{"id":209,"date":"2024-01-11T13:43:53","date_gmt":"2024-01-11T19:43:53","guid":{"rendered":"https:\/\/bridgefamilynetwork.org\/?page_id=209"},"modified":"2026-01-21T09:30:59","modified_gmt":"2026-01-21T15:30:59","slug":"intake-form","status":"publish","type":"page","link":"https:\/\/bridgefamilynetwork.org\/es\/intake-form\/","title":{"rendered":"Intake Form"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.21.0&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#5cc4bb&#8221; custom_padding=&#8221;7px||15px|||&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.21.0&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;|auto|-8px|auto||&#8221; custom_padding=&#8221;20px||20px|||&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.21.0&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.23.4&#8243; _module_preset=&#8221;default&#8221; text_font=&#8221;Montserrat||||||||&#8221; text_text_color=&#8221;#FFFFFF&#8221; text_font_size=&#8221;24px&#8221; text_letter_spacing=&#8221;7px&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p style=\"text-align: center;\">INTAKE FORM<\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.22.1&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;rgba(0,62,96,0.11)&#8221; custom_margin=&#8221;||||false|false&#8221; custom_padding=&#8221;4px||38px||false|false&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row column_structure=&#8221;3_4,1_4&#8243; _builder_version=&#8221;4.20.2&#8243; _module_preset=&#8221;default&#8221; custom_padding=&#8221;11px||20px|||&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;3_4&#8243; _builder_version=&#8221;4.20.2&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; text_font=&#8221;|600|||||||&#8221; text_font_size=&#8221;18px&#8221; text_line_height=&#8221;1.5em&#8221; custom_margin=&#8221;||-6px|||&#8221; custom_padding=&#8221;15px||0px|||&#8221; hover_enabled=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243;]<\/p>\n<p style=\"text-align: left;\">If you\u2019re connecting to a navigator directly through The BRIDGE website, then you\u2019re not currently involved with any of our partner organizations. You may be eligible to receive navigation if:<\/p>\n<ul>\n<li style=\"text-align: left;\">you\u2019re a resident of Douglas County<\/li>\n<li style=\"text-align: left;\">you\u2019re pregnant or a caregiver for a child younger than age 19 OR you are a young adult up to the age of 26<\/li>\n<li style=\"text-align: left;\">you don\u2019t have an open CPS case<\/li>\n<\/ul>\n<p>[\/et_pb_text][\/et_pb_column][et_pb_column type=&#8221;1_4&#8243; _builder_version=&#8221;4.20.2&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_image src=&#8221;https:\/\/bridgefamilynetwork.org\/wp-content\/uploads\/2024\/09\/BRIDGE-Navigator-01.jpg&#8221; _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; title_text=&#8221;BRIDGE Navigator 01&#8243; hover_enabled=&#8221;0&#8243; sticky_enabled=&#8221;0&#8243;][\/et_pb_image][\/et_pb_column][\/et_pb_row][et_pb_row column_structure=&#8221;1_2,1_2&#8243; _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#003e60&#8243; custom_padding=&#8221;19px|||||&#8221; border_radii=&#8221;on|15px|15px|15px|15px&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;1_2&#8243; _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; text_text_color=&#8221;#FFFFFF&#8221; custom_margin=&#8221;|15px||15px|false|true&#8221; custom_padding=&#8221;||||false|false&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p style=\"text-align: center;\"><strong>Need help in Spanish?<\/strong><\/p>\n<p style=\"text-align: center;\">Call (402) 384-4670 or email <strong><a href=\"mailto:info@bridgefamilynetwork.org\">info@bridgefamilynetwork.org<\/a><\/strong> \u00a0and a Spanish-speaking staff member will assist you.<\/p>\n<p>[\/et_pb_text][\/et_pb_column][et_pb_column type=&#8221;1_2&#8243; _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; text_text_color=&#8221;#FFFFFF&#8221; custom_margin=&#8221;|15px||15px|false|true&#8221; custom_padding=&#8221;||||false|false&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p style=\"text-align: center;\"><strong>\u00bfNecesita ayuda en espa\u00f1ol?<\/strong><\/p>\n<p style=\"text-align: center;\">Llame al (402) 384-4670 o env\u00ede un correo electr\u00f3nico a info@bridgefamilynetwork.org y un miembro de nuestro personal que habla espa\u00f1ol le atender\u00e1.<\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; custom_padding=&#8221;16px||24px|||&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.22.1&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.22.1&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p>After you submit the form, a BRIDGE navigator will reach out to families via phone or text within two business days to schedule an appointment for a needs assessment.<\/p>\n<p>[\/et_pb_text][et_pb_code _builder_version=&#8221;4.22.1&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar 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Navigator<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/es\/wp-json\/wp\/v2\/pages\/209' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_62\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_62'>Company<\/label><div class='ginput_container'><input name='input_62' id='input_1_62' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_62'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_1_34\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">A little about you<\/h3><\/div><div id=\"field_1_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_15'>Your Name<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_1_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>What name do you go by?<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_1_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Full Legal Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><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_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_38\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_38'>Race\/Ethnicity (select all that apply)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_38' id='input_1_38' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Native American or Alaska Native' >Native American or Alaska Native<\/option><option value='Asian' >Asian<\/option><option value='Black or African American' >Black or African American<\/option><option value='Hispanic or Latino' >Hispanic or Latino<\/option><option value='Middle Eastern or North African' >Middle Eastern or North African<\/option><option value='Native Hawaiian or Pacific Islander' >Native Hawaiian or Pacific Islander<\/option><option value='White' >White<\/option><option value='Prefer not to say' >Prefer not to say<\/option><option value='Prefer to self identify' >Prefer to self identify<\/option><\/select><\/div><\/div><div id=\"field_1_39\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_39'>Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_39' id='input_1_39' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><option value='Prefer not to say' >Prefer not to say<\/option><\/select><\/div><\/div><div id=\"field_1_43\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_43'>Are you currently pregnant or expecting a child? (Mother or Father)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_43' id='input_1_43' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Prefer not to say' >Prefer not to say<\/option><\/select><\/div><\/div><div id=\"field_1_47\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_47'>Total number of adults in the household<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_47' id='input_1_47' type='number' step='any' min='0' max='10' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_47\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_47'>Please enter a number from <strong>0<\/strong> to <strong>10<\/strong>.