div id=\"field_15_118\"  class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_118\"><h3 class=\"gsection_title\">6.1 Activit\u00e9 du parent ayant droit<\/h3><\/div><fieldset id=\"field_15_185\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_185\"><legend class='gfield_label gform-field-label'  >6.1.1 Votre \u00e9tat de sant\u00e9 vous emp\u00eache-t-il de vous occuper de votre enfant malade?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_15_185'>\n\t\t\t<div class='gchoice gchoice_15_185_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_185' type='radio' value='Oui'  id='choice_15_185_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_185_0' id='label_15_185_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_185_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_185' type='radio' value='Non'  id='choice_15_185_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_185_1' id='label_15_185_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_186\"  class=\"gfield gfield--type-signature gfield--width-half field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_186\"><label class='gfield_label gform-field-label' for='input_15_186' >Pri\u00e8re de joindre une attestation m\u00e9dicale pr\u00e9cisant cette incapacit\u00e9 \u00e0 la fin du formulaire et de signer l&#039;autorisation suivante:<\/label><div class='gfield_description' id='gfield_description_15_186'>En signant l'assur\u00e9(e) ou son\/sa repr\u00e9sentant(e) l\u00e9gal(e) autorise le service des allocations sp\u00e9ciales AMINH \u00e0 prendre les renseignements n\u00e9cessaires \u00e0 la d\u00e9termination du bien-fond\u00e9 de la demande et de l'octroi des prestations aupr\u00e8s de l'assurance-maladie, de l'assurance perte de gain maladie, de l'assurance accident, de l'assurance-invalidit\u00e9 ainsi qu'\u00e0 des m\u00e9decins traitants. <\/div><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_15_186_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_15_186_valid' id='input_15_186_valid' \/><canvas id='input_15_186' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_15_117\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_117\"><label class='gfield_label gform-field-label' for='input_15_117' >6.1.2 Profession<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_117' id='input_15_117' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_15_119\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_119\"><label class='gfield_label gform-field-label' for='input_15_119' >6.1.3 Employeur<\/label><div class='ginput_container ginput_container_text'><input name='input_119' id='input_15_119' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_120\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_120\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Depuis quand?<\/legend><div id='input_15_120' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_15_120_2_container'>\n                                            <label for='input_15_120_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number'  name='input_120[]' id='input_15_120_2' value=''   aria-required='false'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_15_120_1_container'>\n                                        <label for='input_15_120_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                        <input type='number'  name='input_120[]' id='input_15_120_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_15_120_3_container'>\n                                            <label for='input_15_120_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number'  name='input_120[]' id='input_15_120_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><div id=\"field_15_121\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_121\"><label class='gfield_label gform-field-label' for='input_15_121' >6.1.4 Horaire de travail ou taux de travail lors de l&#039;engagement<\/label><div class='ginput_container ginput_container_text'><input name='input_121' id='input_15_121' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_122\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_122\"><legend class='gfield_label gform-field-label'  >6.1.5 Avez-vous modifi\u00e9 cet horaire pour vous occuper de votre enfant?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_15_122'>\n\t\t\t<div class='gchoice gchoice_15_122_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='Oui'  id='choice_15_122_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_122_0' id='label_15_122_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_122_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='Non'  id='choice_15_122_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_122_1' id='label_15_122_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_123\"  class=\"gfield gfield--type-textarea gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_123\"><label class='gfield_label gform-field-label' for='input_15_123' >But et motif de cette r\u00e9duction ou interruption de l\u2019activit\u00e9 lucrative et depuis quand ?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_123' id='input_15_123' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_15_124\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_124\"><label class='gfield_label gform-field-label' for='input_15_124' >6.1.6 Si vous n&#039;exercez pas ou plus d&#039;activit\u00e9 lucrative...<\/label><div class='gfield_description' id='gfield_description_15_124'>Merci de mentionner les activit\u00e9s exerc\u00e9es auparavant (y compris avant votre arriv\u00e9e en suisse) en pr\u00e9cisant la date de d\u00e9but et de fin de l\u2019activit\u00e9 ainsi que le taux.