{"id":4307,"date":"2025-04-16T14:47:20","date_gmt":"2025-04-16T14:47:20","guid":{"rendered":"https:\/\/actionfh.ca\/become-a-member\/active-or-supporting-member-registration\/"},"modified":"2025-04-24T17:53:13","modified_gmt":"2025-04-24T17:53:13","slug":"active-or-supporting-member-registration","status":"publish","type":"page","link":"https:\/\/actionfh.ca\/en\/become-a-member\/active-or-supporting-member-registration\/","title":{"rendered":"Active or Supporting Member Registration"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"4307\" class=\"elementor elementor-4307 elementor-4203\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-d1470e2 e-flex e-con-boxed e-con e-parent\" data-id=\"d1470e2\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-c6e6ce9 e-con-full e-flex e-con e-child\" data-id=\"c6e6ce9\" data-element_type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-ae91151 e-con-full e-flex e-con e-child\" data-id=\"ae91151\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-17ed86f fil-ariane elementor-widget elementor-widget-breadcrumbs\" data-id=\"17ed86f\" data-element_type=\"widget\" data-widget_type=\"breadcrumbs.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<nav aria-label=\"breadcrumbs\" class=\"rank-math-breadcrumb\"><p><span class=\"last\">Home<\/span><\/p><\/nav>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7c664d8 elementor-widget elementor-widget-heading\" data-id=\"7c664d8\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Renewal or Member Registration Active or Supporting Member<\/h1>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-d3e3cad e-con-full elementor-hidden-mobile e-flex e-con e-child\" data-id=\"d3e3cad\" data-element_type=\"container\">\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-9441af3 e-flex e-con-boxed e-con e-parent\" data-id=\"9441af3\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-53c7e70 e-con-full e-flex e-con e-child\" data-id=\"53c7e70\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-57072b7 elementor-widget__width-initial elementor-widget elementor-widget-text-editor\" data-id=\"57072b7\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<p>You can also complete this form by phone by calling us at 514-218-6368 ext. 4, or you can download the Word version <a href=\"https:\/\/actionfh.ca\/wp-content\/uploads\/2025\/04\/FORMULAIRE-DE-RENOUVELLEMENT-OU-DADHESION_FR.docx\">here<\/a>.<\/p><p>For Word versions, you can return your completed form to us at projet@actionfh.ca. You can also mail it to us at our offices: <\/p><p>469 Jean-Talon West<br>Local 101<br>Montr\u00e9al, (Qc)<br>H3N 1R4<\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-e14d1be e-flex e-con-boxed e-con e-child\" data-id=\"e14d1be\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-ae41743 elementor-widget-divider--view-line elementor-widget elementor-widget-divider\" data-id=\"ae41743\" data-element_type=\"widget\" data-widget_type=\"divider.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-divider\">\n\t\t\t<span class=\"elementor-divider-separator\">\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-40d1721 elementor-widget elementor-widget-heading\" data-id=\"40d1721\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Renewal or Registration Form<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-94c8330 e-con-full e-flex e-con e-child\" data-id=\"94c8330\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-175169a e-con-full e-flex e-con e-child\" data-id=\"175169a\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-a4771e4 elementor-widget__width-inherit elementor-widget elementor-widget-html\" data-id=\"a4771e4\" data-element_type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<div class=\"form-contact\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f4316-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"4316\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/4307#wpcf7-f4316-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"4316\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f4316-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<div class=\"one-col\">\n\t<div class=\"label-div\">\n\t\t<p>I would like to * <span class=\"wpcf7-form-control-wrap\" data-name=\"JeSouhaite\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required checkbox-value\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"JeSouhaite[]\" value=\"Renew my membership\" \/><span class=\"wpcf7-list-item-label\">Renew my membership<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"JeSouhaite[]\" value=\"Become a member\" \/><span class=\"wpcf7-list-item-label\">Become a member<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"one-col\">\n\t<div class=\"label-div\">\n\t\t<p>Which membership category best suits you?