<\/div><\/div><\/div><div id=\"field_1_42\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_42'>Based on the number of individuals in your household, is your income below 200% of the poverty level?\u2009<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_42' id='input_1_42' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_1_49\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_49'>What is the highest level of education you have completed?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_49' id='input_1_49' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Less than high school' >Less than high school<\/option><option value='High school diploma or GED' >High school diploma or GED<\/option><option value='Some college, no degree' >Some college, no degree<\/option><option value='Certificate or trade credential' >Certificate or trade credential<\/option><option value='Associate degree' >Associate degree<\/option><option value='Bachelor&#039;s degree' >Bachelor&#039;s degree<\/option><option value='Graduate or professional degree' >Graduate or professional degree<\/option><option value='Prefer not to answer' >Prefer not to answer<\/option><\/select><\/div><\/div><div id=\"field_1_41\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_41'>Do you currently have any health insurance?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_41' id='input_1_41' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes, Private\/ACA' >Yes, Private\/ACA<\/option><option value='Yes, Medicaid' >Yes, Medicaid<\/option><option value='Yes, Medicare' >Yes, Medicare<\/option><option value='Medicaid in Process (application filled out)' >Medicaid in Process (application filled out)<\/option><option value='No' >No<\/option><option value='Choose not to answer' >Choose not to answer<\/option><\/select><\/div><\/div><div id=\"field_1_53\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_53'>Do you have a disability?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_53' id='input_1_53' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_1_54\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_54'>Does your child have a disability?<\/label><div class='ginput_container ginput_container_select'><select name='input_54' id='input_1_54' class='large gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_1_40\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_40'>Minor Assent (Only complete if the participant is a minor, if the participant is NOT a minor select N\/A): &quot;As a minor participating in this program, I give permission for my information to be shared and used to help improve the program.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_40' id='input_1_40' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='N\/A' >N\/A<\/option><\/select><\/div><\/div><div id=\"field_1_3\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below 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_text\">(Required)<\/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 mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' 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'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_3' class='gform_hidden' value='https:\/\/bridgefamilynetwork.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_13'>Number of Children<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_13\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_13'>How many children live in the household?<\/div><\/div><div id=\"field_1_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_56'>1st Child&#039;s first and last name<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_1_56' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_56\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_56'>List the first and last name for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'>1st Child&#039;s date of birth<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_1_14' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_14\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_14'>List the birthday for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_55\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_55'>2nd Child&#039;s first and last name<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_1_55' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_55\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_55'>List the first and last name for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_29\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_29'>2nd Child&#039;s date of birth<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_1_29' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_29\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_29'>List the birthday for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_61\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_61'>3rd Child&#039;s first and last name<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_1_61' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_61\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_61'>List the first and last name for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_30\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_30'>3rd Child&#039;s date of birth<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_1_30' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_30\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_30'>List the birthday for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_60\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_60'>4th Child&#039;s first and last name<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_1_60' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_60\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_60'>List the first and last name for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_28'>4th Child&#039;s date of birth<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_1_28' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_28\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_28'>List the birthday for each child, under age 19, living in your home.