{"id":12959,"date":"2021-04-29T20:52:52","date_gmt":"2021-04-29T20:52:52","guid":{"rendered":"https:\/\/clone.arsacs.com\/?page_id=12959"},"modified":"2026-04-14T14:08:58","modified_gmt":"2026-04-14T18:08:58","slug":"register","status":"publish","type":"page","link":"https:\/\/2026.arsacs.com\/fr\/register\/","title":{"rendered":"Register"},"content":{"rendered":"<div class=\"et_pb_section_0 et_pb_section et_section_regular et_block_section\">\n<div class=\"et_pb_row_0 et_pb_row et_block_row\">\n<div class=\"et_pb_column_0 et_pb_column et_pb_column_4_4 et-last-child et_block_column et_pb_css_mix_blend_mode_passthrough\">\n<div class=\"et_pb_text_0 et_pb_text et_pb_bg_layout_light et_pb_module et_block_module\"><div class=\"et_pb_text_inner\"><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_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Register a Patient Diagnosed with ARSACS<\/h3>\n                            <p class='gform_description'><p>This is an easy and simple on-line registry. Please fill out the form to subscribe to the International ARSACS Patient Registry. All fields marked with (*) are required.<\/p>\r\n<p><strong>You must have legal authority to provide personal information concerning another person<\/strong><\/p><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/fr\/wp-json\/wp\/v2\/pages\/12959#gf_1' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_1_51\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_51'>URL<\/label><div class='gfield_description' id='gfield_description_1_51'>Ce champ n\u2019est utilis\u00e9 qu\u2019\u00e0 des fins de validation et devrait rester inchang\u00e9.<\/div><div class='ginput_container'><input name='input_51' id='input_1_51' type='text' value='' autocomplete='new-password'\/><\/div><\/li><li id=\"field_1_18\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Identification of person entering the data<\/h2><\/li><li id=\"field_1_1\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >The diagnosed ARSACS person that I am registering is<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_1'>\n\t\t\t<li class='gchoice gchoice_1_1_0'>\n\t\t\t\t<input name='input_1' type='radio' value='myself (18 years or older)'  id='choice_1_1_0'    \/>\n\t\t\t\t<label for='choice_1_1_0' id='label_1_1_0' class='gform-field-label gform-field-label--type-inline'>myself (18 years or older)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_1_1'>\n\t\t\t\t<input name='input_1' type='radio' value='a person for whom I have legal authority to consent to having his \/ her personal information entered in the register (eg, a parent, a guardian).'  id='choice_1_1_1'    \/>\n\t\t\t\t<label for='choice_1_1_1' id='label_1_1_1' class='gform-field-label gform-field-label--type-inline'>a person for whom I have legal authority to consent to having his \/ her personal information entered in the register (eg, a parent, a guardian).<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_41' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-41' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_1_38\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Contact information for person entering the data<\/h2><\/li><li id=\"field_1_19\" class=\"gfield gfield--type-name gfield--input-type-name 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' >Your Name<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_1_19'>\n                            \n                            <span id='input_1_19_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_19.3' id='input_1_19_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_19_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_19_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_19.6' id='input_1_19_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_19_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_50\" class=\"gfield gfield--type-address gfield--input-type-address 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' >Your Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \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_1_50' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_50_1_container' >\n                                        <input type='text' name='input_50.1' id='input_1_50_1' value=''    aria-required='true'    \/>\n                                        <label for='input_1_50_1' id='input_1_50_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_50_3_container' >\n                                    <input type='text' name='input_50.3' id='input_1_50_3' value=''    aria-required='true'    \/>\n                                    <label for='input_1_50_3' id='input_1_50_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_1_50_4_container' >\n                                        <input type='text' name='input_50.4' id='input_1_50_4' value=''      aria-required='true'    \/>\n                                        <label for='input_1_50_4' id='input_1_50_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_1_50_5_container' >\n                                    <input type='text' name='input_50.5' id='input_1_50_5' value=''    aria-required='true'    \/>\n                                    <label for='input_1_50_5' id='input_1_50_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Code postal<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_1_50_6_container' >\n                                        <select name='input_50.6' id='input_1_50_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Afrique du Sud' >Afrique du Sud<\/option><option value='Albanie' >Albanie<\/option><option value='Alg\u00e9rie' >Alg\u00e9rie<\/option><option value='Allemagne' >Allemagne<\/option><option value='Andorre' >Andorre<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctique' >Antarctique<\/option><option value='Antigua-et-Barbuda' >Antigua-et-Barbuda<\/option><option value='Arabie Saoudite' >Arabie Saoudite<\/option><option value='Argentine' >Argentine<\/option><option value='Arm\u00e9nie' >Arm\u00e9nie<\/option><option value='Aruba' >Aruba<\/option><option value='Australie' >Australie<\/option><option value='Autriche' >Autriche<\/option><option value='Azerba\u00efdjan' >Azerba\u00efdjan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahre\u00efn' >Bahre\u00efn<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Belarus' >Belarus<\/option><option