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_124' id='input_15_124' class='textarea large'  aria-describedby=\"gfield_description_15_124\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_15_193\"  class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_193\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >6.1.7 Informations concernant le revenu d\u00e9t\u00e9rminant unifi\u00e9<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_193.1' id='input_15_193_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_15_193_1' >Le parent ayant droit confirme avoir pris connaissance des informations concernant <a href=\"https:\/\/www.vd.ch\/aides-financieres-et-soutien-social\/aides-financieres-et-comment-les-demander\/rdu\" target=\"_blank\"> le revenu d\u00e9terminant unifi\u00e9 (RDU)<\/a>.<\/label><input type='hidden' name='input_193.2' value='Le parent ayant droit confirme avoir pris connaissance des informations concernant &lt;a href=&quot;https:\/\/www.vd.ch\/aides-financieres-et-soutien-social\/aides-financieres-et-comment-les-demander\/rdu&quot; target=&quot;_blank&quot;&gt; le revenu d\u00e9terminant unifi\u00e9 (RDU)&lt;\/a&gt;.' class='gform_hidden' \/><input type='hidden' name='input_193.3' value='27' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_15_196\"  class=\"gfield gfield--type-signature gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_196\"><label class='gfield_label gform-field-label' for='input_15_196' >Signature du parent ayant droit<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_15_196_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_15_196_valid' id='input_15_196_valid' \/><canvas id='input_15_196' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_15_129\"  class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_129\"><h3 class=\"gsection_title\">6.2 Activit\u00e9 du deuxi\u00e8me parent<\/h3><\/div><fieldset id=\"field_15_183\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_183\"><legend class='gfield_label gform-field-label'  >6.2.1 Votre \u00e9tat de sant\u00e9 vous emp\u00eache-t-il de vous occuper de votre enfant malade?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_15_183'>\n\t\t\t<div class='gchoice gchoice_15_183_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_183' type='radio' value='Oui'  id='choice_15_183_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_183_0' id='label_15_183_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_183_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_183' type='radio' value='Non'  id='choice_15_183_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_183_1' id='label_15_183_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_184\"  class=\"gfield gfield--type-signature gfield--width-half field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_184\"><label class='gfield_label gform-field-label' for='input_15_184' >Pri\u00e8re de joindre une attestation m\u00e9dicale pr\u00e9cisant cette incapacit\u00e9 \u00e0 la fin du formulaire et de signer l&#039;autorisation suivante:<\/label><div class='gfield_description' id='gfield_description_15_184'>En signant l'assur\u00e9(e) ou son\/sa repr\u00e9sentant(e) l\u00e9gal(e) autorise le service des allocations sp\u00e9ciales AMINH \u00e0 prendre les renseignements n\u00e9cessaires \u00e0 la d\u00e9termination du bien-fond\u00e9 de la demande et de l'octroi des prestations aupr\u00e8s de l'assurance-maladie, de l'assurance perte de gain maladie, de l'assurance accident, de l'assurance-invalidit\u00e9 ainsi qu'\u00e0 des m\u00e9decins traitants. <\/div><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_15_184_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_15_184_valid' id='input_15_184_valid' \/><canvas id='input_15_184' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_15_131\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_131\"><label class='gfield_label gform-field-label' for='input_15_131' >6.2.2 Profession<\/label><div class='ginput_container ginput_container_text'><input name='input_131' id='input_15_131' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_15_132\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_132\"><label class='gfield_label gform-field-label' for='input_15_132' >6.2.3 Employeur<\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_15_132' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_133\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_133\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Depuis quand?<\/legend><div id='input_15_133' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_15_133_2_container'>\n                                            <label for='input_15_133_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number'  name='input_133[]' id='input_15_133_2' value=''   aria-required='false'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_15_133_1_container'>\n                                        <label for='input_15_133_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                        <input type='number'  name='input_133[]' id='input_15_133_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_15_133_3_container'>\n                                            <label for='input_15_133_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number'  name='input_133[]' id='input_15_133_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><div id=\"field_15_134\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_134\"><label class='gfield_label gform-field-label' for='input_15_134' >6.2.4 Horaire de travail ou taux de travail lors de l&#039;engagement<\/label><div class='ginput_container ginput_container_text'><input name='input_134' id='input_15_134' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_135\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_135\"><legend class='gfield_label gform-field-label'  >6.2.5 Avez-vous modifi\u00e9 cet horaire pour vous occuper de votre enfant?