{"id":246,"date":"2020-12-17T13:33:42","date_gmt":"2020-12-17T13:33:42","guid":{"rendered":"http:\/\/startsmartmodoc.t29dev.com\/?page_id=246"},"modified":"2023-11-13T12:43:22","modified_gmt":"2023-11-13T20:43:22","slug":"get-started","status":"publish","type":"page","link":"https:\/\/wizard.first5mendocino.org\/espanol\/get-started\/","title":{"rendered":"Empezar"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"246\" class=\"elementor elementor-246\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-6af4e14 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"6af4e14\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\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-50 elementor-top-column elementor-element elementor-element-1d444a4\" data-id=\"1d444a4\" 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-6315d42 elementor-widget elementor-widget-breadcrumbs\" data-id=\"6315d42\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"breadcrumbs.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<p id=\"breadcrumbs\"><span><span><a href=\"https:\/\/wizard.first5mendocino.org\/\">Home<\/a><\/span><\/span><\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6c75848 eael-gravity-form-button-custom elementor-widget elementor-widget-eael-gravity-form\" data-id=\"6c75848\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"eael-gravity-form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t<div class=\"eael-contact-form eael-gravity-form eael-contact-form-align-default\">\n\t\t        <script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_2' style='display:none'><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/espanol\/wp-json\/wp\/v2\/pages\/246#gf_2' data-formid='2' novalidate><input id=\"gpnf_session_hash_2\" type=\"hidden\" name=\"gpnf_session_hash\" value=\"87ca24a0022b\">\n                        <div class='gform-body gform_body'><div id='gform_page_2_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_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_2_2\" class=\"gfield gfield--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\"  ><h1>Tell us about yourself<\/h1><\/li><li id=\"field_2_34\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>A service provider assisted me to enter this information with my permission.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_34'>\n\t\t\t<li class='gchoice gchoice_2_34_0'>\n\t\t\t\t<input name='input_34' type='radio' value='Yes'  id='choice_2_34_0'    \/>\n\t\t\t\t<label for='choice_2_34_0' id='label_2_34_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_34_1'>\n\t\t\t\t<input name='input_34' type='radio' value='No'  id='choice_2_34_1'    \/>\n\t\t\t\t<label for='choice_2_34_1' id='label_2_34_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_48\" class=\"gfield gfield--type-text gfield--width-full 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_2_48'><span class='gform-field-label__text'>Service Provider Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_2_48' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_49\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield--width-full 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_2_49'><span class='gform-field-label__text'>Service Provider Phone Number<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_49' id='input_2_49' type='tel' value='' class='large'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_2_50\" class=\"gfield gfield--type-email gfield--width-full 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_2_50'><span class='gform-field-label__text'>Service Provider Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_50' id='input_2_50' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_41\" class=\"gfield gfield--type-select gfield--width-full 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_2_41'><span class='gform-field-label__text'>I am a resident of Mendocino County<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_41' id='input_2_41' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Yes' selected='selected'>Yes<\/option><\/select><\/div><\/li><li id=\"field_2_1\" class=\"gfield gfield--type-name field_sublabel_above gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_1'>\n                            \n                            <span id='input_2_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_2_1_3' class='gform-field-label gform-field-label--type-sub '>First Name<\/label>\n                                                    <input type='text' name='input_1.3' id='input_2_1_3' value=''   aria-required='false'   placeholder='First Name'  \/>\n                                                <\/span>\n                            \n                            <span id='input_2_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_2_1_6' class='gform-field-label gform-field-label--type-sub '>Last Name<\/label>\n                                                            <input type='text' name='input_1.6' id='input_2_1_6' value=''   aria-required='false'   placeholder='Last Name'  \/>\n                                                        <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_45\" class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_45'><span class='gform-field-label__text'>Date of Birth<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_45' id='input_2_45' class='large gfield_select'     aria-invalid=\"false\" ><option value='over' >I am over 18 years of age<\/option><option