<\/div><\/div><div id=\"field_1_59\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_59'>5th Child&#039;s first and last name<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_1_59' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_59\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_59'>List the first and last name for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_36'>5th Child&#039;s date of birth<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_1_36' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_36\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_36'>List the birthday for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_58\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_58'>6th Child&#039;s first and last name<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_1_58' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_58\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_58'>List the first and last name for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_37'>6th Child&#039;s date of birth<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_1_37' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_37\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_37'>List the birthday for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_57\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_57'>7th Child&#039;s first and last name<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_1_57' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_57\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_57'>If there are more than seven children under age 19 living in your home, list them at the end of this form. <\/div><\/div><div id=\"field_1_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_35'>7th Child&#039;s date of birth<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_1_35' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_35\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_35'>If there are more than seven children under age 19 living in your home, list them at the end of this form. <\/div><\/div><div id=\"field_1_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below 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_51'>First and Last Name of all children listed above<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_1_51' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_51\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_51'>If you have no children in the household, type N\/A<\/div><\/div><div id=\"field_1_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_1_4' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_1_5' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_1_10\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip 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 '>Street Address<\/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 '>City<\/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 '>State<\/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 \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_10.6' id='input_1_10_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_18'>County<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_1_18' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_33\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">What are some ways we can help you?<\/h3><\/div><fieldset id=\"field_1_12\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Need<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_12'><div class='gchoice gchoice_1_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='Daily Living (telephone, clothes, hygiene)'  id='choice_1_12_1'   aria-describedby=\"gfield_description_1_12\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_1' id='label_1_12_1' class='gform-field-label gform-field-label--type-inline'>Daily Living (telephone, clothes, hygiene)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='Dentist'  id='choice_1_12_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_2' id='label_1_12_2' class='gform-field-label gform-field-label--type-inline'>Dentist<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.3' type='checkbox'  value='Education'  id='choice_1_12_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_3' id='label_1_12_3' class='gform-field-label gform-field-label--type-inline'>Education<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.4' type='checkbox'  value='Finances'  id='choice_1_12_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_4' id='label_1_12_4' class='gform-field-label gform-field-label--type-inline'>Finances<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.5' type='checkbox'  value='General Life Skills'  id='choice_1_12_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_5' id='label_1_12_5' class='gform-field-label gform-field-label--type-inline'>General Life Skills<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.6' type='checkbox'  value='Housing'  id='choice_1_12_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_6' id='label_1_12_6' class='gform-field-label gform-field-label--type-inline'>Housing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.7' type='checkbox'  value='Legal Help'  id='choice_1_12_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_7' id='label_1_12_7' class='gform-field-label gform-field-label--type-inline'>Legal Help<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.8' type='checkbox'  value='Mental Health'  id='choice_1_12_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_8' id='label_1_12_8' class='gform-field-label gform-field-label--type-inline'>Mental Health<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.9' type='checkbox'  value='Parenting Assistance'  id='choice_1_12_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_9' id='label_1_12_9' class='gform-field-label gform-field-label--type-inline'>Parenting Assistance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.11' type='checkbox'  value='Substance Abuse'  id='choice_1_12_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_11' id='label_1_12_11' class='gform-field-label gform-field-label--type-inline'>Substance Abuse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.12' type='checkbox'  value='Supportive Relationships'  id='choice_1_12_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_12' id='label_1_12_12' class='gform-field-label gform-field-label--type-inline'>Supportive Relationships<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.13' type='checkbox'  value='Transportation'  id='choice_1_12_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_13' id='label_1_12_13' class='gform-field-label gform-field-label--type-inline'>Transportation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.14' type='checkbox'  value='Utilities'  id='choice_1_12_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_14' id='label_1_12_14' class='gform-field-label gform-field-label--type-inline'>Utilities<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.15' type='checkbox'  value='Other'  id='choice_1_12_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_15' id='label_1_12_15' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_12'>What is your most urgent need? Check all that apply.