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"categoriemembre\"><span class=\"wpcf7-form-control wpcf7-checkbox checkbox-value\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"categoriemembre[]\" value=\"Active Member\" \/><span class=\"wpcf7-list-item-label\">Active Member<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"categoriemembre[]\" value=\"Supporting Member\" \/><span class=\"wpcf7-list-item-label\">Supporting Member<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<h3>Active or Supporting Member Identification\n<\/h3>\n<div class=\"multi-col\">\n\t<p><label>First name or Pseudo * <span class=\"wpcf7-form-control-wrap\" data-name=\"your-lastname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-lastname\" \/><\/span><\/label><label>Nom <span class=\"wpcf7-form-control-wrap\" data-name=\"your-firstname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-firstname\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<div class=\"multi-col\">\n\t<p><label>Pronoun(s) used <span class=\"wpcf7-form-control-wrap\" data-name=\"Pronomsutilisse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Pronomsutilisse\" \/><\/span><\/label><label>Courriel *<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<div class=\"multi-col\">\n\t<p><label>Telephone <span class=\"wpcf7-form-control-wrap\" data-name=\"your-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-phone\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<div class=\"one-col\">\n\t<div class=\"label-div\">\n\t\t<p>Age range * <span class=\"wpcf7-form-control-wrap\" data-name=\"age\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox checkbox-value\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"age\" value=\"15 to 18 y\/o\" \/><span class=\"wpcf7-list-item-label\">15 to 18 y\/o<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"age\" value=\"18 to 35 y\/o\" \/><span class=\"wpcf7-list-item-label\">18 to 35 y\/o<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"age\" value=\"36 to 49 y\/o\" \/><span class=\"wpcf7-list-item-label\">36 to 49 y\/o<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"age\" value=\"50 to 65 y\/o\" \/><span class=\"wpcf7-list-item-label\">50 to 65 y\/o<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"age\" value=\"66 and over\" \/><span class=\"wpcf7-list-item-label\">66 and over<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"age\" value=\"I prefer not to answer\" \/><span class=\"wpcf7-list-item-label\">I prefer not to answer<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<hr \/>\n<h3>SPECIAL NEEDS\n<\/h3>\n<p>This section helps us provide you with the best possible experience at our workshops and other events\n<\/p>\n<div class=\"one-col\">\n\t<div class=\"label-div\">\n\t\t<p>What type of disability do you have? Multiple answers possible<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"typehandicap\"><span class=\"wpcf7-form-control wpcf7-checkbox checkbox-value\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"typehandicap[]\" value=\"Visual\" \/><span class=\"wpcf7-list-item-label\">Visual<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"typehandicap[]\" value=\"Hearing impair\" \/><span class=\"wpcf7-list-item-label\">Hearing impair<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"typehandicap[]\" value=\"Motor\" \/><span class=\"wpcf7-list-item-label\">Motor<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"typehandicap[]\" value=\"Cognitive\" \/><span class=\"wpcf7-list-item-label\">Cognitive<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"typehandicap[]\" value=\"Mental health disorder\" \/><span class=\"wpcf7-list-item-label\">Mental health disorder<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"typehandicap[]\" value=\"Neurological\" \/><span class=\"wpcf7-list-item-label\">Neurological<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"typehandicap[]\" value=\"Intellectual disability\" \/><span class=\"wpcf7-list-item-label\">Intellectual disability<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"typehandicap[]\" value=\"Autism spectrum disorder\" \/><span class=\"wpcf7-list-item-label\">Autism spectrum disorder<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"typehandicap[]\" value=\"None\" \/><span class=\"wpcf7-list-item-label\">None<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"typehandicap[]\" value=\"I prefer not to answer\" \/><span class=\"wpcf7-list-item-label\">I prefer not to answer<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"one-col\">\n\t<div class=\"label-div\">\n\t\t<p>Do you have any special needs to ensure your full participation?<span class=\"wpcf7-form-control-wrap\" data-name=\"besoin\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required checkbox-value\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"besoin[]\" value=\"Large prints documents\" \/><span class=\"wpcf7-list-item-label\">Large prints documents<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"besoin[]\" value=\"Braille documents\" \/><span class=\"wpcf7-list-item-label\">Braille documents<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"besoin[]\" value=\"Captioning\" \/><span class=\"wpcf7-list-item-label\">Captioning<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"besoin[]\" value=\"Help with feeding yourself\" \/><span class=\"wpcf7-list-item-label\">Help with feeding yourself<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"besoin[]\" value=\"Help to go to the bathroom\" \/><span class=\"wpcf7-list-item-label\">Help to go to the bathroom<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"besoin[]\" value=\"Other (specify) :\" \/><span class=\"wpcf7-list-item-label\">Other (specify) :<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"one-col\">\n\t<p><label><span class=\"wpcf7-form-control-wrap\" data-name=\"besoin-autre\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"besoin-autre\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<hr \/>\n<h3>COMMUNICATION\n<\/h3>\n<p>Action Femmes et Handicap communicates with its members by e-mail through a monthly newsletter and occasional communications when necessary.