{"id":965,"date":"2019-01-24T14:38:13","date_gmt":"2019-01-24T18:38:13","guid":{"rendered":"https:\/\/www.programmeproches.ca\/?page_id=965"},"modified":"2023-11-28T09:28:02","modified_gmt":"2023-11-28T14:28:02","slug":"application-form","status":"publish","type":"page","link":"https:\/\/www.programmeproches.ca\/en\/forms\/application-form\/","title":{"rendered":"Application form"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column][vc_column_text]<\/p>\n<h1><a id=\"demandeur\" contenteditable=\"false\" class=\"mce-item-anchor\"><\/a>Application form<\/h1>\n<hr>\n<p>[\/vc_column_text][vc_column_text css=&#8221;.vc_custom_1620762570280{padding-top: 4% !important;padding-right: 6% !important;padding-bottom: 4% !important;padding-left: 6% !important;background-color: #fffbf4 !important;}&#8221;]For printing, use the <a href=\"https:\/\/programmeproches.ca\/wp-content\/uploads\/2021\/05\/Proches-Application-Form_En_21-05.pdf\" data-mce-href=\"https:\/\/programmeproches.ca\/wp-content\/uploads\/2021\/05\/Proches-Application-Form_En_21-05.pdf\">PDF version of the form<\/a>.<\/p>\n<p>[\/vc_column_text][vc_column_text]<\/p>\n<hr \/>\n<p><a href=\"#save\">It is possible to save your form if you have not finished filling it out (option available at the end of the form).<\/a><\/p>\n<p><span style=\"color: #ff0000;\"><strong>*<\/strong><\/span> indicates required fields[\/vc_column_text]<div class=\"grve-element grve-image grve-align-left\" style=\"\"><img loading=\"lazy\" decoding=\"async\" width=\"160\" height=\"65\" src=\"https:\/\/www.programmeproches.ca\/wp-content\/uploads\/2018\/12\/icon_ssl_protection_logo_small.png\" class=\"attachment-full size-full\" alt=\"\" srcset=\"https:\/\/www.programmeproches.ca\/wp-content\/uploads\/2018\/12\/icon_ssl_protection_logo_small.png 1x,https:\/\/www.programmeproches.ca\/wp-content\/uploads\/2018\/12\/icon_ssl_protection_logo.png 2x\" title=\"\"><\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_5' style='display:none'><div id='gf_5' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/en\/wp-json\/wp\/v2\/pages\/965#gf_5' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_104\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_104'>Company<\/label><div class='ginput_container'><input name='input_104' id='input_5_104' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_5_104'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_5_2\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Information on the applicant<\/h3><\/div><fieldset id=\"field_5_76\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name(s) of the applicant<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_76'>\n                            \n                            <span id='input_5_76_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_76.3' id='input_5_76_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_76_3' class='gform-field-label gform-field-label--type-sub '>First name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_76_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_76.6' id='input_5_76_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_76_6' class='gform-field-label gform-field-label--type-sub '>Last name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_5_5\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_5_5' class='ginput_container ginput_complex gform-grid-row'>\n                                            <div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_5_5_3_container'>\n                                                <input type='number' maxlength='4' name='input_5[]' id='input_5_5_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                                <label for='input_5_5_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                            <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_5_5_1_container'>\n                                                <input type='number' maxlength='2' name='input_5[]' id='input_5_5_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                                <label for='input_5_5_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                            <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_5_5_2_container'>\n                                                <input type='number' maxlength='2' name='input_5[]' id='input_5_5_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                                <label for='input_5_5_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                           <\/div>\n                                        <\/div><\/fieldset><div id=\"field_5_86\" class=\"gfield gfield--type-html bloc-note gfield_html gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >N.B.: Children under 18 must be assisted by their legal guardian, who must also sign in the space provided at the bottom of the form.<\/div><div id=\"field_5_22\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_22'>Sex<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_5_22' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_7\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Complete address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_5_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_7_1_container' >\n                                        <label for='input_5_7_1' id='input_5_7_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_7.1' id='input_5_7_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_7_3_container' >\n                                    <label for='input_5_7_3' id='input_5_7_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_7.3' id='input_5_7_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_7_4_container' >\n                                        <label for='input_5_7_4' id='input_5_7_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                        <input type='text' name='input_7.4' id='input_5_7_4' value=''      aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_7_5_container' >\n                                    <label for='input_5_7_5' id='input_5_7_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                    <input type='text' name='input_7.5' id='input_5_7_5' value=''    aria-required='true'    \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_5_7_6_container' >\n                                        <label for='input_5_7_6' id='input_5_7_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                        <select name='input_7.6' id='input_5_7_6'   aria-required='true'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' selected='selected'>Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option> <\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_5_8\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_8'>Telephone number\u200a\u200a<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_5_8' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_10\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Email address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_5_10_container'>\n                                <span id='input_5_10_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_5_10' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                    <input class='' type='email' name='input_10' id='input_5_10' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                <\/span>\n                                <span id='input_5_10_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_5_10_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                    <input class='' type='email' name='input_10_2' id='input_5_10_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_5_102\" class=\"gfield gfield--type-html gfield--width-full bloc-note gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Please note that we will contact through this email address. If you do not have an email address, we will contact you by mail.