value='Belgique' >Belgique<\/option><option value='Belize' >Belize<\/option><option value='Bermudes' >Bermudes<\/option><option value='Bhoutan' >Bhoutan<\/option><option value='Bolivie' >Bolivie<\/option><option value='Bonaire, Saint-Eustache et Saba' >Bonaire, Saint-Eustache et Saba<\/option><option value='Bosnie-Herz\u00e9govine' >Bosnie-Herz\u00e9govine<\/option><option value='Botswana' >Botswana<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Br\u00e9sil' >Br\u00e9sil<\/option><option value='Bulgarie' >Bulgarie<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9nin' >B\u00e9nin<\/option><option value='Cambodge' >Cambodge<\/option><option value='Cameroun' >Cameroun<\/option><option value='Canada' >Canada<\/option><option value='Cap-Vert' >Cap-Vert<\/option><option value='Chili' >Chili<\/option><option value='Chine' >Chine<\/option><option value='Chypre' >Chypre<\/option><option value='Colombie' >Colombie<\/option><option value='Comores' >Comores<\/option><option value='Congo' >Congo<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatie' >Croatie<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d\u2019Ivoire' >C\u00f4te d\u2019Ivoire<\/option><option value='Danemark' >Danemark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominique' >Dominique<\/option><option value='Espagne' >Espagne<\/option><option value='Estonie' >Estonie<\/option><option value='Eswatini' >Eswatini<\/option><option value='Fidji' >Fidji<\/option><option value='Finlande' >Finlande<\/option><option value='France' >France<\/option><option value='Gabon' >Gabon<\/option><option value='Gambie' >Gambie<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Grenade' >Grenade<\/option><option value='Groenland' >Groenland<\/option><option value='Gr\u00e8ce' >Gr\u00e8ce<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernesey' >Guernesey<\/option><option value='Guin\u00e9e' >Guin\u00e9e<\/option><option value='Guin\u00e9e Fran\u00e7aise' >Guin\u00e9e Fran\u00e7aise<\/option><option value='Guin\u00e9e \u00e9quatoriale' >Guin\u00e9e \u00e9quatoriale<\/option><option value='Guin\u00e9e-Bissau' >Guin\u00e9e-Bissau<\/option><option value='Guyane' >Guyane<\/option><option value='G\u00e9orgie' >G\u00e9orgie<\/option><option value='Ha\u00efti' >Ha\u00efti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hongrie' >Hongrie<\/option><option value='Iles Aland' >Iles Aland<\/option><option value='Inde' >Inde<\/option><option value='Indon\u00e9sie' >Indon\u00e9sie<\/option><option value='Irak' >Irak<\/option><option value='Iran' >Iran<\/option><option value='Irlande' >Irlande<\/option><option value='Islande' >Islande<\/option><option value='Isra\u00ebl' >Isra\u00ebl<\/option><option value='Italie' >Italie<\/option><option value='Jama\u00efque' >Jama\u00efque<\/option><option value='Japon' >Japon<\/option><option value='Jersey' >Jersey<\/option><option value='Jordanie' >Jordanie<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kirghizistan' >Kirghizistan<\/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='Kowe\u00eft' >Kowe\u00eft<\/option><option value='La Barbade' >La Barbade<\/option><option value='La R\u00e9union' >La R\u00e9union<\/option><option value='Lesotho' >Lesotho<\/option><option value='Lettonie' >Lettonie<\/option><option value='Liban' >Liban<\/option><option value='Liberia' >Liberia<\/option><option value='Libye' >Libye<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituanie' >Lituanie<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malaisie' >Malaisie<\/option><option value='Malawi' >Malawi<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malte' >Malte<\/option><option value='Maroc' >Maroc<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritanie' >Mauritanie<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexique' >Mexique<\/option><option value='Micron\u00e9sie' >Micron\u00e9sie<\/option><option value='Moldavie' >Moldavie<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolie' >Mongolie<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mont\u00e9n\u00e9gro' >Mont\u00e9n\u00e9gro<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibie' >Namibie<\/option><option value='Nauru' >Nauru<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nig\u00e9ria' >Nig\u00e9ria<\/option><option value='Niue' >Niue<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Norv\u00e8ge' >Norv\u00e8ge<\/option><option value='Nouvelle Cal\u00e9donie' >Nouvelle Cal\u00e9donie<\/option><option value='Nouvelle-Z\u00e9lande' >Nouvelle-Z\u00e9lande<\/option><option value='N\u00e9pal' >N\u00e9pal<\/option><option value='Oman' >Oman<\/option><option value='Ouganda' >Ouganda<\/option><option value='Ouzb\u00e9kistan' >Ouzb\u00e9kistan<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Panama' >Panama<\/option><option value='Papouasie-Nouvelle-Guin\u00e9e' >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value='Paraguay' >Paraguay<\/option><option value='Pays-Bas' >Pays-Bas<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Pologne' >Pologne<\/option><option value='Polyn\u00e9sie fran\u00e7aise' >Polyn\u00e9sie fran\u00e7aise<\/option><option value='Porto Rico' >Porto Rico<\/option><option value='Portugal' >Portugal<\/option><option value='P\u00e9rou' >P\u00e9rou<\/option><option value='Qatar' >Qatar<\/option><option value='Roumanie' >Roumanie<\/option><option value='Royaume-Uni' >Royaume-Uni<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9publique Dominicaine' >R\u00e9publique Dominicaine<\/option><option value='R\u00e9publique centrafricaine' >R\u00e9publique centrafricaine<\/option><option value='R\u00e9publique d\u00e9mocratique du Congo' >R\u00e9publique d\u00e9mocratique du Congo<\/option><option value='R\u00e9publique d\u00e9mocratique populaire Lao' >R\u00e9publique d\u00e9mocratique populaire Lao<\/option><option value='Sahara occidental' >Sahara occidental<\/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 Martin' >Saint Martin<\/option><option value='Saint-Christophe-et-Nevis' >Saint-Christophe-et-Nevis<\/option><option value='Saint-Marin' >Saint-Marin<\/option><option value='Saint-Martin' >Saint-Martin<\/option><option value='Saint-Pierre-et-Miquelon' >Saint-Pierre-et-Miquelon<\/option><option value='Saint-Si\u00e8ge' >Saint-Si\u00e8ge<\/option><option value='Saint-Vincent-et-les Grenadines' >Saint-Vincent-et-les