value='under' >I am under 18 years of age<\/option><\/select><\/div><\/li><li id=\"field_2_4\" class=\"gfield gfield--type-phone gfield--phone-format-standard gf_left_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_2_4'><span class='gform-field-label__text'>Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_2_4' type='tel' value='' class='medium'  placeholder='Phone'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_2_5\" class=\"gfield gfield--type-email 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_2_5'><span class='gform-field-label__text'>Email<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_2_5' type='email' value='' class='medium'   placeholder='Email'  aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_46\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Contact Preferences<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_46'><li class='gchoice gchoice_2_46_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.1' type='checkbox'  value='Okay to Call'  id='choice_2_46_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_46_1' id='label_2_46_1' class='gform-field-label gform-field-label--type-inline'>Okay to Call<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_46_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.2' type='checkbox'  value='Okay to Text'  id='choice_2_46_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_46_2' id='label_2_46_2' class='gform-field-label gform-field-label--type-inline'>Okay to Text<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_32\" class=\"gfield gfield--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_2_32'><span class='gform-field-label__text'>ZIP Code<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_32' id='input_2_32' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='95410' >95410 Albion<\/option><option value='95415' >95415 Boonville<\/option><option value='95417' >95417 Branscomb<\/option><option value='95418' >95418 Calpella<\/option><option value='95420' >95420 Caspar<\/option><option value='95427' >95427 Comptche<\/option><option value='95428' >95428 Covelo<\/option><option value='95429' >95429 Dos Rios<\/option><option value='95432' >95432 Elk<\/option><option value='95437' >95437 Fort Bragg<\/option><option value='95445' >95445 Gualala<\/option><option value='95449' >95449 Hopland<\/option><option value='95454' >95454 Laytonville<\/option><option value='95456' >95456 Little River<\/option><option value='95459' >95459 Manchester<\/option><option value='95460' >95460 Mendocino<\/option><option value='95463' >95463 Navarro<\/option><option value='95466' >95466 Philo<\/option><option value='95468' >95468 Point Arena<\/option><option value='95469' >95469 Potter Valley<\/option><option value='95470' >95470 Redwood Valley<\/option><option value='95481' >95481 Talmage<\/option><option value='95482' >95482 Ukiah<\/option><option value='95488' >95488 Westport<\/option><option value='95490' >95490 Willits<\/option><option value='95494' >95494 Yorkville<\/option><option value='95585' >95585 Leggett<\/option><option value='95587' >95587 Piercy<\/option><\/select><\/div><\/li><li id=\"field_2_15\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_15'><span class='gform-field-label__text'>Race \/ Ethnicity<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_15' id='input_2_15' class='medium gfield_select'     aria-invalid=\"false\" ><option value='American Indian\/Alaskan Native' >American Indian\/Alaskan Native<\/option><option value='Asian' >Asian<\/option><option value='Black\/African American' >Black\/African American<\/option><option value='Native Hawaiian\/Other Pacific Islander' >Native Hawaiian\/Other Pacific Islander<\/option><option value='White' >White<\/option><option value='Hispanic\/Latino' >Hispanic\/Latino<\/option><option value='Multiple Races' >Multiple Races<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_2_16\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_16'><span class='gform-field-label__text'>Language Preference<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_2_16' class='medium gfield_select'     aria-invalid=\"false\" ><option value='english' >English<\/option><option value='spanish' >Spanish<\/option><option value='other' >Other<\/option><\/select><\/div><\/li><li id=\"field_2_17\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_17'><span class='gform-field-label__text'>Gender<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_17' id='input_2_17' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Female' >Female<\/option><option value='Male' >Male<\/option><option value='Non-Binary' >Non-Binary<\/option><option value='Trans' >Trans<\/option><option value='Other or Not Disclosed' >Other or Not Disclosed<\/option><\/select><\/div><\/li><li id=\"field_2_18\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Disability Status<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_18'><li class='gchoice gchoice_2_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='disabled'  id='choice_2_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_18_1' id='label_2_18_1' class='gform-field-label gform-field-label--type-inline'>I am disabled<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_47\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Single Parent Household<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_47'><li class='gchoice gchoice_2_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='Yes'  id='choice_2_47_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_47_1' id='label_2_47_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_19\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_19'><span class='gform-field-label__text'>Number of People Living in Household<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_2_19' class='medium gfield_select'     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><\/select><\/div><\/li><li id=\"field_2_20\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Are you or your partner pregnant?