<\/div><div id=\"field_5_12\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_12'>What is your relationship to the victim?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_12'>N.B.: You are considered to be the victim\u2019s spouse if you were joined by marriage or civil union, or if you considered yourselves as spouses in a civil union and had been living together as a couple for at least one year, had\/will have a child together, had adopted a child together or if one of you had adopted the child of the other during your union.<\/div><div class='ginput_container ginput_container_select'><select name='input_12' id='input_5_12' class='medium gfield_select'  aria-describedby=\"gfield_description_5_12\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Spouse' >Spouse<\/option><option value='Child' >Child<\/option><option value='Parent' >Parent<\/option><option value='Brother \/ sister' >Brother \/ sister<\/option><option value='Grandparent' >Grandparent<\/option><option value='Intimate partner (date of beginning of relationship)' >Intimate partner (date of beginning of relationship)<\/option><option value='Child of victim\u2019s spouse' >Child of victim\u2019s spouse<\/option><option value='Spouse of victim\u2019s parent' >Spouse of victim\u2019s parent<\/option><option value='Uncle \/ aunt' >Uncle \/ aunt<\/option><option value='Nephew \/ niece' >Nephew \/ niece<\/option><option value='Cousin' >Cousin<\/option><option value='Parent of victim\u2019s spouse' >Parent of victim\u2019s spouse<\/option><option value='Child\u2019s spouse' >Child\u2019s spouse<\/option><option value='Friend' >Friend<\/option><option value='Work colleague' >Work colleague<\/option><option value='Other \u2013 please specify:' >Other \u2013 please specify:<\/option><\/select><\/div><\/div><fieldset id=\"field_5_13\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Statut:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_13'>\n\t\t\t<div class='gchoice gchoice_5_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Married'  id='choice_5_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_13_0' id='label_5_13_0' class='gform-field-label gform-field-label--type-inline'>Married<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Civil union'  id='choice_5_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_13_1' id='label_5_13_1' class='gform-field-label gform-field-label--type-inline'>Civil union<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='De facto (common-law) spouse \u2013 date when you started living together'  id='choice_5_13_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_13_2' id='label_5_13_2' class='gform-field-label gform-field-label--type-inline'>De facto (common-law) spouse \u2013 date when you started living together<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_13_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Spouse with child(ren)'  id='choice_5_13_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_13_3' id='label_5_13_3' class='gform-field-label gform-field-label--type-inline'>Spouse with child(ren)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_14\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Intimate partner<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_5_14' class='ginput_container ginput_complex gform-grid-row'>\n                                            <div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_5_14_3_container'>\n                                                <input type='number' maxlength='4' name='input_14[]' id='input_5_14_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                                <label for='input_5_14_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                            <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_5_14_1_container'>\n                                                <input type='number' maxlength='2' name='input_14[]' id='input_5_14_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                                <label for='input_5_14_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                            <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_5_14_2_container'>\n                                                <input type='number' maxlength='2' name='input_14[]' id='input_5_14_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                                <label for='input_5_14_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                           <\/div>\n                                        <\/div><\/fieldset><fieldset id=\"field_5_74\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >De facto (common-law) spouse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_5_74'>Date when you started living together: <\/div><div id='input_5_74' class='ginput_container ginput_complex gform-grid-row'>\n                                            <div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_5_74_3_container'>\n                                                <input type='number' maxlength='4' name='input_74[]' id='input_5_74_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                                <label for='input_5_74_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                            <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_5_74_1_container'>\n                                                <input type='number' maxlength='2' name='input_74[]' id='input_5_74_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                                <label for='input_5_74_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                            <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_5_74_2_container'>\n                                                <input type='number' maxlength='2' name='input_74[]' id='input_5_74_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                                <label for='input_5_74_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                           <\/div>\n                                        <\/div><\/fieldset><div id=\"field_5_15\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_15'>Other \u2013 please specify:<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_5_15' type='text' value='' class='medium'    placeholder='Please specify:'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_19\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_19'>Additional information on your relationship with the deceased:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_19' id='input_5_19' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Language<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_5_20'>Language