Grenadines<\/option><option value='Sainte-Lucie' >Sainte-Lucie<\/option><option value='Salvador' >Salvador<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa am\u00e9ricaines' >Samoa am\u00e9ricaines<\/option><option value='Sao Tom\u00e9 et Principe' >Sao Tom\u00e9 et Principe<\/option><option value='Serbie' >Serbie<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapour' >Singapour<\/option><option value='Slovaquie' >Slovaquie<\/option><option value='Slov\u00e9nie' >Slov\u00e9nie<\/option><option value='Somalie' >Somalie<\/option><option value='Soudan' >Soudan<\/option><option value='Soudan du Sud' >Soudan du Sud<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Suisse' >Suisse<\/option><option value='Suriname' >Suriname<\/option><option value='Su\u00e8de' >Su\u00e8de<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='S\u00e9n\u00e9gal' >S\u00e9n\u00e9gal<\/option><option value='Tadjikistan' >Tadjikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Ta\u00efwan' >Ta\u00efwan<\/option><option value='Tchad' >Tchad<\/option><option value='Terres australes Fran\u00e7aises' >Terres australes Fran\u00e7aises<\/option><option value='Territoire britannique de l&#039;oc\u00e9an Indien' >Territoire britannique de l&#039;oc\u00e9an Indien<\/option><option value='Tha\u00eflande' >Tha\u00eflande<\/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='Trinit\u00e9 et Tobago' >Trinit\u00e9 et Tobago<\/option><option value='Tunisie' >Tunisie<\/option><option value='Turkm\u00e9nistan' >Turkm\u00e9nistan<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='Ukraine' >Ukraine<\/option><option value='Uruguay' >Uruguay<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Wallis et Futuna' >Wallis et Futuna<\/option><option value='Y\u00e9men' >Y\u00e9men<\/option><option value='Zambie' >Zambie<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c9gypte' >\u00c9gypte<\/option><option value='\u00c9mirats arabes unis' >\u00c9mirats arabes unis<\/option><option value='\u00c9quateur' >\u00c9quateur<\/option><option value='\u00c9rythr\u00e9e' >\u00c9rythr\u00e9e<\/option><option value='\u00c9tat palestinien' >\u00c9tat palestinien<\/option><option value='\u00c9tats-Unis' >\u00c9tats-Unis<\/option><option value='\u00c9thiopie' >\u00c9thiopie<\/option><option value='\u00cele Bouvet' >\u00cele Bouvet<\/option><option value='\u00cele Maurice' >\u00cele Maurice<\/option><option value='\u00cele de Man' >\u00cele de Man<\/option><option value='\u00cele de Norfolk' >\u00cele de Norfolk<\/option><option value='\u00cele de No\u00ebl' >\u00cele de No\u00ebl<\/option><option value='\u00celes Cayman' >\u00celes Cayman<\/option><option value='\u00celes Cocos' >\u00celes Cocos<\/option><option value='\u00celes Cook' >\u00celes Cook<\/option><option value='\u00celes Falkland' >\u00celes Falkland<\/option><option value='\u00celes F\u00e9ro\u00e9' >\u00celes F\u00e9ro\u00e9<\/option><option value='\u00celes Mariannes du Nord' >\u00celes Mariannes du Nord<\/option><option value='\u00celes Marshall' >\u00celes Marshall<\/option><option value='\u00celes Salomon' >\u00celes Salomon<\/option><option value='\u00celes Turques-et-Ca\u00efques' >\u00celes Turques-et-Ca\u00efques<\/option><option value='\u00celes Vierges am\u00e9ricaines' >\u00celes Vierges am\u00e9ricaines<\/option><option value='\u00celes Vierges britanniques' >\u00celes Vierges britanniques<\/option><option value='\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis' >\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><\/select>\n                                        <label for='input_1_50_6' id='input_1_50_6_label' class='gform-field-label gform-field-label--type-sub '>Pays<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_21\" class=\"gfield gfield--type-email gfield--input-type-email 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' >Your Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_21'>Registration confirmation will be sent to this email address.<\/div><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_1_21_container'>\n                                <span id='input_1_21_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_21' id='input_1_21' value=''    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_1_21\" \/>\n                                    <label for='input_1_21' class='gform-field-label gform-field-label--type-sub '>Enter Email Address<\/label>\n                                <\/span>\n                                <span id='input_1_21_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_21_2' id='input_1_21_2' value=''    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_1_21\" \/>\n                                    <label for='input_1_21_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email Address<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_1_36\" class=\"gfield gfield--type-email gfield--input-type-email 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' >Second Email (optional)<\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_1_36_container'>\n                                <span id='input_1_36_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_36' id='input_1_36' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_1_36' class='gform-field-label gform-field-label--type-sub '>Enter 2nd Email<\/label>\n                                <\/span>\n                                <span id='input_1_36_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_36_2' id='input_1_36_2' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_1_36_2' class='gform-field-label gform-field-label--type-sub '>Confirm 2nd Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_1_22\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_22'>Your Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_22' id='input_1_22' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_23\" class=\"gfield gfield--type-select gfield--input-type-select 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_1_23'>Relationship with the ARSACS patient who has the authority to consent for that person<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_23' id='input_1_23' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Parent' >Parent<\/option><option