<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_20'><li class='gchoice gchoice_2_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='pregnant'  id='choice_2_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_20_1' id='label_2_20_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_21\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_21'><span class='gform-field-label__text'>Due Date<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_2_21'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_21'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_2_21' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_2_21' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_2_21' aria-label='Due Date: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/li><li id=\"field_2_22\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Are You Experiencing a High Risk Pregnancy?<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_22'><li class='gchoice gchoice_2_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='high_risk_pregnancy'  id='choice_2_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_1' id='label_2_22_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_23\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Do you need to travel outside Mendocino County for medical appointments related to pregnancy?<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_23'><li class='gchoice gchoice_2_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='travel_outside_county_for_pregnancy_appts'  id='choice_2_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_1' id='label_2_23_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_24\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_24'><span class='gform-field-label__text'>Employment Status<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_24' id='input_2_24' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Unemployed Seeking Employment' >Unemployed Seeking Employment<\/option><option value='Unemployed Not Seeking Employment' >Unemployed Not Seeking Employment<\/option><option value='Student' >Student<\/option><option value='Employed Full-Time' >Employed Full-Time<\/option><option value='Employed Part-Time' >Employed Part-Time<\/option><option value='Self-Employed' >Self-Employed<\/option><\/select><\/div><\/li><li id=\"field_2_25\" class=\"gfield gfield--type-select field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_25'><span class='gform-field-label__text'>Monthly Household Income Before Taxes<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_25' id='input_2_25' class='medium gfield_select'  aria-describedby=\"gfield_description_2_25\"   aria-invalid=\"false\" ><option value='$0 - $1,437' >$0 - $1,437<\/option><option value='$1,438 - $1,810' >$1,438 - $1,810<\/option><option value='$1,811 - $2,183' >$1,811 - $2,183<\/option><option value='$2,184 - $2,557' >$2,184 - $2,557<\/option><option value='$2,558 - $2,930' >$2,558 - $2,930<\/option><option value='$2,931 - $3,303' >$2,931 - $3,303<\/option><option value='$3,304 - $3,677' >$3,304 - $3,677<\/option><option value='$3,678 - $4,040' >$3,678 - $4,040<\/option><option value='$4,041 - $4,730+' >$4,041 - $4,730+<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_2_25'>*Best Guess<\/div><\/li><li id=\"field_2_26\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_26'><span class='gform-field-label__text'>Housing Status<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_2_26' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Own home' >Own home<\/option><option value='Renting a house \/ apartment \/ room' >Renting a house \/ apartment \/ room<\/option><option value='Living with friend \/ family temporarily' >Living with friend \/ family temporarily<\/option><option value='Living in a hotel \/ motel' >Living in a hotel \/ motel<\/option><option value='Living in car \/ park \/ campground \/ public space' >Living in car \/ park \/ campground \/ public space<\/option><\/select><\/div><\/li><li id=\"field_2_27\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Check all that apply<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_27'><li class='gchoice gchoice_2_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='medi_cal'  id='choice_2_27_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_1' id='label_2_27_1' class='gform-field-label gform-field-label--type-inline'>I have Medi-Cal<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='receive_tanf_or_calworks'  id='choice_2_27_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_2' id='label_2_27_2' class='gform-field-label gform-field-label--type-inline'>I have TANF or CalWorks<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_27_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.3' type='checkbox'  value='receive_calfresh_or_foodstamps'  id='choice_2_27_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_3' id='label_2_27_3' class='gform-field-label gform-field-label--type-inline'>I recieve Calfresh\/Food