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_15_135'>\n\t\t\t<div class='gchoice gchoice_15_135_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_135' type='radio' value='Oui'  id='choice_15_135_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_135_0' id='label_15_135_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_135_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_135' type='radio' value='Non'  id='choice_15_135_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_135_1' id='label_15_135_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_136\"  class=\"gfield gfield--type-textarea gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_136\"><label class='gfield_label gform-field-label' for='input_15_136' >But et motif de cette r\u00e9duction ou interruption de l\u2019activit\u00e9 lucrative et depuis quand ?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_136' id='input_15_136' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_15_137\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_137\"><label class='gfield_label gform-field-label' for='input_15_137' >6.2.6 Si vous n&#039;exercez pas ou plus d&#039;activit\u00e9 lucrative...<\/label><div class='gfield_description' id='gfield_description_15_137'>Merci de mentionner les activit\u00e9s exerc\u00e9es auparavant (y compris avant votre arriv\u00e9e en suisse) en pr\u00e9cisant la date de d\u00e9but et de fin de l\u2019activit\u00e9 ainsi que le taux.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_137' id='input_15_137' class='textarea large'  aria-describedby=\"gfield_description_15_137\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_15_194\"  class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_194\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >6.2.7 Informations concernant le revenu d\u00e9t\u00e9rminant unifi\u00e9<\/legend><div class='ginput_container ginput_container_consent'><input name='input_194.1' id='input_15_194_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_15_194_1' >Le parent 2 confirme avoir pris connaissance des informations concernant <a href=\"https:\/\/www.vd.ch\/aides-financieres-et-soutien-social\/aides-financieres-et-comment-les-demander\/rdu\" target=\"_blank\"> le revenu d\u00e9terminant unifi\u00e9 (RDU)<\/a>.<\/label><input type='hidden' name='input_194.2' value='Le parent 2 confirme avoir pris connaissance des informations concernant &lt;a href=&quot;https:\/\/www.vd.ch\/aides-financieres-et-soutien-social\/aides-financieres-et-comment-les-demander\/rdu&quot; target=&quot;_blank&quot;&gt; le revenu d\u00e9terminant unifi\u00e9 (RDU)&lt;\/a&gt;.' class='gform_hidden' \/><input type='hidden' name='input_194.3' value='27' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_15_198\"  class=\"gfield gfield--type-signature gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_198\"><label class='gfield_label gform-field-label' for='input_15_198' >Signature du parent 2<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_15_198_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_15_198_valid' id='input_15_198_valid' \/><canvas id='input_15_198' width='300' height='180'><\/canvas><\/div><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_15_167' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Pr\u00e9c\u00e9dent'  onclick='jQuery(\"#gform_target_page_number_15\").val(\"5\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_15\").val(\"5\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_15_167' class='gform_next_button gform-theme-button button' value='Suivant'  onclick='jQuery(\"#gform_target_page_number_15\").val(\"7\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_15\").val(\"7\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_15_7' class='gform_page' data-js='page-field-id-167' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_15_7' class='gform_fields top_label form_sublabel_above description_below'><div id=\"field_15_138\"  class=\"gfield gfield--type-section gsection field_sublabel_above gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_138\"><h3 class=\"gsection_title\">7. Adresse de paiement<\/h3><div class='gsection_description' id='gfield_description_15_138'>Merci de choisir entre le compte postal (CCP) ou le compte bancaire<\/div><\/div><div id=\"field_15_150\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_150\"><label class='gfield_label gform-field-label' for='input_15_150' >Choisir mon compte de paiement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_150' id='input_15_150' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>--Veuillez s\u00e9lectionner--<\/option><option value='Compte de ch\u00e8que postal (CCP)' >Compte de ch\u00e8que postal (CCP)<\/option><option value='Compte bancaire (IBAN)' >Compte bancaire (IBAN)<\/option><\/select><\/div><\/div><div id=\"field_15_141\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_141\"><label class='gfield_label gform-field-label' for='input_15_141' >N\u00b0 de compte de ch\u00e8que postal (CCP)<\/label><div class='ginput_container ginput_container_text'><input name='input_141' id='input_15_141' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_142\"  class=\"gfield gfield--type-name gfield--width-half field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_142\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Titulaire du compte<\/legend><div class='gfield_description' id='gfield_description_15_142'>Si le titulaire du compte n'est pas le parent ayant droit, pri\u00e8re de joindre la demande d'autorisation au bas de ce formulaire. <\/div><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_15_142'>\n                            \n                            <span id='input_15_142_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_15_142_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                    <input type='text' name='input_142.3' id='input_15_142_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_15_142_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_15_142_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                            <input type='text' name='input_142.6' id='input_15_142_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_15_144\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_144\"><label class='gfield_label