{"id":181,"date":"2017-04-10T20:44:58","date_gmt":"2017-04-10T20:44:58","guid":{"rendered":"https:\/\/aimint.org\/wellspring\/?page_id=181"},"modified":"2018-07-20T15:06:09","modified_gmt":"2018-07-20T15:06:09","slug":"application","status":"publish","type":"page","link":"https:\/\/aimint.org\/wellspring\/application\/","title":{"rendered":"Application"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; fullwidth=&#8221;on&#8221; admin_label=&#8221;Header Section&#8221; _builder_version=&#8221;3.9&#8243; background_image=&#8221;https:\/\/aimint.org\/wellspring\/wp-content\/uploads\/sites\/37\/2017\/04\/p2200671860-o276975029-4.jpg&#8221; parallax=&#8221;on&#8221; top_divider_style=&#8221;clouds2&#8243; top_divider_color=&#8221;rgba(255,255,255,0.3)&#8221; top_divider_height=&#8221;100%&#8221; bottom_divider_height=&#8221;30px&#8221;][et_pb_fullwidth_header title=&#8221;Application&#8221; subhead=&#8221;Wellspring Application&#8221; text_orientation=&#8221;center&#8221; _builder_version=&#8221;3.9&#8243; title_level=&#8221;h2&#8243; title_font=&#8221;Rubik|700||on|||||&#8221; title_text_color=&#8221;#ff7355&#8243; title_font_size=&#8221;16px&#8221; title_letter_spacing=&#8221;5px&#8221; title_line_height=&#8221;2em&#8221; content_font=&#8221;Rubik||||||||&#8221; content_font_size=&#8221;18px&#8221; content_line_height=&#8221;2em&#8221; subhead_font=&#8221;Rubik|700|||||||&#8221; subhead_text_color=&#8221;rgba(0,0,0,0.8)&#8221; subhead_font_size=&#8221;50px&#8221; subhead_font_size_phone=&#8221;30px&#8221; subhead_font_size_last_edited=&#8221;on|phone&#8221; subhead_line_height=&#8221;1.4em&#8221; background_color=&#8221;rgba(255,255,255,0)&#8221; use_background_color_gradient=&#8221;on&#8221; background_color_gradient_start=&#8221;rgba(255,255,255,0.7)&#8221; background_color_gradient_end=&#8221;#ffffff&#8221; background_size=&#8221;contain&#8221; background_position=&#8221;bottom_center&#8221; custom_button_two=&#8221;on&#8221; button_two_text_size=&#8221;16px&#8221; button_two_text_color=&#8221;#ffffff&#8221; button_two_bg_color=&#8221;rgba(0,0,0,0.6)&#8221; button_two_border_width=&#8221;15px&#8221; button_two_border_color=&#8221;rgba(210,159,104,0)&#8221; button_two_border_radius=&#8221;100px&#8221; button_two_letter_spacing=&#8221;0px&#8221; button_two_font=&#8221;Rubik|700|||||||&#8221; button_two_use_icon=&#8221;off&#8221; button_two_bg_color_hover=&#8221;#ff8a70&#8243; button_two_border_radius_hover=&#8221;100px&#8221; custom_button_one=&#8221;on&#8221; button_one_text_size=&#8221;16px&#8221; button_one_text_color=&#8221;#ffffff&#8221; button_one_bg_color=&#8221;#ff7355&#8243; button_one_border_width=&#8221;15px&#8221; button_one_border_color=&#8221;rgba(210,159,104,0)&#8221; button_one_border_radius=&#8221;100px&#8221; button_one_letter_spacing=&#8221;0px&#8221; button_one_font=&#8221;Rubik|700|||||||&#8221; button_one_use_icon=&#8221;off&#8221; button_one_bg_color_hover=&#8221;#ff8a70&#8243; button_one_border_radius_hover=&#8221;100px&#8221; background_layout=&#8221;light&#8221; custom_margin=&#8221;|||&#8221; custom_padding=&#8221;8vw||4vw|&#8221; animation_style=&#8221;slide&#8221; animation_direction=&#8221;bottom&#8221; animation_intensity_slide=&#8221;1%&#8221;]<\/p>\n<p style=\"text-align: center\">Welcome to the Wellspring Academy application form. Please take the time to carefully fill out each section\u00a0to provide us with the information we need to best serve you and your family.<\/p>\n<p>[\/et_pb_fullwidth_header][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;3.9&#8243; custom_padding=&#8221;54px|0px|54px|0px&#8221;][et_pb_row custom_padding=&#8221;14px|20px|14px|20px|true|true&#8221; _builder_version=&#8221;3.9&#8243; background_color=&#8221;rgba(0,0,0,0.04)&#8221; border_radii=&#8221;on|10px|10px|10px|10px&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;3.0.47&#8243; parallax=&#8221;off&#8221; parallax_method=&#8221;on&#8221;][et_pb_code _builder_version=&#8221;3.9&#8243;]<div class=\"frm_forms  with_frm_style frm_style_formidable-style-2\" id=\"frm_form_5_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_namlb\" >\n<div class=\"frm_form_fields  frm_page_num_1\">\n<fieldset>\n<legend class=\"frm_hidden\">Application Form<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"5\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_5\" id=\"frm_hide_fields_5\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"namlb\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_5\" name=\"frm_submit_entry_5\" value=\"5712b82180\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wellspring\/wp-json\/wp\/v2\/pages\/181\" \/><div id=\"frm_field_64_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_we3zy\" class=\"frm_primary_label\">Student First Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_we3zy\" name=\"item_meta[64]\" value=\"\"  data-reqmsg=\"Student First Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Student First Name is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_65_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_yvpwl\" class=\"frm_primary_label\">Last Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_yvpwl\" name=\"item_meta[65]\" value=\"\"  data-reqmsg=\"Last Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last Name is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_66_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_8kqff\" class=\"frm_primary_label\">Age\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"number\" id=\"field_8kqff\" name=\"item_meta[66]\" value=\"\" data-reqmsg=\"Age cannot be blank.\" aria-required=\"true\" data-invmsg=\"Age is invalid\" aria-invalid=\"false\"   min=\"0\" max=\"100\" step=\"any\" \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_67_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_f0vf0\" class=\"frm_primary_label\">Birth Date\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_f0vf0\" name=\"item_meta[67]\" value=\"\"  maxlength=\"10\" data-reqmsg=\"Birth Date cannot be blank.