value='Guardian' >Guardian<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_42' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_42' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-42' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_1_9\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Patient Information<\/h2><\/li><li id=\"field_1_2\" class=\"gfield gfield--type-name gfield--input-type-name 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' >Name<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_1_2'>\n                            \n                            <span id='input_1_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_1_2_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_2_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_1_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_2_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_3\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon dob 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_1_3'>Date of Birth<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_3' id='input_1_3' type='text' value='' class='datepicker gform-datepicker ymd_slash datepicker_with_icon gdatepicker_with_icon'   placeholder='yyyy\/mm\/dd' aria-describedby=\"input_1_3_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_3_date_format' class='screen-reader-text'>YYYY slash MM slash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_3' class='gform_hidden' value='https:\/\/2026.arsacs.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_6'>\n\t\t\t<li class='gchoice gchoice_1_6_0'>\n\t\t\t\t<input name='input_6' type='radio' value='Male'  id='choice_1_6_0'    \/>\n\t\t\t\t<label for='choice_1_6_0' id='label_1_6_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_6_1'>\n\t\t\t\t<input name='input_6' type='radio' value='Female'  id='choice_1_6_1'    \/>\n\t\t\t\t<label for='choice_1_6_1' id='label_1_6_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_45' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_45' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-45' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_1_48\" class=\"gfield gfield--type-number gfield--input-type-number age gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_48'>Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_48' id='input_1_48' type='number' step='any' min='1' max='120' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_48\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_48'>Veuillez saisir un nombre entre <strong>1<\/strong> et <strong>120<\/strong>.<\/div><\/div><\/li><li id=\"field_1_46\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Patient is under 18 years old<\/h2><\/li><li id=\"field_1_5\" class=\"gfield gfield--type-text gfield--input-type-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' for='input_1_5'>Name of Parent\/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_5' id='input_1_5' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_26\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >We're sorry, but we can not allow a person under 18 years old register themselves. Please ask a parent or guardian to fill out this form on your behalf. <\/li><li id=\"field_1_47\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Patient Contact Information<\/h2><\/li><li id=\"field_1_10\" class=\"gfield gfield--type-address gfield--input-type-address 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' >Address<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 has_country ginput_container_address gform-grid-row' id='input_1_10' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_10_1_container' >\n                                        <input type='text' name='input_10.1' id='input_1_10_1' value=''    aria-required='true'    \/>\n                                        <label for='input_1_10_1' id='input_1_10_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_1_10_2_container' >\n                                        <input type='text' name='input_10.2' id='input_1_10_2' value=''     aria-required='false'   \/>\n                                        <label for='input_1_10_2' id='input_1_10_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_1_10_3_container' >\n                                    <input type='text' name='input_10.3' id='input_1_10_3' value=''    aria-required='true'    \/>\n                                    <label for='input_1_10_3' id='input_1_10_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_1_10_4_container' >\n                                        <input type='text' name='input_10.4' id='input_1_10_4' value=''      aria-required='true'    \/>\n                                        <label for='input_1_10_4' id='input_1_10_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_1_10_5_container' >\n                                    <input type='text' name='input_10.5' id='input_1_10_5' value=''    aria-required='true'    \/>\n                                    <label for='input_1_10_5' id='input_1_10_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Code postal<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_1_10_6_container' >\n                                        <select name='input_10.6' id='input_1_10_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Afrique du Sud' >Afrique du Sud<\/option><option value='Albanie' >Albanie<\/option><option value='Alg\u00e9rie' >Alg\u00e9rie<\/option><option value='Allemagne' >Allemagne<\/option><option value='Andorre' >Andorre<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctique' >Antarctique<\/option><option value='Antigua-et-Barbuda' >Antigua-et-Barbuda<\/option><option value='Arabie Saoudite' >Arabie Saoudite<\/option><option value='Argentine' >Argentine<\/option><option value='Arm\u00e9nie' >Arm\u00e9nie<\/option><option value='Aruba' >Aruba<\/option><option value='Australie' >Australie<\/option><option value='Autriche' >Autriche<\/option><option value='Azerba\u00efdjan' >Azerba\u00efdjan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahre\u00efn' >Bahre\u00efn<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Belarus' >Belarus<\/option><option value='Belgique' >Belgique<\/option><option value='Belize' >Belize<\/option><option value='Bermudes' >Bermudes<\/option><option value='Bhoutan' >Bhoutan<\/option><option value='Bolivie' >Bolivie<\/option><option value='Bonaire, Saint-Eustache et Saba' >Bonaire, Saint-Eustache et