{"id":96,"date":"2018-09-10T15:28:54","date_gmt":"2018-09-10T22:28:54","guid":{"rendered":"https:\/\/kern.org\/early-childhood-education\/?page_id=96"},"modified":"2018-09-10T15:28:54","modified_gmt":"2018-09-10T22:28:54","slug":"pre-enrollment-application","status":"publish","type":"page","link":"https:\/\/kern.org\/early-childhood-education\/pre-enrollment-application\/","title":{"rendered":"Pre-Enrollment Application"},"content":{"rendered":"<div class=\"alert alert-warning\">After you complete the pre-application you will be contacted for additional information. <strong>PLEASE NOTE:<\/strong> All information will need to be verified with hard copies prior to enrollment.<\/div>\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar 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#112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><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='\/early-childhood-education\/wp-json\/wp\/v2\/pages\/96#gf_1' data-formid='1' novalidate>\n        <div id='gf_progressbar_wrapper_1' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>4<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_25\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Family Identification<\/h2><\/li><li id=\"field_1_24\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_24'>Are you a single parent\/caretaker?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_24' id='input_1_24' class='medium gfield_select' tabindex='1'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_1_9\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Parent\/Caretaker Information (A)<\/h3><\/li><li id=\"field_1_1\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_third gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_1'>Name of parent\/caretaker<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_1_1' type='text' value='' class='medium'  aria-describedby=\"gfield_description_1_1\" tabindex='2'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_1'>(full name, include middle initial)<\/div><\/li><li id=\"field_1_2\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_2'>Social Security Number<\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_1_2' type='text' value='' class='medium'  aria-describedby=\"gfield_description_1_2\" tabindex='3'   aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_2'>optional<\/div><\/li><li id=\"field_1_3\" class=\"gfield gfield--type-select gfield--input-type-select gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_3'>Gender<\/label><div class='ginput_container ginput_container_select'><select name='input_3' id='input_1_3' class='medium gfield_select' tabindex='4'    aria-invalid=\"false\" ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><option value='Prefer Not to Answer' >Prefer Not to Answer<\/option><\/select><\/div><\/li><li id=\"field_1_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'>Phone no. (home)<\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_1_4' type='tel' value='' class='medium' tabindex='5'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_5\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Phone no. (other)<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_1_5' type='tel' value='' class='medium' tabindex='6'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_6\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_6' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_6_1_container' >\n                                        <input type='text' name='input_6.1' id='input_1_6_1' value='' tabindex='7'   aria-required='true'    \/>\n                                        <label for='input_1_6_1' id='input_1_6_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_6_2_container' >\n                                        <input type='text' name='input_6.2' id='input_1_6_2' value='' tabindex='8'    aria-required='false'   \/>\n                                        <label for='input_1_6_2' id='input_1_6_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_6_3_container' >\n                                    <input type='text' name='input_6.3' id='input_1_6_3' value='' tabindex='9'   aria-required='true'    \/>\n                                    <label for='input_1_6_3' id='input_1_6_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_6_4_container' >\n                                        <input type='text' name='input_6.4' id='input_1_6_4' value='' tabindex='11'     aria-required='true'    \/>\n                                        <label for='input_1_6_4' id='input_1_6_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_6_5_container' >\n                                    <input type='text' name='input_6.5' id='input_1_6_5' value='' tabindex='12'   aria-required='true'    \/>\n                                    <label for='input_1_6_5' id='input_1_6_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_6.6' id='input_1_6_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_87\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_87'>Employer Name<\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_1_87' type='text' value='' class='medium'   tabindex='13'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_10\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>Employer Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_1_10' type='tel' value='' class='medium' tabindex='14'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_7\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Employer Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_7_1_container' >\n                                        <input type='text' name='input_7.1' id='input_1_7_1' value='' tabindex='15'   aria-required='false'    \/>\n                                        <label for='input_1_7_1' id='input_1_7_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_7_2_container' >\n                                        <input type='text' name='input_7.2' id='input_1_7_2' value='' tabindex='16'    aria-required='false'   \/>\n                                        <label