\" aria-required=\"true\" data-invmsg=\"Birth Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_68_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_49q7g\" class=\"frm_primary_label\">Nationality\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[68]\" id=\"field_49q7g\"  data-placeholder=\"Please Select One\"  placeholder=\"Please Select One\" data-reqmsg=\"Nationality cannot be blank.\" aria-required=\"true\" data-invmsg=\"Nationality is invalid\" class=\"auto_width\" aria-invalid=\"false\"  >\n\t\t<option  class=\"frm-select-placeholder\" value=\"\" data-placeholder=\"true\">Please Select One<\/option><option  value=\"Afghan\">Afghan<\/option><option  value=\"Albanian\">Albanian<\/option><option  value=\"Algerian\">Algerian<\/option><option  value=\"American\">American<\/option><option  value=\"Andorran\">Andorran<\/option><option  value=\"Angolan\">Angolan<\/option><option  value=\"Antiguans\">Antiguans<\/option><option  value=\"Argentinean\">Argentinean<\/option><option  value=\"Armenian\">Armenian<\/option><option  value=\"Australian\">Australian<\/option><option  value=\"Austrian\">Austrian<\/option><option  value=\"Azerbaijani\">Azerbaijani<\/option><option  value=\"Bahamian\">Bahamian<\/option><option  value=\"Bahraini\">Bahraini<\/option><option  value=\"Bangladeshi\">Bangladeshi<\/option><option  value=\"Barbadian\">Barbadian<\/option><option  value=\"Barbudans\">Barbudans<\/option><option  value=\"Batswana\">Batswana<\/option><option  value=\"Belarusian\">Belarusian<\/option><option  value=\"Belgian\">Belgian<\/option><option  value=\"Belizean\">Belizean<\/option><option  value=\"Beninese\">Beninese<\/option><option  value=\"Bhutanese\">Bhutanese<\/option><option  value=\"Bolivian\">Bolivian<\/option><option  value=\"Bosnian\">Bosnian<\/option><option  value=\"Brazilian\">Brazilian<\/option><option  value=\"British\">British<\/option><option  value=\"Bruneian\">Bruneian<\/option><option  value=\"Bulgarian\">Bulgarian<\/option><option  value=\"Burkinabe\">Burkinabe<\/option><option  value=\"Burmese\">Burmese<\/option><option  value=\"Burundian\">Burundian<\/option><option  value=\"Cambodian\">Cambodian<\/option><option  value=\"Cameroonian\">Cameroonian<\/option><option  value=\"Canadian\">Canadian<\/option><option  value=\"Cape Verdean\">Cape Verdean<\/option><option  value=\"Central African\">Central African<\/option><option  value=\"Chadian\">Chadian<\/option><option  value=\"Chilean\">Chilean<\/option><option  value=\"Chinese\">Chinese<\/option><option  value=\"Colombian\">Colombian<\/option><option  value=\"Comoran\">Comoran<\/option><option  value=\"Congolese\">Congolese<\/option><option  value=\"Congolese\">Congolese<\/option><option  value=\"Costa Rican\">Costa Rican<\/option><option  value=\"Croatian\">Croatian<\/option><option  value=\"Cuban\">Cuban<\/option><option  value=\"Cypriot\">Cypriot<\/option><option  value=\"Czech\">Czech<\/option><option  value=\"Danish\">Danish<\/option><option  value=\"Djibouti\">Djibouti<\/option><option  value=\"Dominican\">Dominican<\/option><option  value=\"Dominican\">Dominican<\/option><option  value=\"Dutch\">Dutch<\/option><option  value=\"Dutchman\">Dutchman<\/option><option  value=\"Dutchwoman\">Dutchwoman<\/option><option  value=\"East Timorese\">East Timorese<\/option><option  value=\"Ecuadorean\">Ecuadorean<\/option><option  value=\"Egyptian\">Egyptian<\/option><option  value=\"Emirian\">Emirian<\/option><option  value=\"Equatorial Guinean\">Equatorial Guinean<\/option><option  value=\"Eritrean\">Eritrean<\/option><option  value=\"Estonian\">Estonian<\/option><option  value=\"Ethiopian\">Ethiopian<\/option><option  value=\"Fijian\">Fijian<\/option><option  value=\"Filipino\">Filipino<\/option><option  value=\"Finnish\">Finnish<\/option><option  value=\"French\">French<\/option><option  value=\"Gabonese\">Gabonese<\/option><option  value=\"Gambian\">Gambian<\/option><option  value=\"Georgian\">Georgian<\/option><option  value=\"German\">German<\/option><option  value=\"Ghanaian\">Ghanaian<\/option><option  value=\"Greek\">Greek<\/option><option  value=\"Grenadian\">Grenadian<\/option><option  value=\"Guatemalan\">Guatemalan<\/option><option  value=\"Guinea-Bissauan\">Guinea-Bissauan<\/option><option  value=\"Guinean\">Guinean<\/option><option  value=\"Guyanese\">Guyanese<\/option><option  value=\"Haitian\">Haitian<\/option><option  value=\"Herzegovinian\">Herzegovinian<\/option><option  value=\"Honduran\">Honduran<\/option><option  value=\"Hungarian\">Hungarian<\/option><option  value=\"I-Kiribati\">I-Kiribati<\/option><option  value=\"Icelander\">Icelander<\/option><option  value=\"Indian\">Indian<\/option><option  value=\"Indonesian\">Indonesian<\/option><option  value=\"Iranian\">Iranian<\/option><option  value=\"Iraqi\">Iraqi<\/option><option  value=\"Irish\">Irish<\/option><option  value=\"Irish\">Irish<\/option><option  value=\"Israeli\">Israeli<\/option><option  value=\"Italian\">Italian<\/option><option  value=\"Ivorian\">Ivorian<\/option><option  value=\"Jamaican\">Jamaican<\/option><option  value=\"Japanese\">Japanese<\/option><option  value=\"Jordanian\">Jordanian<\/option><option  value=\"Kazakhstani\">Kazakhstani<\/option><option  value=\"Kenyan\">Kenyan<\/option><option  value=\"Kittian and Nevisian\">Kittian and Nevisian<\/option><option  value=\"Kuwaiti\">Kuwaiti<\/option><option  value=\"Kyrgyz\">Kyrgyz<\/option><option  value=\"Laotian\">Laotian<\/option><option  value=\"Latvian\">Latvian<\/option><option  value=\"Lebanese\">Lebanese<\/option><option  value=\"Liberian\">Liberian<\/option><option  value=\"Libyan\">Libyan<\/option><option  value=\"Liechtensteiner\">Liechtensteiner<\/option><option  value=\"Lithuanian\">Lithuanian<\/option><option  value=\"Luxembourger\">Luxembourger<\/option><option  value=\"Macedonian\">Macedonian<\/option><option  value=\"Malagasy\">Malagasy<\/option><option  value=\"Malawian\">Malawian<\/option><option  value=\"Malaysian\">Malaysian<\/option><option  value=\"Maldivan\">Maldivan<\/option><option  value=\"Malian\">Malian<\/option><option  value=\"Maltese\">Maltese<\/option><option  value=\"Marshallese\">Marshallese<\/option><option  value=\"Mauritanian\">Mauritanian<\/option><option  value=\"Mauritian\">Mauritian<\/option><option  value=\"Mexican\">Mexican<\/option><option  value=\"Micronesian\">Micronesian<\/option><option  