{"id":560,"date":"2026-09-02T13:34:07","date_gmt":"2026-09-02T18:34:07","guid":{"rendered":"https:\/\/bridgefamilynetwork.org\/?page_id=560"},"modified":"2026-09-16T12:27:27","modified_gmt":"2026-09-16T17:27:27","slug":"form-test","status":"publish","type":"page","link":"https:\/\/bridgefamilynetwork.org\/es\/form-test\/","title":{"rendered":"Form Test"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.27.8&#8243; _module_preset=&#8221;default&#8221; width=&#8221;100%&#8221; module_alignment=&#8221;center&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.27.8&#8243; _module_preset=&#8221;default&#8221; width=&#8221;100%&#8221; module_alignment=&#8221;center&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.27.8&#8243; _module_preset=&#8221;default&#8221; custom_padding=&#8221;20px|20px|20px|20px|true|true&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_code 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#112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: 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-btn-bg-color-hover-tertiary: #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 Bridge Family Navigator<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/es\/wp-json\/wp\/v2\/pages\/560' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_above description_above validation_above' data-column-layout='fill'><fieldset id=\"field_5_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"3d4f6b23\" data-field-span=\"12\"><legend id='gfield_label_5_31' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Usted necesita ser contactado por un Navegador que habla Espa\u00f1ol?<\/span><\/legend><div class='gfield_description' id='gfield_description_5_31'>(Do you need to be contacted by a Spanish-speaking Navigator?)<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_31'>\n\t\t\t<div class='gchoice gchoice_5_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_5_31_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_31\" aria-labelledby=\"label_5_31_0 gfield_label_5_31\"   \/>\n\t\t\t\t\t<label for='choice_5_31_0' id='label_5_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_5_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_5_31_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_31_1' id='label_5_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_4\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"1f3e7ea5\" data-field-span=\"12\"><legend id='gfield_label_5_4' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Full Legal Name<\/span><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_5_4'>\n                            \n                            <span id='input_5_4_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_5_4_3' id='input_5_4_3_label' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_4.3' id='input_5_4_3' value=''   aria-required='true'     aria-labelledby=\"input_5_4_3_label gfield_label_5_4\"\/>\n                                                <\/span>\n                            \n                            <span id='input_5_4_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_5_4_6' id='input_5_4_6_label' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_4.6' id='input_5_4_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"e4654008\" data-field-span=\"12\"><label id='gfield_label_5_3' class='gfield_label gform-field-label' for='input_5_3'><span class='gform-field-label__text'>What name do you go by?<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_5_3' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_58\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"ee1a7140\" data-field-span=\"6\"><label id='gfield_label_5_58' class='gfield_label gform-field-label' for='input_5_58'><span class='gform-field-label__text'>Phone Number<\/span><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_58' id='input_5_58' type='tel' value='' class='large'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_5_59\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"ee1a7140\" data-field-span=\"6\"><label id='gfield_label_5_59' class='gfield_label gform-field-label' for='input_5_59'><span class='gform-field-label__text'>Email Address<\/span><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_59' id='input_5_59' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_5_21\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"e38efd23\" data-field-span=\"12\"><legend id='gfield_label_5_21' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><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_5_21' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_21_1_container' >\n                                        <label for='input_5_21_1' id='input_5_21_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_21.1' id='input_5_21_1' value=''    aria-required='true'    aria-labelledby=\"input_5_21_1_label gfield_label_5_21\"\/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_21_3_container' >\n                                    <label for='input_5_21_3' id='input_5_21_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_21.3' id='input_5_21_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_21_4_container' >\n                                        <label for='input_5_21_4' id='input_5_21_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                        <select name='input_21.4' id='input_5_21_4'     aria-required='true'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' selected='selected'>Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_21_5_container' >\n                                    <label for='input_5_21_5' id='input_5_21_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                    <input type='text' name='input_21.5' id='input_5_21_5' value=''    aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_21.6' id='input_5_21_6' value='US' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_5_52\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"634beff1\" data-field-span=\"12\"><label id='gfield_label_5_52' class='gfield_label gform-field-label' for='input_5_52'><span class='gform-field-label__text'>In which county do you live?<\/span><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_52' id='input_5_52' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Douglas' >Douglas<\/option><option value='Washington' >Washington<\/option><option value='Dodge' >Dodge<\/option><option value='Saunders' >Saunders<\/option><option value='Sarpy' >Sarpy<\/option><option value='Pottawattamie' >Pottawattamie<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><fieldset id=\"field_5_8\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gf_list_3col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"e4504f61\" data-field-span=\"12\"><legend id='gfield_label_5_8' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Race\/Ethnicity (select all that apply)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_8'>\n\t\t\t<div class='gchoice gchoice_5_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Native American or Alaskan Native'  id='choice_5_8_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_5_8_0 gfield_label_5_8\"   \/>\n\t\t\t\t\t<label for='choice_5_8_0' id='label_5_8_0' class='gform-field-label gform-field-label--type-inline'>Native American or Alaskan Native<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Asian'  id='choice_5_8_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_8_1' id='label_5_8_1' class='gform-field-label gform-field-label--type-inline'>Asian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_8_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Black or African American'  id='choice_5_8_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_8_2' id='label_5_8_2' class='gform-field-label gform-field-label--type-inline'>Black or African American<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_8_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Hispanic or Latino'  id='choice_5_8_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_8_3' id='label_5_8_3' class='gform-field-label gform-field-label--type-inline'>Hispanic or Latino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_8_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Middle Eastern or North African'  id='choice_5_8_4' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_8_4' id='label_5_8_4' class='gform-field-label gform-field-label--type-inline'>Middle Eastern or North African<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_8_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Native Hawaiian or Pacific Islander'  id='choice_5_8_5' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_8_5' id='label_5_8_5' class='gform-field-label gform-field-label--type-inline'>Native Hawaiian or Pacific Islander<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_8_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='White'  id='choice_5_8_6' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_8_6' id='label_5_8_6' class='gform-field-label gform-field-label--type-inline'>White<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_8_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Prefer not to say'  id='choice_5_8_7' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_8_7' id='label_5_8_7' class='gform-field-label gform-field-label--type-inline'>Prefer not to say<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_8_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Prefer to self identify'  id='choice_5_8_8' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_8_8' id='label_5_8_8' class='gform-field-label gform-field-label--type-inline'>Prefer to self identify<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"10d4766c\" data-field-span=\"12\"><legend id='gfield_label_5_6' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Sex<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_6'>\n\t\t\t<div class='gchoice gchoice_5_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Male'  id='choice_5_6_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_5_6_0 gfield_label_5_6\"   \/>\n\t\t\t\t\t<label for='choice_5_6_0' id='label_5_6_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Female'  id='choice_5_6_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_6_1' id='label_5_6_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_6_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Prefer not to say'  id='choice_5_6_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_6_2' id='label_5_6_2' class='gform-field-label gform-field-label--type-inline'>Prefer not to say<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_17\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"a2d0ba7e\" data-field-span=\"6\"><label id='gfield_label_5_17' class='gfield_label gform-field-label' for='input_5_17'><span class='gform-field-label__text'>Your Date of Birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_17'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_17'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_17' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_17' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_17' aria-label='Your Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_10\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"a2d0ba7e\" data-field-span=\"6\"><label id='gfield_label_5_10' class='gfield_label gform-field-label' for='input_5_10'><span class='gform-field-label__text'>Total number of adults in the household<\/span><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_10' id='input_5_10' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_5_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"9b8d2ebd\" data-field-span=\"6\"><legend id='gfield_label_5_9' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you currently pregnant or expecting a child? (Mother or Father)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_9'>\n\t\t\t<div class='gchoice gchoice_5_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Yes'  id='choice_5_9_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_5_9_0 gfield_label_5_9\"   \/>\n\t\t\t\t\t<label for='choice_5_9_0' id='label_5_9_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_5_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='No'  id='choice_5_9_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_9_1' id='label_5_9_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_53\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"9b8d2ebd\" data-field-span=\"6\"><label id='gfield_label_5_53' class='gfield_label gform-field-label' for='input_5_53'><span class='gform-field-label__text'>Expected Due Date<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_53'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_53'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_53' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_53' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_53' aria-label='Expected Due Date: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_5_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"24e790b0\" data-field-span=\"12\"><legend id='gfield_label_5_11' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Based on the number of individuals in your household, is your income below 200% of the poverty level?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_11'>\n\t\t\t<div class='gchoice gchoice_5_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Yes'  id='choice_5_11_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_5_11_0 gfield_label_5_11\"   \/>\n\t\t\t\t\t<label for='choice_5_11_0' id='label_5_11_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_5_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='No'  id='choice_5_11_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_11_1' id='label_5_11_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"1918cdf9\" data-field-span=\"12\"><legend id='gfield_label_5_12' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>What is the highest level of education you have completed?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_12'>\n\t\t\t<div class='gchoice gchoice_5_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Less than high school'  id='choice_5_12_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_5_12_0 gfield_label_5_12\"   \/>\n\t\t\t\t\t<label for='choice_5_12_0' id='label_5_12_0' class='gform-field-label gform-field-label--type-inline'>Less than high school<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='High school diploma or GED'  id='choice_5_12_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_12_1' id='label_5_12_1' class='gform-field-label gform-field-label--type-inline'>High school diploma or GED<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Some college, no degree'  id='choice_5_12_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_12_2' id='label_5_12_2' class='gform-field-label gform-field-label--type-inline'>Some college, no degree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Certificate or trade credential'  id='choice_5_12_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_12_3' id='label_5_12_3' class='gform-field-label gform-field-label--type-inline'>Certificate or trade credential<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Associate degree'  id='choice_5_12_4' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_12_4' id='label_5_12_4' class='gform-field-label gform-field-label--type-inline'>Associate degree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Bachelor&#039;s degree'  id='choice_5_12_5' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_12_5' id='label_5_12_5' class='gform-field-label gform-field-label--type-inline'>Bachelor's degree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Graduate or professional degree'  id='choice_5_12_6' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_12_6' id='label_5_12_6' class='gform-field-label gform-field-label--type-inline'>Graduate or professional degree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Prefer not to answer'  id='choice_5_12_7' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_12_7' id='label_5_12_7' class='gform-field-label gform-field-label--type-inline'>Prefer not to answer<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"3471d0c9\" data-field-span=\"12\"><legend id='gfield_label_5_13' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you currently have any health insurance?