{"id":21,"date":"2019-08-20T23:28:46","date_gmt":"2019-08-20T21:28:46","guid":{"rendered":"http:\/\/microsites.diocesemontreal.org\/microsites\/sasmad\/?page_id=21"},"modified":"2021-11-02T13:32:43","modified_gmt":"2021-11-02T17:32:43","slug":"inscription-beneficiaire","status":"publish","type":"page","link":"https:\/\/microsites.diocesemontreal.org\/microsites\/sasmad\/inscription-beneficiaire\/","title":{"rendered":"Inscription B\u00e9n\u00e9ficiaire"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; fullwidth=&#8221;on&#8221; _builder_version=&#8221;4.6.0&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_fullwidth_header title=&#8221;Formulaire d&#8217;admission b\u00e9n\u00e9ficiaire&#8221; _builder_version=&#8221;4.6.0&#8243; _module_preset=&#8221;default&#8221; content_font_size=&#8221;18px&#8221; background_image=&#8221;https:\/\/microsites.diocesemontreal.org\/microsites\/sasmad\/wp-content\/uploads\/sites\/27\/2020\/09\/thomas-willmott-JwbRlo52UFU-unsplash-scaled.jpg&#8221; custom_padding=&#8221;103px||132px|||&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p>Une de nos coordonnatrices communiquera avec vous pour faire le suivi \u00a0qui correspond. N<span>ous cherchons \u00e0 r\u00e9pondre \u00e0 votre demande dans les plus brefs d\u00e9lais selon la disponibilit\u00e9 de nos b\u00e9n\u00e9voles.<\/span><\/p>\n<p>[\/et_pb_fullwidth_header][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.11.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.11.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.11.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.11.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<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 gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_10' >\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">INSCRIPTION B\u00c9N\u00c9FICIAIRE<\/h3>\n                            <p class='gform_description'>Formulaire pour inscrire les nouveaux b\u00e9n\u00e9ficiaires au service d'accompagnement spirituel SASMAD<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_10'  action='\/microsites\/sasmad\/wp-json\/wp\/v2\/pages\/21' data-formid='10' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_10' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_10_1\" class=\"gfield gfield--type-name gf_scroll_text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><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_10_1'>\n                            \n                            <span id='input_10_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_10_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_10_1_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_10_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_10_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_10_1_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_10_118\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_118'>Date de naissance<\/label><div class='gfield_description' id='gfield_description_10_118'>Date de naissance du b\u00e9n\u00e9ficiaire<\/div><div class='ginput_container ginput_container_date'>\n                            <input name='input_118' id='input_10_118' type='text' value='' class='datepicker gform-datepicker ymd_slash datepicker_no_icon gdatepicker-no-icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_10_118_date_format gfield_description_10_118\" aria-invalid=\"false\" \/>\n                            <span id='input_10_118_date_format' class='screen-reader-text'>AAAA slash MM slash JJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_118' class='gform_hidden' value='https:\/\/microsites.diocesemontreal.org\/microsites\/sasmad\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_10_104\" class=\"gfield gfield--type-select gfield--width-full 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_10_104'>Sexe<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_10_104'>Indiquez si la personne \u00e0 accompagner est un homme ou une femme.<\/div><div class='ginput_container ginput_container_select'><select name='input_104' id='input_10_104' class='medium gfield_select'  aria-describedby=\"gfield_description_10_104\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Femme' >Femme<\/option><option value='Homme' >Homme<\/option><\/select><\/div><\/li><li id=\"field_10_117\" class=\"gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_117'>Courriel de la personne qui remplit ce formulaire<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_117' id='input_10_117' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_10_131\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_131'>Date de l&#039;envoi de la demande<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_131' id='input_10_131' type='text' value='' class='datepicker gform-datepicker ymd_slash datepicker_no_icon gdatepicker-no-icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_10_131_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_131_date_format' class='screen-reader-text'>AAAA slash MM slash JJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_131' class='gform_hidden' value='https:\/\/microsites.diocesemontreal.org\/microsites\/sasmad\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_10_129\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_129'>Milieu de Vie (Domicile\/ R\u00e9sidence\/ \u00c9tablissement de soins) :<\/label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_10_129' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_121\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_10_121' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_10_121_1_container' >\n                                        <input type='text' name='input_121.1' id='input_10_121_1' value=''    aria-required='true'    \/>\n                                        <label for='input_10_121_1' id='input_10_121_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_10_121_2_container' >\n                                        <input type='text' name='input_121.2' id='input_10_121_2' value=''     aria-required='false'   \/>\n                                        <label for='input_10_121_2' id='input_10_121_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_10_121_3_container' >\n                                    <input type='text' name='input_121.3' id='input_10_121_3' value=''    aria-required='true'    \/>\n                                    <label for='input_10_121_3' id='input_10_121_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_10_121_4_container' >\n                                        <input