gform-field-label' for='input_15_144' >Nom de la banque<\/label><div class='ginput_container ginput_container_text'><input name='input_144' id='input_15_144' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_15_145\"  class=\"gfield gfield--type-address gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_145\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Adresse de la banque<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip ginput_container_address gform-grid-row' id='input_15_145' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_15_145_1_container' >\n                                        <label for='input_15_145_1' id='input_15_145_1_label' class='gform-field-label gform-field-label--type-sub '>Rue et n\u00b0<\/label>\n                                        <input type='text' name='input_145.1' id='input_15_145_1' value=''    aria-required='false'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_15_145_3_container' >\n                                    <label for='input_15_145_3' id='input_15_145_3_label' class='gform-field-label gform-field-label--type-sub '>Code postal (NPA)<\/label>\n                                    <input type='text' name='input_145.3' id='input_15_145_3' value=''    aria-required='false'    \/>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_145.4' id='input_15_145_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_15_145_5_container' >\n                                    <label for='input_15_145_5' id='input_15_145_5_label' class='gform-field-label gform-field-label--type-sub '>Localit\u00e9<\/label>\n                                    <input type='text' name='input_145.5' id='input_15_145_5' value=''    aria-required='false'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_145.6' id='input_15_145_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_15_146\"  class=\"gfield gfield--type-name gfield--width-half field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_146\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Titulaire du compte<\/legend><div class='gfield_description' id='gfield_description_15_146'>Si le titulaire du compte n'est pas le parent ayant droit, pri\u00e8re de joindre la demande d'autorisation lors de la derni\u00e8re \u00e9tape de ce formulaire. \nIndiquer le nom et pr\u00e9nom figurant sur la carte.<\/div><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_15_146'>\n                            \n                            <span id='input_15_146_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_15_146_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                    <input type='text' name='input_146.3' id='input_15_146_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_15_146_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_15_146_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                            <input type='text' name='input_146.6' id='input_15_146_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_15_128\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_128\"><label class='gfield_label gform-field-label' for='input_15_128' >IBAN<\/label><div class='ginput_container ginput_container_text'><input name='input_128' id='input_15_128' type='text' value='' class='large'    placeholder='CH-__ ____ ____ ____ ____ _'  aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_15_168' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Pr\u00e9c\u00e9dent'  onclick='jQuery(\"#gform_target_page_number_15\").val(\"6\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_15\").val(\"6\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_15_168' class='gform_next_button gform-theme-button button' value='Suivant'  onclick='jQuery(\"#gform_target_page_number_15\").val(\"8\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_15\").val(\"8\");  jQuery(\"#gform_15\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_15_8' class='gform_page' data-js='page-field-id-168' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_15_8' class='gform_fields top_label form_sublabel_above description_below'><div id=\"field_15_169\"  class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_169\"><h3 class=\"gsection_title\">8. Annexes<\/h3><\/div><fieldset id=\"field_15_212\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_above gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_212\"><legend class='gfield_label gform-field-label'  >Envoi d&#039;une copie de la demande AMINH<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_15_212'>\n\t\t\t<div class='gchoice gchoice_15_212_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='Oui'  id='choice_15_212_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_15_212\"   \/>\n\t\t\t\t\t<label for='choice_15_212_0' id='label_15_212_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_212_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='Non'  id='choice_15_212_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_212_1' id='label_15_212_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_15_212'>Souhaitez-vous envoyer une copie de cette demande \u00e0 une autre personne?