{"id":731,"date":"2025-05-31T18:19:07","date_gmt":"2025-05-31T18:19:07","guid":{"rendered":"https:\/\/friendshipmission.org\/love1\/?page_id=731"},"modified":"2025-05-31T18:19:08","modified_gmt":"2025-05-31T18:19:08","slug":"shelter-application","status":"publish","type":"page","link":"https:\/\/friendshipmission.org\/love1\/shelter-application\/","title":{"rendered":"Shelter Application"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-977f2d4e-e1d2-41ce-98e8-363ff89ddeb9 wpforms-render-modern\" id=\"wpforms-677\"><form id=\"wpforms-form-677\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"677\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/love1\/wp-json\/wp\/v2\/pages\/731\" data-token=\"054b231458079d2e34fbdb8111f93803\" data-token-time=\"1776651642\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-page-indicator progress\" data-indicator=\"progress\" data-indicator-color=\"#066aab\" data-scroll=\"0\" role=\"progressbar\" aria-valuenow=\"1\" aria-valuemin=\"1\" aria-valuemax=\"6\" tabindex=\"-1\"><span class=\"wpforms-page-indicator-page-title\" ><\/span><span class=\"wpforms-page-indicator-page-title-sep\" style=\"display:none;\"> &#8211; <\/span><span class=\"wpforms-page-indicator-steps\">Step <span class=\"wpforms-page-indicator-steps-current\">1<\/span> of 6<\/span><div class=\"wpforms-page-indicator-page-progress-wrap\"><div class=\"wpforms-page-indicator-page-progress\" style=\"width:16.666666666667%;background-color:#066aab\"><\/div><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-677-field_72-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"72\"><\/div><div id=\"wpforms-677-field_6-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_6\">Today&#039;s Date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-677-field_6\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-small\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"1\" data-disable-todays-date=\"0\" data-input=\"true\" name=\"wpforms[fields][6][date]\" aria-errormessage=\"wpforms-677-field_6-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-677-field_8-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"8\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-677-field_4-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"4\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-677-field_4\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][4][first]\" aria-errormessage=\"wpforms-677-field_4-error\" required><label for=\"wpforms-677-field_4\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-fifth\"><input type=\"text\" id=\"wpforms-677-field_4-middle\" class=\"wpforms-field-name-middle\" name=\"wpforms[fields][4][middle]\" aria-errormessage=\"wpforms-677-field_4-middle-error\" ><label for=\"wpforms-677-field_4-middle\" class=\"wpforms-field-sublabel after\">Middle<\/label><\/div><div class=\"wpforms-field-row-block wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-677-field_4-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][4][last]\" aria-errormessage=\"wpforms-677-field_4-last-error\" required><label for=\"wpforms-677-field_4-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-677-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_7\">Do you use any other names? If so, please list here.<\/label><input type=\"text\" id=\"wpforms-677-field_7\" class=\"wpforms-field-small\" name=\"wpforms[fields][7]\" aria-errormessage=\"wpforms-677-field_7-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-677-field_70-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"70\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_78-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"78\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_78\">Telephone Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-677-field_78\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][78]\" aria-errormessage=\"wpforms-677-field_78-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_79-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"79\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_79\">Social Security Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-677-field_79\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][79]\" aria-errormessage=\"wpforms-677-field_79-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_12-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"12\"><fieldset><legend class=\"wpforms-field-label\">Date of Birth <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-date-dropdown-wrap wpforms-field-medium\"><select name=\"wpforms[fields][12][date][m]\" id=\"wpforms-677-field_12-month\" class=\"wpforms-field-date-time-date-month wpforms-field-required\" aria-label=\"Month\"  required><option value=\"\" class=\"placeholder\" selected disabled>MM<\/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><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><select name=\"wpforms[fields][12][date][d]\" id=\"wpforms-677-field_12-day\" class=\"wpforms-field-date-time-date-day wpforms-field-required\" aria-label=\"Day\"  required><option value=\"\" class=\"placeholder\" selected disabled>DD<\/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><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><select name=\"wpforms[fields][12][date][y]\" id=\"wpforms-677-field_12-year\" class=\"wpforms-field-date-time-date-year wpforms-field-required\" aria-label=\"Year\"  required><option value=\"\" class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" >2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><\/select><\/div><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_17-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-modern\" data-field-type=\"select\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_17\">Gender <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-677-field_17\" class=\"wpforms-field-medium wpforms-field-required choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][17]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'><\/option><option value=\"Female\"  class=\"choice-1 depth-1\"  >Female<\/option><option value=\"Male\"  class=\"choice-2 depth-1\"  >Male<\/option><option value=\"Transgender Female to Male\"  class=\"choice-3 depth-1\"  >Transgender Female to Male<\/option><option value=\"Transgender Male to Female\"  class=\"choice-4 depth-1\"  >Transgender Male to Female<\/option><option value=\"Gender Non-conforming\"  class=\"choice-5 depth-1\"  >Gender Non-conforming<\/option><option value=\"Client does not know\"  class=\"choice-6 depth-1\"  >Client does not know<\/option><option