type='text' name='input_121.4' id='input_10_121_4' value=''      aria-required='true'    \/>\n                                        <label for='input_10_121_4' id='input_10_121_4_label' class='gform-field-label gform-field-label--type-sub '>\u00c9tat\/Province\/R\u00e9gion<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_10_121_5_container' >\n                                    <input type='text' name='input_121.5' id='input_10_121_5' value=''    aria-required='true'    \/>\n                                    <label for='input_10_121_5' id='input_10_121_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_121.6' id='input_10_121_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_10_119\" class=\"gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_119'>T\u00e9l\u00e9phone 1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_119' id='input_10_119' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_122\" class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_122'>T\u00e9l\u00e9phone 2<\/label><div class='ginput_container ginput_container_phone'><input name='input_122' id='input_10_122' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_42\" 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_10_42'>Paroisse<\/label><div class='gfield_description' id='gfield_description_10_42'>SVP indiquer la paroisse plus pr\u00e8s de chez vous ou la communaut\u00e9 d'appartenance<\/div><div class='ginput_container ginput_container_text'><input name='input_42' id='input_10_42' type='text' value='' class='medium'  aria-describedby=\"gfield_description_10_42\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_123\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_123'>Secteur<\/label><div class='gfield_description' id='gfield_description_10_123'>(Laval\/ Repentigny, Centre, Est, Ouest, Anglophone)<\/div><div class='ginput_container ginput_container_text'><input name='input_123' id='input_10_123' type='text' value='' class='medium'  aria-describedby=\"gfield_description_10_123\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_124\" class=\"gfield gfield--type-text gfield--width-full 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_10_124'>Langues parl\u00e9es<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_10_124'>SVP indiquez toutes les langues que vous parlez<\/div><div class='ginput_container ginput_container_text'><input name='input_124' id='input_10_124' type='text' value='' class='large'  aria-describedby=\"gfield_description_10_124\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_125\" class=\"gfield gfield--type-text gfield--width-full 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_10_125'>Langues pour l&#039;accompagnement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_10_125'>SVP indiquez la \/les langue(s) de votre pr\u00e9f\u00e9rence pour les visites d'accompagnement<\/div><div class='ginput_container ginput_container_text'><input name='input_125' id='input_10_125' type='text' value='' class='large'  aria-describedby=\"gfield_description_10_125\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_60\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_60'>\u00c9tat de sant\u00e9<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_60' id='input_10_60' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_10_112\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full 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 gfield_label_before_complex' >Besoins exprim\u00e9s :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_10_112'>Cochez tous les choix applicables<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_10_112'><li class='gchoice gchoice_10_112_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.1' type='checkbox'  value='J&#039;aimerais recevoir des visites d&#039;un b\u00e9n\u00e9vole pour parler et m&#039;exprimer'  id='choice_10_112_1'   aria-describedby=\"gfield_description_10_112\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_10_112_1' id='label_10_112_1' class='gform-field-label gform-field-label--type-inline'>J'aimerais recevoir des visites d'un b\u00e9n\u00e9vole pour parler et m'exprimer<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_112_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.2' type='checkbox'  value='J&#039;aimerais recevoir le sacrement du pardon et\/ou la communion'  id='choice_10_112_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_112_2' id='label_10_112_2' class='gform-field-label gform-field-label--type-inline'>J'aimerais recevoir le sacrement du pardon et\/ou la communion<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_112_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.3' type='checkbox'  value='J&#039;aimerais parler \u00e0 un pr\u00eatre'  id='choice_10_112_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_112_3' id='label_10_112_3' class='gform-field-label gform-field-label--type-inline'>J'aimerais parler \u00e0 un pr\u00eatre<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_112_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.4' type='checkbox'  value='Autres (expliquez ci-dessous)'  id='choice_10_112_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_112_4' id='label_10_112_4' class='gform-field-label gform-field-label--type-inline'>Autres (expliquez ci-dessous)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_10_126\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_126'>Autres motifs ou besoins<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_126' id='input_10_126' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_10_127\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_127'>B\u00e9n\u00e9ficiaire r\u00e9f\u00e9r\u00e9 par : (Nom complet\/ Titre ou lien\/ T\u00e9l\u00e9phone\/ Demandes Sp\u00e9cifiques)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_127' id='input_10_127' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_10_128\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_128'>R\u00e9f\u00e9rence familiale en cas d&#039;urgence (nom complet\/ adresse\/ courriel\/ lien avec le b\u00e9n\u00e9ficiaire\/ t\u00e9l\u00e9phone (s)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_128' id='input_10_128' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_10_101\" 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_10_101'>Avez-vous  d&#039;autres commentaires ?<\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_10_101' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_116\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Merci beaucoup de votre demande!