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_13'>\n\t\t\t<div class='gchoice gchoice_5_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Yes, Private\/ACA'  id='choice_5_13_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_5_13_0 gfield_label_5_13\"   \/>\n\t\t\t\t\t<label for='choice_5_13_0' id='label_5_13_0' class='gform-field-label gform-field-label--type-inline'>Yes, Private\/ACA<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Yes, Medicaid'  id='choice_5_13_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_13_1' id='label_5_13_1' class='gform-field-label gform-field-label--type-inline'>Yes, Medicaid<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Yes, Medicare'  id='choice_5_13_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_13_2' id='label_5_13_2' class='gform-field-label gform-field-label--type-inline'>Yes, Medicare<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_13_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Medicaid in Process (application filled out)'  id='choice_5_13_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_13_3' id='label_5_13_3' class='gform-field-label gform-field-label--type-inline'>Medicaid in Process (application filled out)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_13_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='No'  id='choice_5_13_4' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_13_4' id='label_5_13_4' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_13_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Choose not to answer'  id='choice_5_13_5' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_13_5' id='label_5_13_5' class='gform-field-label gform-field-label--type-inline'>Choose not to answer<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"4f4dd8e8\" data-field-span=\"6\"><legend id='gfield_label_5_14' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you have a disability?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_14'>\n\t\t\t<div class='gchoice gchoice_5_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Yes'  id='choice_5_14_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_5_14_0 gfield_label_5_14\"   \/>\n\t\t\t\t\t<label for='choice_5_14_0' id='label_5_14_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_5_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='No'  id='choice_5_14_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_14_1' id='label_5_14_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"4f4dd8e8\" data-field-span=\"6\"><legend id='gfield_label_5_15' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Does your child have a disability?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_15'>\n\t\t\t<div class='gchoice gchoice_5_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Yes'  id='choice_5_15_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_5_15_0 gfield_label_5_15\"   \/>\n\t\t\t\t\t<label for='choice_5_15_0' id='label_5_15_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_5_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='No'  id='choice_5_15_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_15_1' id='label_5_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col gfield--width-half gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"6f396fe7\" data-field-span=\"6\"><legend id='gfield_label_5_16' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Minor Assent<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_5_16'>(Only complete if the participant is a minor, if the participant is NOT a minor select N\/A): \"As a minor participating in this program, I give permission for my information to be shared and used to help improve the program.\"<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_16'>\n\t\t\t<div class='gchoice gchoice_5_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Yes'  id='choice_5_16_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_16\" aria-labelledby=\"label_5_16_0 gfield_label_5_16\"   \/>\n\t\t\t\t\t<label for='choice_5_16_0' id='label_5_16_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_5_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='No'  id='choice_5_16_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_16_1' id='label_5_16_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_16_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='N\/A'  id='choice_5_16_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_16_2' id='label_5_16_2' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_32\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"6f396fe7\" data-field-span=\"6\"><label id='gfield_label_5_32' class='gfield_label gform-field-label' for='input_5_32'><span class='gform-field-label__text'>Number of Children<\/span><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_32' id='input_5_32' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='0' >None<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><\/select><\/div><\/div><div id=\"field_5_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"c08c1d3d\" data-field-span=\"6\"><label id='gfield_label_5_19' class='gfield_label gform-field-label' for='input_5_19'><span class='gform-field-label__text'>1st Child&#039;s first and last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_19'>List the first and last name for each child, under age 19, living in your home.<\/div><div class='ginput_container ginput_container_text'><input name='input_19' id='input_5_19' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_19\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_20\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"c08c1d3d\" data-field-span=\"6\"><label id='gfield_label_5_20' class='gfield_label gform-field-label' for='input_5_20'><span class='gform-field-label__text'>1st Child&#039;s date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_20'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_20'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_20' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_20' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_20' aria-label='1st Child's date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"a29abe35\" data-field-span=\"6\"><label id='gfield_label_5_33' class='gfield_label gform-field-label' for='input_5_33'><span class='gform-field-label__text'>2nd Child&#039;s first and last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_33'>List the first and last name for each child, under age 19, living in your home.<\/div><div class='ginput_container ginput_container_text'><input name='input_33' id='input_5_33' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_33\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_34\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"a29abe35\" data-field-span=\"6\"><label id='gfield_label_5_34' class='gfield_label gform-field-label' for='input_5_34'><span class='gform-field-label__text'>2nd Child&#039;s date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_34'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_34'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_34' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_34' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_34' aria-label='2nd Child's date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"65e3b63a\" data-field-span=\"6\"><label id='gfield_label_5_35' class='gfield_label gform-field-label' for='input_5_35'><span class='gform-field-label__text'>3rd Child&#039;s first and last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_35'>List the first and last name for each child, under age 19, living in your home.<\/div><div class='ginput_container ginput_container_text'><input name='input_35' id='input_5_35' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_35\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_36\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"65e3b63a\" data-field-span=\"6\"><label id='gfield_label_5_36' class='gfield_label gform-field-label' for='input_5_36'><span class='gform-field-label__text'>3rd Child&#039;s date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_36'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_36'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_36' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_36' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_36' aria-label='3rd Child's date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"61066e5d\" data-field-span=\"6\"><label id='gfield_label_5_37' class='gfield_label gform-field-label' for='input_5_37'><span class='gform-field-label__text'>4th Child&#039;s first and last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_37'>List the first and last name for each child, under age 19, living in your home.<\/div><div class='ginput_container ginput_container_text'><input name='input_37' id='input_5_37' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_37\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_38\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"61066e5d\" data-field-span=\"6\"><label id='gfield_label_5_38' class='gfield_label gform-field-label' for='input_5_38'><span class='gform-field-label__text'>4th Child&#039;s date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_38'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_38'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_38' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_38' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_38' aria-label='4th Child's date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_39\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"87ff2b46\" data-field-span=\"6\"><label id='gfield_label_5_39' class='gfield_label gform-field-label' for='input_5_39'><span class='gform-field-label__text'>5th Child&#039;s first and last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_39'>List the first and last name for each child, under age 19, living in your home.<\/div><div class='ginput_container ginput_container_text'><input name='input_39' id='input_5_39' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_39\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_40\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"87ff2b46\" data-field-span=\"6\"><label id='gfield_label_5_40' class='gfield_label gform-field-label' for='input_5_40'><span class='gform-field-label__text'>5th Child&#039;s date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_40'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_40'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_40' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_40' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_40' aria-label='5th Child's date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_41\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"70900b01\" data-field-span=\"6\"><label id='gfield_label_5_41' class='gfield_label gform-field-label' for='input_5_41'><span class='gform-field-label__text'>6th Child&#039;s first and last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_41'>List the first and last name for each child, under age 19, living in your home.<\/div><div class='ginput_container ginput_container_text'><input name='input_41' id='input_5_41' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_41\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_42\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"70900b01\" data-field-span=\"6\"><label id='gfield_label_5_42' class='gfield_label gform-field-label' for='input_5_42'><span class='gform-field-label__text'>6th Child&#039;s date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_42'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_42'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_42' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_42' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_42' aria-label='6th Child's date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"c5b48f93\" data-field-span=\"6\"><label id='gfield_label_5_43' class='gfield_label gform-field-label' for='input_5_43'><span class='gform-field-label__text'>7th Child&#039;s first and last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_43'>List the first and last name for each child, under age 19, living in your home.<\/div><div class='ginput_container ginput_container_text'><input name='input_43' id='input_5_43' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_43\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_44\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"c5b48f93\" data-field-span=\"6\"><label id='gfield_label_5_44' class='gfield_label gform-field-label' for='input_5_44'><span class='gform-field-label__text'>7th Child&#039;s date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_44'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_44'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_44' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_44' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_44' aria-label='7th Child's date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_45\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"f5ad5855\" data-field-span=\"6\"><label id='gfield_label_5_45' class='gfield_label gform-field-label' for='input_5_45'><span class='gform-field-label__text'>8th Child&#039;s first and last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_45'>List the first and last name for each child, under age 19, living in your home.<\/div><div class='ginput_container ginput_container_text'><input name='input_45' id='input_5_45' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_45\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_46\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"f5ad5855\" data-field-span=\"6\"><label id='gfield_label_5_46' class='gfield_label gform-field-label' for='input_5_46'><span class='gform-field-label__text'>8th Child&#039;s date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_46'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_46'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_46' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_46' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_46' aria-label='8th Child's date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_48\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"d38f5088\" data-field-span=\"6\"><label id='gfield_label_5_48' class='gfield_label gform-field-label' for='input_5_48'><span class='gform-field-label__text'>9th Child&#039;s first and last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_48'>List the first and last name for each child, under age 19, living in your home.