for='input_1_7_2' id='input_1_7_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_7_3_container' >\n                                    <input type='text' name='input_7.3' id='input_1_7_3' value='' tabindex='17'   aria-required='false'    \/>\n                                    <label for='input_1_7_3' id='input_1_7_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_7_4_container' >\n                                        <input type='text' name='input_7.4' id='input_1_7_4' value='' tabindex='19'     aria-required='false'    \/>\n                                        <label for='input_1_7_4' id='input_1_7_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_7_5_container' >\n                                    <input type='text' name='input_7.5' id='input_1_7_5' value='' tabindex='20'   aria-required='false'    \/>\n                                    <label for='input_1_7_5' id='input_1_7_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_7.6' id='input_1_7_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_89\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_89'>Training Name<\/label><div class='ginput_container ginput_container_text'><input name='input_89' id='input_1_89' type='text' value='' class='medium'   tabindex='21'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_88\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_88'>Training Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_88' id='input_1_88' type='tel' value='' class='medium' tabindex='22'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_83\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Training Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_83' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_83_1_container' >\n                                        <input type='text' name='input_83.1' id='input_1_83_1' value='' tabindex='23'   aria-required='false'    \/>\n                                        <label for='input_1_83_1' id='input_1_83_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_83_2_container' >\n                                        <input type='text' name='input_83.2' id='input_1_83_2' value='' tabindex='24'    aria-required='false'   \/>\n                                        <label for='input_1_83_2' id='input_1_83_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_83_3_container' >\n                                    <input type='text' name='input_83.3' id='input_1_83_3' value='' tabindex='25'   aria-required='false'    \/>\n                                    <label for='input_1_83_3' id='input_1_83_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_83_4_container' >\n                                        <input type='text' name='input_83.4' id='input_1_83_4' value='' tabindex='27'     aria-required='false'    \/>\n                                        <label for='input_1_83_4' id='input_1_83_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_83_5_container' >\n                                    <input type='text' name='input_83.5' id='input_1_83_5' value='' tabindex='28'   aria-required='false'    \/>\n                                    <label for='input_1_83_5' id='input_1_83_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_83.6' id='input_1_83_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_11\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Days and working\/training hours<\/h4><\/li><li id=\"field_1_12\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>Monday<\/label><div class='ginput_container ginput_container_number'><input name='input_12' id='input_1_12' type='number' step='any'   value='' class='small' tabindex='29'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_13\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_13'>Tuesday<\/label><div class='ginput_container ginput_container_number'><input name='input_13' id='input_1_13' type='number' step='any'   value='' class='small' tabindex='30'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_14\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'>Wednesday<\/label><div class='ginput_container ginput_container_number'><input name='input_14' id='input_1_14' type='number' step='any'   value='' class='small' tabindex='31'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_15\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_15'>Thursday<\/label><div class='ginput_container ginput_container_number'><input name='input_15' id='input_1_15' type='number' step='any'   value='' class='small' tabindex='32'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_16\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>Friday<\/label><div class='ginput_container ginput_container_number'><input name='input_16' id='input_1_16' type='number' step='any'   value='' class='small' tabindex='33'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_17\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_17'>Monday - Friday<\/label><div class='ginput_container ginput_container_number'><input name='input_17' id='input_1_17' type='text' step='any' min='0' max='24' value='' class='small gform-text-input-reset' tabindex='34' readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_18\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_18'>Saturday<\/label><div class='ginput_container ginput_container_number'><input name='input_18' id='input_1_18' type='number' step='any'   value='' class='small' tabindex='35'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_19\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_19'>Sunday<\/label><div class='ginput_container ginput_container_number'><input name='input_19' id='input_1_19' type='number' step='any'   value='' class='small' tabindex='36'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_20\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_20'>Monday - Sunday<\/label><div class='ginput_container ginput_container_number'><input name='input_20' id='input_1_20' type='text' step='any' min='0' max='24' value='' class='small gform-text-input-reset' tabindex='37' readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_92' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='38' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-92' 