Saba<\/option><option value='Bosnie-Herz\u00e9govine' >Bosnie-Herz\u00e9govine<\/option><option value='Botswana' >Botswana<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Br\u00e9sil' >Br\u00e9sil<\/option><option value='Bulgarie' >Bulgarie<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9nin' >B\u00e9nin<\/option><option value='Cambodge' >Cambodge<\/option><option value='Cameroun' >Cameroun<\/option><option value='Canada' >Canada<\/option><option value='Cap-Vert' >Cap-Vert<\/option><option value='Chili' >Chili<\/option><option value='Chine' >Chine<\/option><option value='Chypre' >Chypre<\/option><option value='Colombie' >Colombie<\/option><option value='Comores' >Comores<\/option><option value='Congo' >Congo<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatie' >Croatie<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d\u2019Ivoire' >C\u00f4te d\u2019Ivoire<\/option><option value='Danemark' >Danemark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominique' >Dominique<\/option><option value='Espagne' >Espagne<\/option><option value='Estonie' >Estonie<\/option><option value='Eswatini' >Eswatini<\/option><option value='Fidji' >Fidji<\/option><option value='Finlande' >Finlande<\/option><option value='France' >France<\/option><option value='Gabon' >Gabon<\/option><option value='Gambie' >Gambie<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Grenade' >Grenade<\/option><option value='Groenland' >Groenland<\/option><option value='Gr\u00e8ce' >Gr\u00e8ce<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernesey' >Guernesey<\/option><option value='Guin\u00e9e' >Guin\u00e9e<\/option><option value='Guin\u00e9e Fran\u00e7aise' >Guin\u00e9e Fran\u00e7aise<\/option><option value='Guin\u00e9e \u00e9quatoriale' >Guin\u00e9e \u00e9quatoriale<\/option><option value='Guin\u00e9e-Bissau' >Guin\u00e9e-Bissau<\/option><option value='Guyane' >Guyane<\/option><option value='G\u00e9orgie' >G\u00e9orgie<\/option><option value='Ha\u00efti' >Ha\u00efti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hongrie' >Hongrie<\/option><option value='Iles Aland' >Iles Aland<\/option><option value='Inde' >Inde<\/option><option value='Indon\u00e9sie' >Indon\u00e9sie<\/option><option value='Irak' >Irak<\/option><option value='Iran' >Iran<\/option><option value='Irlande' >Irlande<\/option><option value='Islande' >Islande<\/option><option value='Isra\u00ebl' >Isra\u00ebl<\/option><option value='Italie' >Italie<\/option><option value='Jama\u00efque' >Jama\u00efque<\/option><option value='Japon' >Japon<\/option><option value='Jersey' >Jersey<\/option><option value='Jordanie' >Jordanie<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kirghizistan' >Kirghizistan<\/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='Kowe\u00eft' >Kowe\u00eft<\/option><option value='La Barbade' >La Barbade<\/option><option value='La R\u00e9union' >La R\u00e9union<\/option><option value='Lesotho' >Lesotho<\/option><option value='Lettonie' >Lettonie<\/option><option value='Liban' >Liban<\/option><option value='Liberia' >Liberia<\/option><option value='Libye' >Libye<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituanie' >Lituanie<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malaisie' >Malaisie<\/option><option value='Malawi' >Malawi<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malte' >Malte<\/option><option value='Maroc' >Maroc<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritanie' >Mauritanie<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexique' >Mexique<\/option><option value='Micron\u00e9sie' >Micron\u00e9sie<\/option><option value='Moldavie' >Moldavie<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolie' >Mongolie<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mont\u00e9n\u00e9gro' >Mont\u00e9n\u00e9gro<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibie' >Namibie<\/option><option value='Nauru' >Nauru<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nig\u00e9ria' >Nig\u00e9ria<\/option><option value='Niue' >Niue<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Norv\u00e8ge' >Norv\u00e8ge<\/option><option value='Nouvelle Cal\u00e9donie' >Nouvelle Cal\u00e9donie<\/option><option value='Nouvelle-Z\u00e9lande' >Nouvelle-Z\u00e9lande<\/option><option value='N\u00e9pal' >N\u00e9pal<\/option><option value='Oman' >Oman<\/option><option value='Ouganda' >Ouganda<\/option><option value='Ouzb\u00e9kistan' >Ouzb\u00e9kistan<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Panama' >Panama<\/option><option value='Papouasie-Nouvelle-Guin\u00e9e' >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value='Paraguay' >Paraguay<\/option><option value='Pays-Bas' >Pays-Bas<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Pologne' >Pologne<\/option><option value='Polyn\u00e9sie fran\u00e7aise' >Polyn\u00e9sie fran\u00e7aise<\/option><option value='Porto Rico' >Porto Rico<\/option><option value='Portugal' >Portugal<\/option><option value='P\u00e9rou' >P\u00e9rou<\/option><option value='Qatar' >Qatar<\/option><option value='Roumanie' >Roumanie<\/option><option value='Royaume-Uni' >Royaume-Uni<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9publique Dominicaine' >R\u00e9publique Dominicaine<\/option><option value='R\u00e9publique centrafricaine' >R\u00e9publique centrafricaine<\/option><option value='R\u00e9publique d\u00e9mocratique du Congo' >R\u00e9publique d\u00e9mocratique du Congo<\/option><option value='R\u00e9publique d\u00e9mocratique populaire Lao' >R\u00e9publique d\u00e9mocratique populaire Lao<\/option><option value='Sahara occidental' >Sahara occidental<\/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 Martin' >Saint Martin<\/option><option value='Saint-Christophe-et-Nevis' >Saint-Christophe-et-Nevis<\/option><option value='Saint-Marin' >Saint-Marin<\/option><option value='Saint-Martin' >Saint-Martin<\/option><option value='Saint-Pierre-et-Miquelon' >Saint-Pierre-et-Miquelon<\/option><option value='Saint-Si\u00e8ge' >Saint-Si\u00e8ge<\/option><option value='Saint-Vincent-et-les Grenadines' >Saint-Vincent-et-les Grenadines<\/option><option value='Sainte-Lucie' >Sainte-Lucie<\/option><option value='Salvador' >Salvador<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa am\u00e9ricaines' >Samoa am\u00e9ricaines<\/option><option value='Sao Tom\u00e9 et Principe' >Sao Tom\u00e9 et Principe<\/option><option