<\/div><div class='ginput_container ginput_container_text'><input name='input_48' id='input_5_48' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_48\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_49\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"d38f5088\" data-field-span=\"6\"><label id='gfield_label_5_49' class='gfield_label gform-field-label' for='input_5_49'><span class='gform-field-label__text'>9th Child&#039;s date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_49'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_49'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_49' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_49' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_49' aria-label='9th Child's date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_50\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"7aa1e01f\" data-field-span=\"6\"><label id='gfield_label_5_50' class='gfield_label gform-field-label' for='input_5_50'><span class='gform-field-label__text'>10th Child&#039;s first and last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_50'>List the first and last name for each child, under age 19, living in your home.<\/div><div class='ginput_container ginput_container_text'><input name='input_50' id='input_5_50' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_50\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_51\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"7aa1e01f\" data-field-span=\"6\"><label id='gfield_label_5_51' class='gfield_label gform-field-label' for='input_5_51'><span class='gform-field-label__text'>10th Child&#039;s date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_51'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_51'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_51' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_51' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_51' aria-label='10th Child's date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_47\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"cd2ae7dc\" data-field-span=\"12\"><h3 class=\"gsection_title\">What are some ways we can help you?<\/h3><\/div><fieldset id=\"field_5_25\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-checkbox gf_list_4col gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"532535f8\" data-field-span=\"12\"><legend id='gfield_label_5_25' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Need<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_5_25'>What is your most urgent need? Check all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_25'><div class='gchoice gchoice_5_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='Daily Living (telephone, clothes, hygiene)'  id='choice_5_25_1'   aria-describedby=\"gfield_description_5_25\" aria-labelledby=\"label_5_25_1 gfield_label_5_25\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_1' id='label_5_25_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_5_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='Dentist'  id='choice_5_25_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_2' id='label_5_25_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_5_25_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.3' type='checkbox'  value='Education'  id='choice_5_25_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_3' id='label_5_25_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_5_25_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.4' type='checkbox'  value='Finances'  id='choice_5_25_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_4' id='label_5_25_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_5_25_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.5' type='checkbox'  value='General Life Skills'  id='choice_5_25_5'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_5' id='label_5_25_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_5_25_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.6' type='checkbox'  value='Housing'  id='choice_5_25_6'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_6' id='label_5_25_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_5_25_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.7' type='checkbox'  value='Legal Help'  id='choice_5_25_7'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_7' id='label_5_25_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_5_25_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.8' type='checkbox'  value='Mental Health'  id='choice_5_25_8'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_8' id='label_5_25_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_5_25_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.9' type='checkbox'  value='Parenting Assistance'  id='choice_5_25_9'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_9' id='label_5_25_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_5_25_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.11' type='checkbox'  value='Substance Abuse'  id='choice_5_25_11'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_11' id='label_5_25_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_5_25_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.12' type='checkbox'  value='Supportive Relationships'  id='choice_5_25_12'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_12' id='label_5_25_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_5_25_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.13' type='checkbox'  value='Transportation'  id='choice_5_25_13'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_13' id='label_5_25_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_5_25_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.14' type='checkbox'  value='Utilities'  id='choice_5_25_14'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_14' id='label_5_25_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_5_25_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.15' type='checkbox'  value='Other'  id='choice_5_25_15'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_15' id='label_5_25_15' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"2cd61e39\" data-field-span=\"12\"><label id='gfield_label_5_54' class='gfield_label gform-field-label' for='input_5_54'><span class='gform-field-label__text'>What resource(s) are you looking for not listed above?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_54'>Please describe your need.<\/div><div class='ginput_container ginput_container_text'><input name='input_54' id='input_5_54' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_54\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_26\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"72e906db\" data-field-span=\"12\"><h3 class=\"gsection_title\">How did you find us?<\/h3><\/div><div id=\"field_5_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"c1b47244\" data-field-span=\"12\"><label id='gfield_label_5_27' class='gfield_label gform-field-label' for='input_5_27'><span class='gform-field-label__text'>Who referred you to The Bridge?<\/span><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_27' id='input_5_27' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_28\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"3ba54988\" data-field-span=\"12\"><legend id='gfield_label_5_28' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>What school district(s) do your children attend?<\/span><\/legend><div class='gfield_description' id='gfield_description_5_28'>Check all that apply.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_28'>\n\t\t\t<div class='gchoice gchoice_5_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Omaha Public Schools'  id='choice_5_28_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_28\" aria-labelledby=\"label_5_28_0 gfield_label_5_28\"   \/>\n\t\t\t\t\t<label for='choice_5_28_0' id='label_5_28_0' class='gform-field-label gform-field-label--type-inline'>Omaha Public Schools<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Millard Public Schools'  id='choice_5_28_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_28_1' id='label_5_28_1' class='gform-field-label gform-field-label--type-inline'>Millard Public Schools<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_28_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Ralston Public Schools'  id='choice_5_28_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_28_2' id='label_5_28_2' class='gform-field-label gform-field-label--type-inline'>Ralston Public Schools<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_28_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Westside Community Schools'  id='choice_5_28_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_28_3' id='label_5_28_3' class='gform-field-label gform-field-label--type-inline'>Westside Community Schools<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_28_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Other'  id='choice_5_28_4' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_28_4' id='label_5_28_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_29\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gf_list_3col gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"81f93ace\" data-field-span=\"12\"><legend id='gfield_label_5_29' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>What is the best time of day to contact you?<\/span><\/legend><div class='gfield_description' id='gfield_description_5_29'>Check all that apply.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_29'>\n\t\t\t<div class='gchoice gchoice_5_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Morning'  id='choice_5_29_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_29\" aria-labelledby=\"label_5_29_0 gfield_label_5_29\"   \/>\n\t\t\t\t\t<label for='choice_5_29_0' id='label_5_29_0' class='gform-field-label gform-field-label--type-inline'>Morning<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Afternoon'  id='choice_5_29_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_29_1' id='label_5_29_1' class='gform-field-label gform-field-label--type-inline'>Afternoon<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_29_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Evening after 5:00 p.m.'  id='choice_5_29_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_29_2' id='label_5_29_2' class='gform-field-label gform-field-label--type-inline'>Evening after 5:00 p.m.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"17790fc6\" data-field-span=\"12\"><legend id='gfield_label_5_30' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Consent<\/span><\/legend><div class='gfield_description' id='gfield_description_5_30'>Can The Bridge add your information to the Find Help database?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_30'>\n\t\t\t<div class='gchoice gchoice_5_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_5_30_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_30\" aria-labelledby=\"label_5_30_0 gfield_label_5_30\"   \/>\n\t\t\t\t\t<label for='choice_5_30_0' id='label_5_30_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_5_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_5_30_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_30_1' id='label_5_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_55\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"79d7bef8\" data-field-span=\"12\"><label id='gfield_label_5_55' class='gfield_label gform-field-label' for='input_5_55'><span class='gform-field-label__text'>CAPTCHA<\/span><\/label><div id='input_5_55' class='ginput_container ginput_recaptcha' data-sitekey='6LdD670rAAAAAA64gGiNw5YKz8v5S4ElbLr-li2p'  data-theme='light' 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name='gform_currency' data-currency='USD' value='eUR3cxosSTG9Ek6thnHBAW7t3pcxvy0RIYCYasicHg53Gb56BOE7avlp3KfrxWgtBfHMgzYOS\/t6DX+ffUa7qeK8XXKMC5phr67HwjZ+8b1Eowg=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_5' 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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: #112337;--gf-color-secondary-contrast-rgb: 17, 35, 55;--gf-color-secondary-darker: #F5F5F5;--gf-color-secondary-lighter: #FFFFFF;--gf-color-out-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-out-ctrl-light-rgb: 17, 35, 55;--gf-color-out-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-out-ctrl-light-lighter: #F5F5F5;--gf-color-out-ctrl-dark: #585e6a;--gf-color-out-ctrl-dark-rgb: 88, 94, 106;--gf-color-out-ctrl-dark-darker: #112337;--gf-color-out-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-color-in-ctrl: #fff;--gf-color-in-ctrl-rgb: 255, 255, 255;--gf-color-in-ctrl-contrast: #112337;--gf-color-in-ctrl-contrast-rgb: 17, 35, 55;--gf-color-in-ctrl-darker: #F5F5F5;--gf-color-in-ctrl-lighter: #FFFFFF;--gf-color-in-ctrl-primary: #204ce5;--gf-color-in-ctrl-primary-rgb: 32, 76, 229;--gf-color-in-ctrl-primary-contrast: #fff;--gf-color-in-ctrl-primary-contrast-rgb: 255, 255, 255;--gf-color-in-ctrl-primary-darker: #001AB3;--gf-color-in-ctrl-primary-lighter: #527EFF;--gf-color-in-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-in-ctrl-light-rgb: 17, 35, 55;--gf-color-in-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-in-ctrl-light-lighter: #F5F5F5;--gf-color-in-ctrl-dark: #585e6a;--gf-color-in-ctrl-dark-rgb: 88, 94, 106;--gf-color-in-ctrl-dark-darker: #112337;--gf-color-in-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-radius: 3px;--gf-font-size-secondary: 14px;--gf-font-size-tertiary: 13px;--gf-icon-ctrl-number: url(\"data:image\/svg+xml,%3Csvg width='8' height='14' viewBox='0 0 8 14' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-select: url(\"data:image\/svg+xml,%3Csvg width='10' height='6' viewBox='0 0 10 6' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-search: url(\"data:image\/svg+xml,%3Csvg width='640' height='640' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: 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-btn-bg-color-hover-tertiary: #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\/560' 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' data-column-layout='fill'><div id=\"field_1_68\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"><label id='gfield_label_1_68' class='gfield_label gform-field-label' for='input_1_68'><span class='gform-field-label__text'>URL<\/span><\/label><div class='ginput_container'><input name='input_68' id='input_1_68' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_68'>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\" data-group-id=\"b6d11375\" data-field-span=\"12\"><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\" data-group-id=\"d0be5b86\" data-field-span=\"6\"><label id='gfield_label_1_15' class='gfield_label gform-field-label' for='input_1_15'><span class='gform-field-label__text'>Your Name<\/span><\/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\" data-group-id=\"d0be5b86\" data-field-span=\"6\"><label id='gfield_label_1_16' class='gfield_label gform-field-label' for='input_1_16'><span class='gform-field-label__text'>What name do you go by?<\/span><\/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\" data-group-id=\"102471df\" data-field-span=\"12\"><legend id='gfield_label_1_1' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Full Legal Name<\/span><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'     aria-labelledby=\"input_1_1_3_label gfield_label_1_1\"\/>\n                                                    <label for='input_1_1_3' id='input_1_1_3_label' 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' id='input_1_1_6_label' 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\" data-group-id=\"b0f0906f\" data-field-span=\"12\"><label id='gfield_label_1_38' class='gfield_label gform-field-label' for='input_1_38'><span class='gform-field-label__text'>Race\/Ethnicity (select all that apply)<\/span><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\" data-group-id=\"d6daee27\" data-field-span=\"12\"><label id='gfield_label_1_39' class='gfield_label gform-field-label' for='input_1_39'><span class='gform-field-label__text'>Sex<\/span><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\" data-group-id=\"73534bfd\" data-field-span=\"12\"><label id='gfield_label_1_43' class='gfield_label gform-field-label' for='input_1_43'><span class='gform-field-label__text'>Are you currently pregnant or expecting a child? (Mother or Father)<\/span><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\" data-group-id=\"c71310d6\" data-field-span=\"12\"><label id='gfield_label_1_47' class='gfield_label gform-field-label' for='input_1_47'><span class='gform-field-label__text'>Total number of adults in the household<\/span><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\" data-group-id=\"3e761782\" data-field-span=\"12\"><label id='gfield_label_1_42' class='gfield_label gform-field-label' for='input_1_42'><span class='gform-field-label__text'>Based on the number of individuals in your household, is your income below 200% of the poverty level?