{"id":364,"date":"2023-05-17T21:35:29","date_gmt":"2023-05-17T21:35:29","guid":{"rendered":"https:\/\/communitycare-odu.com\/?page_id=364"},"modified":"2023-05-18T17:05:02","modified_gmt":"2023-05-18T17:05:02","slug":"parent-patient-release-form","status":"publish","type":"page","link":"https:\/\/communitycare-odu.com\/?page_id=364","title":{"rendered":"Parent\/Patient Release Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"364\" class=\"elementor elementor-364\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-40553cfc elementor-section-height-min-height elementor-section-content-middle elementor-section-full_width elementor-section-stretched elementor-section-height-default elementor-section-items-middle\" data-id=\"40553cfc\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;stretch_section&quot;:&quot;section-stretched&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-16 elementor-top-column elementor-element elementor-element-7de89177\" data-id=\"7de89177\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-16 elementor-top-column elementor-element elementor-element-34e6839f\" data-id=\"34e6839f\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-8af7baa elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"8af7baa\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;motion_fx_motion_fx_scrolling&quot;:&quot;yes&quot;,&quot;_animation&quot;:&quot;fadeInDown&quot;,&quot;motion_fx_devices&quot;:[&quot;desktop&quot;,&quot;tablet&quot;,&quot;mobile&quot;]}\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Parent\/Patient Release Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-66 elementor-top-column elementor-element elementor-element-2d5c6f94\" data-id=\"2d5c6f94\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-c2c2e96 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"c2c2e96\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-e5847c0\" data-id=\"e5847c0\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-fb15ae8 elementor-widget elementor-widget-wpforms\" data-id=\"fb15ae8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"wpforms-container-save-resume\"><div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-365\"><form id=\"wpforms-form-365\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"365\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F364\" data-token=\"11dba427682429530066742bec297efb\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-365-field_14-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"14\"><h3 id=\"wpforms-365-field_14\" name=\"wpforms[fields][14]\">Student\/Child&#039;s Signature<\/h3><div class=\"wpforms-field-description\">Student\/Child's Signature<\/div><\/div><div id=\"wpforms-365-field_6-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_6\">Date <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-365-field_6\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][6][date]\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-365-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_0\">Child&#039;s Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-365-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" required><label for=\"wpforms-365-field_0\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-365-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" required><label for=\"wpforms-365-field_0-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-365-field_53-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_53\">Child&#039;s Social Security Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-365-field_53\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][53]\" required><\/div><div id=\"wpforms-365-field_7-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_7\">Child&#039;s Date of Birth <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-365-field_7\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][7][date]\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-365-field_11-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_11\">Child&#039;s Sex <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-365-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" required=\"required\"><option value=\"Male\" >Male<\/option><option value=\"Female\" >Female<\/option><option value=\"Other\/Decline to answer\" >Other\/Decline to answer<\/option><\/select><\/div><div id=\"wpforms-365-field_56-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_56\">Child&#039;s Race <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-365-field_56\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][56][]\" required=\"required\" multiple=\"multiple\"><option value=\"American Indian or Alaska Native\" >American Indian or Alaska Native<\/option><option value=\"Asian\" >Asian<\/option><option value=\"Black or African American\" >Black or African American<\/option><option value=\"Native Hawaiian or Other Pacific Islander\" >Native Hawaiian or Other Pacific Islander<\/option><option value=\"White\" >White<\/option><\/select><\/div><div id=\"wpforms-365-field_57-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_57\">Child&#039;s Ethnicity <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-365-field_57\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-365-field_57_1\" name=\"wpforms[fields][57]\" value=\"Hispanic or Latino or Spanish Origin\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-365-field_57_1\">Hispanic or Latino or Spanish Origin<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-365-field_57_2\" name=\"wpforms[fields][57]\" value=\"Not Hispanic or Latino or Spanish Origin\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-365-field_57_2\">Not Hispanic or Latino or Spanish Origin<\/label><\/li><\/ul><\/div><div id=\"wpforms-365-field_37-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_37\">Child&#039;s Primary Language Spoken <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-365-field_37\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][37]\" required><\/div><div id=\"wpforms-365-field_58-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"58\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_58\">Name of Parent\/Legal Guardian <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-365-field_58\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][58]\" required><\/div><div id=\"wpforms-365-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_1\">Parent\/Legal Guardian&#039;s Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-365-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-365-field_4-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_4\">Parent\/Legal Guardian&#039;s Cell Phone Number<\/label><input type=\"tel\" id=\"wpforms-365-field_4\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][4]\" ><\/div><div id=\"wpforms-365-field_9-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_9\">Parent\/Legal Guardian&#039;s Home Phone Number<\/label><input type=\"tel\" id=\"wpforms-365-field_9\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][9]\" ><\/div><div id=\"wpforms-365-field_10-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_10\">Parent\/Legal Guardian&#039;s Work Phone Number<\/label><input type=\"tel\" id=\"wpforms-365-field_10\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][10]\" ><\/div><div id=\"wpforms-365-field_8-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_8\">Can We Leave a Message?