value=\"Moldovan\">Moldovan<\/option><option  value=\"Monacan\">Monacan<\/option><option  value=\"Mongolian\">Mongolian<\/option><option  value=\"Moroccan\">Moroccan<\/option><option  value=\"Mosotho\">Mosotho<\/option><option  value=\"Motswana\">Motswana<\/option><option  value=\"Mozambican\">Mozambican<\/option><option  value=\"Namibian\">Namibian<\/option><option  value=\"Nauruan\">Nauruan<\/option><option  value=\"Nepalese\">Nepalese<\/option><option  value=\"Netherlander\">Netherlander<\/option><option  value=\"New Zealander\">New Zealander<\/option><option  value=\"Ni-Vanuatu\">Ni-Vanuatu<\/option><option  value=\"Nicaraguan\">Nicaraguan<\/option><option  value=\"Nigerian\">Nigerian<\/option><option  value=\"Nigerien\">Nigerien<\/option><option  value=\"North Korean\">North Korean<\/option><option  value=\"Northern Irish\">Northern Irish<\/option><option  value=\"Norwegian\">Norwegian<\/option><option  value=\"Omani\">Omani<\/option><option  value=\"Pakistani\">Pakistani<\/option><option  value=\"Palauan\">Palauan<\/option><option  value=\"Panamanian\">Panamanian<\/option><option  value=\"Papua New Guinean\">Papua New Guinean<\/option><option  value=\"Paraguayan\">Paraguayan<\/option><option  value=\"Peruvian\">Peruvian<\/option><option  value=\"Polish\">Polish<\/option><option  value=\"Portuguese\">Portuguese<\/option><option  value=\"Qatari\">Qatari<\/option><option  value=\"Romanian\">Romanian<\/option><option  value=\"Russian\">Russian<\/option><option  value=\"Rwandan\">Rwandan<\/option><option  value=\"Saint Lucian\">Saint Lucian<\/option><option  value=\"Salvadoran\">Salvadoran<\/option><option  value=\"Samoan\">Samoan<\/option><option  value=\"San Marinese\">San Marinese<\/option><option  value=\"Sao Tomean\">Sao Tomean<\/option><option  value=\"Saudi\">Saudi<\/option><option  value=\"Scottish\">Scottish<\/option><option  value=\"Senegalese\">Senegalese<\/option><option  value=\"Serbian\">Serbian<\/option><option  value=\"Seychellois\">Seychellois<\/option><option  value=\"Sierra Leonean\">Sierra Leonean<\/option><option  value=\"Singaporean\">Singaporean<\/option><option  value=\"Slovakian\">Slovakian<\/option><option  value=\"Slovenian\">Slovenian<\/option><option  value=\"Solomon Islander\">Solomon Islander<\/option><option  value=\"Somali\">Somali<\/option><option  value=\"South African\">South African<\/option><option  value=\"South Korean\">South Korean<\/option><option  value=\"Spanish\">Spanish<\/option><option  value=\"Sri Lankan\">Sri Lankan<\/option><option  value=\"Sudanese\">Sudanese<\/option><option  value=\"Surinamer\">Surinamer<\/option><option  value=\"Swazi\">Swazi<\/option><option  value=\"Swedish\">Swedish<\/option><option  value=\"Swiss\">Swiss<\/option><option  value=\"Syrian\">Syrian<\/option><option  value=\"Taiwanese\">Taiwanese<\/option><option  value=\"Tajik\">Tajik<\/option><option  value=\"Tanzanian\">Tanzanian<\/option><option  value=\"Thai\">Thai<\/option><option  value=\"Togolese\">Togolese<\/option><option  value=\"Tongan\">Tongan<\/option><option  value=\"Trinidadian or Tobagonian\">Trinidadian or Tobagonian<\/option><option  value=\"Tunisian\">Tunisian<\/option><option  value=\"Turkish\">Turkish<\/option><option  value=\"Tuvaluan\">Tuvaluan<\/option><option  value=\"Ugandan\">Ugandan<\/option><option  value=\"Ukrainian\">Ukrainian<\/option><option  value=\"Uruguayan\">Uruguayan<\/option><option  value=\"Uzbekistani\">Uzbekistani<\/option><option  value=\"Venezuelan\">Venezuelan<\/option><option  value=\"Vietnamese\">Vietnamese<\/option><option  value=\"Welsh\">Welsh<\/option><option  value=\"Welsh\">Welsh<\/option><option  value=\"Yemenite\">Yemenite<\/option><option  value=\"Zambian\">Zambian<\/option><option  value=\"Zimbabwean\">Zimbabwean<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_69_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_rglq3\" class=\"frm_primary_label\">Passport #\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_rglq3\" name=\"item_meta[69]\" value=\"\"  data-reqmsg=\"Passport # cannot be blank.\" aria-required=\"true\" data-invmsg=\"Passport # is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_70_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_md2tc\" class=\"frm_primary_label\">Male\/Female\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[70]\" id=\"field_md2tc\"  data-placeholder=\"Please Select One\"  placeholder=\"Please Select One\" data-reqmsg=\"Male\/Female cannot be blank.\" aria-required=\"true\" data-invmsg=\"Male\/Female is invalid\" class=\"auto_width\" aria-invalid=\"false\"  >\n\t\t<option  class=\"frm-select-placeholder\" value=\"\" data-placeholder=\"true\">Please Select One<\/option><option  value=\"Male\">Male<\/option><option  value=\"Female\">Female<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_71_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_vat7k\" class=\"frm_primary_label\">Grade currently Completing\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[71]\" id=\"field_vat7k\"  data-placeholder=\"Please Select One\"  placeholder=\"Please Select One\" data-reqmsg=\"Grade currently Completing cannot be blank.\" aria-required=\"true\" data-invmsg=\"Grade currently Completing is invalid\" class=\"auto_width\" aria-invalid=\"false\"  >\n\t\t<option  class=\"frm-select-placeholder\" value=\"\" data-placeholder=\"true\">Please Select One<\/option><option  value=\"Kindergarten\">Kindergarten<\/option><option  value=\"First Grade\">First Grade<\/option><option  value=\"Second Grade\">Second Grade<\/option><option  value=\"Third Grade\">Third Grade<\/option><option  value=\"Fourth Grade\">Fourth Grade<\/option><option  value=\"Fifth Grade\">Fifth Grade<\/option><option  value=\"Sixth Grade\">Sixth Grade<\/option><option  value=\"Seventh Grade\">Seventh Grade<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_72_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_na3zs\" class=\"frm_primary_label\">Please list previous schools or schooling\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[72]\" id=\"field_na3zs\" rows=\"5\"  data-reqmsg=\"Please list previous schools or schooling cannot be blank.