\u2009<\/span><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\" data-group-id=\"9838a342\" data-field-span=\"12\"><label id='gfield_label_1_49' class='gfield_label gform-field-label' for='input_1_49'><span class='gform-field-label__text'>What is the highest level of education you have completed?<\/span><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\" data-group-id=\"116793b8\" data-field-span=\"12\"><label id='gfield_label_1_41' class='gfield_label gform-field-label' for='input_1_41'><span class='gform-field-label__text'>Do you currently have any health insurance?<\/span><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\" data-group-id=\"2319677f\" data-field-span=\"12\"><label id='gfield_label_1_53' class='gfield_label gform-field-label' for='input_1_53'><span class='gform-field-label__text'>Do you have a disability?<\/span><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\" data-group-id=\"45a98ed7\" data-field-span=\"12\"><label id='gfield_label_1_54' class='gfield_label gform-field-label' for='input_1_54'><span class='gform-field-label__text'>Does your child have a disability?<\/span><\/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\" data-group-id=\"b785fbcb\" data-field-span=\"12\"><label id='gfield_label_1_40' class='gfield_label gform-field-label' for='input_1_40'><span class='gform-field-label__text'>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><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-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"b770954e\" data-field-span=\"6\"><label id='gfield_label_1_3' class='gfield_label gform-field-label' for='input_1_3'><span class='gform-field-label__text'>Date of Birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_1_3'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_3'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_1_3' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_1_3' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_1_3' aria-label='Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/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\" data-group-id=\"b770954e\" data-field-span=\"6\"><label id='gfield_label_1_13' class='gfield_label gform-field-label' for='input_1_13'><span class='gform-field-label__text'>Number of Children<\/span><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\" data-group-id=\"c596b3d7\" data-field-span=\"6\"><label id='gfield_label_1_56' class='gfield_label gform-field-label' for='input_1_56'><span class='gform-field-label__text'>1st Child&#039;s first and last name<\/span><\/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\" data-group-id=\"c596b3d7\" data-field-span=\"6\"><label id='gfield_label_1_14' class='gfield_label gform-field-label' for='input_1_14'><span class='gform-field-label__text'>1st Child&#039;s date of birth<\/span><\/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\"  placeholder='99\/99\/9999'  aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/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\" data-group-id=\"65829183\" data-field-span=\"6\"><label id='gfield_label_1_55' class='gfield_label gform-field-label' for='input_1_55'><span class='gform-field-label__text'>2nd Child&#039;s first and last name<\/span><\/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\" data-group-id=\"65829183\" data-field-span=\"6\"><label id='gfield_label_1_29' class='gfield_label gform-field-label' for='input_1_29'><span class='gform-field-label__text'>2nd Child&#039;s date of birth<\/span><\/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\"  placeholder='99\/99\/9999'  aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/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\" data-group-id=\"6df97d16\" data-field-span=\"6\"><label id='gfield_label_1_61' class='gfield_label gform-field-label' for='input_1_61'><span class='gform-field-label__text'>3rd Child&#039;s first and last name<\/span><\/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\" data-group-id=\"6df97d16\" data-field-span=\"6\"><label id='gfield_label_1_30' class='gfield_label gform-field-label' for='input_1_30'><span class='gform-field-label__text'>3rd Child&#039;s date of birth<\/span><\/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\"  placeholder='99\/99\/9999'  aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/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\" data-group-id=\"e36a663b\" data-field-span=\"6\"><label id='gfield_label_1_60' class='gfield_label gform-field-label' for='input_1_60'><span class='gform-field-label__text'>4th Child&#039;s first and last name<\/span><\/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\" data-group-id=\"e36a663b\" data-field-span=\"6\"><label id='gfield_label_1_28' class='gfield_label gform-field-label' for='input_1_28'><span class='gform-field-label__text'>4th Child&#039;s date of birth<\/span><\/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\"  placeholder='99\/99\/9999'  aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/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\" data-group-id=\"b4056b12\" data-field-span=\"6\"><label id='gfield_label_1_59' class='gfield_label gform-field-label' for='input_1_59'><span class='gform-field-label__text'>5th Child&#039;s first and last name<\/span><\/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\" data-group-id=\"b4056b12\" data-field-span=\"6\"><label id='gfield_label_1_36' class='gfield_label gform-field-label' for='input_1_36'><span class='gform-field-label__text'>5th Child&#039;s date of birth<\/span><\/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\"  placeholder='99\/99\/9999'  aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/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\" data-group-id=\"cb4e1ee8\" data-field-span=\"6\"><label id='gfield_label_1_58' class='gfield_label gform-field-label' for='input_1_58'><span class='gform-field-label__text'>6th Child&#039;s first and last name<\/span><\/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\" data-group-id=\"cb4e1ee8\" data-field-span=\"6\"><label id='gfield_label_1_37' class='gfield_label gform-field-label' for='input_1_37'><span class='gform-field-label__text'>6th Child&#039;s date of birth<\/span><\/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\"  placeholder='99\/99\/9999'  aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/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\" data-group-id=\"24de5b88\" data-field-span=\"6\"><label id='gfield_label_1_57' class='gfield_label gform-field-label' for='input_1_57'><span class='gform-field-label__text'>7th Child&#039;s first and last name<\/span><\/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'>List the first and last name for each child, under age 19, living in your home. <\/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\" data-group-id=\"24de5b88\" data-field-span=\"6\"><label id='gfield_label_1_35' class='gfield_label gform-field-label' for='input_1_35'><span class='gform-field-label__text'>7th Child&#039;s date of birth<\/span><\/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\"  placeholder='99\/99\/9999'  aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/div><div class='gfield_description' id='gfield_description_1_35'>List the birthday for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_62\" 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\" data-group-id=\"8d8fa435\" data-field-span=\"6\"><label id='gfield_label_1_62' class='gfield_label gform-field-label' for='input_1_62'><span class='gform-field-label__text'>8th Child&#039;s first and last name<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_1_62' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_62\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_62'>List the first and last name for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_63\" 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\" data-group-id=\"8d8fa435\" data-field-span=\"6\"><label id='gfield_label_1_63' class='gfield_label gform-field-label' for='input_1_63'><span class='gform-field-label__text'>8th Child&#039;s date of birth<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_1_63' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_63\"  placeholder='99\/99\/9999'  aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/div><div class='gfield_description' id='gfield_description_1_63'>List the birthday for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_64\" 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\" data-group-id=\"0f3d735b\" data-field-span=\"6\"><label id='gfield_label_1_64' class='gfield_label gform-field-label' for='input_1_64'><span class='gform-field-label__text'>9th Child&#039;s first and last name<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_1_64' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_64\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_64'>List the first and last name for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_65\" 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\" data-group-id=\"0f3d735b\" data-field-span=\"6\"><label id='gfield_label_1_65' class='gfield_label gform-field-label' for='input_1_65'><span class='gform-field-label__text'>9th Child&#039;s date of birth<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_1_65' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_65\"  placeholder='99\/99\/9999'  aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/div><div class='gfield_description' id='gfield_description_1_65'>List the birthday for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_67\" 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\" data-group-id=\"41d06920\" data-field-span=\"6\"><label id='gfield_label_1_67' class='gfield_label gform-field-label' for='input_1_67'><span class='gform-field-label__text'>10th Child&#039;s first and last name<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_1_67' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_67\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_67'>If there are more than ten children under age 19 living in your home, list them at the end of this form. <\/div><\/div><div id=\"field_1_66\" 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\" data-group-id=\"41d06920\" data-field-span=\"6\"><label id='gfield_label_1_66' class='gfield_label gform-field-label' for='input_1_66'><span class='gform-field-label__text'>10th Child&#039;s date of birth<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_1_66' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_66\"  placeholder='99\/99\/9999'  aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/div><div class='gfield_description' id='gfield_description_1_66'>List the birthday for each child, under age 19, living in your home. <\/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\" data-group-id=\"14b23fb3\" data-field-span=\"12\"><label id='gfield_label_1_51' class='gfield_label gform-field-label' for='input_1_51'><span class='gform-field-label__text'>First and Last Name of all children listed above<\/span><\/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--phone-format-standard gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"bcdeeb66\" data-field-span=\"6\"><label id='gfield_label_1_4' class='gfield_label gform-field-label' for='input_1_4'><span class='gform-field-label__text'>Phone Number<\/span><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'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/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\" data-group-id=\"bcdeeb66\" data-field-span=\"6\"><label id='gfield_label_1_5' class='gfield_label gform-field-label' for='input_1_5'><span class='gform-field-label__text'>Email Address<\/span><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\" data-group-id=\"63e971e1\" data-field-span=\"12\"><legend id='gfield_label_1_10' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><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'    aria-labelledby=\"input_1_10_1_label gfield_label_1_10\"\/>\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\" data-group-id=\"9bc512d4\" data-field-span=\"12\"><label id='gfield_label_1_18' class='gfield_label gform-field-label' for='input_1_18'><span class='gform-field-label__text'>County<\/span><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\" data-group-id=\"d28eca3f\" data-field-span=\"12\"><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 gfield--choice-align-vertical\" data-group-id=\"3913ccc1\" data-field-span=\"6\"><legend id='gfield_label_1_12' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Need<\/span><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\" aria-labelledby=\"label_1_12_1 gfield_label_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 gfield--choice-align-vertical\" data-group-id=\"3913ccc1\" data-field-span=\"6\"><legend id='gfield_label_1_19' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Usted necesita ser contactado por un Navegador que habla Espa\u00f1ol?<\/span><\/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 )'  aria-labelledby=\"label_1_19_0 gfield_label_1_19\"   \/>\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\" data-group-id=\"9d4ce1c5\" data-field-span=\"12\"><label id='gfield_label_1_44' class='gfield_label gform-field-label' for='input_1_44'><span class='gform-field-label__text'>If you chose &quot;Other&quot;, please specify your needs.<\/span><\/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\" data-group-id=\"83de97d0\" data-field-span=\"12\"><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\" data-group-id=\"6ad85b1c\" data-field-span=\"12\"><label id='gfield_label_1_21' class='gfield_label gform-field-label' for='input_1_21'><span class='gform-field-label__text'>Who referred you to The BRIDGE?<\/span><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 gfield--choice-align-vertical\" data-group-id=\"279dd909\" data-field-span=\"12\"><legend id='gfield_label_1_23' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>What school district do your children attend?<\/span><\/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\" aria-labelledby=\"label_1_23_1 gfield_label_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 gfield--choice-align-vertical\" data-group-id=\"ca2b7ba1\" data-field-span=\"12\"><legend id='gfield_label_1_25' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>What is the best time of day to contact you?