of correspondence<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_20'>\n\t\t\t<div class='gchoice gchoice_5_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='French'  id='choice_5_20_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_20\"   \/>\n\t\t\t\t\t<label for='choice_5_20_0' id='label_5_20_0' class='gform-field-label gform-field-label--type-inline'>French<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='English'  id='choice_5_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_20_1' id='label_5_20_1' class='gform-field-label gform-field-label--type-inline'>English<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_21\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Information on the deceased<\/h3><\/div><fieldset id=\"field_5_23\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name of the deceased<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_23'>\n                            \n                            <span id='input_5_23_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_23.3' id='input_5_23_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_23_3' class='gform-field-label gform-field-label--type-sub '>First name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_23_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_23.6' id='input_5_23_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_23_6' class='gform-field-label gform-field-label--type-sub '>Last name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_5_24\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_5_24' class='ginput_container ginput_complex gform-grid-row'>\n                                            <div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_5_24_3_container'>\n                                                <input type='number' maxlength='4' name='input_24[]' id='input_5_24_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                                <label for='input_5_24_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                            <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_5_24_1_container'>\n                                                <input type='number' maxlength='2' name='input_24[]' id='input_5_24_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                                <label for='input_5_24_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                            <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_5_24_2_container'>\n                                                <input type='number' maxlength='2' name='input_24[]' id='input_5_24_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                                <label for='input_5_24_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                           <\/div>\n                                        <\/div><\/fieldset><fieldset id=\"field_5_25\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date of the criminal act<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_5_25' class='ginput_container ginput_complex gform-grid-row'>\n                                            <div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_5_25_3_container'>\n                                                <input type='number' maxlength='4' name='input_25[]' id='input_5_25_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                                <label for='input_5_25_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                            <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_5_25_1_container'>\n                                                <input type='number' maxlength='2' name='input_25[]' id='input_5_25_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                                <label for='input_5_25_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                            <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_5_25_2_container'>\n                                                <input type='number' maxlength='2' name='input_25[]' id='input_5_25_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                                <label for='input_5_25_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                           <\/div>\n                                        <\/div><\/fieldset><div id=\"field_5_27\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Information on the criminal act<\/h3><\/div><fieldset id=\"field_5_97\" class=\"gfield gfield--type-list gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name(s) of the accused<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">First name<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Last name<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_97_cell1 gform-grid-col' data-label='First name'><input aria-invalid='false' aria-required=\"true\"  aria-label='First name, Row 1' data-aria-label-template='First name, Row {0}' type='text' name='input_97[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_97_cell2 gform-grid-col' data-label='Last name'><input aria-invalid='false' aria-required=\"true\"  aria-label='Last name, Row 1' data-aria-label-template='Last name, Row {0}' type='text' name='input_97[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 10)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 10)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_5_29\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_29'>Court file number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_5_29' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_88\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Accusation<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_88'><div class='gchoice gchoice_5_88_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.1' type='checkbox'  value='Homicide'  id='choice_5_88_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_88_1' id='label_5_88_1' class='gform-field-label gform-field-label--type-inline'>Homicide<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_88_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.2' type='checkbox'  value='Criminal negligence causing death'  id='choice_5_88_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_88_2' id='label_5_88_2' class='gform-field-label gform-field-label--type-inline'>Criminal negligence causing death<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_88_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.3' type='checkbox'  value='Dangerous driving causing death'  id='choice_5_88_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_88_3' id='label_5_88_3' class='gform-field-label gform-field-label--type-inline'>Dangerous driving causing death<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_88_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.4' type='checkbox'  value='Impaired driving causing death'  id='choice_5_88_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_88_4' id='label_5_88_4' class='gform-field-label gform-field-label--type-inline'>Impaired driving causing death<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_88_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.5' type='checkbox'  value='Other'  id='choice_5_88_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_88_5' id='label_5_88_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_89\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_89'>Please specify:<\/label><div class='ginput_container ginput_container_text'><input name='input_89' id='input_5_89' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_87\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have any connection with one of the accused individuals?