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 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 This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Fields marked with an asterisk (*) are mandatory