<\/span><\/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\" aria-labelledby=\"label_1_25_1 gfield_label_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 gfield--choice-align-vertical\" data-group-id=\"5bd6423d\" data-field-span=\"12\"><legend id='gfield_label_1_31' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Consent<\/span><\/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\" aria-labelledby=\"label_1_31_0 gfield_label_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\" data-group-id=\"6c798602\" data-field-span=\"12\"><label id='gfield_label_1_45' class='gfield_label gform-field-label' for='input_1_45'><span class='gform-field-label__text'>CAPTCHA<\/span><\/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'> <button type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> \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='75mBqr454VPTFRnUjwBY8mCykoBZd03nsX5\/ah5Tc1C9bVyovjg5Jkcp7NfmDTSQKLgAffUWxNKum\/DA5Lvj3oytyQQtDmPjx+B\/nfbNJsxzjLg=' \/>\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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var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: 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-btn-bg-color-hover-tertiary: #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 Bridge Family Navigator<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/es\/wp-json\/wp\/v2\/pages\/560' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_above description_above validation_above' data-column-layout='fill'><fieldset id=\"field_5_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"3d4f6b23\" data-field-span=\"12\"><legend id='gfield_label_5_31' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Usted necesita ser contactado por un Navegador que habla Espa\u00f1ol?<\/span><\/legend><div class='gfield_description' id='gfield_description_5_31'>(Do you need to be contacted by a Spanish-speaking Navigator?)<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_31'>\n\t\t\t<div class='gchoice gchoice_5_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_5_31_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_31\" aria-labelledby=\"label_5_31_0 gfield_label_5_31\"   \/>\n\t\t\t\t\t<label for='choice_5_31_0' id='label_5_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_5_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_5_31_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_31_1' id='label_5_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_4\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"1f3e7ea5\" data-field-span=\"12\"><legend id='gfield_label_5_4' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Full Legal Name<\/span><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_5_4'>\n                            \n                            <span id='input_5_4_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_5_4_3' id='input_5_4_3_label' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_4.3' id='input_5_4_3' value=''   aria-required='true'     aria-labelledby=\"input_5_4_3_label gfield_label_5_4\"\/>\n                                                <\/span>\n                            \n                            <span id='input_5_4_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_5_4_6' id='input_5_4_6_label' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_4.6' id='input_5_4_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"e4654008\" data-field-span=\"12\"><label id='gfield_label_5_3' class='gfield_label gform-field-label' for='input_5_3'><span class='gform-field-label__text'>What name do you go by?<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_5_3' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_58\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"ee1a7140\" data-field-span=\"6\"><label id='gfield_label_5_58' class='gfield_label gform-field-label' for='input_5_58'><span class='gform-field-label__text'>Phone Number<\/span><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_58' id='input_5_58' type='tel' value='' class='large'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_5_59\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"ee1a7140\" data-field-span=\"6\"><label id='gfield_label_5_59' class='gfield_label gform-field-label' for='input_5_59'><span class='gform-field-label__text'>Email Address<\/span><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_59' id='input_5_59' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_5_21\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"e38efd23\" data-field-span=\"12\"><legend id='gfield_label_5_21' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><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_5_21' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_21_1_container' >\n                                        <label for='input_5_21_1' id='input_5_21_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_21.1' id='input_5_21_1' value=''    aria-required='true'    aria-labelledby=\"input_5_21_1_label gfield_label_5_21\"\/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_21_3_container' >\n                                    <label for='input_5_21_3' id='input_5_21_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_21.3' id='input_5_21_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_21_4_container' >\n                                        <label for='input_5_21_4' id='input_5_21_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                        <select name='input_21.4' id='input_5_21_4'     aria-required='true'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' selected='selected'>Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_21_5_container' >\n                                    <label for='input_5_21_5' id='input_5_21_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                    <input type='text' name='input_21.5' id='input_5_21_5' value=''    aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_21.6' id='input_5_21_6' value='US' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_5_52\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"634beff1\" data-field-span=\"12\"><label id='gfield_label_5_52' class='gfield_label gform-field-label' for='input_5_52'><span class='gform-field-label__text'>In which county do you live?<\/span><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_52' id='input_5_52' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Douglas' >Douglas<\/option><option value='Washington' >Washington<\/option><option value='Dodge' >Dodge<\/option><option value='Saunders' >Saunders<\/option><option value='Sarpy' >Sarpy<\/option><option value='Pottawattamie' >Pottawattamie<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><fieldset id=\"field_5_8\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gf_list_3col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"e4504f61\" data-field-span=\"12\"><legend id='gfield_label_5_8' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Race\/Ethnicity (select all that apply)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_8'>\n\t\t\t<div class='gchoice gchoice_5_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Native American or Alaskan Native'  id='choice_5_8_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_5_8_0 gfield_label_5_8\"   \/>\n\t\t\t\t\t<label for='choice_5_8_0' id='label_5_8_0' class='gform-field-label gform-field-label--type-inline'>Native American or Alaskan Native<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Asian'  id='choice_5_8_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_8_1' id='label_5_8_1' class='gform-field-label gform-field-label--type-inline'>Asian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_8_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Black or African American'  id='choice_5_8_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_8_2' id='label_5_8_2' class='gform-field-label gform-field-label--type-inline'>Black or African American<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_8_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Hispanic or Latino'  id='choice_5_8_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_8_3' id='label_5_8_3' class='gform-field-label gform-field-label--type-inline'>Hispanic or Latino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_8_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Middle Eastern or North African'  id='choice_5_8_4' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_8_4' id='label_5_8_4' class='gform-field-label gform-field-label--type-inline'>Middle Eastern or North African<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_8_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Native Hawaiian or Pacific Islander'  id='choice_5_8_5' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_8_5' id='label_5_8_5' class='gform-field-label gform-field-label--type-inline'>Native Hawaiian or Pacific Islander<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_8_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='White'  id='choice_5_8_6' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_8_6' id='label_5_8_6' class='gform-field-label gform-field-label--type-inline'>White<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_8_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Prefer not to say'  id='choice_5_8_7' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_8_7' id='label_5_8_7' class='gform-field-label gform-field-label--type-inline'>Prefer not to say<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_8_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Prefer to self identify'  id='choice_5_8_8' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_8_8' id='label_5_8_8' class='gform-field-label gform-field-label--type-inline'>Prefer to self identify<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"10d4766c\" data-field-span=\"12\"><legend id='gfield_label_5_6' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Sex<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_6'>\n\t\t\t<div class='gchoice gchoice_5_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Male'  id='choice_5_6_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_5_6_0 gfield_label_5_6\"   \/>\n\t\t\t\t\t<label for='choice_5_6_0' id='label_5_6_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Female'  id='choice_5_6_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_6_1' id='label_5_6_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_6_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Prefer not to say'  id='choice_5_6_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_6_2' id='label_5_6_2' class='gform-field-label gform-field-label--type-inline'>Prefer not to say<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_17\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"a2d0ba7e\" data-field-span=\"6\"><label id='gfield_label_5_17' class='gfield_label gform-field-label' for='input_5_17'><span class='gform-field-label__text'>Your Date of Birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_17'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_17'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_17' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_17' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_17' aria-label='Your Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_10\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"a2d0ba7e\" data-field-span=\"6\"><label id='gfield_label_5_10' class='gfield_label gform-field-label' for='input_5_10'><span class='gform-field-label__text'>Total number of adults in the household<\/span><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_10' id='input_5_10' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_5_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"9b8d2ebd\" data-field-span=\"6\"><legend id='gfield_label_5_9' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you currently pregnant or expecting a child? (Mother or Father)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_9'>\n\t\t\t<div class='gchoice gchoice_5_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Yes'  id='choice_5_9_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_5_9_0 gfield_label_5_9\"   \/>\n\t\t\t\t\t<label for='choice_5_9_0' id='label_5_9_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_5_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='No'  id='choice_5_9_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_9_1' id='label_5_9_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_53\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"9b8d2ebd\" data-field-span=\"6\"><label id='gfield_label_5_53' class='gfield_label gform-field-label' for='input_5_53'><span class='gform-field-label__text'>Expected Due Date<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_53'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_53'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_53' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_53' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_53' aria-label='Expected Due Date: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_5_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"24e790b0\" data-field-span=\"12\"><legend id='gfield_label_5_11' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Based on the number of individuals in your household, is your income below 200% of the poverty level?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_11'>\n\t\t\t<div class='gchoice gchoice_5_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Yes'  id='choice_5_11_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_5_11_0 gfield_label_5_11\"   \/>\n\t\t\t\t\t<label for='choice_5_11_0' id='label_5_11_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_5_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='No'  id='choice_5_11_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_11_1' id='label_5_11_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"1918cdf9\" data-field-span=\"12\"><legend id='gfield_label_5_12' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>What is the highest level of education you have completed?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_12'>\n\t\t\t<div class='gchoice gchoice_5_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Less than high school'  id='choice_5_12_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_5_12_0 gfield_label_5_12\"   \/>\n\t\t\t\t\t<label for='choice_5_12_0' id='label_5_12_0' class='gform-field-label gform-field-label--type-inline'>Less than high school<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='High school diploma or GED'  id='choice_5_12_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_12_1' id='label_5_12_1' class='gform-field-label gform-field-label--type-inline'>High school diploma or GED<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Some college, no degree'  id='choice_5_12_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_12_2' id='label_5_12_2' class='gform-field-label gform-field-label--type-inline'>Some college, no degree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Certificate or trade credential'  id='choice_5_12_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_12_3' id='label_5_12_3' class='gform-field-label gform-field-label--type-inline'>Certificate or trade credential<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Associate degree'  id='choice_5_12_4' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_12_4' id='label_5_12_4' class='gform-field-label gform-field-label--type-inline'>Associate degree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Bachelor&#039;s degree'  id='choice_5_12_5' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_12_5' id='label_5_12_5' class='gform-field-label gform-field-label--type-inline'>Bachelor's degree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Graduate or professional degree'  id='choice_5_12_6' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_12_6' id='label_5_12_6' class='gform-field-label gform-field-label--type-inline'>Graduate or professional degree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Prefer not to answer'  id='choice_5_12_7' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_12_7' id='label_5_12_7' class='gform-field-label gform-field-label--type-inline'>Prefer not to answer<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"3471d0c9\" data-field-span=\"12\"><legend id='gfield_label_5_13' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you currently have any health insurance?