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_87'>\n\t\t\t<div class='gchoice gchoice_5_87_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='No'  id='choice_5_87_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_87_0' id='label_5_87_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_87_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='If so, what is the nature of your connection?'  id='choice_5_87_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_87_1' id='label_5_87_1' class='gform-field-label gform-field-label--type-inline'>If so, what is the nature of your connection?<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_98\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_98'>Connection with one of the accused individuals:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_98' id='input_5_98' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_99\" class=\"gfield gfield--type-list gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Next known date you will appear in court.<\/legend><div class='gfield_description' id='gfield_description_5_99'> Enter the nature and date of the proceeding:<\/div><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Date<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Nature<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_99_cell1 gform-grid-col' data-label='Date'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_99\" aria-label='Date, Row 1' data-aria-label-template='Date, Row {0}' type='text' name='input_99[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_99_cell2 gform-grid-col' data-label='Nature'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_99\" aria-label='Nature, Row 1' data-aria-label-template='Nature, Row {0}' type='text' name='input_99[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 20)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 20)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_5_45\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Additional information<\/h3><\/div><div id=\"field_5_46\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_46'>Are you a member of an ethnocultural minority?<\/label><div class='gfield_description' id='gfield_description_5_46'>If so, please specify:<\/div><div class='ginput_container ginput_container_text'><input name='input_46' id='input_5_46' type='text' value='' class='medium'  aria-describedby=\"gfield_description_5_46\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_47\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_47'>Are you a member of a First Nation?<\/label><div class='gfield_description' id='gfield_description_5_47'>If so, please specify:<\/div><div class='ginput_container ginput_container_text'><input name='input_47' id='input_5_47' type='text' value='' class='medium'  aria-describedby=\"gfield_description_5_47\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_48\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_48'>Are you living with a disability?<\/label><div class='gfield_description' id='gfield_description_5_48'>If so, please specify: <\/div><div class='ginput_container ginput_container_text'><input name='input_48' id='input_5_48' type='text' value='' class='medium'  aria-describedby=\"gfield_description_5_48\"    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_50\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >How did you hear about the Reimbursement Program for Family and Close Friends?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_50'>\n\t\t\t<div class='gchoice gchoice_5_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Someone working in an organization \u2013 please specify the name of the organization'  id='choice_5_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_50_0' id='label_5_50_0' class='gform-field-label gform-field-label--type-inline'>Someone working in an organization \u2013 please specify the name of the organization<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Police officer'  id='choice_5_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_50_1' id='label_5_50_1' class='gform-field-label gform-field-label--type-inline'>Police officer<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_50_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Publicity (poster, brochure, etc.)'  id='choice_5_50_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_50_2' id='label_5_50_2' class='gform-field-label gform-field-label--type-inline'>Publicity (poster, brochure, etc.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_50_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Internet search'  id='choice_5_50_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_50_3' id='label_5_50_3' class='gform-field-label gform-field-label--type-inline'>Internet search<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_50_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='gf_other_choice'  id='choice_5_50_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_50_4' id='label_5_50_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_5_50_other' class='gchoice_other_control' name='input_50_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_58\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_58'>The name of the organization:<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_5_58' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_51\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_51'>Did a worker in an organization help you complete this form?<\/label><div class='gfield_description' id='gfield_description_5_51'>If so, which organization?<\/div><div class='ginput_container ginput_container_text'><input name='input_51' id='input_5_51' type='text' value='' class='medium'  aria-describedby=\"gfield_description_5_51\"    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_80\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you currently receiving or have you ever received services from a CAVAC (Crime Victim Assistance Centre)?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_80'>\n\t\t\t<div class='gchoice gchoice_5_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='No' checked='checked' id='choice_5_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_80_0' id='label_5_80_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='If so, which one (which region)?'  id='choice_5_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_80_1' id='label_5_80_1' class='gform-field-label gform-field-label--type-inline'>If so, which one (which region)?