Your name * Your first name * Your birth date * Your address * Your phone number * Your email * Disability type * Person in a folding manual wheelchair Person in a manual wheelchair Person in electric wheelchair Person with intellectual disability Semi-disabled person Visually impaired person Blind person Please tick the relevant box(es) Mobility Inclusion Card * Upload Copy of both sides of your CMI (mobility and inclusion card) with the mention disability. One file only.5 MB limit.Allowed types: jpg, jpeg, png, pdf. Your place of care CAPTCHA Submit Fields marked with an asterisk (*) are mandatory