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 validation_below'><li id=\"field_1_23\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Parent\/Caretaker Information (B)<\/h3><\/li><li id=\"field_1_26\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_third gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_26'>Name of parent\/caretaker<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_1_26' type='text' value='' class='medium'  aria-describedby=\"gfield_description_1_26\" tabindex='39'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_26'>(full name, include middle initial)<\/div><\/li><li id=\"field_1_27\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_27'>Social Security Number<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_1_27' type='text' value='' class='medium'  aria-describedby=\"gfield_description_1_27\" tabindex='40'   aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_27'>optional<\/div><\/li><li id=\"field_1_28\" class=\"gfield gfield--type-select gfield--input-type-select gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_28'>Gender<\/label><div class='ginput_container ginput_container_select'><select name='input_28' id='input_1_28' class='medium gfield_select' tabindex='41'    aria-invalid=\"false\" ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><option value='Prefer Not to Answer' >Prefer Not to Answer<\/option><\/select><\/div><\/li><li id=\"field_1_29\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_29'>Phone no. (home)<\/label><div class='ginput_container ginput_container_phone'><input name='input_29' id='input_1_29' type='tel' value='' class='medium' tabindex='42'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_30\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_30'>Phone no. (other)<\/label><div class='ginput_container ginput_container_phone'><input name='input_30' id='input_1_30' type='tel' value='' class='medium' tabindex='43'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_31\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_31' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_31_1_container' >\n                                        <input type='text' name='input_31.1' id='input_1_31_1' value='' tabindex='44'   aria-required='true'    \/>\n                                        <label for='input_1_31_1' id='input_1_31_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_31_2_container' >\n                                        <input type='text' name='input_31.2' id='input_1_31_2' value='' tabindex='45'    aria-required='false'   \/>\n                                        <label for='input_1_31_2' id='input_1_31_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_31_3_container' >\n                                    <input type='text' name='input_31.3' id='input_1_31_3' value='' tabindex='46'   aria-required='true'    \/>\n                                    <label for='input_1_31_3' id='input_1_31_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_31_4_container' >\n                                        <input type='text' name='input_31.4' id='input_1_31_4' value='' tabindex='48'     aria-required='true'    \/>\n                                        <label for='input_1_31_4' id='input_1_31_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_31_5_container' >\n                                    <input type='text' name='input_31.5' id='input_1_31_5' value='' tabindex='49'   aria-required='true'    \/>\n                                    <label for='input_1_31_5' id='input_1_31_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_31.6' id='input_1_31_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_90\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_90'>Employer Name<\/label><div class='ginput_container ginput_container_text'><input name='input_90' id='input_1_90' type='text' value='' class='medium'   tabindex='50'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_33\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_33'>Employer Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_33' id='input_1_33' type='tel' value='' class='medium' tabindex='51'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_32\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Employer Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_32' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_32_1_container' >\n                                        <input type='text' name='input_32.1' id='input_1_32_1' value='' tabindex='52'   aria-required='false'    \/>\n                                        <label for='input_1_32_1' id='input_1_32_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_32_2_container' >\n                                        <input type='text' name='input_32.2' id='input_1_32_2' value='' tabindex='53'    aria-required='false'   \/>\n                                        <label for='input_1_32_2' id='input_1_32_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_32_3_container' >\n                                    <input type='text' name='input_32.3' id='input_1_32_3' value='' tabindex='54'   aria-required='false'    \/>\n                                    <label for='input_1_32_3' id='input_1_32_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_32_4_container' >\n                                        <input type='text' name='input_32.4' id='input_1_32_4' value='' tabindex='56'     aria-required='false'    \/>\n                                        <label for='input_1_32_4' id='input_1_32_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_32_5_container' >\n                                    <input type='text' name='input_32.5' id='input_1_32_5' value='' tabindex='57'   aria-required='false'    \/>\n                                    <label for='input_1_32_5' id='input_1_32_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_32.6' id='input_1_32_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_91\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_91'>Training Name<\/label><div