Online Inquiry
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<ul class="er_fld_row"><li class="er_fld_type_section er_fld_selected" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Online Inquiry Form</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_Name_First_A"> <i class="fa fa-font"></i><label class="er_fld_label required">First Name</label><input name="CST_1" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Middle Name</label><input name="CST_2" type="text" class="er_fld_width100 er_fld_blank"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_Name_Last_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name</label><input name="CST_3" type="text" class="er_fld_required"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 20%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Marital Status</label><select name="CST_20"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Single/Never Married">Single/Never Married</option><option value="Long Term Relationship">Long Term Relationship</option><option value="Cohabitating">Cohabitating</option><option value="Married">Married</option><option value="Separated">Separated</option><option value="Divorced">Divorced</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Address_Street_1"> <i class="fa fa-font"></i><label class="er_fld_label required">Address Line 1</label><input name="CST_4" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Address_Street_2"> <i class="fa fa-font"></i><label class="er_fld_label required">Address Line 2</label><input name="CST_5" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_Address_City"> <i class="fa fa-font"></i><label class="er_fld_label required">City</label><input name="CST_6" type="text" class="er_fld_required"></li><li class="er_fld_type_dropdown" draggable="false" map_to="FH_Address_State" style="width: 20%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">State</label><select name="CST_9" class="er_fld_required"><option value="Alabama">Alabama</option><option value="Alaska">Alaska</option><option value="Arizona">Arizona</option><option value="Arkansas">Arkansas</option><option value="California">California</option><option value="Colorado">Colorado</option><option value="Connecticut">Connecticut</option><option value="Delaware">Delaware</option><option value="Florida">Florida</option><option value="Georgia">Georgia</option><option value="Hawaii">Hawaii</option><option value="Idaho">Idaho</option><option value="IllinoisIndiana">IllinoisIndiana</option><option value="Iowa">Iowa</option><option value="Kansas">Kansas</option><option value="Kentucky">Kentucky</option><option value="Louisiana">Louisiana</option><option value="Maine">Maine</option><option value="Maryland">Maryland</option><option value="Massachusetts">Massachusetts</option><option value="Michigan">Michigan</option><option value="Minnesota">Minnesota</option><option value="Mississippi">Mississippi</option><option value="Missouri">Missouri</option><option value="MontanaNebraska">MontanaNebraska</option><option value="Nevada">Nevada</option><option value="New Hampshire">New Hampshire</option><option value="New Jersey">New Jersey</option><option value="New Mexico">New Mexico</option><option value="New York">New York</option><option value="North Carolina">North Carolina</option><option value="North Dakota">North Dakota</option><option value="Ohio">Ohio</option><option value="Oklahoma">Oklahoma</option><option value="Oregon">Oregon</option><option value="PennsylvaniaRhode Island">PennsylvaniaRhode Island</option><option value="South Carolina">South Carolina</option><option value="South Dakota">South Dakota</option><option value="Tennessee">Tennessee</option><option value="Texas">Texas</option><option value="Utah">Utah</option><option value="Vermont">Vermont</option><option value="Virginia" selected="">Virginia</option><option value="Washington">Washington</option><option value="West Virginia">West Virginia</option><option value="Wisconsin">Wisconsin</option><option value="Wyoming">Wyoming</option></select></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label required">County</label><input name="CST_7" type="text" class="er_fld_required" value=""></li><li class="er_fld_type_number" draggable="false" style="width: 20%;" map_to="FH_Address_Zip"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Zip Code</label><input name="CST_8" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 100%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Please list names and ages of all individuals residing in the home</label><textarea name="CST_19" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Preferred method of contact</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_10" value="Email" checked="">Email</label><label class="er_option"><input class="type_radio" type="radio" name="CST_10" value="Cell Phone">Cell Phone</label><label class="er_option"><input class="type_radio" type="radio" name="CST_10" value="Work Phone">Work Phone</label><label class="er_option"><input class="type_radio" type="radio" name="CST_10" value="Mail">Mail</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_10" value="Other:">Other:<input class="cst_Other" name="CST_10_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Best time to reach you?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_16" value="Morning">Morning</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_16" value="Afternoon">Afternoon</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_16" value="Early evening">Early evening</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_16" value="Weekends">Weekends</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_16" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_16_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_number" draggable="false" map_to="FH_Phone_Home" style="width: 33.3333%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Best number to reach you:</label><input name="CST_11" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_EMail"> <i class="fa fa-font"></i><label class="er_fld_label required">Primary email address</label><input name="CST_12" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" map_to="FH_Inquiry_Why_Parents" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Why are you interested in Foster Care?</label><textarea name="CST_14" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Please describe any experience you have had with foster or respite care?</label><textarea name="CST_17" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Please describe any experience you have had working with children who have had unique needs. </label><textarea name="CST_18" style="width:100%;"></textarea></li></ul><ul id="er_row_last" class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" map_to="FH_ReferralSource"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Who referred you?</label><select name="CST_21" class="er_fld_desc er_fld_required"><option value="Internet Search" selected="">Internet Search</option><option value="Friend">Friend</option><option value="Pastor">Pastor</option><option value="Social Media">Social Media</option><option value="Community Event">Community Event</option><option value="Foster Care Agency">Foster Care Agency</option></select></li></ul>
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