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_13'>\n\t\t\t<div class='gchoice gchoice_5_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Yes, Private\/ACA'  id='choice_5_13_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_5_13_0 gfield_label_5_13\"   \/>\n\t\t\t\t\t<label for='choice_5_13_0' id='label_5_13_0' class='gform-field-label gform-field-label--type-inline'>Yes, Private\/ACA<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Yes, Medicaid'  id='choice_5_13_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_13_1' id='label_5_13_1' class='gform-field-label gform-field-label--type-inline'>Yes, Medicaid<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Yes, Medicare'  id='choice_5_13_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_13_2' id='label_5_13_2' class='gform-field-label gform-field-label--type-inline'>Yes, Medicare<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_13_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Medicaid in Process (application filled out)'  id='choice_5_13_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_13_3' id='label_5_13_3' class='gform-field-label gform-field-label--type-inline'>Medicaid in Process (application filled out)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_13_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='No'  id='choice_5_13_4' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_13_4' id='label_5_13_4' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_13_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Choose not to answer'  id='choice_5_13_5' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_13_5' id='label_5_13_5' class='gform-field-label gform-field-label--type-inline'>Choose not to answer<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"4f4dd8e8\" data-field-span=\"6\"><legend id='gfield_label_5_14' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you have a disability?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_14'>\n\t\t\t<div class='gchoice gchoice_5_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Yes'  id='choice_5_14_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_5_14_0 gfield_label_5_14\"   \/>\n\t\t\t\t\t<label for='choice_5_14_0' id='label_5_14_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_5_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='No'  id='choice_5_14_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_14_1' id='label_5_14_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"4f4dd8e8\" data-field-span=\"6\"><legend id='gfield_label_5_15' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Does your child have a disability?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_15'>\n\t\t\t<div class='gchoice gchoice_5_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Yes'  id='choice_5_15_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_5_15_0 gfield_label_5_15\"   \/>\n\t\t\t\t\t<label for='choice_5_15_0' id='label_5_15_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_5_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='No'  id='choice_5_15_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_15_1' id='label_5_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col gfield--width-half gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"6f396fe7\" data-field-span=\"6\"><legend id='gfield_label_5_16' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Minor Assent<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_5_16'>(Only complete if the participant is a minor, if the participant is NOT a minor select N\/A): \"As a minor participating in this program, I give permission for my information to be shared and used to help improve the program.\"<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_16'>\n\t\t\t<div class='gchoice gchoice_5_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Yes'  id='choice_5_16_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_16\" aria-labelledby=\"label_5_16_0 gfield_label_5_16\"   \/>\n\t\t\t\t\t<label for='choice_5_16_0' id='label_5_16_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_5_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='No'  id='choice_5_16_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_16_1' id='label_5_16_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_16_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='N\/A'  id='choice_5_16_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_16_2' id='label_5_16_2' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_32\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"6f396fe7\" data-field-span=\"6\"><label id='gfield_label_5_32' class='gfield_label gform-field-label' for='input_5_32'><span class='gform-field-label__text'>Number of Children<\/span><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_32' id='input_5_32' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='0' >None<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><\/select><\/div><\/div><div id=\"field_5_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"c08c1d3d\" data-field-span=\"6\"><label id='gfield_label_5_19' class='gfield_label gform-field-label' for='input_5_19'><span class='gform-field-label__text'>1st Child&#039;s first and last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_19'>List the first and last name for each child, under age 19, living in your home.<\/div><div class='ginput_container ginput_container_text'><input name='input_19' id='input_5_19' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_19\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_20\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"c08c1d3d\" data-field-span=\"6\"><label id='gfield_label_5_20' class='gfield_label gform-field-label' for='input_5_20'><span class='gform-field-label__text'>1st Child&#039;s date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_20'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_20'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_20' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_20' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_20' aria-label='1st Child's date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"a29abe35\" data-field-span=\"6\"><label id='gfield_label_5_33' class='gfield_label gform-field-label' for='input_5_33'><span class='gform-field-label__text'>2nd Child&#039;s first and last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_33'>List the first and last name for each child, under age 19, living in your home.<\/div><div class='ginput_container ginput_container_text'><input name='input_33' id='input_5_33' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_33\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_34\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"a29abe35\" data-field-span=\"6\"><label id='gfield_label_5_34' class='gfield_label gform-field-label' for='input_5_34'><span class='gform-field-label__text'>2nd Child&#039;s date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_34'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_34'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_34' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_34' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_34' aria-label='2nd Child's date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"65e3b63a\" data-field-span=\"6\"><label id='gfield_label_5_35' class='gfield_label gform-field-label' for='input_5_35'><span class='gform-field-label__text'>3rd Child&#039;s first and last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_35'>List the first and last name for each child, under age 19, living in your home.<\/div><div class='ginput_container ginput_container_text'><input name='input_35' id='input_5_35' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_35\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_36\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"65e3b63a\" data-field-span=\"6\"><label id='gfield_label_5_36' class='gfield_label gform-field-label' for='input_5_36'><span class='gform-field-label__text'>3rd Child&#039;s date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_36'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_36'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_36' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_36' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_36' aria-label='3rd Child's date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"61066e5d\" data-field-span=\"6\"><label id='gfield_label_5_37' class='gfield_label gform-field-label' for='input_5_37'><span class='gform-field-label__text'>4th Child&#039;s first and last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_37'>List the first and last name for each child, under age 19, living in your home.<\/div><div class='ginput_container ginput_container_text'><input name='input_37' id='input_5_37' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_37\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_38\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"61066e5d\" data-field-span=\"6\"><label id='gfield_label_5_38' class='gfield_label gform-field-label' for='input_5_38'><span class='gform-field-label__text'>4th Child&#039;s date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_38'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_38'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_38' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_38' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_38' aria-label='4th Child's date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_39\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"87ff2b46\" data-field-span=\"6\"><label id='gfield_label_5_39' class='gfield_label gform-field-label' for='input_5_39'><span class='gform-field-label__text'>5th Child&#039;s first and last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_39'>List the first and last name for each child, under age 19, living in your home.<\/div><div class='ginput_container ginput_container_text'><input name='input_39' id='input_5_39' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_39\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_40\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"87ff2b46\" data-field-span=\"6\"><label id='gfield_label_5_40' class='gfield_label gform-field-label' for='input_5_40'><span class='gform-field-label__text'>5th Child&#039;s date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_40'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_40'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_40' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_40' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_40' aria-label='5th Child's date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_41\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"70900b01\" data-field-span=\"6\"><label id='gfield_label_5_41' class='gfield_label gform-field-label' for='input_5_41'><span class='gform-field-label__text'>6th Child&#039;s first and last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_41'>List the first and last name for each child, under age 19, living in your home.<\/div><div class='ginput_container ginput_container_text'><input name='input_41' id='input_5_41' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_41\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_42\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"70900b01\" data-field-span=\"6\"><label id='gfield_label_5_42' class='gfield_label gform-field-label' for='input_5_42'><span class='gform-field-label__text'>6th Child&#039;s date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_42'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_42'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_42' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_42' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_42' aria-label='6th Child's date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"c5b48f93\" data-field-span=\"6\"><label id='gfield_label_5_43' class='gfield_label gform-field-label' for='input_5_43'><span class='gform-field-label__text'>7th Child&#039;s first and last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_43'>List the first and last name for each child, under age 19, living in your home.<\/div><div class='ginput_container ginput_container_text'><input name='input_43' id='input_5_43' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_43\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_44\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"c5b48f93\" data-field-span=\"6\"><label id='gfield_label_5_44' class='gfield_label gform-field-label' for='input_5_44'><span class='gform-field-label__text'>7th Child&#039;s date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_44'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_44'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_44' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_44' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_44' aria-label='7th Child's date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_45\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"f5ad5855\" data-field-span=\"6\"><label id='gfield_label_5_45' class='gfield_label gform-field-label' for='input_5_45'><span class='gform-field-label__text'>8th Child&#039;s first and last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_45'>List the first and last name for each child, under age 19, living in your home.<\/div><div class='ginput_container ginput_container_text'><input name='input_45' id='input_5_45' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_45\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_46\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"f5ad5855\" data-field-span=\"6\"><label id='gfield_label_5_46' class='gfield_label gform-field-label' for='input_5_46'><span class='gform-field-label__text'>8th Child&#039;s date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_46'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_46'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_46' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_46' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_46' aria-label='8th Child's date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_48\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"d38f5088\" data-field-span=\"6\"><label id='gfield_label_5_48' class='gfield_label gform-field-label' for='input_5_48'><span class='gform-field-label__text'>9th Child&#039;s first and last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_48'>List the first and last name for each child, under age 19, living in your home.<\/div><div class='ginput_container ginput_container_text'><input name='input_48' id='input_5_48' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_48\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_49\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"d38f5088\" data-field-span=\"6\"><label id='gfield_label_5_49' class='gfield_label gform-field-label' for='input_5_49'><span class='gform-field-label__text'>9th Child&#039;s date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_49'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_49'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_49' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_49' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_49' aria-label='9th Child's date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_50\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"7aa1e01f\" data-field-span=\"6\"><label id='gfield_label_5_50' class='gfield_label gform-field-label' for='input_5_50'><span class='gform-field-label__text'>10th Child&#039;s first and last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_50'>List the first and last name for each child, under age 19, living in your home.