\n<\/p>\n<div class=\"one-col\">\n\t<div class=\"label-div\">\n\t\t<p>Would you like to be added to our mailing list to receive the latest news from AFH?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"communication\"><span class=\"wpcf7-form-control wpcf7-checkbox checkbox-value\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"communication[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"communication[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"communication[]\" value=\"I&#039;m already registered\" \/><span class=\"wpcf7-list-item-label\">I&#039;m already registered<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<hr \/>\n<h3>PAYMENT\n<\/h3>\n<p>If you would like to have your payment mailed to you, here is our mailing address: 469 Jean-Talon West, Suite 101 Montr\u00e9al (Qc) H3N 1R4\n<\/p>\n<div class=\"one-col\">\n\t<div class=\"label-div\">\n\t\t<p>How would you like to pay? * <span class=\"wpcf7-form-control-wrap\" data-name=\"paiement\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required checkbox-value\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"paiement[]\" value=\"By interac transfer, please write to projet@actionfh.ca to know the peocedure.\" \/><span class=\"wpcf7-list-item-label\">By interac transfer, please write to projet@actionfh.ca to know the peocedure.<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"paiement[]\" value=\"By cheque sent by mail\" \/><span class=\"wpcf7-list-item-label\">By cheque sent by mail<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"paiement[]\" value=\"Cash sent by mail\" \/><span class=\"wpcf7-list-item-label\">Cash sent by mail<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"paiement[]\" value=\"As an active member, I would like to benefit from the following membership program.\" \/><span class=\"wpcf7-list-item-label\">As an active member, I would like to benefit from the following membership program.<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"one-col\">\n\t<div class=\"label-div\">\n\t\t<p>Would you like to pay for more than one membership in order to contribute to the program? * <span class=\"wpcf7-form-control-wrap\" data-name=\"Programme-adhesion-suivante\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox checkbox-value\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"Programme-adhesion-suivante\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"Programme-adhesion-suivante\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<hr \/>\n<h3>Authorization for minors\n<\/h3>\n<div class=\"one-col\">\n\t<div class=\"label-div\">\n\t\t<p>Have you completed this form on behalf of a minor? * <span class=\"wpcf7-form-control-wrap\" data-name=\"mineur\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox checkbox-value\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"mineur\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"mineur\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"one-col\">\n\t<div class=\"label-div\">\n\t\t<p>If yes, please indicate your relationship with this person <span class=\"wpcf7-form-control-wrap\" data-name=\"lien-mineur\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox checkbox-value\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"lien-mineur\" value=\"Parent\" \/><span class=\"wpcf7-list-item-label\">Parent<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"lien-mineur\" value=\"Guardian\" \/><span class=\"wpcf7-list-item-label\">Guardian<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"lien-mineur\" value=\"Caregiver\" \/><span class=\"wpcf7-list-item-label\">Caregiver<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<hr \/>\n<h3>Authorization\n<\/h3>\n<div class=\"one-col\">\n\t<div class=\"label-div\">\n\t\t<p>By checking \u201cI agree\u201d you agree that the information you have provided throughout this form will be consulted by the AFH team and kept until you inform us of your wish to end your membership. These answers will be used for communication and statistical purposes only.\n\t\t<\/p>\n\t\t<p>If you choose instead to click on \u201cI decline\u201d below, we will destroy your responses, but it is possible that someone else may have viewed them first.\n\t\t<\/p>\n\t\t<p>If you have completed the form for a minor, the same warning applies. Please ensure that the minor consents.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"autorisation\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox checkbox-value\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"autorisation\" value=\"I AGREE\" \/><span class=\"wpcf7-list-item-label\">I AGREE<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"autorisation\" value=\"I DECLINE\" \/><span class=\"wpcf7-list-item-label\">I DECLINE<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Send\" \/>\n<\/p><div class=\"wpcf7-response-output\" 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