value='Serbie' >Serbie<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapour' >Singapour<\/option><option value='Slovaquie' >Slovaquie<\/option><option value='Slov\u00e9nie' >Slov\u00e9nie<\/option><option value='Somalie' >Somalie<\/option><option value='Soudan' >Soudan<\/option><option value='Soudan du Sud' >Soudan du Sud<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Suisse' >Suisse<\/option><option value='Suriname' >Suriname<\/option><option value='Su\u00e8de' >Su\u00e8de<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='S\u00e9n\u00e9gal' >S\u00e9n\u00e9gal<\/option><option value='Tadjikistan' >Tadjikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Ta\u00efwan' >Ta\u00efwan<\/option><option value='Tchad' >Tchad<\/option><option value='Terres australes Fran\u00e7aises' >Terres australes Fran\u00e7aises<\/option><option value='Territoire britannique de l&#039;oc\u00e9an Indien' >Territoire britannique de l&#039;oc\u00e9an Indien<\/option><option value='Tha\u00eflande' >Tha\u00eflande<\/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='Trinit\u00e9 et Tobago' >Trinit\u00e9 et Tobago<\/option><option value='Tunisie' >Tunisie<\/option><option value='Turkm\u00e9nistan' >Turkm\u00e9nistan<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='Ukraine' >Ukraine<\/option><option value='Uruguay' >Uruguay<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Wallis et Futuna' >Wallis et Futuna<\/option><option value='Y\u00e9men' >Y\u00e9men<\/option><option value='Zambie' >Zambie<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c9gypte' >\u00c9gypte<\/option><option value='\u00c9mirats arabes unis' >\u00c9mirats arabes unis<\/option><option value='\u00c9quateur' >\u00c9quateur<\/option><option value='\u00c9rythr\u00e9e' >\u00c9rythr\u00e9e<\/option><option value='\u00c9tat palestinien' >\u00c9tat palestinien<\/option><option value='\u00c9tats-Unis' >\u00c9tats-Unis<\/option><option value='\u00c9thiopie' >\u00c9thiopie<\/option><option value='\u00cele Bouvet' >\u00cele Bouvet<\/option><option value='\u00cele Maurice' >\u00cele Maurice<\/option><option value='\u00cele de Man' >\u00cele de Man<\/option><option value='\u00cele de Norfolk' >\u00cele de Norfolk<\/option><option value='\u00cele de No\u00ebl' >\u00cele de No\u00ebl<\/option><option value='\u00celes Cayman' >\u00celes Cayman<\/option><option value='\u00celes Cocos' >\u00celes Cocos<\/option><option value='\u00celes Cook' >\u00celes Cook<\/option><option value='\u00celes Falkland' >\u00celes Falkland<\/option><option value='\u00celes F\u00e9ro\u00e9' >\u00celes F\u00e9ro\u00e9<\/option><option value='\u00celes Mariannes du Nord' >\u00celes Mariannes du Nord<\/option><option value='\u00celes Marshall' >\u00celes Marshall<\/option><option value='\u00celes Salomon' >\u00celes Salomon<\/option><option value='\u00celes Turques-et-Ca\u00efques' >\u00celes Turques-et-Ca\u00efques<\/option><option value='\u00celes Vierges am\u00e9ricaines' >\u00celes Vierges am\u00e9ricaines<\/option><option value='\u00celes Vierges britanniques' >\u00celes Vierges britanniques<\/option><option value='\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis' >\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><\/select>\n                                        <label for='input_1_10_6' id='input_1_10_6_label' class='gform-field-label gform-field-label--type-sub '>Pays<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_7\" class=\"gfield gfield--type-email gfield--input-type-email 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' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_1_7_container'>\n                                <span id='input_1_7_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_7' id='input_1_7' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_1_7' class='gform-field-label gform-field-label--type-sub '>Enter Email Address<\/label>\n                                <\/span>\n                                <span id='input_1_7_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_7_2' id='input_1_7_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_1_7_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email Address<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_1_37\" class=\"gfield gfield--type-email gfield--input-type-email 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' >Second Email (optional)<\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_1_37_container'>\n                                <span id='input_1_37_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_37' id='input_1_37' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_1_37' class='gform-field-label gform-field-label--type-sub '>(optional)<\/label>\n                                <\/span>\n                                <span id='input_1_37_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_37_2' id='input_1_37_2' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_1_37_2' class='gform-field-label gform-field-label--type-sub '>Confirm 2nd Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_1_11\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_1_11' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_43' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_43' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_5' class='gform_page' data-js='page-field-id-43' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_5' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_1_12\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Doctor Information (optional)<\/h2><\/li><li id=\"field_1_13\" class=\"gfield gfield--type-text gfield--input-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_1_13'>Name of doctor of the ARSACS patient<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_49\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_49'>Doctor&#039;s Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_49' id='input_1_49' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_14\" class=\"gfield gfield--type-address gfield--input-type-address 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' >Address of Doctor\/Clinic where patient received diagnosis<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_1_14' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_14_1_container' >\n                                        <input