\" aria-required=\"true\" data-invmsg=\"Please list previous schools or schooling is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_73_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_ns92z\" class=\"frm_primary_label\">Grade student is applying to join\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_ns92z\" name=\"item_meta[73]\" value=\"\"  data-reqmsg=\"Grade student is applying to join cannot be blank.\" aria-required=\"true\" data-invmsg=\"Grade student is applying to join is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_74_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_f7dwf\" class=\"frm_primary_label\">All languages the student speaks, reads, or writes\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_f7dwf\" name=\"item_meta[74]\" value=\"\"  data-reqmsg=\"All languages the student speaks, reads, or writes cannot be blank.\" aria-required=\"true\" data-invmsg=\"All languages the student speaks, reads, or writes is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_75_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_7gjbs\" class=\"frm_primary_label\">Language spoken at home\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_7gjbs\" name=\"item_meta[75]\" value=\"\"  data-reqmsg=\"Language spoken at home cannot be blank.\" aria-required=\"true\" data-invmsg=\"Language spoken at home is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_76_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_r3twg\" class=\"frm_primary_label\">Parent's first language(s)\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_r3twg\" name=\"item_meta[76]\" value=\"\"  data-reqmsg=\"Parent&#039;s first language(s) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Parent&#039;s first language(s) is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_77_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_7aj2q\" class=\"frm_primary_label\">Parent 1's First Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_7aj2q\" name=\"item_meta[77]\" value=\"\"  data-reqmsg=\"Parent 1&#039;s First Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Parent 1&#039;s First Name is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_78_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_ly5x2\" class=\"frm_primary_label\">Last Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_ly5x2\" name=\"item_meta[78]\" value=\"\"  data-reqmsg=\"Last Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last Name is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_79_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_6xiut\" class=\"frm_primary_label\">Email Address\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_6xiut\" name=\"item_meta[79]\" value=\"\"  data-reqmsg=\"Email Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email Address is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_80_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_xjq7\" class=\"frm_primary_label\">Cell Phone Number\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_xjq7\" name=\"item_meta[80]\" value=\"\"  style=\"width:115px\" data-reqmsg=\"Cell Phone Number cannot be blank.\" aria-required=\"true\" data-invmsg=\"Cell Phone Number is invalid\" class=\"auto_width\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_81_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_r2g49\" class=\"frm_primary_label\">Parent 2's First Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_r2g49\" name=\"item_meta[81]\" value=\"\"  data-reqmsg=\"Parent 2&#039;s First Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Parent 2&#039;s First Name is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_82_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_ql066\" class=\"frm_primary_label\">Last Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_ql066\" name=\"item_meta[82]\" value=\"\"  data-reqmsg=\"Last Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last Name is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_83_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_cs2m9\" class=\"frm_primary_label\">Email Address\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_cs2m9\" name=\"item_meta[83]\" value=\"\"  data-reqmsg=\"Email Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email Address is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_84_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_dfzzn\" class=\"frm_primary_label\">Cell Phone Number\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_dfzzn\" name=\"item_meta[84]\" value=\"\"  style=\"width:115px\" data-reqmsg=\"Cell Phone Number cannot be blank.\" aria-required=\"true\" data-invmsg=\"Cell Phone Number is invalid\" class=\"auto_width\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_85_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_oaq9\" class=\"frm_primary_label\">Organization Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_oaq9\" name=\"item_meta[85]\" value=\"\"  data-reqmsg=\"Organization Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Organization Name is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_86_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_6a9fw\" class=\"frm_primary_label\">Address\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <fieldset aria-labelledby=\"field_6a9fw_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tAddress<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_86-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_6a9fw_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress\t<\/label>\n\t\t<input type=\"text\" id=\"field_6a9fw_line1\" value=\"\" name=\"item_meta[86][line1]\"  data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_86-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_6a9fw_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress\t<\/label>\n\t\t<input type=\"text\" id=\"field_6a9fw_line2\" value=\"\" name=\"item_meta[86][line2]\"  data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_86-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_6a9fw_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_6a9fw_city\" value=\"\" name=\"item_meta[86][city]\"  