<\/label><ul id=\"wpforms-365-field_8\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-365-field_8_1\" name=\"wpforms[fields][8][]\" value=\"Home\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-365-field_8_1\">Home<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-365-field_8_2\" name=\"wpforms[fields][8][]\" value=\"Cell\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-365-field_8_2\">Cell<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-365-field_8_4\" name=\"wpforms[fields][8][]\" value=\"Work\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-365-field_8_4\">Work<\/label><\/li><\/ul><div class=\"wpforms-field-description\">Please tick all that apply<\/div><\/div><div id=\"wpforms-365-field_3-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_3\">Parent\/Legal Guardian&#039;s Mailing Address <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-365-field_3\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][3][address1]\" required><label for=\"wpforms-365-field_3\" class=\"wpforms-field-sublabel after \">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-365-field_3-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][3][address2]\" ><label for=\"wpforms-365-field_3-address2\" class=\"wpforms-field-sublabel after \">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-365-field_3-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][3][city]\" required><label for=\"wpforms-365-field_3-city\" class=\"wpforms-field-sublabel after \">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-365-field_3-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][3][state]\" required><label for=\"wpforms-365-field_3-state\" class=\"wpforms-field-sublabel after \">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-365-field_3-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][3][postal]\" required><label for=\"wpforms-365-field_3-postal\" class=\"wpforms-field-sublabel after \">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-365-field_3-country\" class=\"wpforms-field-address-country wpforms-field-required\" name=\"wpforms[fields][3][country]\" required><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-365-field_3-country\" class=\"wpforms-field-sublabel after \">Country<\/label><\/div><\/div><\/div><div id=\"wpforms-365-field_19-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_19\">Child&#039;s Current Healthcare Provider\/Doctor<\/label><input type=\"text\" id=\"wpforms-365-field_19\" class=\"wpforms-field-medium\" name=\"wpforms[fields][19]\" ><\/div><div id=\"wpforms-365-field_20-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_20\">May We Send Them Information?<\/label><select id=\"wpforms-365-field_20\" class=\"wpforms-field-medium\" name=\"wpforms[fields][20]\"><option value=\"No\" >No<\/option><option value=\"Yes\" >Yes<\/option><\/select><\/div><div id=\"wpforms-365-field_21-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"21\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_21\">Healthcare Provider\/Doctor Contact Information<\/label><input type=\"text\" id=\"wpforms-365-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\" ><div class=\"wpforms-field-description\">Please add a contact phone number<\/div><\/div><div id=\"wpforms-365-field_38-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"38\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_38\">Child&#039;s Dentist<\/label><input type=\"text\" id=\"wpforms-365-field_38\" class=\"wpforms-field-medium\" name=\"wpforms[fields][38]\" ><\/div><div id=\"wpforms-365-field_39-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_39\">Dentist Contact Information<\/label><input type=\"text\" id=\"wpforms-365-field_39\" class=\"wpforms-field-medium\" name=\"wpforms[fields][39]\" ><div class=\"wpforms-field-description\">Please add a contact phone number<\/div><\/div><div id=\"wpforms-365-field_40-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_40\">Is the Child currently receiving any medication\/medical treatment on a continual basis? <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-365-field_40\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][40]\" required=\"required\"><option value=\"Yes\" >Yes<\/option><option value=\"No\" >No<\/option><\/select><\/div><div id=\"wpforms-365-field_41-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"41\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_41\">Please specify the treatment<\/label><input type=\"text\" id=\"wpforms-365-field_41\" class=\"wpforms-field-medium\" name=\"wpforms[fields][41]\" ><\/div><div id=\"wpforms-365-field_42-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_42\">Please list all allergies that the Patient\/Student may have: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-365-field_42\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][42]\" required><\/div><div id=\"wpforms-365-field_15-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"15\"><h3 id=\"wpforms-365-field_15\" name=\"wpforms[fields][15]\">EMERGENCY CONTACT INFORMATION<\/h3><\/div><div id=\"wpforms-365-field_16-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_16\">Emergency Contact&#039;s Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-365-field_16\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][16][first]\" required><label for=\"wpforms-365-field_16\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-365-field_16-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][16][last]\" required><label for=\"wpforms-365-field_16-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-365-field_17-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_17\">Contact Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-365-field_17\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][17]\" required><\/div><div id=\"wpforms-365-field_18-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_18\">Relation to