Stamps<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_27_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.4' type='checkbox'  value='quitting_tobacco_nicotine_info'  id='choice_2_27_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_4' id='label_2_27_4' class='gform-field-label gform-field-label--type-inline'>I want information about quitting tobacco\/nicotine<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_27_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.5' type='checkbox'  value='concered_second_hand_smoke'  id='choice_2_27_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_5' id='label_2_27_5' class='gform-field-label gform-field-label--type-inline'>I am concerned about health effects of second hand smoke, third hand smoke or vaping<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_31\" class=\"gfield gfield--type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_31' id='input_2_31' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='b436e93a99158f4c97f9dd16' \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <button type='button' id='gform_next_button_2_8' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_2' class='gform_page' data-js='page-field-id-8' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_2_9\" class=\"gfield gfield--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>Dependents <span style=\"font-size: 30px;\">- Including Current Pregnancies<\/span><\/h2><\/li><li id=\"field_2_10\" class=\"gfield gfield--type-form gform-theme__no-reset--children field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_10'><span class='gform-field-label__text'>Dependents<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-1\">\n\t\t\t\t\tName\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f1.label, attr: { 'data-value': f1.label }\"\n\t\t\t\t\tdata-heading=\"Name\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Dependent {0} where Name is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Edit<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Dependent {0} where Name is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Delete<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"3\">\n\t\t\t\tThere are no <span>Entries.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"2\"\n\t\t        data-nestedformid=\"3\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAdd Dependent\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tMaximum number of entries reached.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_10\"\n                id=\"input_2_10\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/li><li id=\"field_2_51\" class=\"gfield gfield--type-captcha gfield--captcha-invisible gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div id='input_2_51' class='ginput_container ginput_recaptcha' data-sitekey='6LcNmf8oAAAAANngDCRxXAuGCDMypYTWlvPBYpt_'  data-theme='light' data-tabindex='-1' data-size='invisible' data-badge='bottomright'><\/div><\/li><\/ul><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><button type='submit' id='gform_previous_button_2' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Back<\/button> <button type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_2' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_2' id='gform_theme_2' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_2' id='gform_style_settings_2' value='' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='ARJ6DCv5KDkFP40RGevwTEOVNoiWn3dVIvfStyhU4Oc\/mrrpmvZJQrvzDvUyy3FR8b1gQdKPOnOej7tKCDcPTLfB3wTSjmxitCvfSXYQCL7JqrQ=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_2' 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  <\/div><\/div>\n                        <\/form>\n                        <\/div>\t\t\t<\/div>\n\n            <script type=\"text\/javascript\">\n                var gf_global = {\"gf_currency_config\":{\"name\":\"U.S. Dollar\",\"symbol_left\":\"$\",\"symbol_right\":\"\",\"symbol_padding\":\"\",\"thousand_separator\":\",\",\"decimal_separator\":\".\",\"decimals\":2,\"code\":\"USD\"},\"base_url\":\"https:\\\/\\\/wizard.first5mendocino.org\\\/wp-content\\\/plugins\\\/gravityforms\",\"number_formats\":[],\"version_hash\":\"c4d28fb39fae534128946d4253b67b2b\",\"countries\":{\"AF\":\"Afghanistan\",\"AX\":\"\\u00c5land Islands\",\"AL\":\"Albania\",\"DZ\":\"Algeria\",\"AS\":\"American Samoa\",\"AD\":\"Andorra\",\"AO\":\"Angola\",\"AI\":\"Anguilla\",\"AQ\":\"Antarctica\",\"AG\":\"Antigua and Barbuda\",\"AR\":\"Argentina\",\"AM\":\"Armenia\",\"AW\":\"Aruba\",\"AU\":\"Australia\",\"AT\":\"Austria\",\"AZ\":\"Azerbaijan\",\"BS\":\"Bahamas\",\"BH\":\"Bahrain\",\"BD\":\"Bangladesh\",\"BB\":\"Barbados\",\"BY\":\"Belarus\",\"BE\":\"Belgium\",\"BZ\":\"Belize\",\"BJ\":\"Benin\",\"BM\":\"Bermuda\",\"BT\":\"Bhutan\",\"BO\":\"Bolivia\",\"BQ\":\"Bonaire, Sint Eustatius and Saba\",\"BA\":\"Bosnia and Herzegovina\",\"BW\":\"Botswana\",\"BV\":\"Bouvet Island\",\"BR\":\"Brazil\",\"IO\":\"British Indian Ocean Territory\",\"BN\":\"Brunei Darussalam\",\"BG\":\"Bulgaria\",\"BF\":\"Burkina Faso\",\"BI\":\"Burundi\",\"CV\":\"Cabo Verde\",\"KH\":\"Cambodia\",\"CM\":\"Cameroon\",\"CA\":\"Canada\",\"KY\":\"Cayman Islands\",\"CF\":\"Central African Republic\",\"TD\":\"Chad\",\"CL\":\"Chile\",\"CN\":\"China\",\"CX\":\"Christmas Island\",\"CC\":\"Cocos Islands\",\"CO\":\"Colombia\",\"KM\":\"Comoros\",\"CD\":\"Congo, Democratic Republic of the\",\"CG\":\"Congo\",\"CK\":\"Cook Islands\",\"CR\":\"Costa 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