<section> <fieldset id="registration_fields" class="account_creation form-group" style="border: none;"> <div class="clearfix"></div> <div class="rf_input_wrapper rf_only_f_0 required form-group text form-group row" data-id="1" data-f="0" data-v="0"> <label class="rf_input_label col-md-3 form-control-label"> Nom du conjoint</label> <div class="col-md-6"> <input type="text" name="fields[1]" data-type="text" value="ANICE" class="text form-control" /> </div> <div class="clearfix"></div> </div> <div class="clearfix"></div> <div class="rf_input_wrapper rf_only_f_0 required form-group text form-group row" data-id="2" data-f="0" data-v="0"> <label class="rf_input_label col-md-3 form-control-label"> Situation familiale</label> <div class="col-md-6"> <input class="rf_checkboxes" type="hidden" data-required="0" value="1"> <select name="fields[2][]" multiple="multiple" class="type_multiboxes multiselect form-control "> <option value="1" >Célibataire </option> <option value="3" >Marié(e) </option> <option value="6" >Pacsé(e) </option> <option value="10" selected="selected">Concubinage </option> </select> <p><small>Maintenez la touche CTRL / Commande enfoncée pour sélectionner plusieurs valeurs.</small></p> </div> <div class="clearfix"></div> </div> <div class="clearfix"></div> <div class="rf_input_wrapper rf_only_f_0 required form-group text form-group row" data-id="3" data-f="0" data-v="0"> <label class="rf_input_label col-md-3 form-control-label"> Nom du 1er enfant</label> <div class="col-md-6"> <input type="text" name="fields[3]" data-type="text" value="LE PAPE LEHNHOF Chloé" class="text form-control" /> </div> <div class="clearfix"></div> </div> <div class="clearfix"></div> <div class="rf_input_wrapper rf_only_f_0 required form-group text form-group row" data-id="4" data-f="0" data-v="0"> <label class="rf_input_label col-md-3 form-control-label"> Date de naissance (1)</label> <div class="col-md-6"> <input class="fields_datapicker form-control validate_field" type="text" data-type="date" name="fields[4]" value="2011-08-19" data-validate="isDate"/> <p class="small">Date formate: <strong>Y-m-d</strong></p> </div> <div class="clearfix"></div> </div> <div class="clearfix"></div> <div class="rf_input_wrapper rf_only_f_0 required form-group text form-group row" data-id="5" data-f="0" data-v="0"> <label class="rf_input_label col-md-3 form-control-label"> Nom du 2ème enfant</label> <div class="col-md-6"> <input type="text" name="fields[5]" data-type="text" value="ANICE Loan" class="text form-control" /> </div> <div class="clearfix"></div> </div> <div class="clearfix"></div> <div class="rf_input_wrapper rf_only_f_0 required form-group text form-group row" data-id="6" data-f="0" data-v="0"> <label class="rf_input_label col-md-3 form-control-label"> Date de naissance (2)</label> <div class="col-md-6"> <input class="fields_datapicker form-control validate_field" type="text" data-type="date" name="fields[6]" value="2007-05-18" data-validate="isDate"/> <p class="small">Date formate: <strong>Y-m-d</strong></p> </div> <div class="clearfix"></div> </div> <div class="clearfix"></div> <div class="rf_input_wrapper rf_only_f_0 required form-group text form-group row" data-id="7" data-f="0" data-v="0"> <label class="rf_input_label col-md-3 form-control-label"> Nom du 3ème enfant</label> <div class="col-md-6"> <input type="text" name="fields[7]" data-type="text" value="" class="text form-control" /> </div> <div class="clearfix"></div> </div> <div class="clearfix"></div> <div class="rf_input_wrapper rf_only_f_0 required form-group text form-group row" data-id="8" data-f="0" data-v="0"> <label class="rf_input_label col-md-3 form-control-label"> Date de naissance (3)</label> <div class="col-md-6"> <input class="fields_datapicker form-control validate_field" type="text" data-type="date" name="fields[8]" value="" data-validate="isDate"/> <p class="small">Date formate: <strong>Y-m-d</strong></p> </div> <div class="clearfix"></div> </div> <div class="clearfix"></div> <div class="rf_input_wrapper rf_only_f_0 required form-group text form-group row" data-id="9" data-f="0" data-v="0"> <label class="rf_input_label