class='ginput_container ginput_container_text'><input name='input_91' id='input_1_91' type='text' value='' class='medium'   tabindex='58'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_86\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_86'>Training Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_86' id='input_1_86' type='tel' value='' class='medium' tabindex='59'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_85\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Training Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_85' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_85_1_container' >\n                                        <input type='text' name='input_85.1' id='input_1_85_1' value='' tabindex='60'   aria-required='false'    \/>\n                                        <label for='input_1_85_1' id='input_1_85_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_85_2_container' >\n                                        <input type='text' name='input_85.2' id='input_1_85_2' value='' tabindex='61'    aria-required='false'   \/>\n                                        <label for='input_1_85_2' id='input_1_85_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_85_3_container' >\n                                    <input type='text' name='input_85.3' id='input_1_85_3' value='' tabindex='62'   aria-required='false'    \/>\n                                    <label for='input_1_85_3' id='input_1_85_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_85_4_container' >\n                                        <input type='text' name='input_85.4' id='input_1_85_4' value='' tabindex='64'     aria-required='false'    \/>\n                                        <label for='input_1_85_4' id='input_1_85_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_85_5_container' >\n                                    <input type='text' name='input_85.5' id='input_1_85_5' value='' tabindex='65'   aria-required='false'    \/>\n                                    <label for='input_1_85_5' id='input_1_85_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_85.6' id='input_1_85_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_34\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Days and working\/training hours<\/h4><\/li><li id=\"field_1_35\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_35'>Monday<\/label><div class='ginput_container ginput_container_number'><input name='input_35' id='input_1_35' type='number' step='any'   value='' class='small' tabindex='66'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_36\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_36'>Tuesday<\/label><div class='ginput_container ginput_container_number'><input name='input_36' id='input_1_36' type='number' step='any'   value='' class='small' tabindex='67'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_37\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_37'>Wednesday<\/label><div class='ginput_container ginput_container_number'><input name='input_37' id='input_1_37' type='number' step='any'   value='' class='small' tabindex='68'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_38\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_38'>Thursday<\/label><div class='ginput_container ginput_container_number'><input name='input_38' id='input_1_38' type='number' step='any'   value='' class='small' tabindex='69'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_39\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_39'>Friday<\/label><div class='ginput_container ginput_container_number'><input name='input_39' id='input_1_39' type='number' step='any'   value='' class='small' tabindex='70'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_40\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_40'>Monday - Friday<\/label><div class='ginput_container ginput_container_number'><input name='input_40' id='input_1_40' type='text' step='any' min='0' max='24' value='' class='small gform-text-input-reset' tabindex='71' readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_41\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_41'>Saturday<\/label><div class='ginput_container ginput_container_number'><input name='input_41' id='input_1_41' type='number' step='any'   value='' class='small' tabindex='72'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_42\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_42'>Sunday<\/label><div class='ginput_container ginput_container_number'><input name='input_42' id='input_1_42' type='number' step='any'   value='' class='small' tabindex='73'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_43\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_43'>Monday - Sunday<\/label><div class='ginput_container ginput_container_number'><input name='input_43' id='input_1_43' type='text' step='any' min='0' max='24' value='' class='small gform-text-input-reset' tabindex='74' readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_93' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous' tabindex='75' \/> <input type='button' id='gform_next_button_1_93' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='76' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-93' 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 validation_below'><li id=\"field_1_45\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Family Eligibility and Reason for Needing Service<\/h2>\n<h4>Family Eligibility Status (check all that apply):<\/h4><\/li><li id=\"field_1_47\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Employed?