Patient\/Student <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-365-field_18\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][18]\" required><\/div><div id=\"wpforms-365-field_23-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"23\"><h3 id=\"wpforms-365-field_23\" name=\"wpforms[fields][23]\">INSURANCE PROVIDER<\/h3><\/div><div id=\"wpforms-365-field_54-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"54\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_54\">Group Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-365-field_54\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][54]\" required><\/div><div id=\"wpforms-365-field_55-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_55\">ID Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-365-field_55\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][55]\" required><\/div><div id=\"wpforms-365-field_27-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_27\">Subscriber <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-365-field_27\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][27]\" required><\/div><div id=\"wpforms-365-field_29-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_29\">Insurance Effective Date <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-365-field_29\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][29][date]\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-365-field_31-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_31\">Insured&#039;s Relationship to Patient<\/label><input type=\"text\" id=\"wpforms-365-field_31\" class=\"wpforms-field-medium\" name=\"wpforms[fields][31]\" ><\/div><div id=\"wpforms-365-field_34-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"34\"><h3 id=\"wpforms-365-field_34\" name=\"wpforms[fields][34]\">FINAL STEPS<\/h3><\/div><div id=\"wpforms-365-field_43-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_43\">Consent to Disclose Records: Records maintained by the Franklin City Public Schools are considered \u201ceducation records\u201d and, as such, are governed by the Federal Family Educational Rights and Privacy Act (\u201cFERPA\u201d). The purpose of this consent is to obtain permission, in accordance with FERPA, from the Student\u2019s parent, legal guardian, or the Student, if the Student is 18 years or older, for the disclosure of the Student\u2019s education records related to those health care services provided by ODU Community Care. <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-365-field_43\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-365-field_43_1\" name=\"wpforms[fields][43][]\" value=\"I consent\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-365-field_43_1\">I consent<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-365-field_43_4\" name=\"wpforms[fields][43][]\" value=\"I do not consent\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-365-field_43_4\">I do not consent<\/label><\/li><\/ul><\/div><div id=\"wpforms-365-field_44-container\" class=\"wpforms-field wpforms-field-signature wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"44\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_44\">By my signature below, I hereby request and authorize the ODU Community Care to: (1) release information related to health care services provided to the Student to the appropriate third-party payor for payment purposes; and (2) exchange information pertaining to the Student\u2019s School Entrance Health Form, and related immunizations and school entrance physicals, for the purposes of fulfilling the Commonwealth of Virginia\u2019s immunization compliance requirements. <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-365-field_44\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][44]\" autocomplete=\"off\" required><div class=\"wpforms-signature-wrap wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-365-field_44-signature\" data-color=\"#000000\"><\/canvas><button class=\"wpforms-signature-clear\" title=\"Clear Signature\">Clear Signature<\/button><\/div><\/div><div id=\"wpforms-365-field_46-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_46\">Consent to Treatment: The purpose of this consent is to obtain permission from the Student\u2019s parent or legal guardian for the provision of health care services, including evaluation and treatment by a licensed healthcare provider who may be overseeing a healthcare student. Except in those limited situations where federal and\/or state laws allow minors to access and consent to treatment without a parent\u2019s or legal guardian\u2019s consent, ODU Community Care must have a written, signed consent from a parent or legal guardian prior to providing health care services to the Student. <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-365-field_46\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-365-field_46_1\" name=\"wpforms[fields][46][]\" value=\"I consent\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-365-field_46_1\">I consent<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-365-field_46_2\" name=\"wpforms[fields][46][]\" value=\"I do not consent\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-365-field_46_2\">I do not consent<\/label><\/li><\/ul><\/div><div id=\"wpforms-365-field_59-container\" class=\"wpforms-field wpforms-field-signature wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"59\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_59\">By my signature below, I hereby request and authorize that the Student may: (1) receive health care services available from, and deemed necessary by, ODU Community Care, which services may include, but shall not be limited to, the administration of medication, treatment of acute illnesses and injuries, wellness check-ups, and immunizations; (2) receive referral care and emergency transportation to other health care providers, as deemed necessary by the ODU Community Care; (3) I have received a copy of the \u201cNotice of Privacy Practices\u201d from ODU Community Care. <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-365-field_59\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][59]\" autocomplete=\"off\" required><div class=\"wpforms-signature-wrap wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-365-field_59-signature\" data-color=\"#000000\"><\/canvas><button class=\"wpforms-signature-clear\" title=\"Clear Signature\">Clear Signature<\/button><\/div><\/div><div id=\"wpforms-365-field_47-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_47\">Consent for Telehealth Services: Telehealth involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and\/or specialist. The