data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_86-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_6a9fw_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\r\n\r\n(put N\/A if this does not apply)\t<\/label>\n\t\t<input type=\"text\" id=\"field_6a9fw_state\" value=\"\" name=\"item_meta[86][state]\"  data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\" \/>\n\t<div class=\"frm_description\">State\/Province\r\n\r\n(put N\/A if this does not apply)<\/div><\/div>\n<div id=\"frm_field_86-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_6a9fw_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\r\n(put N\/A if this does not apply)\t<\/label>\n\t\t<input type=\"text\" id=\"field_6a9fw_zip\" value=\"\" name=\"item_meta[86][zip]\"  data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal\r\n(put N\/A if this does not apply)<\/div><\/div>\n<div id=\"frm_field_86-country_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_6a9fw_country\" class=\"frm_screen_reader frm_hidden\">\n\t\tCountry\t<\/label>\n\t\t\t<select name=\"item_meta[86][country]\" id=\"field_6a9fw_country\"  data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"country-name\">\n\t\t\t<option value=\"\" class=\"\">\n\t\t\t\t \t\t\t<\/option>\n\t\t\t<option  value=\"Afghanistan\" data-code=\"AF\">Afghanistan<\/option><option  value=\"Aland Islands\" data-code=\"AX\">Aland Islands<\/option><option  value=\"Albania\" data-code=\"AL\">Albania<\/option><option  value=\"Algeria\" data-code=\"DZ\">Algeria<\/option><option  value=\"American Samoa\" data-code=\"AS\">American Samoa<\/option><option  value=\"Andorra\" data-code=\"AD\">Andorra<\/option><option  value=\"Angola\" data-code=\"AO\">Angola<\/option><option  value=\"Anguilla\" data-code=\"AI\">Anguilla<\/option><option  value=\"Antarctica\" data-code=\"AQ\">Antarctica<\/option><option  value=\"Antigua and Barbuda\" data-code=\"AG\">Antigua and Barbuda<\/option><option  value=\"Argentina\" data-code=\"AR\">Argentina<\/option><option  value=\"Armenia\" data-code=\"AM\">Armenia<\/option><option  value=\"Aruba\" data-code=\"AW\">Aruba<\/option><option  value=\"Australia\" data-code=\"AU\">Australia<\/option><option  value=\"Austria\" data-code=\"AT\">Austria<\/option><option  value=\"Azerbaijan\" data-code=\"AZ\">Azerbaijan<\/option><option  value=\"Bahamas\" data-code=\"BS\">Bahamas<\/option><option  value=\"Bahrain\" data-code=\"BH\">Bahrain<\/option><option  value=\"Bangladesh\" data-code=\"BD\">Bangladesh<\/option><option  value=\"Barbados\" data-code=\"BB\">Barbados<\/option><option  value=\"Belarus\" data-code=\"BY\">Belarus<\/option><option  value=\"Belgium\" data-code=\"BE\">Belgium<\/option><option  value=\"Belize\" data-code=\"BZ\">Belize<\/option><option  value=\"Benin\" data-code=\"BJ\">Benin<\/option><option  value=\"Bermuda\" data-code=\"BM\">Bermuda<\/option><option  value=\"Bhutan\" data-code=\"BT\">Bhutan<\/option><option  value=\"Bolivia\" data-code=\"BO\">Bolivia<\/option><option  value=\"Bonaire, Sint Eustatius and Saba\">Bonaire, Sint Eustatius and Saba<\/option><option  value=\"Bosnia and Herzegovina\" data-code=\"BA\">Bosnia and Herzegovina<\/option><option  value=\"Botswana\" data-code=\"BW\">Botswana<\/option><option  value=\"Bouvet Island\" data-code=\"BV\">Bouvet Island<\/option><option  value=\"Brazil\" data-code=\"BR\">Brazil<\/option><option  value=\"British Indian Ocean Territory\" data-code=\"IO\">British Indian Ocean Territory<\/option><option  value=\"Brunei\" data-code=\"BN\">Brunei<\/option><option  value=\"Bulgaria\" data-code=\"BG\">Bulgaria<\/option><option  value=\"Burkina Faso\" data-code=\"BF\">Burkina Faso<\/option><option  value=\"Burundi\" data-code=\"BI\">Burundi<\/option><option  value=\"C&ocirc;te d&#039;Ivoire\">C&ocirc;te d&#039;Ivoire<\/option><option  value=\"Cambodia\" data-code=\"KH\">Cambodia<\/option><option  value=\"Cameroon\" data-code=\"CM\">Cameroon<\/option><option  value=\"Canada\" data-code=\"CA\">Canada<\/option><option  value=\"Cape Verde\" data-code=\"CV\">Cape Verde<\/option><option  value=\"Cayman Islands\" data-code=\"KY\">Cayman Islands<\/option><option  value=\"Central African Republic\" data-code=\"CF\">Central African Republic<\/option><option  value=\"Chad\" data-code=\"TD\">Chad<\/option><option  value=\"Chile\" data-code=\"CL\">Chile<\/option><option  value=\"China\" data-code=\"CN\">China<\/option><option  value=\"Christmas Island\" data-code=\"CX\">Christmas Island<\/option><option  value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option  value=\"Colombia\" data-code=\"CO\">Colombia<\/option><option  value=\"Comoros\" data-code=\"KM\">Comoros<\/option><option  value=\"Congo\">Congo<\/option><option  value=\"Cook Islands\" data-code=\"CK\">Cook Islands<\/option><option  value=\"Costa Rica\" data-code=\"CR\">Costa Rica<\/option><option  value=\"Croatia\" data-code=\"HR\">Croatia<\/option><option  value=\"Cuba\" data-code=\"CU\">Cuba<\/option><option  value=\"Curacao\" data-code=\"CW\">Curacao<\/option><option  value=\"Cyprus\" data-code=\"CY\">Cyprus<\/option><option  value=\"Czech Republic\" data-code=\"CZ\">Czech Republic<\/option><option  value=\"Denmark\" data-code=\"DK\">Denmark<\/option><option  value=\"Djibouti\" data-code=\"DJ\">Djibouti<\/option><option  value=\"Dominica\" data-code=\"DM\">Dominica<\/option><option  value=\"Dominican Republic\" data-code=\"DO\">Dominican Republic<\/option><option  value=\"East Timor\" data-code=\"TL\">East Timor<\/option><option  value=\"Ecuador\" data-code=\"EC\">Ecuador<\/option><option  value=\"Egypt\" data-code=\"EG\">Egypt<\/option><option  value=\"El Salvador\" data-code=\"SV\">El Salvador<\/option><option  value=\"Equatorial Guinea\" data-code=\"GQ\">Equatorial Guinea<\/option><option  value=\"Eritrea\" data-code=\"ER\">Eritrea<\/option><option  value=\"Estonia\" data-code=\"EE\">Estonia<\/option><option  value=\"Ethiopia\" data-code=\"ET\">Ethiopia<\/option><option  value=\"Falkland Islands (Malvinas)\">Falkland Islands (Malvinas)<\/option><option  value=\"Faroe Islands\" data-code=\"FO\">Faroe Islands<\/option><option  value=\"Fiji\" data-code=\"FJ\">Fiji<\/option><option  value=\"Finland\" data-code=\"FI\">Finland<\/option><option  