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_47'><li class='gchoice gchoice_1_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='Parent A'  id='choice_1_47_1' tabindex='77'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_47_1' id='label_1_47_1' class='gform-field-label gform-field-label--type-inline'>Parent A<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='Parent B'  id='choice_1_47_2' tabindex='78'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_47_2' id='label_1_47_2' class='gform-field-label gform-field-label--type-inline'>Parent B<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_47_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.3' type='checkbox'  value='Both'  id='choice_1_47_3' tabindex='79'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_47_3' id='label_1_47_3' class='gform-field-label gform-field-label--type-inline'>Both<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_48\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_48'>Monthly Gross: Parent A<\/label><div class='ginput_container ginput_container_number'><input name='input_48' id='input_1_48' type='text' step='any'   value='' class='medium' tabindex='80'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_49\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_49'>Monthly Gross: Parent B<\/label><div class='ginput_container ginput_container_number'><input name='input_49' id='input_1_49' type='text' step='any'   value='' class='medium' tabindex='81'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_51\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Cash Aide?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_51'><li class='gchoice gchoice_1_51_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.1' type='checkbox'  value='Parent A'  id='choice_1_51_1' tabindex='82'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_1' id='label_1_51_1' class='gform-field-label gform-field-label--type-inline'>Parent A<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.2' type='checkbox'  value='Parent B'  id='choice_1_51_2' tabindex='83'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_2' id='label_1_51_2' class='gform-field-label gform-field-label--type-inline'>Parent B<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.3' type='checkbox'  value='Both'  id='choice_1_51_3' tabindex='84'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_3' id='label_1_51_3' class='gform-field-label gform-field-label--type-inline'>Both<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_52\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Protective Services?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_52'><li class='gchoice gchoice_1_52_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.1' type='checkbox'  value='Parent A'  id='choice_1_52_1' tabindex='85'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_52_1' id='label_1_52_1' class='gform-field-label gform-field-label--type-inline'>Parent A<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_52_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.2' type='checkbox'  value='Parent B'  id='choice_1_52_2' tabindex='86'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_52_2' id='label_1_52_2' class='gform-field-label gform-field-label--type-inline'>Parent B<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_52_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.3' type='checkbox'  value='Both'  id='choice_1_52_3' tabindex='87'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_52_3' id='label_1_52_3' class='gform-field-label gform-field-label--type-inline'>Both<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_53\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Unemployment?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_53'><li class='gchoice gchoice_1_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' type='checkbox'  value='Parent A'  id='choice_1_53_1' tabindex='88'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_53_1' id='label_1_53_1' class='gform-field-label gform-field-label--type-inline'>Parent A<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_53_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.2' type='checkbox'  value='Parent B'  id='choice_1_53_2' tabindex='89'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_53_2' id='label_1_53_2' class='gform-field-label gform-field-label--type-inline'>Parent B<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_53_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.3' type='checkbox'  value='Both'  id='choice_1_53_3' tabindex='90'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_53_3' id='label_1_53_3' class='gform-field-label gform-field-label--type-inline'>Both<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_54\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label gfield_label_before_complex' >Social Security?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_54'><li class='gchoice gchoice_1_54_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.1' type='checkbox'  value='Parent A'  id='choice_1_54_1' tabindex='91'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_54_1' id='label_1_54_1' class='gform-field-label gform-field-label--type-inline'>Parent A<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_54_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.2' type='checkbox'  value='Parent B'  id='choice_1_54_2' tabindex='92'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_54_2' id='label_1_54_2' class='gform-field-label gform-field-label--type-inline'>Parent B<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_54_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.3' type='checkbox'  value='Both'  id='choice_1_54_3' tabindex='93'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_54_3' id='label_1_54_3' class='gform-field-label gform-field-label--type-inline'>Both<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_55\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_55'>Other<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_1_55' type='text' value='' class='medium'   tabindex='94'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_56\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Reason for Needing Service (check all that apply):<br>\n(full day enrollment only)<\/h4><\/li><li id=\"field_1_57\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Working?