<\/h2><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_10' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Envoyer'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_10' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_10' id='gform_theme_10' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_10' id='gform_style_settings_10' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_10' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='10' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='CAD' value='F6QQ9fjogjJ67VaB2Baw5BdcsT0iSes8FRWwhvW9blUI4jocpZngRrTeF8hgob8apHLtk1plC0mLUXxQQtCfgzwGM1krHFW7n+nGU\/8kRA1WYoI=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_10' value='WyJbXSIsImNjZGRiMWY4YWYyMGY4Yzc4ZjgzYzg4ZDJlNmU2MjU5Il0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_10' id='gform_target_page_number_10' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_10' id='gform_source_page_number_10' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"ak_\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"174\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 10, 'https:\/\/microsites.diocesemontreal.org\/microsites\/sasmad\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_10').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_10');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_10').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){jQuery('#gform_wrapper_10').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_10').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_10').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_10').val();gformInitSpinner( 10, 'https:\/\/microsites.diocesemontreal.org\/microsites\/sasmad\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [10, current_page]);window['gf_submitting_10'] = 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_10').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [10]);window['gf_submitting_10'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_10').text());}else{jQuery('#gform_10').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"10\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_10\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_10\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_10\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 10, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;             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subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Une de nos coordonnatrices communiquera avec vous pour faire le suivi \u00a0qui correspond. Nous cherchons \u00e0 r\u00e9pondre \u00e0 votre demande dans les plus brefs d\u00e9lais selon la disponibilit\u00e9 de nos b\u00e9n\u00e9voles.\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_10' >\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">INSCRIPTION B\u00c9N\u00c9FICIAIRE<\/h3>\n                            <p class='gform_description'>Formulaire pour inscrire les nouveaux b\u00e9n\u00e9ficiaires au service d'accompagnement spirituel SASMAD<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_10'  action='\/microsites\/sasmad\/wp-json\/wp\/v2\/pages\/21' data-formid='10' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_10' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_10_1\" class=\"gfield gfield--type-name gf_scroll_text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><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_10_1'>\n                            \n                            <span id='input_10_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_10_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_10_1_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_10_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_10_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_10_1_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_10_118\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_118'>Date de naissance<\/label><div class='gfield_description' id='gfield_description_10_118'>Date de naissance du b\u00e9n\u00e9ficiaire<\/div><div class='ginput_container ginput_container_date'>\n                            <input name='input_118' id='input_10_118' type='text' value='' class='datepicker gform-datepicker ymd_slash datepicker_no_icon gdatepicker-no-icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_10_118_date_format gfield_description_10_118\" aria-invalid=\"false\" \/>\n                            <span id='input_10_118_date_format' class='screen-reader-text'>AAAA slash MM slash JJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_118' class='gform_hidden' value='https:\/\/microsites.diocesemontreal.org\/microsites\/sasmad\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_10_104\" class=\"gfield gfield--type-select gfield--width-full 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_10_104'>Sexe<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_10_104'>Indiquez si la personne \u00e0 accompagner est un homme ou une femme.<\/div><div class='ginput_container ginput_container_select'><select name='input_104' id='input_10_104' class='medium gfield_select'  aria-describedby=\"gfield_description_10_104\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Femme' >Femme<\/option><option value='Homme' >Homme<\/option><\/select><\/div><\/li><li id=\"field_10_117\" class=\"gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_117'>Courriel de la personne qui remplit ce formulaire<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_117' id='input_10_117' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_10_131\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_131'>Date de l&#039;envoi de la demande<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_131' id='input_10_131' type='text' value='' class='datepicker gform-datepicker ymd_slash datepicker_no_icon gdatepicker-no-icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_10_131_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_131_date_format' class='screen-reader-text'>AAAA slash MM slash JJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_131' class='gform_hidden' value='https:\/\/microsites.diocesemontreal.org\/microsites\/sasmad\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_10_129\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_129'>Milieu de Vie (Domicile\/ R\u00e9sidence\/ \u00c9tablissement de soins) :<\/label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_10_129' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_121\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_10_121' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_10_121_1_container' >\n                                        <input type='text' name='input_121.1' id='input_10_121_1' value=''    aria-required='true'    \/>\n                                        <label for='input_10_121_1' id='input_10_121_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_10_121_2_container' >\n                                        <input type='text' name='input_121.2' id='input_10_121_2' value=''     aria-required='false'   \/>\n                                        <label for='input_10_121_2' id='input_10_121_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_10_121_3_container' >\n                                    <input type='text' name='input_121.3' id='input_10_121_3' value=''    aria-required='true'    \/>\n                                    <label for='input_10_121_3' id='input_10_121_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_10_121_4_container' >\n                                        <input type='text' name='input_121.4' id='input_10_121_4' value=''      aria-required='true'    \/>\n                                        <label for='input_10_121_4' id='input_10_121_4_label' class='gform-field-label gform-field-label--type-sub '>\u00c9tat\/Province\/R\u00e9gion<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_10_121_5_container' >\n                                    <input type='text' name='input_121.5' id='input_10_121_5' value=''    aria-required='true'    \/>\n                                    <label for='input_10_121_5' id='input_10_121_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_121.6' id='input_10_121_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_10_119\" class=\"gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_119'>T\u00e9l\u00e9phone 1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_119' id='input_10_119' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_122\" class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_122'>T\u00e9l\u00e9phone 2<\/label><div class='ginput_container ginput_container_phone'><input name='input_122' id='input_10_122' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_42\" 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_10_42'>Paroisse<\/label><div class='gfield_description' id='gfield_description_10_42'>SVP indiquer la paroisse plus pr\u00e8s de chez vous ou la communaut\u00e9 d'appartenance<\/div><div class='ginput_container ginput_container_text'><input name='input_42' id='input_10_42' type='text' value='' class='medium'  aria-describedby=\"gfield_description_10_42\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_123\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_123'>Secteur<\/label><div class='gfield_description' id='gfield_description_10_123'>(Laval\/ Repentigny, Centre, Est, Ouest, Anglophone)<\/div><div class='ginput_container ginput_container_text'><input name='input_123' id='input_10_123' type='text' value='' class='medium'  aria-describedby=\"gfield_description_10_123\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_124\" class=\"gfield gfield--type-text gfield--width-full 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_10_124'>Langues parl\u00e9es<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_10_124'>SVP indiquez toutes les langues que vous parlez<\/div><div class='ginput_container ginput_container_text'><input name='input_124' id='input_10_124' type='text' value='' class='large'  aria-describedby=\"gfield_description_10_124\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_125\" class=\"gfield gfield--type-text gfield--width-full 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_10_125'>Langues pour l&#039;accompagnement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_10_125'>SVP indiquez la \/les langue(s) de votre pr\u00e9f\u00e9rence pour les visites d'accompagnement<\/div><div class='ginput_container ginput_container_text'><input name='input_125' id='input_10_125' type='text' value='' class='large'  aria-describedby=\"gfield_description_10_125\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_60\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_60'>\u00c9tat de sant\u00e9<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_60' id='input_10_60' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_10_112\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full 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 gfield_label_before_complex' >Besoins exprim\u00e9s :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_10_112'>Cochez tous les choix applicables<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_10_112'><li class='gchoice gchoice_10_112_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.1' type='checkbox'  value='J&#039;aimerais recevoir des visites d&#039;un b\u00e9n\u00e9vole pour parler et m&#039;exprimer'  id='choice_10_112_1'   aria-describedby=\"gfield_description_10_112\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_10_112_1' id='label_10_112_1' class='gform-field-label gform-field-label--type-inline'>J'aimerais recevoir des visites d'un b\u00e9n\u00e9vole pour parler et m'exprimer<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_112_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.2' type='checkbox'  value='J&#039;aimerais recevoir le sacrement du pardon et\/ou la communion'  id='choice_10_112_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_112_2' id='label_10_112_2' class='gform-field-label gform-field-label--type-inline'>J'aimerais recevoir le sacrement du pardon et\/ou la communion<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_112_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.3' type='checkbox'  value='J&#039;aimerais parler \u00e0 un pr\u00eatre'  id='choice_10_112_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_112_3' id='label_10_112_3' class='gform-field-label gform-field-label--type-inline'>J'aimerais parler \u00e0 un pr\u00eatre<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_112_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.4' type='checkbox'  value='Autres (expliquez ci-dessous)'  id='choice_10_112_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_112_4' id='label_10_112_4' class='gform-field-label gform-field-label--type-inline'>Autres (expliquez ci-dessous)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_10_126\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_126'>Autres motifs ou besoins<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_126' id='input_10_126' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_10_127\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_above 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