value=\"Client refused\"  class=\"choice-7 depth-1\"  >Client refused<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_18-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_18\">Ethnicity <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-677-field_18\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][18]\" required=\"required\"><option value=\"Non-Hispanic\/Non-Latino\"  class=\"choice-1 depth-1\"  >Non-Hispanic\/Non-Latino<\/option><option value=\"Hispanic\/Non-Latino\"  class=\"choice-2 depth-1\"  >Hispanic\/Non-Latino<\/option><option value=\"Client doesn&#039;t know\"  class=\"choice-3 depth-1\"  >Client doesn&#8217;t know<\/option><option value=\"Client refused\"  class=\"choice-4 depth-1\"  >Client refused<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_19-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_19\">Race <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-677-field_19\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][19][]\" required=\"required\" multiple=\"multiple\"><option value=\"African American or Black\"  class=\"choice-1 depth-1\"  >African American or Black<\/option><option value=\"White\"  class=\"choice-5 depth-1\"  >White<\/option><option value=\"Asian\"  class=\"choice-3 depth-1\"  >Asian<\/option><option value=\"American Indian or Alaskan Native\"  class=\"choice-2 depth-1\"  >American Indian or Alaskan Native<\/option><option value=\"Native Hawaiian or Other Pacific Islander\"  class=\"choice-4 depth-1\"  >Native Hawaiian or Other Pacific Islander<\/option><option value=\"Multi-Race\"  class=\"choice-10 depth-1\"  >Multi-Race<\/option><option value=\"Client doesn&#039;t know\"  class=\"choice-8 depth-1\"  >Client doesn&#8217;t know<\/option><option value=\"Client refused\"  class=\"choice-9 depth-1\"  >Client refused<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-677-field_71-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"71\"><div class=\"wpforms-clear wpforms-pagebreak-split\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"1\" data-formid=\"677\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-677-field_9-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"9\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_16-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"16\"><fieldset><legend class=\"wpforms-field-label\">Were you ever active-duty military? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-677-field_16\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_16_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][16][]\" value=\"Yes\" aria-errormessage=\"wpforms-677-field_16_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_16_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_16_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][16][]\" value=\"No\" aria-errormessage=\"wpforms-677-field_16_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_16_2\">No<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_16_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][16][]\" value=\"Client Doesn&#039;t Know\" aria-errormessage=\"wpforms-677-field_16_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_16_4\">Client Doesn&#8217;t Know<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_16_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][16][]\" value=\"Client Refused\" aria-errormessage=\"wpforms-677-field_16_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_16_5\">Client Refused<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_14-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"14\"><fieldset><legend class=\"wpforms-field-label\">Do you have a Continuum ID card? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-677-field_14\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_14_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][14][]\" value=\"Yes\" aria-errormessage=\"wpforms-677-field_14_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_14_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_14_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][14][]\" value=\"No\" aria-errormessage=\"wpforms-677-field_14_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_14_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_15-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"text\" data-field-id=\"15\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_15\">Enter Continuum ID Number<\/label><input type=\"text\" id=\"wpforms-677-field_15\" class=\"wpforms-field-medium\" name=\"wpforms[fields][15]\" aria-errormessage=\"wpforms-677-field_15-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_22-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"22\"><fieldset><legend class=\"wpforms-field-label\">Can you pass a drug test?<\/legend><ul id=\"wpforms-677-field_22\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_22_1\" name=\"wpforms[fields][22][]\" value=\"Yes\" aria-errormessage=\"wpforms-677-field_22_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_22_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_22_2\" name=\"wpforms[fields][22][]\" value=\"No\" aria-errormessage=\"wpforms-677-field_22_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_22_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_20-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"20\"><fieldset><legend class=\"wpforms-field-label\">Do you have a disabling condition?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-677-field_20\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_20_1\" name=\"wpforms[fields][20][]\" value=\"Yes\" aria-errormessage=\"wpforms-677-field_20_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_20_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_20_2\" name=\"wpforms[fields][20][]\" value=\"No\" aria-errormessage=\"wpforms-677-field_20_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_20_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_25-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-modern\" data-field-type=\"select\" data-field-id=\"25\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_25\">Disability Type? (select all that apply)<\/label><select id=\"wpforms-677-field_25\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"1\" name=\"wpforms[fields][25][]\" multiple=\"multiple\"><option value=\"\" class=\"placeholder\" disabled ><\/option><option value=\"Alcohol Abuse\"  class=\"choice-2 depth-1\"  >Alcohol Abuse<\/option><option value=\"Developmental\"  class=\"choice-3 depth-1\"  >Developmental<\/option><option value=\"Drug Abuse\"  class=\"choice-4 depth-1\"  >Drug Abuse<\/option><option value=\"HIV or AIDS\"  class=\"choice-5 depth-1\"  >HIV or AIDS<\/option><option value=\"Mental Health\"  class=\"choice-6 depth-1\"  >Mental Health<\/option><option value=\"Physical\"  class=\"choice-7 depth-1\"  >Physical<\/option><option value=\"Chronic Health Condition (heart, diabetes, etc.)