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_57'><li class='gchoice gchoice_1_57_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.1' type='checkbox'  value='Parent A'  id='choice_1_57_1' tabindex='95'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_57_1' id='label_1_57_1' class='gform-field-label gform-field-label--type-inline'>Parent A<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_57_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.2' type='checkbox'  value='Parent B'  id='choice_1_57_2' tabindex='96'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_57_2' id='label_1_57_2' class='gform-field-label gform-field-label--type-inline'>Parent B<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_57_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.3' type='checkbox'  value='Both'  id='choice_1_57_3' tabindex='97'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_57_3' id='label_1_57_3' class='gform-field-label gform-field-label--type-inline'>Both<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_58\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Education or Training?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_58'><li class='gchoice gchoice_1_58_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.1' type='checkbox'  value='Parent A'  id='choice_1_58_1' tabindex='98'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_1' id='label_1_58_1' class='gform-field-label gform-field-label--type-inline'>Parent A<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_58_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.2' type='checkbox'  value='Parent B'  id='choice_1_58_2' tabindex='99'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_2' id='label_1_58_2' class='gform-field-label gform-field-label--type-inline'>Parent B<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_58_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.3' type='checkbox'  value='Both'  id='choice_1_58_3' tabindex='100'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_3' id='label_1_58_3' class='gform-field-label gform-field-label--type-inline'>Both<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_59\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Parent\/caretaker incapacitated because of medical or psychiatric special needs?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_59'><li class='gchoice gchoice_1_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='Parent A'  id='choice_1_59_1' tabindex='101'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_59_1' id='label_1_59_1' class='gform-field-label gform-field-label--type-inline'>Parent A<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_59_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.2' type='checkbox'  value='Parent B'  id='choice_1_59_2' tabindex='102'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_59_2' id='label_1_59_2' class='gform-field-label gform-field-label--type-inline'>Parent B<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_59_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.3' type='checkbox'  value='Both'  id='choice_1_59_3' tabindex='103'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_59_3' id='label_1_59_3' class='gform-field-label gform-field-label--type-inline'>Both<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_60\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Actively seeking employment?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_60'><li class='gchoice gchoice_1_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='Parent A'  id='choice_1_60_1' tabindex='104'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_60_1' id='label_1_60_1' class='gform-field-label gform-field-label--type-inline'>Parent A<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_60_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.2' type='checkbox'  value='Parent B'  id='choice_1_60_2' tabindex='105'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_60_2' id='label_1_60_2' class='gform-field-label gform-field-label--type-inline'>Parent B<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_60_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.3' type='checkbox'  value='Both'  id='choice_1_60_3' tabindex='106'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_60_3' id='label_1_60_3' class='gform-field-label gform-field-label--type-inline'>Both<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_61\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Seeking permanent housing?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_61'><li class='gchoice gchoice_1_61_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.1' type='checkbox'  value='Parent A'  id='choice_1_61_1' tabindex='107'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_61_1' id='label_1_61_1' class='gform-field-label gform-field-label--type-inline'>Parent A<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_61_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.2' type='checkbox'  value='Parent B'  id='choice_1_61_2' tabindex='108'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_61_2' id='label_1_61_2' class='gform-field-label gform-field-label--type-inline'>Parent B<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_61_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.3' type='checkbox'  value='Both'  id='choice_1_61_3' tabindex='109'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_61_3' id='label_1_61_3' class='gform-field-label gform-field-label--type-inline'>Both<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_62\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Child Protective Services?