type='text' name='input_14.1' id='input_1_14_1' value=''    aria-required='false'    \/>\n                                        <label for='input_1_14_1' id='input_1_14_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_1_14_2_container' >\n                                        <input type='text' name='input_14.2' id='input_1_14_2' value=''     aria-required='false'   \/>\n                                        <label for='input_1_14_2' id='input_1_14_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_1_14_3_container' >\n                                    <input type='text' name='input_14.3' id='input_1_14_3' value=''    aria-required='false'    \/>\n                                    <label for='input_1_14_3' id='input_1_14_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_1_14_4_container' >\n                                        <input type='text' name='input_14.4' id='input_1_14_4' value=''      aria-required='false'    \/>\n                                        <label for='input_1_14_4' id='input_1_14_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_1_14_5_container' >\n                                    <input type='text' name='input_14.5' id='input_1_14_5' value=''    aria-required='false'    \/>\n                                    <label for='input_1_14_5' id='input_1_14_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Code postal<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_1_14_6_container' >\n                                        <select name='input_14.6' id='input_1_14_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Afrique du Sud' >Afrique du Sud<\/option><option value='Albanie' >Albanie<\/option><option value='Alg\u00e9rie' >Alg\u00e9rie<\/option><option value='Allemagne' >Allemagne<\/option><option value='Andorre' >Andorre<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctique' >Antarctique<\/option><option value='Antigua-et-Barbuda' >Antigua-et-Barbuda<\/option><option value='Arabie Saoudite' >Arabie Saoudite<\/option><option value='Argentine' >Argentine<\/option><option value='Arm\u00e9nie' >Arm\u00e9nie<\/option><option value='Aruba' >Aruba<\/option><option value='Australie' >Australie<\/option><option value='Autriche' >Autriche<\/option><option value='Azerba\u00efdjan' >Azerba\u00efdjan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahre\u00efn' >Bahre\u00efn<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Belarus' >Belarus<\/option><option value='Belgique' >Belgique<\/option><option value='Belize' >Belize<\/option><option value='Bermudes' >Bermudes<\/option><option value='Bhoutan' >Bhoutan<\/option><option value='Bolivie' >Bolivie<\/option><option value='Bonaire, Saint-Eustache et Saba' >Bonaire, Saint-Eustache et Saba<\/option><option value='Bosnie-Herz\u00e9govine' >Bosnie-Herz\u00e9govine<\/option><option value='Botswana' >Botswana<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Br\u00e9sil' >Br\u00e9sil<\/option><option value='Bulgarie' >Bulgarie<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9nin' >B\u00e9nin<\/option><option value='Cambodge' >Cambodge<\/option><option value='Cameroun' >Cameroun<\/option><option value='Canada' >Canada<\/option><option value='Cap-Vert' >Cap-Vert<\/option><option value='Chili' >Chili<\/option><option value='Chine' >Chine<\/option><option value='Chypre' >Chypre<\/option><option value='Colombie' >Colombie<\/option><option value='Comores' >Comores<\/option><option value='Congo' >Congo<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatie' >Croatie<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d\u2019Ivoire' >C\u00f4te d\u2019Ivoire<\/option><option value='Danemark' >Danemark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominique' >Dominique<\/option><option value='Espagne' >Espagne<\/option><option value='Estonie' >Estonie<\/option><option value='Eswatini' >Eswatini<\/option><option value='Fidji' >Fidji<\/option><option value='Finlande' >Finlande<\/option><option value='France' >France<\/option><option value='Gabon' >Gabon<\/option><option value='Gambie' >Gambie<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Grenade' >Grenade<\/option><option value='Groenland' >Groenland<\/option><option value='Gr\u00e8ce' >Gr\u00e8ce<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernesey' >Guernesey<\/option><option value='Guin\u00e9e' >Guin\u00e9e<\/option><option value='Guin\u00e9e Fran\u00e7aise' >Guin\u00e9e Fran\u00e7aise<\/option><option value='Guin\u00e9e \u00e9quatoriale' >Guin\u00e9e \u00e9quatoriale<\/option><option value='Guin\u00e9e-Bissau' >Guin\u00e9e-Bissau<\/option><option value='Guyane' >Guyane<\/option><option value='G\u00e9orgie' >G\u00e9orgie<\/option><option value='Ha\u00efti' >Ha\u00efti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hongrie' >Hongrie<\/option><option value='Iles Aland' >Iles Aland<\/option><option value='Inde' >Inde<\/option><option value='Indon\u00e9sie' >Indon\u00e9sie<\/option><option value='Irak' >Irak<\/option><option value='Iran' >Iran<\/option><option value='Irlande' >Irlande<\/option><option value='Islande' >Islande<\/option><option value='Isra\u00ebl' >Isra\u00ebl<\/option><option value='Italie' >Italie<\/option><option value='Jama\u00efque' >Jama\u00efque<\/option><option value='Japon' >Japon<\/option><option value='Jersey' >Jersey<\/option><option value='Jordanie' >Jordanie<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kirghizistan' >Kirghizistan<\/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='Kowe\u00eft' >Kowe\u00eft<\/option><option value='La Barbade' >La Barbade<\/option><option value='La R\u00e9union' >La R\u00e9union<\/option><option value='Lesotho' >Lesotho<\/option><option value='Lettonie' >Lettonie<\/option><option value='Liban' >Liban<\/option><option value='Liberia' >Liberia<\/option><option value='Libye' >Libye<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituanie' >Lituanie<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malaisie' >Malaisie<\/option><option value='Malawi' >Malawi<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malte' >Malte<\/option><option value='Maroc' >Maroc<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritanie' >Mauritanie<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexique' >Mexique<\/option><option value='Micron\u00e9sie' >Micron\u00e9sie<\/option><option