value=\"France\" data-code=\"FR\">France<\/option><option  value=\"French Guiana\" data-code=\"GF\">French Guiana<\/option><option  value=\"French Polynesia\" data-code=\"PF\">French Polynesia<\/option><option  value=\"French Southern Territories\" data-code=\"TF\">French Southern Territories<\/option><option  value=\"Gabon\" data-code=\"GA\">Gabon<\/option><option  value=\"Gambia\" data-code=\"GM\">Gambia<\/option><option  value=\"Georgia\" data-code=\"GE\">Georgia<\/option><option  value=\"Germany\" data-code=\"DE\">Germany<\/option><option  value=\"Ghana\" data-code=\"GH\">Ghana<\/option><option  value=\"Gibraltar\" data-code=\"GI\">Gibraltar<\/option><option  value=\"Greece\" data-code=\"GR\">Greece<\/option><option  value=\"Greenland\" data-code=\"GL\">Greenland<\/option><option  value=\"Grenada\" data-code=\"GD\">Grenada<\/option><option  value=\"Guadeloupe\" data-code=\"GP\">Guadeloupe<\/option><option  value=\"Guam\" data-code=\"GU\">Guam<\/option><option  value=\"Guatemala\" data-code=\"GT\">Guatemala<\/option><option  value=\"Guernsey\" data-code=\"GG\">Guernsey<\/option><option  value=\"Guinea\" data-code=\"GN\">Guinea<\/option><option  value=\"Guinea-Bissau\" data-code=\"GW\">Guinea-Bissau<\/option><option  value=\"Guyana\" data-code=\"GY\">Guyana<\/option><option  value=\"Haiti\" data-code=\"HT\">Haiti<\/option><option  value=\"Heard Island and McDonald Islands\" data-code=\"HM\">Heard Island and McDonald Islands<\/option><option  value=\"Holy See\">Holy See<\/option><option  value=\"Honduras\" data-code=\"HN\">Honduras<\/option><option  value=\"Hong Kong\" data-code=\"HK\">Hong Kong<\/option><option  value=\"Hungary\" data-code=\"HU\">Hungary<\/option><option  value=\"Iceland\" data-code=\"IS\">Iceland<\/option><option  value=\"India\" data-code=\"IN\">India<\/option><option  value=\"Indonesia\" data-code=\"ID\">Indonesia<\/option><option  value=\"Iran\" data-code=\"IR\">Iran<\/option><option  value=\"Iraq\" data-code=\"IQ\">Iraq<\/option><option  value=\"Ireland\" data-code=\"IE\">Ireland<\/option><option  value=\"Isle of Man\" data-code=\"IM\">Isle of Man<\/option><option  value=\"Israel\" data-code=\"IL\">Israel<\/option><option  value=\"Italy\" data-code=\"IT\">Italy<\/option><option  value=\"Jamaica\" data-code=\"JM\">Jamaica<\/option><option  value=\"Japan\" data-code=\"JP\">Japan<\/option><option  value=\"Jersey\" data-code=\"JE\">Jersey<\/option><option  value=\"Jordan\" data-code=\"JO\">Jordan<\/option><option  value=\"Kazakhstan\" data-code=\"KZ\">Kazakhstan<\/option><option  value=\"Kenya\" data-code=\"KE\">Kenya<\/option><option  value=\"Kiribati\" data-code=\"KI\">Kiribati<\/option><option  value=\"Kosovo\" data-code=\"XK\">Kosovo<\/option><option  value=\"Kuwait\" data-code=\"KW\">Kuwait<\/option><option  value=\"Kyrgyzstan\" data-code=\"KG\">Kyrgyzstan<\/option><option  value=\"Laos\" data-code=\"LA\">Laos<\/option><option  value=\"Latvia\" data-code=\"LV\">Latvia<\/option><option  value=\"Lebanon\" data-code=\"LB\">Lebanon<\/option><option  value=\"Lesotho\" data-code=\"LS\">Lesotho<\/option><option  value=\"Liberia\" data-code=\"LR\">Liberia<\/option><option  value=\"Libya\" data-code=\"LY\">Libya<\/option><option  value=\"Liechtenstein\" data-code=\"LI\">Liechtenstein<\/option><option  value=\"Lithuania\" data-code=\"LT\">Lithuania<\/option><option  value=\"Luxembourg\" data-code=\"LU\">Luxembourg<\/option><option  value=\"Macao\" data-code=\"MO\">Macao<\/option><option  value=\"Macedonia\" data-code=\"MK\">Macedonia<\/option><option  value=\"Madagascar\" data-code=\"MG\">Madagascar<\/option><option  value=\"Malawi\" data-code=\"MW\">Malawi<\/option><option  value=\"Malaysia\" data-code=\"MY\">Malaysia<\/option><option  value=\"Maldives\" data-code=\"MV\">Maldives<\/option><option  value=\"Mali\" data-code=\"ML\">Mali<\/option><option  value=\"Malta\" data-code=\"MT\">Malta<\/option><option  value=\"Marshall Islands\" data-code=\"MH\">Marshall Islands<\/option><option  value=\"Martinique\" data-code=\"MQ\">Martinique<\/option><option  value=\"Mauritania\" data-code=\"MR\">Mauritania<\/option><option  value=\"Mauritius\" data-code=\"MU\">Mauritius<\/option><option  value=\"Mayotte\" data-code=\"YT\">Mayotte<\/option><option  value=\"Mexico\" data-code=\"MX\">Mexico<\/option><option  value=\"Micronesia\" data-code=\"FM\">Micronesia<\/option><option  value=\"Moldova\" data-code=\"MD\">Moldova<\/option><option  value=\"Monaco\" data-code=\"MC\">Monaco<\/option><option  value=\"Mongolia\" data-code=\"MN\">Mongolia<\/option><option  value=\"Montenegro\" data-code=\"ME\">Montenegro<\/option><option  value=\"Montserrat\" data-code=\"MS\">Montserrat<\/option><option  value=\"Morocco\" data-code=\"MA\">Morocco<\/option><option  value=\"Mozambique\" data-code=\"MZ\">Mozambique<\/option><option  value=\"Myanmar\" data-code=\"MM\">Myanmar<\/option><option  value=\"Namibia\" data-code=\"NA\">Namibia<\/option><option  value=\"Nauru\" data-code=\"NR\">Nauru<\/option><option  value=\"Nepal\" data-code=\"NP\">Nepal<\/option><option  value=\"Netherlands\" data-code=\"NL\">Netherlands<\/option><option  value=\"New Caledonia\" data-code=\"NC\">New Caledonia<\/option><option  value=\"New Zealand\" data-code=\"NZ\">New Zealand<\/option><option  value=\"Nicaragua\" data-code=\"NI\">Nicaragua<\/option><option  value=\"Niger\" data-code=\"NE\">Niger<\/option><option  value=\"Nigeria\" data-code=\"NG\">Nigeria<\/option><option  value=\"Niue\" data-code=\"NU\">Niue<\/option><option  value=\"Norfolk Island\" data-code=\"NF\">Norfolk Island<\/option><option  value=\"North Korea\" data-code=\"KP\">North Korea<\/option><option  value=\"Northern Mariana Islands\" data-code=\"MP\">Northern Mariana Islands<\/option><option  value=\"Norway\" data-code=\"NO\">Norway<\/option><option  value=\"Oman\" data-code=\"OM\">Oman<\/option><option  value=\"Pakistan\" data-code=\"PK\">Pakistan<\/option><option  value=\"Palau\" data-code=\"PW\">Palau<\/option><option  value=\"Palestine\">Palestine<\/option><option  value=\"Panama\" data-code=\"PA\">Panama<\/option><option  value=\"Papua New Guinea\" data-code=\"PG\">Papua New Guinea<\/option><option  value=\"Paraguay\" data-code=\"PY\">Paraguay<\/option><option  