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_62'><li class='gchoice gchoice_1_62_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.1' type='checkbox'  value='Yes'  id='choice_1_62_1' tabindex='110'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_62_1' id='label_1_62_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_62_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.2' type='checkbox'  value='No'  id='choice_1_62_2' tabindex='111'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_62_2' id='label_1_62_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_63\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Family Adjusted Gross Monthly Income and Size<\/h4><\/li><li id=\"field_1_64\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_64'>Family monthly income<\/label><div class='ginput_container ginput_container_number'><input name='input_64' id='input_1_64' type='text' step='any'   value='' class='medium' tabindex='112'     aria-invalid=\"false\" aria-describedby=\"gfield_description_1_64\" \/><\/div><div class='gfield_description' id='gfield_description_1_64'>The family's adjusted monthly income from all sources<\/div><\/li><li id=\"field_1_65\" class=\"gfield gfield--type-select gfield--input-type-select gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_65'>How many total are in the family size<\/label><div class='ginput_container ginput_container_select'><select name='input_65' id='input_1_65' class='medium gfield_select' tabindex='113'    aria-invalid=\"false\" ><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 or more' >10 or more<\/option><\/select><\/div><\/li><li id=\"field_1_66\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Are you self-employed?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_66'><li class='gchoice gchoice_1_66_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.1' type='checkbox'  value='Yes'  id='choice_1_66_1' tabindex='114'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_66_1' id='label_1_66_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_66_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.2' type='checkbox'  value='No'  id='choice_1_66_2' tabindex='115'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_66_2' id='label_1_66_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_67\" class=\"gfield gfield--type-text gfield--input-type-text gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_67'>Name of Business<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_1_67' type='text' value='' class='medium'   tabindex='116'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_68\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Do you receive child support?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_68'><li class='gchoice gchoice_1_68_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.1' type='checkbox'  value='Yes'  id='choice_1_68_1' tabindex='117'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_68_1' id='label_1_68_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_68_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.2' type='checkbox'  value='No'  id='choice_1_68_2' tabindex='118'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_68_2' id='label_1_68_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_69\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_69'>Amount<\/label><div class='ginput_container ginput_container_number'><input name='input_69' id='input_1_69' type='text' step='any'   value='' class='medium' tabindex='119'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_70\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Do you pay child support?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_70'><li class='gchoice gchoice_1_70_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.1' type='checkbox'  value='Yes'  id='choice_1_70_1' tabindex='120'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_70_1' id='label_1_70_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_70_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.2' type='checkbox'  value='No'  id='choice_1_70_2' tabindex='121'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_70_2' id='label_1_70_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_71\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_71'>Amount<\/label><div class='ginput_container ginput_container_number'><input name='input_71' id='input_1_71' type='text' step='any'   value='' class='medium' tabindex='122'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_72\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Do you receive cash aid?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_72'><li class='gchoice gchoice_1_72_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.1' type='checkbox'  value='Yes'  id='choice_1_72_1' tabindex='123'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_72_1' id='label_1_72_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_72_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.2' type='checkbox'  value='No'  id='choice_1_72_2' tabindex='124'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_72_2' id='label_1_72_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_73\" class=\"gfield gfield--type-number gfield--input-type-number gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_73'>Amount<\/label><div class='ginput_container ginput_container_number'><input name='input_73' id='input_1_73' type='text' step='any'   value='' class='medium' tabindex='125'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_74\" class=\"gfield gfield--type-list gfield--input-type-list gf_list_inline field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Data on Children<\/label><style type=\"text\/css\">\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons {\n\t\t\t\t\t\t\tvertical-align: middle !important;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons img {\n\t\t\t\t\t\t\tbackground-color: transparent !important;\n\t\t\t\t\t\t\tbackground-position: 0 0;\n\t\t\t\t\t\t\tbackground-size: 16px 16px !important;\n\t\t\t\t\t\t\tbackground-repeat: no-repeat;\n\t\t\t\t\t\t\tborder: none !important;\n\t\t\t\t\t\t\twidth: 16px !important;\n\t\t\t\t\t\t\theight: 16px !important;\n\t\t\t\t\t\t\topacity: 0.5;\n\t\t\t\t\t\t\ttransition: opacity .5s ease-out;\n\t\t\t\t\t\t    -moz-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -webkit-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -o-transition: opacity .5s ease-out;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons a:hover img {\n\t\t\t\t\t\t\topacity: 1.0;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\t<\/style><div class='ginput_container ginput_container_list ginput_list'><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_74_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_74_col_2' class='gfield_list_col_even' \/><col