value='Moldavie' >Moldavie<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolie' >Mongolie<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mont\u00e9n\u00e9gro' >Mont\u00e9n\u00e9gro<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibie' >Namibie<\/option><option value='Nauru' >Nauru<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nig\u00e9ria' >Nig\u00e9ria<\/option><option value='Niue' >Niue<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Norv\u00e8ge' >Norv\u00e8ge<\/option><option value='Nouvelle Cal\u00e9donie' >Nouvelle Cal\u00e9donie<\/option><option value='Nouvelle-Z\u00e9lande' >Nouvelle-Z\u00e9lande<\/option><option value='N\u00e9pal' >N\u00e9pal<\/option><option value='Oman' >Oman<\/option><option value='Ouganda' >Ouganda<\/option><option value='Ouzb\u00e9kistan' >Ouzb\u00e9kistan<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Panama' >Panama<\/option><option value='Papouasie-Nouvelle-Guin\u00e9e' >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value='Paraguay' >Paraguay<\/option><option value='Pays-Bas' >Pays-Bas<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Pologne' >Pologne<\/option><option value='Polyn\u00e9sie fran\u00e7aise' >Polyn\u00e9sie fran\u00e7aise<\/option><option value='Porto Rico' >Porto Rico<\/option><option value='Portugal' >Portugal<\/option><option value='P\u00e9rou' >P\u00e9rou<\/option><option value='Qatar' >Qatar<\/option><option value='Roumanie' >Roumanie<\/option><option value='Royaume-Uni' >Royaume-Uni<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9publique Dominicaine' >R\u00e9publique Dominicaine<\/option><option value='R\u00e9publique centrafricaine' >R\u00e9publique centrafricaine<\/option><option value='R\u00e9publique d\u00e9mocratique du Congo' >R\u00e9publique d\u00e9mocratique du Congo<\/option><option value='R\u00e9publique d\u00e9mocratique populaire Lao' >R\u00e9publique d\u00e9mocratique populaire Lao<\/option><option value='Sahara occidental' >Sahara occidental<\/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 Martin' >Saint Martin<\/option><option value='Saint-Christophe-et-Nevis' >Saint-Christophe-et-Nevis<\/option><option value='Saint-Marin' >Saint-Marin<\/option><option value='Saint-Martin' >Saint-Martin<\/option><option value='Saint-Pierre-et-Miquelon' >Saint-Pierre-et-Miquelon<\/option><option value='Saint-Si\u00e8ge' >Saint-Si\u00e8ge<\/option><option value='Saint-Vincent-et-les Grenadines' >Saint-Vincent-et-les Grenadines<\/option><option value='Sainte-Lucie' >Sainte-Lucie<\/option><option value='Salvador' >Salvador<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa am\u00e9ricaines' >Samoa am\u00e9ricaines<\/option><option value='Sao Tom\u00e9 et Principe' >Sao Tom\u00e9 et Principe<\/option><option value='Serbie' >Serbie<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapour' >Singapour<\/option><option value='Slovaquie' >Slovaquie<\/option><option value='Slov\u00e9nie' >Slov\u00e9nie<\/option><option value='Somalie' >Somalie<\/option><option value='Soudan' >Soudan<\/option><option value='Soudan du Sud' >Soudan du Sud<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Suisse' >Suisse<\/option><option value='Suriname' >Suriname<\/option><option value='Su\u00e8de' >Su\u00e8de<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='S\u00e9n\u00e9gal' >S\u00e9n\u00e9gal<\/option><option value='Tadjikistan' >Tadjikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Ta\u00efwan' >Ta\u00efwan<\/option><option value='Tchad' >Tchad<\/option><option value='Terres australes Fran\u00e7aises' >Terres australes Fran\u00e7aises<\/option><option value='Territoire britannique de l&#039;oc\u00e9an Indien' >Territoire britannique de l&#039;oc\u00e9an Indien<\/option><option value='Tha\u00eflande' >Tha\u00eflande<\/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='Trinit\u00e9 et Tobago' >Trinit\u00e9 et Tobago<\/option><option value='Tunisie' >Tunisie<\/option><option value='Turkm\u00e9nistan' >Turkm\u00e9nistan<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='Ukraine' >Ukraine<\/option><option value='Uruguay' >Uruguay<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Wallis et Futuna' >Wallis et Futuna<\/option><option value='Y\u00e9men' >Y\u00e9men<\/option><option value='Zambie' >Zambie<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c9gypte' >\u00c9gypte<\/option><option value='\u00c9mirats arabes unis' >\u00c9mirats arabes unis<\/option><option value='\u00c9quateur' >\u00c9quateur<\/option><option value='\u00c9rythr\u00e9e' >\u00c9rythr\u00e9e<\/option><option value='\u00c9tat palestinien' >\u00c9tat palestinien<\/option><option value='\u00c9tats-Unis' >\u00c9tats-Unis<\/option><option value='\u00c9thiopie' >\u00c9thiopie<\/option><option value='\u00cele Bouvet' >\u00cele Bouvet<\/option><option value='\u00cele Maurice' >\u00cele Maurice<\/option><option value='\u00cele de Man' >\u00cele de Man<\/option><option value='\u00cele de Norfolk' >\u00cele de Norfolk<\/option><option value='\u00cele de No\u00ebl' >\u00cele de No\u00ebl<\/option><option value='\u00celes Cayman' >\u00celes Cayman<\/option><option value='\u00celes Cocos' >\u00celes Cocos<\/option><option value='\u00celes Cook' >\u00celes Cook<\/option><option value='\u00celes Falkland' >\u00celes Falkland<\/option><option value='\u00celes F\u00e9ro\u00e9' >\u00celes F\u00e9ro\u00e9<\/option><option value='\u00celes Mariannes du Nord' >\u00celes Mariannes du Nord<\/option><option value='\u00celes Marshall' >\u00celes Marshall<\/option><option value='\u00celes Salomon' >\u00celes 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gform-field-label--type-inline'>I acknowledge having read the <a href=\"https:\/\/2026.arsacs.com\/privacy-policy\/\" target=\"_blank\">privacy policy<\/a>*<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_40\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox single-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Email Communication Acceptance<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_40'><li class='gchoice gchoice_1_40_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.1' type='checkbox'  value='I agree to receive e-mails from the Foundation regarding opportunities to participate in ARSACS research projects.' checked='checked' id='choice_1_40_1'   \/>\n\t\t\t\t\t\t\t\t<label 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