<\/div><div class='ginput_container ginput_container_text'><input name='input_50' id='input_5_50' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_50\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_51\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half child-block gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"7aa1e01f\" data-field-span=\"6\"><label id='gfield_label_5_51' class='gfield_label gform-field-label' for='input_5_51'><span class='gform-field-label__text'>10th Child&#039;s date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_51'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_51'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_51' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_51' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_51' aria-label='10th Child's date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_47\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"cd2ae7dc\" data-field-span=\"12\"><h3 class=\"gsection_title\">What are some ways we can help you?<\/h3><\/div><fieldset id=\"field_5_25\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-checkbox gf_list_4col gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"532535f8\" data-field-span=\"12\"><legend id='gfield_label_5_25' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Need<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_5_25'>What is your most urgent need? Check all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_25'><div class='gchoice gchoice_5_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='Daily Living (telephone, clothes, hygiene)'  id='choice_5_25_1'   aria-describedby=\"gfield_description_5_25\" aria-labelledby=\"label_5_25_1 gfield_label_5_25\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_1' id='label_5_25_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_5_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='Dentist'  id='choice_5_25_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_2' id='label_5_25_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_5_25_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.3' type='checkbox'  value='Education'  id='choice_5_25_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_3' id='label_5_25_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_5_25_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.4' type='checkbox'  value='Finances'  id='choice_5_25_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_4' id='label_5_25_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_5_25_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.5' type='checkbox'  value='General Life Skills'  id='choice_5_25_5'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_5' id='label_5_25_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_5_25_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.6' type='checkbox'  value='Housing'  id='choice_5_25_6'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_6' id='label_5_25_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_5_25_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.7' type='checkbox'  value='Legal Help'  id='choice_5_25_7'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_7' id='label_5_25_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_5_25_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.8' type='checkbox'  value='Mental Health'  id='choice_5_25_8'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_8' id='label_5_25_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_5_25_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.9' type='checkbox'  value='Parenting Assistance'  id='choice_5_25_9'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_9' id='label_5_25_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_5_25_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.11' type='checkbox'  value='Substance Abuse'  id='choice_5_25_11'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_11' id='label_5_25_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_5_25_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.12' type='checkbox'  value='Supportive Relationships'  id='choice_5_25_12'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_12' id='label_5_25_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_5_25_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.13' type='checkbox'  value='Transportation'  id='choice_5_25_13'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_13' id='label_5_25_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_5_25_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.14' type='checkbox'  value='Utilities'  id='choice_5_25_14'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_14' id='label_5_25_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_5_25_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.15' type='checkbox'  value='Other'  id='choice_5_25_15'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_15' id='label_5_25_15' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"2cd61e39\" data-field-span=\"12\"><label id='gfield_label_5_54' class='gfield_label gform-field-label' for='input_5_54'><span class='gform-field-label__text'>What resource(s) are you looking for not listed above?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_54'>Please describe your need.<\/div><div class='ginput_container ginput_container_text'><input name='input_54' id='input_5_54' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_54\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_26\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"72e906db\" data-field-span=\"12\"><h3 class=\"gsection_title\">How did you find us?<\/h3><\/div><div id=\"field_5_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"c1b47244\" data-field-span=\"12\"><label id='gfield_label_5_27' class='gfield_label gform-field-label' for='input_5_27'><span class='gform-field-label__text'>Who referred you to The Bridge?<\/span><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_27' id='input_5_27' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_28\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"3ba54988\" data-field-span=\"12\"><legend id='gfield_label_5_28' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>What school district(s) do your children attend?<\/span><\/legend><div class='gfield_description' id='gfield_description_5_28'>Check all that apply.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_28'>\n\t\t\t<div class='gchoice gchoice_5_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Omaha Public Schools'  id='choice_5_28_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_28\" aria-labelledby=\"label_5_28_0 gfield_label_5_28\"   \/>\n\t\t\t\t\t<label for='choice_5_28_0' id='label_5_28_0' class='gform-field-label gform-field-label--type-inline'>Omaha Public Schools<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Millard Public Schools'  id='choice_5_28_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_28_1' id='label_5_28_1' class='gform-field-label gform-field-label--type-inline'>Millard Public Schools<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_28_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Ralston Public Schools'  id='choice_5_28_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_28_2' id='label_5_28_2' class='gform-field-label gform-field-label--type-inline'>Ralston Public Schools<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_28_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Westside Community Schools'  id='choice_5_28_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_28_3' id='label_5_28_3' class='gform-field-label gform-field-label--type-inline'>Westside Community Schools<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_28_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Other'  id='choice_5_28_4' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_28_4' id='label_5_28_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_29\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gf_list_3col gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"81f93ace\" data-field-span=\"12\"><legend id='gfield_label_5_29' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>What is the best time of day to contact you?<\/span><\/legend><div class='gfield_description' id='gfield_description_5_29'>Check all that apply.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_29'>\n\t\t\t<div class='gchoice gchoice_5_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Morning'  id='choice_5_29_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_29\" aria-labelledby=\"label_5_29_0 gfield_label_5_29\"   \/>\n\t\t\t\t\t<label for='choice_5_29_0' id='label_5_29_0' class='gform-field-label gform-field-label--type-inline'>Morning<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Afternoon'  id='choice_5_29_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_29_1' id='label_5_29_1' class='gform-field-label gform-field-label--type-inline'>Afternoon<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_29_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Evening after 5:00 p.m.'  id='choice_5_29_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_29_2' id='label_5_29_2' class='gform-field-label gform-field-label--type-inline'>Evening after 5:00 p.m.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\" data-group-id=\"17790fc6\" data-field-span=\"12\"><legend id='gfield_label_5_30' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Consent<\/span><\/legend><div class='gfield_description' id='gfield_description_5_30'>Can The Bridge add your information to the Find Help database?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_30'>\n\t\t\t<div class='gchoice gchoice_5_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_5_30_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_30\" aria-labelledby=\"label_5_30_0 gfield_label_5_30\"   \/>\n\t\t\t\t\t<label for='choice_5_30_0' id='label_5_30_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_5_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_5_30_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_5_30_1' id='label_5_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_55\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\" data-group-id=\"79d7bef8\" data-field-span=\"12\"><label id='gfield_label_5_55' class='gfield_label gform-field-label' for='input_5_55'><span class='gform-field-label__text'>CAPTCHA<\/span><\/label><div id='input_5_55' 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'> <button type='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_5' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_5' id='gform_theme_5' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_5' id='gform_style_settings_5' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_5' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='5' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='Dy6aiW89wUGLSw99oUhtIMa5fLHLQ6r9GCUB4dn9fAv\/RC6MOGOa83pKKNRYG+aoSpKnZ+Q7auB66pnv2dvlZg5b9Ttfq7Wrws8rm\/MuCcILpy8=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_5' 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#527EFF;--gf-color-secondary: #fff;--gf-color-secondary-rgb: 255, 255, 255;--gf-color-secondary-contrast: #112337;--gf-color-secondary-contrast-rgb: 17, 35, 55;--gf-color-secondary-darker: #F5F5F5;--gf-color-secondary-lighter: #FFFFFF;--gf-color-out-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-out-ctrl-light-rgb: 17, 35, 55;--gf-color-out-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-out-ctrl-light-lighter: #F5F5F5;--gf-color-out-ctrl-dark: #585e6a;--gf-color-out-ctrl-dark-rgb: 88, 94, 106;--gf-color-out-ctrl-dark-darker: #112337;--gf-color-out-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-color-in-ctrl: #fff;--gf-color-in-ctrl-rgb: 255, 255, 255;--gf-color-in-ctrl-contrast: #112337;--gf-color-in-ctrl-contrast-rgb: 17, 35, 55;--gf-color-in-ctrl-darker: #F5F5F5;--gf-color-in-ctrl-lighter: #FFFFFF;--gf-color-in-ctrl-primary: #204ce5;--gf-color-in-ctrl-primary-rgb: 32, 76, 229;--gf-color-in-ctrl-primary-contrast: #fff;--gf-color-in-ctrl-primary-contrast-rgb: 255, 255, 255;--gf-color-in-ctrl-primary-darker: #001AB3;--gf-color-in-ctrl-primary-lighter: #527EFF;--gf-color-in-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-in-ctrl-light-rgb: 17, 35, 55;--gf-color-in-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-in-ctrl-light-lighter: #F5F5F5;--gf-color-in-ctrl-dark: #585e6a;--gf-color-in-ctrl-dark-rgb: 88, 94, 106;--gf-color-in-ctrl-dark-darker: #112337;--gf-color-in-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-radius: 3px;--gf-font-size-secondary: 14px;--gf-font-size-tertiary: 13px;--gf-icon-ctrl-number: url(\"data:image\/svg+xml,%3Csvg width='8' height='14' viewBox='0 0 8 14' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-select: url(\"data:image\/svg+xml,%3Csvg width='10' height='6' viewBox='0 0 10 6' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-search: url(\"data:image\/svg+xml,%3Csvg width='640' height='640' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: 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-btn-bg-color-hover-tertiary: #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\/560' 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' data-column-layout='fill'><div id=\"field_1_68\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"><label id='gfield_label_1_68' class='gfield_label gform-field-label' for='input_1_68'><span class='gform-field-label__text'>Facebook<\/span><\/label><div class='ginput_container'><input name='input_68' id='input_1_68' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_68'>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\" data-group-id=\"b6d11375\" data-field-span=\"12\"><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\" data-group-id=\"d0be5b86\" data-field-span=\"6\"><label id='gfield_label_1_15' class='gfield_label gform-field-label' for='input_1_15'><span class='gform-field-label__text'>Your Name<\/span><\/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\" data-group-id=\"d0be5b86\" data-field-span=\"6\"><label id='gfield_label_1_16' class='gfield_label gform-field-label' for='input_1_16'><span class='gform-field-label__text'>What name do you go by?<\/span><\/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\" data-group-id=\"102471df\" data-field-span=\"12\"><legend id='gfield_label_1_1' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Full Legal Name<\/span><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'     aria-labelledby=\"input_1_1_3_label gfield_label_1_1\"\/>\n                                                    <label for='input_1_1_3' id='input_1_1_3_label' 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' id='input_1_1_6_label' 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\" data-group-id=\"b0f0906f\" data-field-span=\"12\"><label id='gfield_label_1_38' class='gfield_label gform-field-label' for='input_1_38'><span class='gform-field-label__text'>Race\/Ethnicity (select all that apply)<\/span><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\" data-group-id=\"d6daee27\" data-field-span=\"12\"><label id='gfield_label_1_39' class='gfield_label gform-field-label' for='input_1_39'><span class='gform-field-label__text'>Sex<\/span><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\" data-group-id=\"73534bfd\" data-field-span=\"12\"><label id='gfield_label_1_43' class='gfield_label gform-field-label' for='input_1_43'><span class='gform-field-label__text'>Are you currently pregnant or expecting a child? (Mother or Father)<\/span><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\" data-group-id=\"c71310d6\" data-field-span=\"12\"><label id='gfield_label_1_47' class='gfield_label gform-field-label' for='input_1_47'><span class='gform-field-label__text'>Total number of adults in the household<\/span><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\" data-group-id=\"3e761782\" data-field-span=\"12\"><label id='gfield_label_1_42' class='gfield_label gform-field-label' for='input_1_42'><span class='gform-field-label__text'>Based on the number of individuals in your household, is your income below 200% of the poverty level?