<\/div><\/fieldset><div id=\"field_15_211\"  class=\"gfield gfield--type-email gfield--width-half field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_211\"><label class='gfield_label gform-field-label' for='input_15_211' >E-mail<\/label><div class='gfield_description' id='gfield_description_15_211'>E-mail de la personne \u00e0 qui vous souhaitez envoyer la copie de la demande<\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_211' id='input_15_211' type='email' value='' class='large'     aria-invalid=\"false\" aria-describedby=\"gfield_description_15_211\" \/>\n                        <\/div><\/div><div id=\"field_15_100\"  class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_100\"><label class='gfield_label gform-field-label' for='gform_browse_button_15_100' >Merci de joindre ici tous les fichiers demand\u00e9s vous concernant dans le formulaire<\/label><div class='gfield_description' id='gfield_description_15_100'>(jugement actuel de l'autorit\u00e9 parentale, d\u00e9cision SESAF, d\u00e9cision UAT, procuration de Pro Infirmis  et\/ou autorisation bancaire)\n\n<\/div><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_15_100' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_15_100&quot;,&quot;container&quot;:&quot;gform_multifile_upload_15_100&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_15_100&quot;,&quot;filelist&quot;:&quot;gform_preview_15_100&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/dev.konsept.ch\\\/aivd\\\/?gf_page=22a842b25a0a3bc&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/dev.konsept.ch\\\/aivd\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/dev.konsept.ch\\\/aivd\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Fichiers autoris\\u00e9s&quot;,&quot;extensions&quot;:&quot;jpg,png,pdf&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:15,&quot;field_id&quot;:100},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_15_100&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_15_100' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>D\u00e9posez les fichiers ici ou <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_15_100' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_15_100 gfield_description_15_100\"  >S\u00e9lectionnez des fichiers<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_15_100'>Types de fichiers accept\u00e9s\u00a0: jpg, png, pdf, Taille max. des fichiers\u00a0: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_15_100'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_15_100' class='ginput_preview_list'><\/div><\/div><fieldset id=\"field_15_155\"  class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_155\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Autorisation et signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_155.1' id='input_15_155_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_15_155\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_15_155_1' >J\u2019accepte la politique de confidentialit\u00e9.<\/label><input type='hidden' name='input_155.2' value='J\u2019accepte la politique de confidentialit\u00e9.' class='gform_hidden' \/><input type='hidden' name='input_155.3' value='27' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_15_155'>En signant cette formule le\/la repr\u00e9sentant(e) l\u00e9gal(e) de l\u2019enfant autorise toutes les personnes et tous les offices entrant en consid\u00e9ration, en particulier, les m\u00e9decins, le personnel param\u00e9dical, les \u00e9tablissements hospitaliers, les caisses-maladie\/accidents, les avocat(e)s, les fiduciaires, les assurances publiques et priv\u00e9es, notamment les organes de l\u2019AVS et de l\u2019AI, les organismes publics, les institutions d\u2019assistance priv\u00e9es et les autorit\u00e9s fiscales, \u00e0 donner aux organes charg\u00e9s de l\u2019examen du droit aux allocations sp\u00e9ciales d\u00e9finies ci-dessus les renseignements n\u00e9cessaires \u00e0 la d\u00e9termination du bien-fond\u00e9 de la demande et du droit aux prestations. Nous nous r\u00e9servons le droit de mandater le service Pro Infirmis pour les questions li\u00e9es \u00e0 l\u2019activit\u00e9 lucrative des parents (au besoin, un rendez-vous sera fix\u00e9 avec la famille). Le\/La soussign\u00e9(e) autorise \u00e9galement les organes charg\u00e9s de l\u2019examen du droit \u00e0 qu\u00e9rir les renseignements n\u00e9cessaires aupr\u00e8s des personnes et institutions susmentionn\u00e9es. Le\/La soussign\u00e9(e) certifie avoir r\u00e9pondu de mani\u00e8re compl\u00e8te et v\u00e9ridique. Le\/la soussign\u00e9(e)e) est inform\u00e9(e) que ses donn\u00e9es financi\u00e8res, y compris fiscales, figurant dans le syst\u00e8me d'information du revenu d\u00e9terminant unifi\u00e9 (SI RDU), sont utilis\u00e9es par les autorit\u00e9s concern\u00e9es. Il\/elle autorise le partage des informations n\u00e9cessaires entre tous les services des administrations charg\u00e9es d'octroyer les aides cantonales, ainsi que de l'administration cantonale des imp\u00f4ts, du registre cantonal des personnes, et de la Caisse cantonale de compensation AVS. Le\/la soussign\u00e9(e) donne son accord \u00e0 ce que la Caisse cantonale vaudoise de compensation de l'assurance vieillesse et survivants informe les autorit\u00e9s concern\u00e9es, par le biais du SI RDU, si oui ou non elle re\u00e7oit des prestations compl\u00e9mentaires AVS\/AI. La prestation peut \u00eatre refus\u00e9e ou supprim\u00e9e et le remboursement des sommes ind\u00fbment touch\u00e9es exig\u00e9 si le\/la soussign\u00e9(e) tait des faits importants, dissimule des pi\u00e8ces utiles ou fait des fausses d\u00e9clarations. Des sanctions administratives et\/ou p\u00e9nales sont r\u00e9serv\u00e9es. Le\/la soussign\u00e9(e) s'engage \u00e0 informer les autorit\u00e9s imm\u00e9diatement de tout changement de domicile et de sa situation financi\u00e8re ou personnelle, et des m\u00eames changements des autres membres de son unit\u00e9 \u00e9conomique de r\u00e9f\u00e9rence dont il a connaissance. Les autres membres de son unit\u00e9 \u00e9conomique de r\u00e9f\u00e9rence pertinents pour l\u2019AMINH sont : son conjoint, son concubin s\u2019il est parent de l\u2019enfant en situation de handicap, et les enfants majeurs \u00e9conomiquement d\u00e9pendants du\/de la soussign\u00e9(e), de son conjoint ou de son concubin s\u2019il est aussi parent de l\u2019enfant en situation de handicap.<\/div><\/fieldset><div id=\"field_15_160\"  class=\"gfield gfield--type-turnstile gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_160\"><\/div><\/div><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_15' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Pr\u00e9c\u00e9dent'  onclick='if(window[\"gf_submitting_15\"]){return false;}  if( !jQuery(\"#gform_15\")[0].checkValidity || 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