col-md-3 form-control-label"> Nom du 4ème enfant</label> <div class="col-md-6"> <input type="text" name="fields[9]" data-type="text" value="" class="text form-control" /> </div> <div class="clearfix"></div> </div> <div class="clearfix"></div> <div class="rf_input_wrapper rf_only_f_0 required form-group text form-group row" data-id="10" data-f="0" data-v="0"> <label class="rf_input_label col-md-3 form-control-label"> Date de naissance (4)</label> <div class="col-md-6"> <input class="fields_datapicker form-control validate_field" type="text" data-type="date" name="fields[10]" value="" data-validate="isDate"/> <p class="small">Date formate: <strong>Y-m-d</strong></p> </div> <div class="clearfix"></div> </div> <div class="clearfix"></div> <div class="rf_input_wrapper rf_only_f_0 required form-group text form-group row" data-id="11" data-f="0" data-v="0"> <label class="rf_input_label col-md-3 form-control-label"> Nom du 5ème enfant</label> <div class="col-md-6"> <input type="text" name="fields[11]" data-type="text" value="" class="text form-control" /> </div> <div class="clearfix"></div> </div> <div class="clearfix"></div> <div class="rf_input_wrapper rf_only_f_0 required form-group text form-group row" data-id="12" data-f="0" data-v="0"> <label class="rf_input_label col-md-3 form-control-label"> Date de naissance (5)</label> <div class="col-md-6"> <input class="fields_datapicker form-control validate_field" type="text" data-type="date" name="fields[12]" value="" data-validate="isDate"/> <p class="small">Date formate: <strong>Y-m-d</strong></p> </div> <div class="clearfix"></div> </div> <div class="clearfix"></div> <div class="rf_input_wrapper rf_only_f_0 required form-group text form-group row" data-id="13" data-f="0" data-v="0"> <label class="rf_input_label col-md-3 form-control-label"> Bénéf. assu. décès</label> <div class="col-md-6"> <input type="text" name="fields[13]" data-type="text" value="" class="text form-control" /> </div> <div class="clearfix"></div> </div> <div class="clearfix"></div> <div class="rf_input_wrapper rf_only_f_0 required form-group text form-group row" data-id="14" data-f="0" data-v="0"> <label class="rf_input_label col-md-3 form-control-label"> Affectation</label> <div class="col-md-6"> <input type="text" name="fields[14]" data-type="text" value="" class="text form-control" /> </div> <div class="clearfix"></div> </div> <div class="clearfix"></div> <div class="rf_input_wrapper rf_only_f_0 required form-group text form-group row" data-id="15" data-f="0" data-v="0"> <label class="rf_input_label col-md-3 form-control-label"> Date entrée Amicale</label> <div class="col-md-6"> <input class="fields_datapicker form-control validate_field" type="text" data-type="date" name="fields[15]" value="2025-01-01" data-validate="isDate"/> <p class="small">Date formate: <strong>Y-m-d</strong></p> </div> <div class="clearfix"></div> </div> <div class="clearfix"></div> <div class="rf_input_wrapper rf_only_f_0 required form-group text form-group row" data-id="16" data-f="0" data-v="0"> <label class="rf_input_label col-md-3 form-control-label"> Cotisation</label> <div class="col-md-6"> <select class="select form-control " name="fields[16]" data-type="boolean" data-field="16"> <option value="No" >Non</option> <option value="Yes" selected="selected">Oui</option> </select> </div> <div class="clearfix"></div> </div> <div class="clearfix"></div> <div class="rf_input_wrapper rf_only_f_0 required form-group text form-group row" data-id="17" data-f="0" data-v="0"> <label class="rf_input_label col-md-3 form-control-label"> Photo</label> <div class="col-md-6"> <div id="field_image_17"> <img id="preview-17" class="image_container" src="/modules/registrationfields/views/img/empty.png" title="Cliquez ici pour upload l'image"> <input type="file" name="fields[17]" id="image_17" class="image_input " data-extensions="jpg" data-id="17"> <p>Types de fichiers autorisés: jpg</p> <p class="alert alert-danger error extension_error">Type d'image non autorisé.