<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_52\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_52'>Which CAVAC region:<\/label><div class='gfield_description' id='gfield_description_5_52'>Which region:<\/div><div class='ginput_container ginput_container_text'><input name='input_52' id='input_5_52' type='text' value='' class='medium'  aria-describedby=\"gfield_description_5_52\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_81\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_5_81'>Name of CAVAC worker:<\/label><div class='gfield_description' id='gfield_description_5_81'>Name of CAVAC worker:<\/div><div class='ginput_container ginput_container_text'><input name='input_81' id='input_5_81' type='text' value='' class='medium'  aria-describedby=\"gfield_description_5_81\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_100\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_100'>Contact information:<\/label><div class='gfield_description' id='gfield_description_5_100'>Contact information:<\/div><div class='ginput_container ginput_container_text'><input name='input_100' id='input_5_100' type='text' value='' class='medium'  aria-describedby=\"gfield_description_5_100\"    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_55\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you authorize us to exchange information with this organization in order to help you with your current situation as someone close to a victim who incurred travel expenses in order to attend legal proceedings?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_55'>\n\t\t\t<div class='gchoice gchoice_5_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Yes'  id='choice_5_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_55_0' id='label_5_55_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='No'  id='choice_5_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_55_1' id='label_5_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_82\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you currently receiving or have you ever received  services from another organization in connection with the death of your loved one?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_82'>\n\t\t\t<div class='gchoice gchoice_5_82_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='No' checked='checked' id='choice_5_82_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_82_0' id='label_5_82_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_82_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='If so, please specify the name of the organization'  id='choice_5_82_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_82_1' id='label_5_82_1' class='gform-field-label gform-field-label--type-inline'>If so, please specify the name of the organization<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_83\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_83'>Another organization in connection with the death. Specify the name of the organization:<\/label><div class='gfield_description' id='gfield_description_5_83'>Specify the name of the organization:<\/div><div class='ginput_container ginput_container_text'><input name='input_83' id='input_5_83' type='text' value='' class='medium'  aria-describedby=\"gfield_description_5_83\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_84\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_84'>Another organization in connection with the death. Name of worker:<\/label><div class='gfield_description' id='gfield_description_5_84'>Name of worker:<\/div><div class='ginput_container ginput_container_text'><input name='input_84' id='input_5_84' type='text' value='' class='medium'  aria-describedby=\"gfield_description_5_84\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_101\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_101'>Another organization in connection with the death. Contact information:<\/label><div class='gfield_description' id='gfield_description_5_101'>Contact information:<\/div><div class='ginput_container ginput_container_text'><input name='input_101' id='input_5_101' type='text' value='' class='medium'  aria-describedby=\"gfield_description_5_101\"    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_103\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you authorize us to exchange information with this organization in order to help you with your current situation as someone close to a victim who incurred travel expenses in order to attend legal proceedings?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_103'>\n\t\t\t<div class='gchoice gchoice_5_103_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='Yes'  id='choice_5_103_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_103_0' id='label_5_103_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_103_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='No'  id='choice_5_103_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_103_1' id='label_5_103_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_63\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Declaration<\/h3><\/div><fieldset id=\"field_5_65\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_65.1' id='input_5_65_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_5_65\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_65_1' >I declare that the information provided on this form is accurate.<\/label><input type='hidden' name='input_65.2' value='I declare that the information provided on this form is accurate.' class='gform_hidden' \/><input type='hidden' name='input_65.3' value='23' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_5_65' tabindex='0'>Any declaration of false, incomplete or misleading information will have repercussions on the processing of this application. <\/div><\/fieldset><fieldset id=\"field_5_71\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_5_71' class='ginput_container ginput_complex gform-grid-row'>\n                                            <div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_5_71_3_container'>\n                                                <input type='number' maxlength='4' name='input_71[]' id='input_5_71_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                                <label for='input_5_71_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                            <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_5_71_1_container'>\n                                                <input type='number' maxlength='2' name='input_71[]' id='input_5_71_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                                <label for='input_5_71_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                            <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_5_71_2_container'>\n                                                <input type='number' maxlength='2' name='input_71[]' id='input_5_71_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                                <label for='input_5_71_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                           <\/div>\n                                        <\/div><\/fieldset><fieldset id=\"field_5_77\" class=\"gfield gfield--type-radio gfield--type-choice gform_space field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text' >The applicant is under 18 years of age<\/legend><div class='gfield_description' id='gfield_description_5_77'>The applicant is under 18 years of age<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_77'>\n\t\t\t<div class='gchoice gchoice_5_77_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='No' checked='checked' id='choice_5_77_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_77\"   \/>\n\t\t\t\t\t<label for='choice_5_77_0' id='label_5_77_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_77_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Yes'  id='choice_5_77_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_77_1' id='label_5_77_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_67\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Complete this section only if the applicant is under 18 years of age<\/h3><\/div><div id=\"field_5_68\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_68'>Name of legal guardian<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_5_68' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_95\" class=\"gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_95'>Telephone number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_95' id='input_5_95' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"tel\" \/><\/div><\/div><div id=\"field_5_96\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_96'>Email Adress<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_96' id='input_5_96' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                        <\/div><\/div><fieldset id=\"field_5_69\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Relationship to the applicant<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_69'>\n\t\t\t<div class='gchoice gchoice_5_69_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Parent'  id='choice_5_69_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_69_0' id='label_5_69_0' class='gform-field-label gform-field-label--type-inline'>Parent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_69_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Brother \/ sister'  id='choice_5_69_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_69_1' id='label_5_69_1' class='gform-field-label gform-field-label--type-inline'>Brother \/ sister<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_69_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Grandparent'  id='choice_5_69_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_69_2' id='label_5_69_2' class='gform-field-label gform-field-label--type-inline'>Grandparent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_69_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Spouse of applicant\u2019s parent'  id='choice_5_69_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_69_3' id='label_5_69_3' class='gform-field-label gform-field-label--type-inline'>Spouse of applicant\u2019s parent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_69_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Uncle \/ aunt'  id='choice_5_69_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_69_4' id='label_5_69_4' class='gform-field-label gform-field-label--type-inline'>Uncle \/ aunt<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_69_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='gf_other_choice'  id='choice_5_69_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_69_5' id='label_5_69_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_5_69_other' class='gchoice_other_control' name='input_69_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_93\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Signature of the legal guardian<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_93.1' id='input_5_93_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_5_93\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_93_1' >I declare that the information provided on this form is accurate.<\/label><input type='hidden' name='input_93.2' value='I declare that the information provided on this form is accurate.' class='gform_hidden' \/><input type='hidden' name='input_93.3' value='23' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_5_93' tabindex='0'>Any declaration of false, incomplete or misleading information will have repercussions on the processing of this application.<\/div><\/fieldset><fieldset id=\"field_5_94\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_5_94' class='ginput_container ginput_complex gform-grid-row'>\n                                            <div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_5_94_3_container'>\n                                                <input type='number' maxlength='4' name='input_94[]' id='input_5_94_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                                <label for='input_5_94_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                            <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_5_94_1_container'>\n                                                <input type='number' maxlength='2' name='input_94[]' id='input_5_94_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                                <label for='input_5_94_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                            <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_5_94_2_container'>\n                                                <input type='number' maxlength='2' name='input_94[]' id='input_5_94_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                                <label for='input_5_94_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                           <\/div>\n                                        <\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <button type='button'  id='gform_save_5_footer_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" 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class='gform_hidden' name='gform_save' id='gform_save_5' value='' \/>\n                             <input type='hidden' class='gform_hidden' name='gform_resume_token' id='gform_resume_token_5' value='' \/>\n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='CAD' value='p652CjIrE18s+ARswW+HCsjt0bFk0K3PDXhdy6LwNJfW1BQxmqVlG8LB661LmSIRQlZ3UDpZzVHjn19we7\/RsN67Jh7cgDfyqOEmKKCIdGNYbPk=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_5' 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function() {gformInitSpinner( 5, 'https:\/\/www.programmeproches.ca\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_5').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_5');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_5').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_5').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_5').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_5').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_5').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_5').val();gformInitSpinner( 5, 'https:\/\/www.programmeproches.ca\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [5, current_page]);window['gf_submitting_5'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_5').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_5').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [5]);window['gf_submitting_5'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_5').text());}else{jQuery('#gform_5').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"5\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_5\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_5\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_5\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            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