id='gfield_list_74_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_74_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th scope=\"col\">Full Name of Child Including Middle Initial<\/th><th scope=\"col\">Gender (Male or Female)<\/th><th scope=\"col\">Birth Date (MM\/DD\/YYYY)<\/th><td>&nbsp;<\/td><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_74_cell1' data-label='Full Name of Child Including Middle Initial'><input aria-invalid='false'  aria-describedby=\"gfield_description_1_74\" aria-label='Full Name of Child Including Middle Initial, Row 1' data-aria-label-template='Full Name of Child Including Middle Initial, Row {0}' type='text' name='input_74[]' value='' tabindex='126'  \/><\/td><td class='gfield_list_cell gfield_list_74_cell2' data-label='Gender (Male or Female)'><input aria-invalid='false'  aria-describedby=\"gfield_description_1_74\" aria-label='Gender (Male or Female), Row 1' data-aria-label-template='Gender (Male or Female), Row {0}' type='text' name='input_74[]' value='' tabindex='127'  \/><\/td><td class='gfield_list_cell gfield_list_74_cell3' data-label='Birth Date (MM\/DD\/YYYY)'><input aria-invalid='false'  aria-describedby=\"gfield_description_1_74\" aria-label='Birth Date (MM\/DD\/YYYY), Row 1' data-aria-label-template='Birth Date (MM\/DD\/YYYY), Row {0}' type='text' name='input_74[]' value='' tabindex='128'  \/><\/td><td class='gfield_list_icons'>   <a href='javascript:void(0);' class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)'><img src='https:\/\/kern.org\/early-childhood-education\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' alt='' title='Add a new row' \/><\/a>   <a href='javascript:void(0);' class='delete_list_item' aria-label='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\"><img src='https:\/\/kern.org\/early-childhood-education\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' alt='' title='Remove this row' \/><\/a><\/td><\/tr><\/tbody><\/table><\/div><div class='gfield_description' id='gfield_description_1_74'>List all children residing in the home and counted in the family size. Complete for all children residing in the home.<\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_94' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous' tabindex='129' \/> <input type='button' id='gform_next_button_1_94' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='130' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-94' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_75\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Certification and Signature of Parent\/Caretaker<\/h2>\n<p>1. I understand that I am self-certifying single parent status under penalty of perjury in Section 1 of this document when the single parent\/caretaker box has been checked.<\/p><\/li><li id=\"field_1_76\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_76'>Parent Initials<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_1_76' type='text' value='' class='small'   tabindex='131'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_77\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>2. I will notify the agency within 5 calendar days of any change in my family income, family size, or reason for needing child development services.<\/p>\n<p>3. I understand that the information about my eligibility may be reviewed by representatives of the State of California, the federal government, independent auditors, or others as necessary for the administration of\nthe program.<\/p>\n<p>4. I understand that if the agency denies this application for services, I have the right to appeal.<\/p>\n<p>5. I understand that I must renew my eligibility at least once a year or 3 months for at-risk. I further understand that if I do not renew my eligibility, I will no longer be eligible for subsidized child care services for my child.<\/p>\n<p>6. I understand that I will receive a notice of approval or disapproval of my application within 30 days from the date I sign this form.<\/p>\n<p>7. I understand that this certification is not complete until all documentation is submitted and this form has been reviewed, signed, and dated by an agency representative and signed and dated by me.<\/p>\n<p>8. I certify that my family assets do not exceed $1,000,000; Child Care and Development Block Grant Act Section 658 P (4)(B).<\/p>\n<h4>I declare under penalty of perjury that the above information is true and correct to the best of my knowledge.<\/h4><\/li><li id=\"field_1_78\" class=\"gfield gfield--type-text gfield--input-type-text gf_inline gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_78'>Signature Parent A<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_1_78' type='text' value='' class='medium'  aria-describedby=\"gfield_description_1_78\" tabindex='132'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_78'>(Please print and sign)<\/div><\/li><li id=\"field_1_79\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_79'>Signature Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_79' id='input_1_79' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' tabindex='133'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_79_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_79_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_79' class='gform_hidden' value='https:\/\/kern.org\/early-childhood-education\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_82\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><\/li><li id=\"field_1_80\" class=\"gfield gfield--type-text gfield--input-type-text gf_inline gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_80'>Signature Parent B<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_1_80' type='text' value='' class='medium'  aria-describedby=\"gfield_description_1_80\" tabindex='134'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_80'>(Please print and sign)<\/div><\/li><li id=\"field_1_81\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_81'>Signature Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_81' 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