B: Inscription des personnes valides

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B: Registration of valid persons

Email *

Nom *

Last name

Prénom *

First name

Ville et code postal *

City and zip code

Adresse *

Address

Numéro de téléphone *

Phone number

Quel est votre nationalité? *

What is your nationality?

Êtes-vous un proche d'une personne paralysée? *

Are you related to a paralyzed person?

Oui/Yes

Non/No

So that Neurogel En Marche can continue the development of this therapy, would you like to participate financially monthly or annually for a cure for the paralysis?

Oui/Yes

Non/No

J'accepte de recevoir la newsletter Neurogel En Marche ainsi que des informations par courriel concernant les futures démarches de notre association. *

I agree to receive the Neurogel En Marche newsletter as well as information by email concerning the future steps of our association.

Oui/Yes

Non/No

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