value=\"Peru\" data-code=\"PE\">Peru<\/option><option  value=\"Philippines\" data-code=\"PH\">Philippines<\/option><option  value=\"Pitcairn\" data-code=\"PN\">Pitcairn<\/option><option  value=\"Poland\" data-code=\"PL\">Poland<\/option><option  value=\"Portugal\" data-code=\"PT\">Portugal<\/option><option  value=\"Puerto Rico\" data-code=\"PR\">Puerto Rico<\/option><option  value=\"Qatar\" data-code=\"QA\">Qatar<\/option><option  value=\"Reunion\" data-code=\"RE\">Reunion<\/option><option  value=\"Romania\" data-code=\"RO\">Romania<\/option><option  value=\"Russia\" data-code=\"RU\">Russia<\/option><option  value=\"Rwanda\" data-code=\"RW\">Rwanda<\/option><option  value=\"Saint Barthelemy\" data-code=\"BL\">Saint Barthelemy<\/option><option  value=\"Saint Helena, Ascension and Tristan da Cunha\">Saint Helena, Ascension and Tristan da Cunha<\/option><option  value=\"Saint Kitts and Nevis\" data-code=\"KN\">Saint Kitts and Nevis<\/option><option  value=\"Saint Lucia\" data-code=\"LC\">Saint Lucia<\/option><option  value=\"Saint Martin (French part)\">Saint Martin (French part)<\/option><option  value=\"Saint Pierre and Miquelon\" data-code=\"PM\">Saint Pierre and Miquelon<\/option><option  value=\"Saint Vincent and the Grenadines\" data-code=\"VC\">Saint Vincent and the Grenadines<\/option><option  value=\"Samoa\" data-code=\"WS\">Samoa<\/option><option  value=\"San Marino\" data-code=\"SM\">San Marino<\/option><option  value=\"Sao Tome and Principe\" data-code=\"ST\">Sao Tome and Principe<\/option><option  value=\"Saudi Arabia\" data-code=\"SA\">Saudi Arabia<\/option><option  value=\"Senegal\" data-code=\"SN\">Senegal<\/option><option  value=\"Serbia\" data-code=\"RS\">Serbia<\/option><option  value=\"Seychelles\" data-code=\"SC\">Seychelles<\/option><option  value=\"Sierra Leone\" data-code=\"SL\">Sierra Leone<\/option><option  value=\"Singapore\" data-code=\"SG\">Singapore<\/option><option  value=\"Sint Maarten (Dutch part)\">Sint Maarten (Dutch part)<\/option><option  value=\"Slovakia\" data-code=\"SK\">Slovakia<\/option><option  value=\"Slovenia\" data-code=\"SI\">Slovenia<\/option><option  value=\"Solomon Islands\" data-code=\"SB\">Solomon Islands<\/option><option  value=\"Somalia\" data-code=\"SO\">Somalia<\/option><option  value=\"South Africa\" data-code=\"ZA\">South Africa<\/option><option  value=\"South Georgia and the South Sandwich Islands\" data-code=\"GS\">South Georgia and the South Sandwich Islands<\/option><option  value=\"South Korea\" data-code=\"KR\">South Korea<\/option><option  value=\"South Sudan\" data-code=\"SS\">South Sudan<\/option><option  value=\"Spain\" data-code=\"ES\">Spain<\/option><option  value=\"Sri Lanka\" data-code=\"LK\">Sri Lanka<\/option><option  value=\"Sudan\" data-code=\"SD\">Sudan<\/option><option  value=\"Suriname\" data-code=\"SR\">Suriname<\/option><option  value=\"Svalbard and Jan Mayen\" data-code=\"SJ\">Svalbard and Jan Mayen<\/option><option  value=\"Swaziland\" data-code=\"SZ\">Swaziland<\/option><option  value=\"Sweden\" data-code=\"SE\">Sweden<\/option><option  value=\"Switzerland\" data-code=\"CH\">Switzerland<\/option><option  value=\"Syria\" data-code=\"SY\">Syria<\/option><option  value=\"Taiwan\" data-code=\"TW\">Taiwan<\/option><option  value=\"Tajikistan\" data-code=\"TJ\">Tajikistan<\/option><option  value=\"Tanzania\" data-code=\"TZ\">Tanzania<\/option><option  value=\"Thailand\" data-code=\"TH\">Thailand<\/option><option  value=\"Timor-Leste\">Timor-Leste<\/option><option  value=\"Togo\" data-code=\"TG\">Togo<\/option><option  value=\"Tokelau\" data-code=\"TK\">Tokelau<\/option><option  value=\"Tonga\" data-code=\"TO\">Tonga<\/option><option  value=\"Trinidad and Tobago\" data-code=\"TT\">Trinidad and Tobago<\/option><option  value=\"Tunisia\" data-code=\"TN\">Tunisia<\/option><option  value=\"Turkey\" data-code=\"TR\">Turkey<\/option><option  value=\"Turkmenistan\" data-code=\"TM\">Turkmenistan<\/option><option  value=\"Turks and Caicos Islands\" data-code=\"TC\">Turks and Caicos Islands<\/option><option  value=\"Tuvalu\" data-code=\"TV\">Tuvalu<\/option><option  value=\"Uganda\" data-code=\"UG\">Uganda<\/option><option  value=\"Ukraine\" data-code=\"UA\">Ukraine<\/option><option  value=\"United Arab Emirates\" data-code=\"AE\">United Arab Emirates<\/option><option  value=\"United Kingdom\" data-code=\"GB\">United Kingdom<\/option><option  value=\"United States\" data-code=\"US\">United States<\/option><option  value=\"United States Minor Outlying Islands\" data-code=\"UM\">United States Minor Outlying Islands<\/option><option  value=\"Uruguay\" data-code=\"UY\">Uruguay<\/option><option  value=\"Uzbekistan\" data-code=\"UZ\">Uzbekistan<\/option><option  value=\"Vanuatu\" data-code=\"VU\">Vanuatu<\/option><option  value=\"Vatican City\">Vatican City<\/option><option  value=\"Venezuela\" data-code=\"VE\">Venezuela<\/option><option  value=\"Vietnam\" data-code=\"VN\">Vietnam<\/option><option  value=\"Virgin Islands, British\">Virgin Islands, British<\/option><option  value=\"Virgin Islands, U.S.\">Virgin Islands, U.S.<\/option><option  value=\"Wallis and Futuna\" data-code=\"WF\">Wallis and Futuna<\/option><option  value=\"Western Sahara\" data-code=\"EH\">Western Sahara<\/option><option  value=\"Yemen\" data-code=\"YE\">Yemen<\/option><option  value=\"Zambia\" data-code=\"ZM\">Zambia<\/option><option  value=\"Zimbabwe\" data-code=\"ZW\">Zimbabwe<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">Country<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_87_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_wmze7\" class=\"frm_primary_label\">Email Contact\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_wmze7\" name=\"item_meta[87]\" value=\"\"  data-reqmsg=\"Email Contact cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email Contact is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_88_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_sbs53\" class=\"frm_primary_label\">Cellphone Contact\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_sbs53\" name=\"item_meta[88]\" value=\"\"  style=\"width:115px\" data-reqmsg=\"Cellphone Contact cannot be blank.