<\/div><\/fieldset><fieldset id=\"field_1_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Usted necesita ser contactado por un Navegador que habla Espa\u00f1ol?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_19'>\n\t\t\t<div class='gchoice gchoice_1_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Yes'  id='choice_1_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_0' id='label_1_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_1_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_1' id='label_1_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_44'>If you chose &quot;Other&quot;, please specify your needs.<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_1_44' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_44\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_44'>Provide need details<\/div><\/div><div id=\"field_1_26\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">How did you find us?<\/h3><\/div><div id=\"field_1_21\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_21'>Who referred you to The BRIDGE?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_1_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What school district do your children attend?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_23'><div class='gchoice gchoice_1_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Omaha Public Schools'  id='choice_1_23_1'   aria-describedby=\"gfield_description_1_23\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_1' id='label_1_23_1' class='gform-field-label gform-field-label--type-inline'>Omaha Public Schools<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='Millard Public Schools'  id='choice_1_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_2' id='label_1_23_2' class='gform-field-label gform-field-label--type-inline'>Millard Public Schools<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.3' type='checkbox'  value='Ralston Public Schools'  id='choice_1_23_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_3' id='label_1_23_3' class='gform-field-label gform-field-label--type-inline'>Ralston Public Schools<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.4' type='checkbox'  value='Westside Community Schools'  id='choice_1_23_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_4' id='label_1_23_4' class='gform-field-label gform-field-label--type-inline'>Westside Community Schools<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.5' type='checkbox'  value='Other'  id='choice_1_23_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_5' id='label_1_23_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_23'>Check all that apply. <\/div><\/fieldset><fieldset id=\"field_1_25\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What is the best time of day to contact you?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_25'><div class='gchoice gchoice_1_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='Morning'  id='choice_1_25_1'   aria-describedby=\"gfield_description_1_25\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_25_1' id='label_1_25_1' class='gform-field-label gform-field-label--type-inline'>Morning<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='Afternoon'  id='choice_1_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_25_2' id='label_1_25_2' class='gform-field-label gform-field-label--type-inline'>Afternoon<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_25_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.3' type='checkbox'  value='Evening after 5:00 PM'  id='choice_1_25_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_25_3' id='label_1_25_3' class='gform-field-label gform-field-label--type-inline'>Evening after 5:00 PM<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_25'>Check all that apply. <\/div><\/fieldset><fieldset id=\"field_1_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Consent<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_31'>\n\t\t\t<div class='gchoice gchoice_1_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_1_31_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_31\"   \/>\n\t\t\t\t\t<label for='choice_1_31_0' id='label_1_31_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_1_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_31_1' id='label_1_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_31'>Can The BRIDGE add your information to the Find Help database? <\/div><\/fieldset><div id=\"field_1_45\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_45'>CAPTCHA<\/label><div id='input_1_45' class='ginput_container ginput_recaptcha' data-sitekey='6LdD670rAAAAAA64gGiNw5YKz8v5S4ElbLr-li2p'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='QeUKEjw8HbO6i8ylAFuFDJylQldj2rbIDXMbiEDEUKZJBwX3QDXaz6FfXTEcvVe+KYithKrkSDn9\/ekxPEy2r7PIsEJtSKJtwNx2gTSeLPnL0pc=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' 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You may be eligible to receive navigation if: you\u2019re a resident of Douglas County you\u2019re pregnant or a caregiver for a child younger than age 19 OR you are a young adult up to the age of 26 you don\u2019t have an open CPS case Need help in Spanish? Call (402) 384-4670 or email info@bridgefamilynetwork.org \u00a0and a Spanish-speaking staff member will assist you.\u00bfNecesita ayuda en espa\u00f1ol? Llame al (402) 384-4670 o env\u00ede un correo electr\u00f3nico a info@bridgefamilynetwork.org y un miembro de nuestro personal que habla espa\u00f1ol le atender\u00e1.After you submit the form, a BRIDGE navigator will reach out to families via phone or text within two business days to schedule an appointment for a needs assessment.\n                <div class='gf_browser_gecko gform_wrapper gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_1' style='display:none'><style>#gform_wrapper_1[data-form-index=\"0\"].gform-theme,[data-parent-form=\"1_0\"]{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 229;--gf-color-primary-contrast: #fff;--gf-color-primary-contrast-rgb: 255, 255, 255;--gf-color-primary-darker: #001AB3;--gf-color-primary-lighter: #527EFF;--gf-color-secondary: #fff;--gf-color-secondary-rgb: 255, 255, 255;--gf-color-secondary-contrast: 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var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Connect with a Family Navigator<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/es\/wp-json\/wp\/v2\/pages\/209' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_62\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_62'>Email<\/label><div class='ginput_container'><input name='input_62' id='input_1_62' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_62'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_1_34\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">A little about you<\/h3><\/div><div id=\"field_1_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_15'>Your Name<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_1_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>What name do you go by?