\"  class=\"choice-8 depth-1\"  >Chronic Health Condition (heart, diabetes, etc.)<\/option><option value=\"Other\"  class=\"choice-9 depth-1\"  >Other<\/option><option value=\"Client Doesn&#039;t Know\"  class=\"choice-10 depth-1\"  >Client Doesn&#8217;t Know<\/option><option value=\"Client Refused\"  class=\"choice-11 depth-1\"  >Client Refused<\/option><\/select><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_21-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"text\" data-field-id=\"21\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_21\">If you cannot pass a drug test, for what will you fail?<\/label><input type=\"text\" id=\"wpforms-677-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\" aria-errormessage=\"wpforms-677-field_21-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_24-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_24\">If you take any medication, please list:<\/label><textarea id=\"wpforms-677-field_24\" class=\"wpforms-field-medium\" name=\"wpforms[fields][24]\" aria-errormessage=\"wpforms-677-field_24-error\" ><\/textarea><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_28-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"checkbox\" data-field-id=\"28\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Are you receiving medical treatment for your disability? <\/legend><ul id=\"wpforms-677-field_28\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_28_1\" name=\"wpforms[fields][28][]\" value=\"Yes\" aria-errormessage=\"wpforms-677-field_28_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_28_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_28_2\" name=\"wpforms[fields][28][]\" value=\"No\" aria-errormessage=\"wpforms-677-field_28_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_28_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_27-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"checkbox\" data-field-id=\"27\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Do you expect your disability to be long term?<\/legend><ul id=\"wpforms-677-field_27\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_27_1\" name=\"wpforms[fields][27][]\" value=\"Yes\" aria-errormessage=\"wpforms-677-field_27_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_27_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_27_2\" name=\"wpforms[fields][27][]\" value=\"No\" aria-errormessage=\"wpforms-677-field_27_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_27_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-677-field_50-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_50\">What type of Health Insurance do you have?<\/label><select id=\"wpforms-677-field_50\" class=\"wpforms-field-medium\" name=\"wpforms[fields][50][]\" multiple=\"multiple\"><option value=\"NONE\"  class=\"choice-1 depth-1\"  >NONE<\/option><option value=\"MediCAID\"  class=\"choice-2 depth-1\"  >MediCAID<\/option><option value=\"MediCARE\"  class=\"choice-9 depth-1\"  >MediCARE<\/option><option value=\"State Children Health Insurance Program\"  class=\"choice-3 depth-1\"  >State Children Health Insurance Program<\/option><option value=\"Veteran Administration (VA) Medical Services\"  class=\"choice-4 depth-1\"  >Veteran Administration (VA) Medical Services<\/option><option value=\"Health Insurance obtained through COBRA\"  class=\"choice-5 depth-1\"  >Health Insurance obtained through COBRA<\/option><option value=\"Private Health Insurance\"  class=\"choice-6 depth-1\"  >Private Health Insurance<\/option><option value=\"State Health Insurance for Adults\"  class=\"choice-7 depth-1\"  >State Health Insurance for Adults<\/option><option value=\"Other\"  class=\"choice-8 depth-1\"  >Other<\/option><\/select><\/div><div id=\"wpforms-677-field_74-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"74\"><div class=\"wpforms-clear wpforms-pagebreak-split\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"2\" data-formid=\"677\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"2\" data-formid=\"677\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3  \" data-page=\"3\" style=\"display:none;\">\t\t<div id=\"wpforms-677-field_1-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"1\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-677-field_1\" >take that to<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-677-field_1\" class=\"wpforms-field-medium\" name=\"wpforms[fields][1]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-677-field_37-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"37\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-677-field_32-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"32\"><fieldset><legend class=\"wpforms-field-label\">Have you been continuously homeless for one year? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-677-field_32\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_32_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][32][]\" value=\"Yes\" aria-errormessage=\"wpforms-677-field_32_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_32_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_32_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][32][]\" value=\"No\" aria-errormessage=\"wpforms-677-field_32_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_32_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-677-field_89-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"89\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_89\">What is your relation to the Head of Household? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-677-field_89\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][89]\" required=\"required\"><option value=\"Self\"  class=\"choice-1 depth-1\"  >Self<\/option><option value=\"Family\"  class=\"choice-2 depth-1\"  >Family<\/option><option value=\"Friend\"  class=\"choice-3 depth-1\"  >Friend<\/option><option value=\"Stranger\"  class=\"choice-4 depth-1\"  >Stranger<\/option><\/select><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-677-field_35-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_35\">Where did you stay last night? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-677-field_35\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][35]\" aria-errormessage=\"wpforms-677-field_35-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-677-field_36-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_36\">How long have you been staying where you were last night?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-677-field_36\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][36]\" aria-errormessage=\"wpforms-677-field_36-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-677-field_39-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"39\"><fieldset><legend class=\"wpforms-field-label\">Number of times you have been homeless in the past three years?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-677-field_39\" class=\"wpforms-field-required\"><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_39_6\" name=\"wpforms[fields][39][]\" value=\"Never before now\" aria-errormessage=\"wpforms-677-field_39_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_39_6\">Never before now<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_39_1\" name=\"wpforms[fields][39][]\" value=\"1\" aria-errormessage=\"wpforms-677-field_39_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_39_1\">1<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_39_2\" name=\"wpforms[fields][39][]\" value=\"2\" aria-errormessage=\"wpforms-677-field_39_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_39_2\">2<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_39_4\" name=\"wpforms[fields][39][]\" value=\"3\" aria-errormessage=\"wpforms-677-field_39_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_39_4\">3<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_39_5\" name=\"wpforms[fields][39][]\" value=\"4 or more\" aria-errormessage=\"wpforms-677-field_39_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_39_5\">4 or more<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-677-field_41-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"number\" data-field-id=\"41\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_41\">If 4 or more, what is the total number of months you have been homeless in the past three years?<\/label><input type=\"number\" id=\"wpforms-677-field_41\" class=\"wpforms-field-medium\" name=\"wpforms[fields][41]\" min=\"1\" max=\"36\" step=\"any\" aria-errormessage=\"wpforms-677-field_41-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-677-field_42-container\" class=\"wpforms-field wpforms-field-number\" data-field-type=\"number\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_42\">What is the total number of months that you have continuously been homeless immediately prior to coming to this shelter?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-677-field_42\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][42]\" min=\"1\" max=\"36\" step=\"any\" aria-errormessage=\"wpforms-677-field_42-error\" required><\/div><div id=\"wpforms-677-field_75-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"75\"><div class=\"wpforms-clear wpforms-pagebreak-split\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"3\" data-formid=\"677\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"3\" data-formid=\"677\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-4  \" data-page=\"4\" style=\"display:none;\"><div id=\"wpforms-677-field_51-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"51\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-677-field_52-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"52\"><fieldset><legend class=\"wpforms-field-label\">Are you a domestic violence victim\/survivor?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-677-field_52\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_52_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][52][]\" value=\"Yes\" aria-errormessage=\"wpforms-677-field_52_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_52_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_52_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][52][]\" value=\"No\" aria-errormessage=\"wpforms-677-field_52_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_52_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-677-field_54-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"checkbox\" data-field-id=\"54\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">When did it occur?<\/legend><ul id=\"wpforms-677-field_54\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_54_1\" name=\"wpforms[fields][54][]\" value=\"Past 3 months\" aria-errormessage=\"wpforms-677-field_54_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_54_1\">Past 3 months<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_54_2\" name=\"wpforms[fields][54][]\" value=\"3-6 Months Ago\" aria-errormessage=\"wpforms-677-field_54_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_54_2\">3-6 Months Ago<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_54_4\" name=\"wpforms[fields][54][]\" value=\"6-12 Months Ago\" aria-errormessage=\"wpforms-677-field_54_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_54_4\">6-12 Months Ago<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_54_5\" name=\"wpforms[fields][54][]\" value=\"More than a Year\" aria-errormessage=\"wpforms-677-field_54_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_54_5\">More than a Year<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-677-field_53-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"checkbox\" data-field-id=\"53\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Are you currently fleeing domestic violence?<\/legend><ul id=\"wpforms-677-field_53\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_53_1\" name=\"wpforms[fields][53][]\" value=\"Yes\" aria-errormessage=\"wpforms-677-field_53_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_53_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_53_2\" name=\"wpforms[fields][53][]\" value=\"No\" aria-errormessage=\"wpforms-677-field_53_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_53_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-677-field_76-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"76\"><div class=\"wpforms-clear wpforms-pagebreak-split\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"4\" data-formid=\"677\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"4\" data-formid=\"677\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-5  \" data-page=\"5\" style=\"display:none;\"><div id=\"wpforms-677-field_44-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"44\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_48-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"48\"><fieldset><legend class=\"wpforms-field-label\">Are you currently working? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-677-field_48\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_48_1\" name=\"wpforms[fields][48][]\" value=\"Yes\" aria-errormessage=\"wpforms-677-field_48_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_48_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_48_2\" name=\"wpforms[fields][48][]\" value=\"No\" aria-errormessage=\"wpforms-677-field_48_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_48_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_49-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"text\" data-field-id=\"49\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_49\">When is the last time you had a job?<\/label><input type=\"text\" id=\"wpforms-677-field_49\" class=\"wpforms-field-medium\" name=\"wpforms[fields][49]\" aria-errormessage=\"wpforms-677-field_49-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_43-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_43\">What type of income do you receive? (Select all that apply AND enter amount in the box)   <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-677-field_43\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][43][]\" required=\"required\" multiple=\"multiple\"><option value=\"None\"  class=\"choice-1 depth-1\"  >None<\/option><option value=\"Alimony\"  class=\"choice-2 depth-1\"  >Alimony<\/option><option value=\"Child Support\"  class=\"choice-3 depth-1\"  >Child Support<\/option><option value=\"Earned Income\"  class=\"choice-4 depth-1\"  >Earned Income<\/option><option value=\"General Assistance (HUD)\"  class=\"choice-5 depth-1\"  >General Assistance (HUD)<\/option><option value=\"Other (HUD)\"  class=\"choice-6 depth-1\"  >Other (HUD)<\/option><option value=\"Pension or retirement income from another job\"  class=\"choice-7 depth-1\"  >Pension or retirement income from another job<\/option><option value=\"Private Disability Insurance\"  class=\"choice-8 depth-1\"  >Private Disability Insurance<\/option><option value=\"Retirement Income from Social Security\"  class=\"choice-9 depth-1\"  >Retirement Income from Social Security<\/option><option value=\"SSDI\"  class=\"choice-10 depth-1\"  >SSDI<\/option><option value=\"SSI\"  class=\"choice-11 depth-1\"  >SSI<\/option><option value=\"TANF\"  class=\"choice-12 depth-1\"  >TANF<\/option><option value=\"Unemployment Insurance\"  class=\"choice-13 depth-1\"  >Unemployment Insurance<\/option><option value=\"Veteran NonService Connected Disability Pension\"  class=\"choice-14 depth-1\"  >Veteran NonService Connected Disability Pension<\/option><option value=\"Veteran Service Connected Disability Compensation\"  class=\"choice-15 depth-1\"  >Veteran Service Connected Disability Compensation<\/option><option value=\"Workers Compensation\"  class=\"choice-16 depth-1\"  >Workers Compensation<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_45-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_45\">Amount of monthly income you receive <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-677-field_45\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][45]\" aria-errormessage=\"wpforms-677-field_45-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_46-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-modern\" data-field-type=\"select\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_46\">What type of Non-Cash Benefits do you receive? (Select all that apply AND enter amount in the box) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-677-field_46\" class=\"wpforms-field-medium wpforms-field-required choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"1\" name=\"wpforms[fields][46][]\" required=\"required\" multiple=\"multiple\"><option value=\"\" class=\"placeholder\" disabled ><\/option><option value=\"None\"  class=\"choice-1 depth-1\"  >None<\/option><option value=\"Food Stamps\"  class=\"choice-2 depth-1\"  >Food Stamps<\/option><option value=\"SCHIP\"  class=\"choice-3 depth-1\"  >SCHIP<\/option><option value=\"WIC\"  class=\"choice-4 depth-1\"  >WIC<\/option><option value=\"TANF Child Care Services\"  class=\"choice-5 depth-1\"  >TANF Child Care Services<\/option><option value=\"TANF Transportation Services\"  class=\"choice-6 depth-1\"  >TANF Transportation Services<\/option><option value=\"Other TANF-Funded Services\"  class=\"choice-7 depth-1\"  >Other TANF-Funded Services<\/option><option value=\"Section 8, Public Housing, or other ongoing rental assistance\"  class=\"choice-8 depth-1\"  >Section 8, Public Housing, or other ongoing rental assistance<\/option><option value=\"Temporary Rental Assistance\"  class=\"choice-9 depth-1\"  >Temporary Rental Assistance<\/option><option value=\"Other Source, name in box\"  class=\"choice-17 depth-1\"  >Other Source, name in box<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_47-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_47\">Amount of non-cash benefits you receive <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-677-field_47\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][47]\" aria-errormessage=\"wpforms-677-field_47-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><\/div><\/div><\/div><\/div><div id=\"wpforms-677-field_77-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"77\"><div class=\"wpforms-clear wpforms-pagebreak-split\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"5\" data-formid=\"677\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"5\" data-formid=\"677\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-6 last \" data-page=\"6\" style=\"display:none;\"><div id=\"wpforms-677-field_56-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"56\"><fieldset><legend class=\"wpforms-field-label\">Are you bringing children into shelter with you? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-677-field_56\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_56_1\" name=\"wpforms[fields][56][]\" value=\"Yes\" aria-errormessage=\"wpforms-677-field_56_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_56_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_56_2\" name=\"wpforms[fields][56][]\" value=\"No\" aria-errormessage=\"wpforms-677-field_56_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_56_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-677-field_57-container\" class=\"wpforms-field wpforms-field-repeater wpforms-conditional-field wpforms-conditional-show wpforms-field-repeater-display-blocks\" data-rows-min=\"1\" data-rows-max=\"10\" data-clone-num=\"2\" data-field-type=\"repeater\" data-field-id=\"57\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tChild\n\t\t\t<\/h3><input type=\"hidden\" class=\"wpforms-field-repeater-clone-list\" name=\"wpforms[fields][57][clone_list]\" value=\"[]\"><script type=\"text\/html\" class=\"tmpl-wpforms-field-repeater-template-57-677\"><div id=\"wpforms-677-repeater-field_57-clone_{CLONE}\" class=\"wpforms-field-repeater-clone-wrap\" data-clone=\"{CLONE}\">\n\t\t\t\t<h3 class=\"wpforms-field-repeater-block-title\">\n\t\t\t\tChild <span class=\"wpforms-wpforms-field-repeater-block-num\">#{CLONE}<\/span>\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-medium wpforms-field-repeater-display-blocks wpforms-field-repeater-preset-33-33-33\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_65_{CLONE}-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"65_{CLONE}\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_65_{CLONE}\">Relationship to Head of Household<\/label><input type=\"text\" id=\"wpforms-677-field_65_{CLONE}\" class=\"wpforms-field-medium\" name=\"wpforms[fields][65_{CLONE}]\" aria-errormessage=\"wpforms-677-field_65_{CLONE}-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_58_{CLONE}-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"58_{CLONE}\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_58_{CLONE}\">Childs First Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-677-field_58_{CLONE}\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][58_{CLONE}]\" aria-errormessage=\"wpforms-677-field_58_{CLONE}-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_90_{CLONE}-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"90_{CLONE}\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_90_{CLONE}\">Childs Last Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-677-field_90_{CLONE}\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][90_{CLONE}]\" aria-errormessage=\"wpforms-677-field_90_{CLONE}-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_59_{CLONE}-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"59_{CLONE}\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_59_{CLONE}\">Social Security Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-677-field_59_{CLONE}\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][59_{CLONE}]\" aria-errormessage=\"wpforms-677-field_59_{CLONE}-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_61_{CLONE}-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-modern\" data-field-type=\"select\" data-field-id=\"61_{CLONE}\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_61_{CLONE}\">Gender<\/label><select id=\"wpforms-677-field_61_{CLONE}\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][61_{CLONE}]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'><\/option><option value=\"Female\"  class=\"choice-1 depth-1\"  >Female<\/option><option value=\"Male\"  class=\"choice-2 depth-1\"  >Male<\/option><option value=\"Transgender Female to Male\"  class=\"choice-3 depth-1\"  >Transgender Female to Male<\/option><option value=\"Transgender Male to Female\"  class=\"choice-4 depth-1\"  >Transgender Male to Female<\/option><option value=\"Gender Non-conforming\"  class=\"choice-5 depth-1\"  >Gender Non-conforming<\/option><option value=\"Client does not know\"  class=\"choice-6 depth-1\"  >Client does not know<\/option><option value=\"Client refused\"  class=\"choice-7 depth-1\"  >Client refused<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_60_{CLONE}-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"60_{CLONE}\"><fieldset><legend class=\"wpforms-field-label\">Date Of Birth <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-date-dropdown-wrap wpforms-field-medium\"><select name=\"wpforms[fields][60_{CLONE}][date][m]\" id=\"wpforms-677-field_60_{CLONE}-month\" class=\"wpforms-field-date-time-date-month wpforms-field-required\" aria-label=\"Month\"  required><option value=\"\" class=\"placeholder\" selected disabled>MM<\/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><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><select name=\"wpforms[fields][60_{CLONE}][date][d]\" id=\"wpforms-677-field_60_{CLONE}-day\" class=\"wpforms-field-date-time-date-day wpforms-field-required\" aria-label=\"Day\"  required><option value=\"\" class=\"placeholder\" selected disabled>DD<\/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><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><select name=\"wpforms[fields][60_{CLONE}][date][y]\" id=\"wpforms-677-field_60_{CLONE}-year\" class=\"wpforms-field-date-time-date-year wpforms-field-required\" aria-label=\"Year\"  required><option value=\"\" class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" >2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><\/select><\/div><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_68_{CLONE}-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"68_{CLONE}\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_68_{CLONE}\">Health Insurance Carrier<\/label><input type=\"text\" id=\"wpforms-677-field_68_{CLONE}\" class=\"wpforms-field-medium\" name=\"wpforms[fields][68_{CLONE}]\" aria-errormessage=\"wpforms-677-field_68_{CLONE}-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_62_{CLONE}-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"62_{CLONE}\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_62_{CLONE}\">Ethnicity<\/label><select id=\"wpforms-677-field_62_{CLONE}\" class=\"wpforms-field-medium\" name=\"wpforms[fields][62_{CLONE}]\"><option value=\"Non-Hispanic\/Non-Latino\"  class=\"choice-1 depth-1\"  >Non-Hispanic\/Non-Latino<\/option><option value=\"Hispanic\/Non-Latino\"  class=\"choice-2 depth-1\"  >Hispanic\/Non-Latino<\/option><option value=\"Client doesn&#039;t know\"  class=\"choice-3 depth-1\"  >Client doesn't know<\/option><option value=\"Client refused\"  class=\"choice-4 depth-1\"  >Client refused<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_63_{CLONE}-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"63_{CLONE}\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_63_{CLONE}\">Race ( select all the apply)<\/label><select id=\"wpforms-677-field_63_{CLONE}\" class=\"wpforms-field-medium\" name=\"wpforms[fields][63_{CLONE}][]\" multiple=\"multiple\"><option value=\"African American or Black\"  class=\"choice-1 depth-1\"  >African American or Black<\/option><option value=\"White\"  class=\"choice-5 depth-1\"  >White<\/option><option value=\"Asian\"  class=\"choice-3 depth-1\"  >Asian<\/option><option value=\"American Indian or Alaskan Native\"  class=\"choice-2 depth-1\"  >American Indian or Alaskan Native<\/option><option value=\"Native Hawaiian or Other Pacific Islander\"  class=\"choice-4 depth-1\"  >Native Hawaiian or Other Pacific Islander<\/option><option value=\"Multi-Race\"  class=\"choice-7 depth-1\"  >Multi-Race<\/option><option value=\"Client doesn&#039;t know\"  class=\"choice-8 depth-1\"  >Client doesn't know<\/option><option value=\"Client refused\"  class=\"choice-9 depth-1\"  >Client refused<\/option><\/select><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_64_{CLONE}-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"64_{CLONE}\"><fieldset><legend class=\"wpforms-field-label\">Are they disabled?