{"id":1552,"date":"2023-03-21T15:43:09","date_gmt":"2023-03-21T15:43:09","guid":{"rendered":"https:\/\/www.albacareservices.org\/?page_id=1552"},"modified":"2023-03-21T15:50:51","modified_gmt":"2023-03-21T15:50:51","slug":"intake-form","status":"publish","type":"page","link":"https:\/\/www.albacareservices.org\/intake-form\/","title":{"rendered":"Intake Form"},"content":{"rendered":"<div class=\"vc_row wpb_row vc_row-fluid vc_custom_1679413844805\"><div class=\"wpb_column vc_column_container vc_col-sm-12 sc_layouts_column_icons_position_left\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\">\n                <div class='gf_browser_chrome gform_wrapper' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_1' id='gform_1'  action='\/wp-json\/wp\/v2\/pages\/1552#gf_1'>\n                        <div class='gform_body'><div id='gform_page_1_1' class='gform_page' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><li id='field_1_1'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Name<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value='' aria-label='First name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_1_1_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value='' aria-label='Last name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_1_1_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id='field_1_4'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_4' >Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_1_4' type='text' value='' class='large'    aria-invalid=\"false\"  \/><\/div><\/li><li id='field_1_5'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_5' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_1_5' type='text' value='' class='large'     aria-invalid=\"false\" \/>\n                        <\/div><\/li><li id='field_1_6'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_1_6' >\n                         <span class='ginput_full address_line_1' id='input_1_6_1_container' >\n                                        <input type='text' name='input_6.1' id='input_1_6_1' value=''    \/>\n                                        <label for='input_1_6_1' id='input_1_6_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2' id='input_1_6_2_container' >\n                                        <input type='text' name='input_6.2' id='input_1_6_2' value=''   \/>\n                                        <label for='input_1_6_2' id='input_1_6_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_1_6_3_container' >\n                                    <input type='text' name='input_6.3' id='input_1_6_3' value=''    \/>\n                                    <label for='input_1_6_3' id='input_1_6_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state' id='input_1_6_4_container' >\n                                        <input type='text' name='input_6.4' id='input_1_6_4' value=''      \/>\n                                        <label for='input_1_6_4' id='input_1_6_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip' id='input_1_6_5_container' >\n                                    <input type='text' name='input_6.5' id='input_1_6_5' value=''    \/>\n                                    <label for='input_1_6_5' id='input_1_6_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country' id='input_1_6_6_container' >\n                                        <select name='input_6.6' id='input_1_6_6'   ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_1_6_6' id='input_1_6_6_label' >Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id='field_1_10'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_10' >Relationship Status<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_10' id='input_1_10' class='medium gfield_select'   aria-required=\"true\" aria-invalid=\"false\"><option value='Single' >Single<\/option><option value='Married' >Married<\/option><option value='In a Relationship' >In a Relationship<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id='field_1_9'  class='gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label'  ><span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_9.1' id='input_1_9_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gfield_consent_label\" for='input_1_9_1' >I am at least 21 years of age<\/label><span class='gfield_required'>*<\/span><input type='hidden' name='input_9.2' value='I am at least 21 years of age' class='gform_hidden' \/><input type='hidden' name='input_9.3' value='1' class='gform_hidden' \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                         <input type='button' id='gform_next_button_1_7' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_below'><li id='field_1_11'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_11' >Have you lived in a state other than California in the last five years?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_11' id='input_1_11' class='medium gfield_select'   aria-required=\"true\" aria-invalid=\"false\"><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id='field_1_14'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_14' >Please identify each state you&#039;ve resided in below:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_14' id='input_1_14' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_1_13'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_13' >Have you or any other adult living in your home been arrested or investigated by CPS?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_13' id='input_1_13' class='medium gfield_select'   aria-required=\"true\" aria-invalid=\"false\"><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id='field_1_12'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_12' >What was the reason and in what county?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_1_12' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_1_15'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_15' >Do you have a daycare license?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_15' id='input_1_15' class='medium gfield_select'   aria-required=\"true\" aria-invalid=\"false\"><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id='field_1_20'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_20' >How many children does your license allow you to care for?<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_1_20' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_1_18' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"1\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"1\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_18' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_below'><li id='field_1_21'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_21' >Have you ever been certified or RFA approved with another FFA or with the County?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_21' id='input_1_21' class='medium gfield_select'   aria-required=\"true\" aria-invalid=\"false\"><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id='field_1_22'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_22' >Did you have any investigation(s)? If so, please explain below:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_1_22' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_1_23'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_23' >Can you and partner complete RFA Orientation and Pre-approval training?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_23' id='input_1_23' class='medium gfield_select'   aria-required=\"true\" aria-invalid=\"false\"><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_1_27' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"2\"); 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if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/><\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_1_30' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_30' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_5' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_5' class='gform_fields top_label form_sublabel_below description_below'><li id='field_1_32'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_32' >What type of home do you live in?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_32' id='input_1_32' class='medium gfield_select'   aria-required=\"true\" aria-invalid=\"false\"><option value='Apartment' >Apartment<\/option><option value='Condominium' >Condominium<\/option><option value='House' >House<\/option><option value='Trailer' >Trailer<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id='field_1_33'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_33' >How many stories is your home?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_33' id='input_1_33' class='medium gfield_select'   aria-required=\"true\" aria-invalid=\"false\"><option value='One' >One<\/option><option value='Two' >Two<\/option><option value='Three' >Three<\/option><\/select><\/div><\/li><li id='field_1_34'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_34' >Number of bedrooms?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_34' id='input_1_34' type='text'    value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><div class='instruction '>Please enter a number from <strong>1<\/strong> to <strong>20<\/strong>.<\/div><\/div><\/li><li id='field_1_35'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_35' >How many people live in the home?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_35' id='input_1_35' type='text'    value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><div class='instruction '>Please enter a number from <strong>1<\/strong> to <strong>20<\/strong>.<\/div><\/div><\/li><li id='field_1_37'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_37' >Do you own a swimming pool or jacuzzi?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_37' id='input_1_37' class='medium gfield_select'   aria-required=\"true\" aria-invalid=\"false\"><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id='field_1_38'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_38' >Do any of the windows at home have bars?<\/label><div class='ginput_container ginput_container_select'><select name='input_38' id='input_1_38' class='medium gfield_select'    aria-invalid=\"false\"><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id='field_1_40'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >The home has space for:<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_40'><li class='gchoice_1_40_1'>\n\t\t\t\t\t\t\t\t<input name='input_40.1' type='checkbox'  value='Children'  id='choice_1_40_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_40_1' id='label_1_40_1'>Children<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_1_40_2'>\n\t\t\t\t\t\t\t\t<input name='input_40.2' type='checkbox'  value='Infants'  id='choice_1_40_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_40_2' id='label_1_40_2'>Infants<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li>\n                            <\/ul><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_1' class='gform_previous_button button' value='Previous'  onclick='if(window[\"gf_submitting_1\"]){return false;}  window[\"gf_submitting_1\"]=true; 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