<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_1_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Full Legal Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><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_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_38\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_38'>Race\/Ethnicity (select all that apply)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_38' id='input_1_38' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Native American or Alaska Native' >Native American or Alaska Native<\/option><option value='Asian' >Asian<\/option><option value='Black or African American' >Black or African American<\/option><option value='Hispanic or Latino' >Hispanic or Latino<\/option><option value='Middle Eastern or North African' >Middle Eastern or North African<\/option><option value='Native Hawaiian or Pacific Islander' >Native Hawaiian or Pacific Islander<\/option><option value='White' >White<\/option><option value='Prefer not to say' >Prefer not to say<\/option><option value='Prefer to self identify' >Prefer to self identify<\/option><\/select><\/div><\/div><div id=\"field_1_39\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_39'>Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_39' id='input_1_39' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><option value='Prefer not to say' >Prefer not to say<\/option><\/select><\/div><\/div><div id=\"field_1_43\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_43'>Are you currently pregnant or expecting a child? (Mother or Father)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_43' id='input_1_43' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Prefer not to say' >Prefer not to say<\/option><\/select><\/div><\/div><div id=\"field_1_47\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_47'>Total number of adults in the household<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_47' id='input_1_47' type='number' step='any' min='0' max='10' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_47\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_47'>Please enter a number from <strong>0<\/strong> to <strong>10<\/strong>.<\/div><\/div><\/div><div id=\"field_1_42\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_42'>Based on the number of individuals in your household, is your income below 200% of the poverty level?\u2009<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_42' id='input_1_42' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_1_49\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_49'>What is the highest level of education you have completed?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_49' id='input_1_49' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Less than high school' >Less than high school<\/option><option value='High school diploma or GED' >High school diploma or GED<\/option><option value='Some college, no degree' >Some college, no degree<\/option><option value='Certificate or trade credential' >Certificate or trade credential<\/option><option value='Associate degree' >Associate degree<\/option><option value='Bachelor&#039;s degree' >Bachelor&#039;s degree<\/option><option value='Graduate or professional degree' >Graduate or professional degree<\/option><option value='Prefer not to answer' >Prefer not to answer<\/option><\/select><\/div><\/div><div id=\"field_1_41\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_41'>Do you currently have any health insurance?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_41' id='input_1_41' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes, Private\/ACA' >Yes, Private\/ACA<\/option><option value='Yes, Medicaid' >Yes, Medicaid<\/option><option value='Yes, Medicare' >Yes, Medicare<\/option><option value='Medicaid in Process (application filled out)' >Medicaid in Process (application filled out)<\/option><option value='No' >No<\/option><option value='Choose not to answer' >Choose not to answer<\/option><\/select><\/div><\/div><div id=\"field_1_53\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_53'>Do you have a disability?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_53' id='input_1_53' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_1_54\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_54'>Does your child have a disability?<\/label><div class='ginput_container ginput_container_select'><select name='input_54' id='input_1_54' class='large gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_1_40\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_40'>Minor Assent (Only complete if the participant is a minor, if the participant is NOT a minor select N\/A): &quot;As a minor participating in this program, I give permission for my information to be shared and used to help improve the program.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_40' id='input_1_40' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='N\/A' >N\/A<\/option><\/select><\/div><\/div><div id=\"field_1_3\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below 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_text\">(Required)<\/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 mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' 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'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_3' class='gform_hidden' value='https:\/\/bridgefamilynetwork.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_13'>Number of Children<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_13\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_13'>How many children live in the household?