<\/legend><ul id=\"wpforms-677-field_64_{CLONE}\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_64_{CLONE}_1\" name=\"wpforms[fields][64_{CLONE}][]\" value=\"Yes\" aria-errormessage=\"wpforms-677-field_64_{CLONE}_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_64_{CLONE}_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_64_{CLONE}_2\" name=\"wpforms[fields][64_{CLONE}][]\" value=\"No\" aria-errormessage=\"wpforms-677-field_64_{CLONE}_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_64_{CLONE}_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_66_{CLONE}-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"66_{CLONE}\"><fieldset><legend class=\"wpforms-field-label\">Health Insurance?<\/legend><ul id=\"wpforms-677-field_66_{CLONE}\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_66_{CLONE}_1\" name=\"wpforms[fields][66_{CLONE}][]\" value=\"Yes\" aria-errormessage=\"wpforms-677-field_66_{CLONE}_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_66_{CLONE}_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_66_{CLONE}_2\" name=\"wpforms[fields][66_{CLONE}][]\" value=\"No\" aria-errormessage=\"wpforms-677-field_66_{CLONE}_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_66_{CLONE}_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div class=\"wpforms-field-repeater-display-blocks-buttons\" data-button-type=\"buttons_with_icons\">\n\t\t\t\t<button type=\"button\" class=\"wpforms-field-repeater-button-add\">\n\t\t\t\t\t<svg width=\"16\" height=\"17\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.129 7.984v1.032a.392.392 0 0 1-.387.387H8.903v2.839a.392.392 0 0 1-.387.387H7.484a.373.373 0 0 1-.387-.387V9.403H4.258a.373.373 0 0 1-.387-.387V7.984c0-.194.161-.387.387-.387h2.839V4.758c0-.193.161-.387.387-.387h1.032c.194 0 .387.194.387.387v2.839h2.839c.193 0 .387.193.387.387ZM16 8.5c0 4.42-3.58 8-8 8s-8-3.58-8-8 3.58-8 8-8 8 3.58 8 8Zm-1.548 0c0-3.548-2.904-6.452-6.452-6.452A6.45 6.45 0 0 0 1.548 8.5 6.43 6.43 0 0 0 8 14.952 6.45 6.45 0 0 0 14.452 8.5Z\" fill=\"currentColor\"\/><\/svg><span>Add Another Child<\/span>\n\t\t\t\t<\/button>\n\t\t\t\t<button type=\"button\" class=\"wpforms-field-repeater-button-remove wpforms-disabled\">\n\t\t\t\t\t<svg width=\"16\" height=\"17\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M4.258 9.403a.373.373 0 0 1-.387-.387V7.984c0-.194.161-.387.387-.387h7.484c.193 0 .387.193.387.387v1.032a.392.392 0 0 1-.387.387H4.258ZM16 8.5c0 4.42-3.58 8-8 8s-8-3.58-8-8 3.58-8 8-8 8 3.58 8 8Zm-1.548 0c0-3.548-2.904-6.452-6.452-6.452A6.45 6.45 0 0 0 1.548 8.5 6.43 6.43 0 0 0 8 14.952 6.45 6.45 0 0 0 14.452 8.5Z\" fill=\"currentColor\"\/><\/svg><span>Remove<\/span>\n\t\t\t\t<\/button>\n\t\t\t<\/div>\n\t\t\t<\/div><\/script><div class=\"wpforms-field-layout-rows wpforms-field-medium wpforms-field-repeater-display-blocks wpforms-field-repeater-preset-33-33-33\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_65-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"65\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_65\">Relationship to Head of Household<\/label><input type=\"text\" id=\"wpforms-677-field_65\" class=\"wpforms-field-medium\" name=\"wpforms[fields][65]\" aria-errormessage=\"wpforms-677-field_65-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_58-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"58\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_58\">Childs First Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-677-field_58\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][58]\" aria-errormessage=\"wpforms-677-field_58-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_90-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"90\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_90\">Childs Last Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-677-field_90\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][90]\" aria-errormessage=\"wpforms-677-field_90-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_59-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"59\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_59\">Social Security Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-677-field_59\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][59]\" aria-errormessage=\"wpforms-677-field_59-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_61-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-modern\" data-field-type=\"select\" data-field-id=\"61\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_61\">Gender<\/label><select id=\"wpforms-677-field_61\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][61]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'><\/option><option value=\"Female\"  class=\"choice-1 depth-1\"  >Female<\/option><option value=\"Male\"  class=\"choice-2 depth-1\"  >Male<\/option><option value=\"Transgender Female to Male\"  class=\"choice-3 depth-1\"  >Transgender Female to Male<\/option><option value=\"Transgender Male to Female\"  class=\"choice-4 depth-1\"  >Transgender Male to Female<\/option><option value=\"Gender Non-conforming\"  class=\"choice-5 depth-1\"  >Gender Non-conforming<\/option><option value=\"Client does not know\"  class=\"choice-6 depth-1\"  >Client does not know<\/option><option value=\"Client refused\"  class=\"choice-7 depth-1\"  >Client refused<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_60-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"60\"><fieldset><legend class=\"wpforms-field-label\">Date Of Birth <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-date-dropdown-wrap wpforms-field-medium\"><select name=\"wpforms[fields][60][date][m]\" id=\"wpforms-677-field_60-month\" class=\"wpforms-field-date-time-date-month wpforms-field-required\" aria-label=\"Month\"  required><option value=\"\" class=\"placeholder\" selected