</p> </div> </div> <div class="clearfix"></div> </div> <div class="clearfix"></div> <div class="rf_input_wrapper rf_only_f_0 required form-group text form-group row" data-id="18" data-f="0" data-v="0"> <label class="rf_input_label col-md-3 form-control-label"> Autorisation d&#039;afficher photos où vous apparaissez</label> <div class="col-md-6"> <select class="select form-control " name="fields[18]" data-type="boolean" data-field="18"> <option value="No" >Non</option> <option value="Yes" selected="selected">Oui</option> </select> </div> <div class="clearfix"></div> </div> <div class="clearfix"></div> <div class="rf_input_wrapper rf_only_f_0 required form-group text form-group row" data-id="19" data-f="0" data-v="0"> <label class="rf_input_label col-md-3 form-control-label"> Capital loisir (en Euro) au 01/06/2024</label> <div class="col-md-6"> <input type="text" name="fields[19]" data-type="text" class="text form-control" /> </div> <div class="clearfix"></div> </div> </fieldset> <div class="form-group row "> <label class="col-md-3 form-control-label required"></label> <div class="col-md-6"> <div id="gdpr_consent" class="gdpr_module_105"> <span class="custom-checkbox"> <label class="psgdpr_consent_message"> <input id="psgdpr_consent_checkbox_105" name="psgdpr_consent_checkbox" type="checkbox" value="1" class="psgdpr_consent_checkboxes_105"> <span><i class="material-icons rtl-no-flip checkbox-checked psgdpr_consent_icon"></i></span> <span><p style="margin:0px;font-size:13px;line-height:normal;font-family:'Helvetica Neue';">En soumettant ce formulaire, j’accepte que l’Amicale des SPP de Dijon recueille mes données. J'accepte que les informations saisies soient utilisées par l’Amicale des SPP de Dijon pour le traitement de ma demande. Pour en savoir plus sur la gestion de vos données personnelles et pour exercer vos droits, reportez vous à la page Politique de confidentialité des données.</p></span> </label> </span> </div> <script type="text/javascript"> var psgdpr_front_controller = "https://www.amicalesppdijon.fr/module/psgdpr/FrontAjaxGdpr"; psgdpr_front_controller = psgdpr_front_controller.replace(/\amp;/g,''); var psgdpr_id_customer = "0"; var psgdpr_customer_token = "da39a3ee5e6b4b0d3255bfef95601890afd80709"; var psgdpr_id_guest = "0"; var psgdpr_guest_token = "3961fb65afd7698da9b2dd71fd6763cb7e002a69"; document.addEventListener('DOMContentLoaded', function() { let psgdpr_id_module = "105"; let parentForm = $('.gdpr_module_' + psgdpr_id_module).closest('form'); let toggleFormActive = function() { let parentForm = $('.gdpr_module_' + psgdpr_id_module).closest('form'); let checkbox = $('#psgdpr_consent_checkbox_' + psgdpr_id_module); let element = $('.gdpr_module_' + psgdpr_id_module); let iLoopLimit = 0; // by default forms submit will be disabled, only will enable if agreement checkbox is checked if (element.prop('checked') != true) { element.closest('form').find('[type="submit"]').attr('disabled', 'disabled'); } $(document).on("change" ,'.psgdpr_consent_checkboxes_' + psgdpr_id_module, function() { if ($(this).prop('checked') == true) { $(this).closest('form').find('[type="submit"]').removeAttr('disabled'); } else { $(this).closest('form').find('[type="submit"]').attr('disabled', 'disabled'); } }); } // Triggered on page loading toggleFormActive(); $(document).on('submit', parentForm, function(event) { $.ajax({ data: 'POST', url: psgdpr_front_controller, data: { ajax: true, action: 'AddLog', id_customer: psgdpr_id_customer, customer_token: psgdpr_customer_token, id_guest: psgdpr_id_guest, guest_token: psgdpr_guest_token, id_module: psgdpr_id_module, }, error: function (err) { console.log(err); } }); }); }); </script> </div> </div> <style> .rf_no_display { display: none;} #registration_fields .radio-inline, #registration_fields .checkbox { display: inline-block; margin-right: 3%} #registration_fields .radio-inline .radio, #registration_fields .checkbox .checker { display:inline-block; padding-right: 3px; vertical-align: middle} </style> </section> <div class="captcha_register form-group row required register page_product ver17"> <div class="pa-captcha-inf col-md-6"> <input type="hidden" name="g-recaptcha-response" value=""/> </div> <div class="col-md-3 form-control-comment"></div></div>