information may be used for diagnosis, therapy, follow-up, and education. It may include sharing of the patient medical record, medical images, live two-way audio and video and output data from medical devices that include sound and video files. <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-365-field_47\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-365-field_47_1\" name=\"wpforms[fields][47][]\" value=\"I consent\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-365-field_47_1\">I consent<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-365-field_47_4\" name=\"wpforms[fields][47][]\" value=\"I do not consent\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-365-field_47_4\">I do not consent<\/label><\/li><\/ul><\/div><div id=\"wpforms-365-field_49-container\" class=\"wpforms-field wpforms-field-signature wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"49\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_49\">By my signature below, I hereby request and authorize the ODU Community Care to: (3) release information related to health care services provided to the Student to the appropriate third-party payor for payment purposes; and (4) exchange information pertaining to the Student\u2019s School Entrance Health Form, and related immunizations and school entrance physicals, for the purposes of fulfilling the Commonwealth of Virginia\u2019s immunization compliance requirements. <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-365-field_49\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][49]\" autocomplete=\"off\" required><div class=\"wpforms-signature-wrap wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-365-field_49-signature\" data-color=\"#000000\"><\/canvas><button class=\"wpforms-signature-clear\" title=\"Clear Signature\">Clear Signature<\/button><\/div><\/div><div id=\"wpforms-365-field_51-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_51\">The above checked consents are authorized for the length of time the Student is enrolled at the Franklin City Public School System. I may choose to withdraw any consents at any time. Any consent withdrawal must be communicated, in writing, to the ODU Community Care. I understand that even if I, as the Student\u2019s parent or legal guardian, withdraw consent for the Student to receive health care services at the ODU Community Care, the Student may still seek treatment in those situations where federal and\/or state laws allow minors to access and consent to treatment without a parent\u2019s or legal guardian\u2019s consent. <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-365-field_51\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][51]\" autocomplete=\"off\" required><div class=\"wpforms-signature-wrap wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-365-field_51-signature\" data-color=\"#000000\"><\/canvas><button class=\"wpforms-signature-clear\" title=\"Clear Signature\">Clear Signature<\/button><\/div><div class=\"wpforms-field-description\">Parent\/Legal Guardian's Signature<\/div><\/div><div id=\"wpforms-365-field_62-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"62\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_62\">Date <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-365-field_62\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][62][date]\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-365-field_61-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"61\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-365-field_61\">Student\/Child&#039;s Signature <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-365-field_61\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][61]\" autocomplete=\"off\" required><div class=\"wpforms-signature-wrap wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-365-field_61-signature\" data-color=\"#000000\"><\/canvas><button class=\"wpforms-signature-clear\" title=\"Clear Signature\">Clear Signature<\/button><\/div><div class=\"wpforms-field-description\">Student\/Child's Signature<\/div><\/div><div id=\"wpforms-365-field_52-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"52\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_52\">Date <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-365-field_52\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][52][date]\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-365-field_32-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_32\">How Did You Hear About Us?<\/label><ul id=\"wpforms-365-field_32\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-365-field_32_1\" name=\"wpforms[fields][32]\" value=\"Internet\/Search Engine\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-365-field_32_1\">Internet\/Search Engine<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-365-field_32_2\" name=\"wpforms[fields][32]\" value=\"Friend Referal\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-365-field_32_2\">Friend Referal<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-365-field_32_3\" name=\"wpforms[fields][32]\" value=\"Social Media\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-365-field_32_3\">Social Media<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-365-field_32_4\" name=\"wpforms[fields][32]\" value=\"Referral\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-365-field_32_4\">Referral<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-365-field_32_5\" name=\"wpforms[fields][32]\" value=\"TV\/Radio\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-365-field_32_5\">TV\/Radio<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-365-field_32_6\" name=\"wpforms[fields][32]\" value=\"Third-Party Review\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-365-field_32_6\">Third-Party Review<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-365-field_32_7\" name=\"wpforms[fields][32]\" value=\"Other\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-365-field_32_7\">Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-365-field_35-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"35\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_35\">If other, please specify<\/label><input type=\"text\" id=\"wpforms-365-field_35\" class=\"wpforms-field-medium\" name=\"wpforms[fields][35]\" ><\/div><div id=\"wpforms-365-field_33-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-365-field_33\">Additional Questions or Comments<\/label><textarea id=\"wpforms-365-field_33\" class=\"wpforms-field-medium\" name=\"wpforms[fields][33]\" ><\/textarea><\/div><\/div><!-- .wpforms-field-container --><div 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