Online Inquiry
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<ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 33.333333333333336%;"><i class="fa fa-header"></i><label>Applicant/Parent 1</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" 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" value="" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Name_Last_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name</label><input name="CST_2" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 100%;"><i class="fa fa-header"></i><label>Applicant/Parent 2 (Optional)</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Name_First_B"> <i class="fa fa-font"></i><label class="er_fld_label">First Name</label><input name="CST_14" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Name_Last_B"> <i class="fa fa-font"></i><label class="er_fld_label">Last Name</label><input name="CST_13" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Address_Street_1"> <i class="fa fa-font"></i><label class="er_fld_label required">Address Line 1 (Street Address)</label><input name="CST_3" type="text" value="" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Address_Street_2"> <i class="fa fa-font"></i><label class="er_fld_label">Address Line 2 (Apt., Ste, Unit Number)</label><input name="CST_4" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;" map_to="FH_Address_City"> <i class="fa fa-font"></i><label class="er_fld_label required">City </label><input name="CST_5" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;" map_to="FH_Address_State"> <i class="fa fa-font"></i><label class="er_fld_label required">State </label><input name="CST_6" type="text" class="er_fld_required" value="Ohio"></li><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;" map_to="FH_Address_Zip"> <i class="fa fa-font"></i><label class="er_fld_label required">Zip Code </label><input name="CST_7" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">What is your preferred method of Contact?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_8" value="Email ">Email </label><label class="er_option"><input class="type_radio" type="radio" name="CST_8" value="Phone ">Phone </label><label class="er_option"><input class="type_radio" type="radio" name="CST_8" 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_8" value="Other:">Other:<input class="cst_Other" name="CST_8_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;" map_to="FH_EMail"> <i class="fa fa-font"></i><label class="er_fld_label required">Primary Email Address</label><input name="CST_9" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;" map_to="FH_Phone_Mobile"> <i class="fa fa-font"></i><label class="er_fld_label required">Primary Phone Number</label><input name="CST_10" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_selected" style="white-space: normal; width: 100%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Are you interested in?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_15" value="Foster Care Only">Foster Care Only</label><label class="er_option"><input class="type_radio" type="radio" name="CST_15" value="Adoption Only">Adoption Only</label><label class="er_option"><input class="type_radio" type="radio" name="CST_15" value="Foster Care and Adoption">Foster Care and Adoption</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_15" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_15_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 100%;" map_to="FH_ReferralSource"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">How did you hear about us?</label><textarea name="CST_12" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio sortable-chosen" style="white-space: normal; width: 100%;" draggable="true"><i class="fa fa-circle-o"></i><label class="er_fld_label">Would you like an Application?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_11" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_11" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_11" value="Other:">Other:<input class="cst_Other" name="CST_11_Other" type="text"></label> </li></ul>
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