<\/div><\/div><div id=\"field_1_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_56'>1st Child&#039;s first and last name<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_1_56' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_56\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_56'>List the first and last name for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'>1st Child&#039;s date of birth<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_1_14' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_14\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_14'>List the birthday for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_55\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_55'>2nd Child&#039;s first and last name<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_1_55' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_55\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_55'>List the first and last name for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_29\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_29'>2nd Child&#039;s date of birth<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_1_29' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_29\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_29'>List the birthday for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_61\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_61'>3rd Child&#039;s first and last name<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_1_61' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_61\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_61'>List the first and last name for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_30\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_30'>3rd Child&#039;s date of birth<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_1_30' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_30\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_30'>List the birthday for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_60\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_60'>4th Child&#039;s first and last name<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_1_60' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_60\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_60'>List the first and last name for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_28'>4th Child&#039;s date of birth<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_1_28' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_28\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_28'>List the birthday for each child, under age 19, living in your home.<\/div><\/div><div id=\"field_1_59\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_59'>5th Child&#039;s first and last name<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_1_59' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_59\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_59'>List the first and last name for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_36'>5th Child&#039;s date of birth<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_1_36' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_36\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_36'>List the birthday for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_58\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_58'>6th Child&#039;s first and last name<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_1_58' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_58\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_58'>List the first and last name for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_37'>6th Child&#039;s date of birth<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_1_37' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_37\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_37'>List the birthday for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_57\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_57'>7th Child&#039;s first and last name<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_1_57' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_57\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_57'>If there are more than seven children under age 19 living in your home, list them at the end of this form. <\/div><\/div><div id=\"field_1_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_35'>7th Child&#039;s date of birth<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_1_35' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_35\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_35'>If there are more than seven children under age 19 living in your home, list them at the end of this form. <\/div><\/div><div id=\"field_1_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below 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_51'>First and Last Name of all children listed above<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_1_51' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_51\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_51'>If you have no children in the household, type N\/A<\/div><\/div><div id=\"field_1_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_1_4' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_1_5' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_1_10\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip 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 '>Street Address<\/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 '>City<\/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 '>State<\/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 \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_10.6' id='input_1_10_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_18'>County<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_1_18' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_33\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">What are some ways we can help you?<\/h3><\/div><fieldset id=\"field_1_12\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Need<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_12'><div class='gchoice gchoice_1_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='Daily Living (telephone, clothes, hygiene)'  id='choice_1_12_1'   aria-describedby=\"gfield_description_1_12\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_1' id='label_1_12_1' class='gform-field-label gform-field-label--type-inline'>Daily Living (telephone, clothes, hygiene)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='Dentist'  id='choice_1_12_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_2' id='label_1_12_2' class='gform-field-label gform-field-label--type-inline'>Dentist<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.3' type='checkbox'  value='Education'  id='choice_1_12_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_3' id='label_1_12_3' class='gform-field-label gform-field-label--type-inline'>Education<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.4' type='checkbox'  value='Finances'  id='choice_1_12_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_4' id='label_1_12_4' class='gform-field-label gform-field-label--type-inline'>Finances<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.5' type='checkbox'  value='General Life Skills'  id='choice_1_12_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_5' id='label_1_12_5' class='gform-field-label gform-field-label--type-inline'>General Life Skills<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.6' type='checkbox'  value='Housing'  id='choice_1_12_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_6' id='label_1_12_6' class='gform-field-label