disabled>MM<\/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><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><select name=\"wpforms[fields][60][date][d]\" id=\"wpforms-677-field_60-day\" class=\"wpforms-field-date-time-date-day wpforms-field-required\" aria-label=\"Day\"  required><option value=\"\" class=\"placeholder\" selected disabled>DD<\/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><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><select name=\"wpforms[fields][60][date][y]\" id=\"wpforms-677-field_60-year\" class=\"wpforms-field-date-time-date-year wpforms-field-required\" aria-label=\"Year\"  required><option value=\"\" class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" >2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><\/select><\/div><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_68-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"68\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_68\">Health Insurance Carrier<\/label><input type=\"text\" id=\"wpforms-677-field_68\" class=\"wpforms-field-medium\" name=\"wpforms[fields][68]\" aria-errormessage=\"wpforms-677-field_68-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_62-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"62\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_62\">Ethnicity<\/label><select id=\"wpforms-677-field_62\" class=\"wpforms-field-medium\" name=\"wpforms[fields][62]\"><option value=\"Non-Hispanic\/Non-Latino\"  class=\"choice-1 depth-1\"  >Non-Hispanic\/Non-Latino<\/option><option value=\"Hispanic\/Non-Latino\"  class=\"choice-2 depth-1\"  >Hispanic\/Non-Latino<\/option><option value=\"Client doesn&#039;t know\"  class=\"choice-3 depth-1\"  >Client doesn&#8217;t know<\/option><option value=\"Client refused\"  class=\"choice-4 depth-1\"  >Client refused<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_63-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"63\"><label class=\"wpforms-field-label\" for=\"wpforms-677-field_63\">Race ( select all the apply)<\/label><select id=\"wpforms-677-field_63\" class=\"wpforms-field-medium\" name=\"wpforms[fields][63][]\" multiple=\"multiple\"><option value=\"African American or Black\"  class=\"choice-1 depth-1\"  >African American or Black<\/option><option value=\"White\"  class=\"choice-5 depth-1\"  >White<\/option><option value=\"Asian\"  class=\"choice-3 depth-1\"  >Asian<\/option><option value=\"American Indian or Alaskan Native\"  class=\"choice-2 depth-1\"  >American Indian or Alaskan Native<\/option><option value=\"Native Hawaiian or Other Pacific Islander\"  class=\"choice-4 depth-1\"  >Native Hawaiian or Other Pacific Islander<\/option><option value=\"Multi-Race\"  class=\"choice-7 depth-1\"  >Multi-Race<\/option><option value=\"Client doesn&#039;t know\"  class=\"choice-8 depth-1\"  >Client doesn&#8217;t know<\/option><option value=\"Client refused\"  class=\"choice-9 depth-1\"  >Client refused<\/option><\/select><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_64-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"64\"><fieldset><legend class=\"wpforms-field-label\">Are they disabled?<\/legend><ul id=\"wpforms-677-field_64\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_64_1\" name=\"wpforms[fields][64][]\" value=\"Yes\" aria-errormessage=\"wpforms-677-field_64_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_64_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_64_2\" name=\"wpforms[fields][64][]\" value=\"No\" aria-errormessage=\"wpforms-677-field_64_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_64_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-677-field_66-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"66\"><fieldset><legend class=\"wpforms-field-label\">Health Insurance?<\/legend><ul id=\"wpforms-677-field_66\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_66_1\" name=\"wpforms[fields][66][]\" value=\"Yes\" aria-errormessage=\"wpforms-677-field_66_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_66_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-677-field_66_2\" name=\"wpforms[fields][66][]\" value=\"No\" aria-errormessage=\"wpforms-677-field_66_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-677-field_66_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div class=\"wpforms-field-repeater-display-blocks-buttons\" data-button-type=\"buttons_with_icons\">\n\t\t\t\t<button type=\"button\" class=\"wpforms-field-repeater-button-add\">\n\t\t\t\t\t<svg width=\"16\" height=\"17\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.129 7.984v1.032a.392.392 0 0 1-.387.387H8.903v2.839a.392.392 0 0 1-.387.387H7.484a.373.373 0 0 1-.387-.387V9.403H4.258a.373.373 0 0 1-.387-.387V7.984c0-.194.161-.387.387-.387h2.839V4.758c0-.193.161-.387.387-.387h1.032c.194 0 .387.194.387.387v2.839h2.839c.193 0 .387.193.387.387ZM16 8.5c0 4.42-3.58 8-8 8s-8-3.58-8-8 3.58-8 8-8 8 3.58 8 8Zm-1.548 0c0-3.548-2.904-6.452-6.452-6.452A6.45 6.45 0 0 0 1.548 8.5 6.43 6.43 0 0 0 8 14.952 6.45 6.45 0 0 0 14.452 8.5Z\" fill=\"currentColor\"\/><\/svg><span>Add Another Child<\/span>\n\t\t\t\t<\/button>\n\t\t\t\t<button type=\"button\" class=\"wpforms-field-repeater-button-remove wpforms-disabled\">\n\t\t\t\t\t<svg width=\"16\" height=\"17\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M4.258 9.403a.373.373 0 0 1-.387-.387V7.984c0-.194.161-.387.387-.387h7.484c.193 0 .387.193.387.387v1.032a.392.392 0 0 1-.387.387H4.258ZM16 8.5c0 4.42-3.58 8-8 8s-8-3.58-8-8 3.58-8 8-8 8 3.58 8 8Zm-1.548 0c0-3.548-2.904-6.452-6.452-6.452A6.45 6.45 0 0 0 1.548 8.5 6.43 6.43 0 0 0 8 14.952 6.45 6.45 0 0 0 14.452 8.5Z\" fill=\"currentColor\"\/><\/svg><span>Remove<\/span>\n\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"wpforms-677-field_82-container\" class=\"wpforms-field wpforms-field-divider wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"divider\" data-field-id=\"82\" style=\"display:none;\"><h3 id=\"wpforms-677-field_82\" aria-errormessage=\"wpforms-677-field_82-error\" 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style=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\" data-rule-recaptcha=\"1\"><\/div><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"677\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/friendshipmission.org\/love1\/wp-json\/wp\/v2\/pages\/731\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-677\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/friendshipmission.org\/love1\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container 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