\u2009<\/span><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\" data-group-id=\"9838a342\" data-field-span=\"12\"><label id='gfield_label_1_49' class='gfield_label gform-field-label' for='input_1_49'><span class='gform-field-label__text'>What is the highest level of education you have completed?<\/span><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\" data-group-id=\"116793b8\" data-field-span=\"12\"><label id='gfield_label_1_41' class='gfield_label gform-field-label' for='input_1_41'><span class='gform-field-label__text'>Do you currently have any health insurance?<\/span><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\" data-group-id=\"2319677f\" data-field-span=\"12\"><label id='gfield_label_1_53' class='gfield_label gform-field-label' for='input_1_53'><span class='gform-field-label__text'>Do you have a disability?<\/span><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\" data-group-id=\"45a98ed7\" data-field-span=\"12\"><label id='gfield_label_1_54' class='gfield_label gform-field-label' for='input_1_54'><span class='gform-field-label__text'>Does your child have a disability?<\/span><\/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\" data-group-id=\"b785fbcb\" data-field-span=\"12\"><label id='gfield_label_1_40' class='gfield_label gform-field-label' for='input_1_40'><span class='gform-field-label__text'>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><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-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"b770954e\" data-field-span=\"6\"><label id='gfield_label_1_3' class='gfield_label gform-field-label' for='input_1_3'><span class='gform-field-label__text'>Date of Birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_1_3'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_3'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_1_3' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_1_3' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_1_3' aria-label='Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/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\" data-group-id=\"b770954e\" data-field-span=\"6\"><label id='gfield_label_1_13' class='gfield_label gform-field-label' for='input_1_13'><span class='gform-field-label__text'>Number of Children<\/span><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\" data-group-id=\"c596b3d7\" data-field-span=\"6\"><label id='gfield_label_1_56' class='gfield_label gform-field-label' for='input_1_56'><span class='gform-field-label__text'>1st Child&#039;s first and last name<\/span><\/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\" data-group-id=\"c596b3d7\" data-field-span=\"6\"><label id='gfield_label_1_14' class='gfield_label gform-field-label' for='input_1_14'><span class='gform-field-label__text'>1st Child&#039;s date of birth<\/span><\/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\"  placeholder='99\/99\/9999'  aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/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\" data-group-id=\"65829183\" data-field-span=\"6\"><label id='gfield_label_1_55' class='gfield_label gform-field-label' for='input_1_55'><span class='gform-field-label__text'>2nd Child&#039;s first and last name<\/span><\/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\" data-group-id=\"65829183\" data-field-span=\"6\"><label id='gfield_label_1_29' class='gfield_label gform-field-label' for='input_1_29'><span class='gform-field-label__text'>2nd Child&#039;s date of birth<\/span><\/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\"  placeholder='99\/99\/9999'  aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/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\" data-group-id=\"6df97d16\" data-field-span=\"6\"><label id='gfield_label_1_61' class='gfield_label gform-field-label' for='input_1_61'><span class='gform-field-label__text'>3rd Child&#039;s first and last name<\/span><\/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\" data-group-id=\"6df97d16\" data-field-span=\"6\"><label id='gfield_label_1_30' class='gfield_label gform-field-label' for='input_1_30'><span class='gform-field-label__text'>3rd Child&#039;s date of birth<\/span><\/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\"  placeholder='99\/99\/9999'  aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/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\" data-group-id=\"e36a663b\" data-field-span=\"6\"><label id='gfield_label_1_60' class='gfield_label gform-field-label' for='input_1_60'><span class='gform-field-label__text'>4th Child&#039;s first and last name<\/span><\/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\" data-group-id=\"e36a663b\" data-field-span=\"6\"><label id='gfield_label_1_28' class='gfield_label gform-field-label' for='input_1_28'><span class='gform-field-label__text'>4th Child&#039;s date of birth<\/span><\/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\"  placeholder='99\/99\/9999'  aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/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\" data-group-id=\"b4056b12\" data-field-span=\"6\"><label id='gfield_label_1_59' class='gfield_label gform-field-label' for='input_1_59'><span class='gform-field-label__text'>5th Child&#039;s first and last name<\/span><\/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\" data-group-id=\"b4056b12\" data-field-span=\"6\"><label id='gfield_label_1_36' class='gfield_label gform-field-label' for='input_1_36'><span class='gform-field-label__text'>5th Child&#039;s date of birth<\/span><\/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\"  placeholder='99\/99\/9999'  aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/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\" data-group-id=\"cb4e1ee8\" data-field-span=\"6\"><label id='gfield_label_1_58' class='gfield_label gform-field-label' for='input_1_58'><span class='gform-field-label__text'>6th Child&#039;s first and last name<\/span><\/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\" data-group-id=\"cb4e1ee8\" data-field-span=\"6\"><label id='gfield_label_1_37' class='gfield_label gform-field-label' for='input_1_37'><span class='gform-field-label__text'>6th Child&#039;s date of birth<\/span><\/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\"  placeholder='99\/99\/9999'  aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/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\" data-group-id=\"24de5b88\" data-field-span=\"6\"><label id='gfield_label_1_57' class='gfield_label gform-field-label' for='input_1_57'><span class='gform-field-label__text'>7th Child&#039;s first and last name<\/span><\/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'>List the first and last name for each child, under age 19, living in your home. <\/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\" data-group-id=\"24de5b88\" data-field-span=\"6\"><label id='gfield_label_1_35' class='gfield_label gform-field-label' for='input_1_35'><span class='gform-field-label__text'>7th Child&#039;s date of birth<\/span><\/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\"  placeholder='99\/99\/9999'  aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/div><div class='gfield_description' id='gfield_description_1_35'>List the birthday for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_62\" 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\" data-group-id=\"8d8fa435\" data-field-span=\"6\"><label id='gfield_label_1_62' class='gfield_label gform-field-label' for='input_1_62'><span class='gform-field-label__text'>8th Child&#039;s first and last name<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_1_62' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_62\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_62'>List the first and last name for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_63\" 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\" data-group-id=\"8d8fa435\" data-field-span=\"6\"><label id='gfield_label_1_63' class='gfield_label gform-field-label' for='input_1_63'><span class='gform-field-label__text'>8th Child&#039;s date of birth<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_1_63' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_63\"  placeholder='99\/99\/9999'  aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/div><div class='gfield_description' id='gfield_description_1_63'>List the birthday for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_64\" 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\" data-group-id=\"0f3d735b\" data-field-span=\"6\"><label id='gfield_label_1_64' class='gfield_label gform-field-label' for='input_1_64'><span class='gform-field-label__text'>9th Child&#039;s first and last name<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_1_64' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_64\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_64'>List the first and last name for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_65\" 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\" data-group-id=\"0f3d735b\" data-field-span=\"6\"><label id='gfield_label_1_65' class='gfield_label gform-field-label' for='input_1_65'><span class='gform-field-label__text'>9th Child&#039;s date of birth<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_1_65' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_65\"  placeholder='99\/99\/9999'  aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/div><div class='gfield_description' id='gfield_description_1_65'>List the birthday for each child, under age 19, living in your home. <\/div><\/div><div id=\"field_1_67\" 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\" data-group-id=\"41d06920\" data-field-span=\"6\"><label id='gfield_label_1_67' class='gfield_label gform-field-label' for='input_1_67'><span class='gform-field-label__text'>10th Child&#039;s first and last name<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_1_67' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_67\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_67'>If there are more than ten children under age 19 living in your home, list them at the end of this form. <\/div><\/div><div id=\"field_1_66\" 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\" data-group-id=\"41d06920\" data-field-span=\"6\"><label id='gfield_label_1_66' class='gfield_label gform-field-label' for='input_1_66'><span class='gform-field-label__text'>10th Child&#039;s date of birth<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_1_66' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_66\"  placeholder='99\/99\/9999'  aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/div><div class='gfield_description' id='gfield_description_1_66'>List the birthday for each child, under age 19, living in your home. <\/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\" data-group-id=\"14b23fb3\" data-field-span=\"12\"><label id='gfield_label_1_51' class='gfield_label gform-field-label' for='input_1_51'><span class='gform-field-label__text'>First and Last Name of all children listed above<\/span><\/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--phone-format-standard gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"bcdeeb66\" data-field-span=\"6\"><label id='gfield_label_1_4' class='gfield_label gform-field-label' for='input_1_4'><span class='gform-field-label__text'>Phone Number<\/span><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'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/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\" data-group-id=\"bcdeeb66\" data-field-span=\"6\"><label id='gfield_label_1_5' class='gfield_label gform-field-label' for='input_1_5'><span class='gform-field-label__text'>Email Address<\/span><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\" data-group-id=\"63e971e1\" data-field-span=\"12\"><legend id='gfield_label_1_10' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><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'    aria-labelledby=\"input_1_10_1_label gfield_label_1_10\"\/>\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\" data-group-id=\"9bc512d4\" data-field-span=\"12\"><label id='gfield_label_1_18' class='gfield_label gform-field-label' for='input_1_18'><span class='gform-field-label__text'>County<\/span><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\" data-group-id=\"d28eca3f\" data-field-span=\"12\"><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 gfield--choice-align-vertical\" data-group-id=\"3913ccc1\" data-field-span=\"6\"><legend id='gfield_label_1_12' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Need<\/span><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\" aria-labelledby=\"label_1_12_1 gfield_label_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 gfield--choice-align-vertical\" data-group-id=\"3913ccc1\" data-field-span=\"6\"><legend id='gfield_label_1_19' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Usted necesita ser contactado por un Navegador que habla Espa\u00f1ol?<\/span><\/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 )'  aria-labelledby=\"label_1_19_0 gfield_label_1_19\"   \/>\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\" data-group-id=\"9d4ce1c5\" data-field-span=\"12\"><label id='gfield_label_1_44' class='gfield_label gform-field-label' for='input_1_44'><span class='gform-field-label__text'>If you chose &quot;Other&quot;, please specify your needs.<\/span><\/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\" data-group-id=\"83de97d0\" data-field-span=\"12\"><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\" data-group-id=\"6ad85b1c\" data-field-span=\"12\"><label id='gfield_label_1_21' class='gfield_label gform-field-label' for='input_1_21'><span class='gform-field-label__text'>Who referred you to The BRIDGE?<\/span><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 gfield--choice-align-vertical\" data-group-id=\"279dd909\" data-field-span=\"12\"><legend id='gfield_label_1_23' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>What school district do your children attend?<\/span><\/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\" aria-labelledby=\"label_1_23_1 gfield_label_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 gfield--choice-align-vertical\" data-group-id=\"ca2b7ba1\" data-field-span=\"12\"><legend id='gfield_label_1_25' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>What is the best time of day to contact you?<\/span><\/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\" aria-labelledby=\"label_1_25_1 gfield_label_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 gfield--choice-align-vertical\" data-group-id=\"5bd6423d\" data-field-span=\"12\"><legend id='gfield_label_1_31' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Consent<\/span><\/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\" aria-labelledby=\"label_1_31_0 gfield_label_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\" data-group-id=\"6c798602\" data-field-span=\"12\"><label id='gfield_label_1_45' class='gfield_label gform-field-label' for='input_1_45'><span class='gform-field-label__text'>CAPTCHA<\/span><\/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 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