gform-field-label--type-inline'>Housing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.7' type='checkbox'  value='Legal Help'  id='choice_1_12_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_7' id='label_1_12_7' class='gform-field-label gform-field-label--type-inline'>Legal Help<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.8' type='checkbox'  value='Mental Health'  id='choice_1_12_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_8' id='label_1_12_8' class='gform-field-label gform-field-label--type-inline'>Mental Health<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.9' type='checkbox'  value='Parenting Assistance'  id='choice_1_12_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_9' id='label_1_12_9' class='gform-field-label gform-field-label--type-inline'>Parenting Assistance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.11' type='checkbox'  value='Substance Abuse'  id='choice_1_12_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_11' id='label_1_12_11' class='gform-field-label gform-field-label--type-inline'>Substance Abuse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.12' type='checkbox'  value='Supportive Relationships'  id='choice_1_12_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_12' id='label_1_12_12' class='gform-field-label gform-field-label--type-inline'>Supportive Relationships<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.13' type='checkbox'  value='Transportation'  id='choice_1_12_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_13' id='label_1_12_13' class='gform-field-label gform-field-label--type-inline'>Transportation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.14' type='checkbox'  value='Utilities'  id='choice_1_12_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_14' id='label_1_12_14' class='gform-field-label gform-field-label--type-inline'>Utilities<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.15' type='checkbox'  value='Other'  id='choice_1_12_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_15' id='label_1_12_15' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_12'>What is your most urgent need? Check all that apply.<\/div><\/fieldset><fieldset id=\"field_1_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Usted necesita ser contactado por un Navegador que habla Espa\u00f1ol?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_19'>\n\t\t\t<div class='gchoice gchoice_1_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Yes'  id='choice_1_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_0' id='label_1_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_1_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_1' id='label_1_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_44'>If you chose &quot;Other&quot;, please specify your needs.<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_1_44' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_44\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_44'>Provide need details<\/div><\/div><div id=\"field_1_26\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">How did you find us?<\/h3><\/div><div id=\"field_1_21\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_21'>Who referred you to The BRIDGE?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_1_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What school district do your children attend?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_23'><div class='gchoice gchoice_1_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Omaha Public Schools'  id='choice_1_23_1'   aria-describedby=\"gfield_description_1_23\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_1' id='label_1_23_1' class='gform-field-label gform-field-label--type-inline'>Omaha Public Schools<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='Millard Public Schools'  id='choice_1_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_2' id='label_1_23_2' class='gform-field-label gform-field-label--type-inline'>Millard Public Schools<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.3' type='checkbox'  value='Ralston Public Schools'  id='choice_1_23_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_3' id='label_1_23_3' class='gform-field-label gform-field-label--type-inline'>Ralston Public Schools<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.4' type='checkbox'  value='Westside Community Schools'  id='choice_1_23_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_4' id='label_1_23_4' class='gform-field-label gform-field-label--type-inline'>Westside Community Schools<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.5' type='checkbox'  value='Other'  id='choice_1_23_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_5' id='label_1_23_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_23'>Check all that apply. <\/div><\/fieldset><fieldset id=\"field_1_25\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What is the best time of day to contact you?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_25'><div class='gchoice gchoice_1_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='Morning'  id='choice_1_25_1'   aria-describedby=\"gfield_description_1_25\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_25_1' id='label_1_25_1' class='gform-field-label gform-field-label--type-inline'>Morning<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='Afternoon'  id='choice_1_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_25_2' id='label_1_25_2' class='gform-field-label gform-field-label--type-inline'>Afternoon<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_25_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.3' type='checkbox'  value='Evening after 5:00 PM'  id='choice_1_25_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_25_3' id='label_1_25_3' class='gform-field-label gform-field-label--type-inline'>Evening after 5:00 PM<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_25'>Check all that apply. <\/div><\/fieldset><fieldset id=\"field_1_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Consent<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_31'>\n\t\t\t<div class='gchoice gchoice_1_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_1_31_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_31\"   \/>\n\t\t\t\t\t<label for='choice_1_31_0' id='label_1_31_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_1_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_31_1' id='label_1_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_31'>Can The BRIDGE add your information to the Find Help database? <\/div><\/fieldset><div id=\"field_1_45\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_45'>CAPTCHA<\/label><div id='input_1_45' class='ginput_container ginput_recaptcha' data-sitekey='6LdD670rAAAAAA64gGiNw5YKz8v5S4ElbLr-li2p'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' 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