\" aria-required=\"true\" data-invmsg=\"Cellphone Contact is invalid\" class=\"auto_width\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_89_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_op5iu\" class=\"frm_primary_label\">Family Address\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <fieldset aria-labelledby=\"field_op5iu_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tFamily Address<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_89-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_op5iu_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tFamily Address\t<\/label>\n\t\t<input type=\"text\" id=\"field_op5iu_line1\" value=\"\" name=\"item_meta[89][line1]\"  data-reqmsg=\"Family Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Family Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_89-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_op5iu_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tFamily Address\t<\/label>\n\t\t<input type=\"text\" id=\"field_op5iu_line2\" value=\"\" name=\"item_meta[89][line2]\"  data-reqmsg=\"Family Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Family Address is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_89-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_op5iu_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_op5iu_city\" value=\"\" name=\"item_meta[89][city]\"  data-reqmsg=\"Family Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Family Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_89-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_op5iu_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\t<\/label>\n\t\t<input type=\"text\" id=\"field_op5iu_state\" value=\"\" name=\"item_meta[89][state]\"  data-reqmsg=\"Family Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Family Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\" \/>\n\t<div class=\"frm_description\">State\/Province<\/div><\/div>\n<div id=\"frm_field_89-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_op5iu_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_op5iu_zip\" value=\"\" name=\"item_meta[89][zip]\"  data-reqmsg=\"Family Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Family Address is invalid\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal<\/div><\/div>\n<div id=\"frm_field_89-country_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_op5iu_country\" class=\"frm_screen_reader frm_hidden\">\n\t\tCountry\t<\/label>\n\t\t\t<select name=\"item_meta[89][country]\" id=\"field_op5iu_country\"  data-reqmsg=\"Family Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Family Address is invalid\" aria-invalid=\"false\"   autocomplete=\"country-name\">\n\t\t\t<option value=\"\" class=\"\">\n\t\t\t\t \t\t\t<\/option>\n\t\t\t<option  value=\"Afghanistan\" data-code=\"AF\">Afghanistan<\/option><option  value=\"Aland Islands\" data-code=\"AX\">Aland Islands<\/option><option  value=\"Albania\" data-code=\"AL\">Albania<\/option><option  value=\"Algeria\" data-code=\"DZ\">Algeria<\/option><option  value=\"American Samoa\" data-code=\"AS\">American Samoa<\/option><option  value=\"Andorra\" data-code=\"AD\">Andorra<\/option><option  value=\"Angola\" data-code=\"AO\">Angola<\/option><option  value=\"Anguilla\" data-code=\"AI\">Anguilla<\/option><option  value=\"Antarctica\" data-code=\"AQ\">Antarctica<\/option><option  value=\"Antigua and Barbuda\" data-code=\"AG\">Antigua and Barbuda<\/option><option  value=\"Argentina\" data-code=\"AR\">Argentina<\/option><option  value=\"Armenia\" data-code=\"AM\">Armenia<\/option><option  value=\"Aruba\" data-code=\"AW\">Aruba<\/option><option  value=\"Australia\" data-code=\"AU\">Australia<\/option><option  value=\"Austria\" data-code=\"AT\">Austria<\/option><option  value=\"Azerbaijan\" data-code=\"AZ\">Azerbaijan<\/option><option  value=\"Bahamas\" data-code=\"BS\">Bahamas<\/option><option  value=\"Bahrain\" data-code=\"BH\">Bahrain<\/option><option  value=\"Bangladesh\" data-code=\"BD\">Bangladesh<\/option><option  value=\"Barbados\" data-code=\"BB\">Barbados<\/option><option  value=\"Belarus\" data-code=\"BY\">Belarus<\/option><option  value=\"Belgium\" data-code=\"BE\">Belgium<\/option><option  value=\"Belize\" data-code=\"BZ\">Belize<\/option><option  value=\"Benin\" data-code=\"BJ\">Benin<\/option><option  value=\"Bermuda\" data-code=\"BM\">Bermuda<\/option><option  value=\"Bhutan\" data-code=\"BT\">Bhutan<\/option><option  value=\"Bolivia\" data-code=\"BO\">Bolivia<\/option><option  value=\"Bonaire, Sint Eustatius and Saba\">Bonaire, Sint Eustatius and Saba<\/option><option  value=\"Bosnia and Herzegovina\" data-code=\"BA\">Bosnia and Herzegovina<\/option><option  value=\"Botswana\" data-code=\"BW\">Botswana<\/option><option  value=\"Bouvet Island\" data-code=\"BV\">Bouvet Island<\/option><option  value=\"Brazil\" data-code=\"BR\">Brazil<\/option><option  value=\"British Indian Ocean Territory\" data-code=\"IO\">British Indian Ocean Territory<\/option><option  value=\"Brunei\" data-code=\"BN\">Brunei<\/option><option  value=\"Bulgaria\" data-code=\"BG\">Bulgaria<\/option><option  value=\"Burkina Faso\" data-code=\"BF\">Burkina Faso<\/option><option  value=\"Burundi\" data-code=\"BI\">Burundi<\/option><option  value=\"C&ocirc;te d&#039;Ivoire\">C&ocirc;te d&#039;Ivoire<\/option><option  value=\"Cambodia\" data-code=\"KH\">Cambodia<\/option><option  value=\"Cameroon\" data-code=\"CM\">Cameroon<\/option><option  value=\"Canada\" data-code=\"CA\">Canada<\/option><option  value=\"Cape Verde\" data-code=\"CV\">Cape Verde<\/option><option  value=\"Cayman Islands\" data-code=\"KY\">Cayman Islands<\/option><option  value=\"Central African Republic\" data-code=\"CF\">Central African Republic<\/option><option  value=\"Chad\" data-code=\"TD\">Chad<\/option><option  value=\"Chile\" data-code=\"CL\">Chile<\/option><option  value=\"China\" data-code=\"CN\">China<\/option><option  value=\"Christmas Island\" data-code=\"CX\">Christmas Island<\/option><option  value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option  value=\"Colombia\" data-code=\"CO\">Colombia<\/option><option  value=\"Comoros\" data-code=\"KM\">Comoros<\/option><option  value=\"Congo\">Congo<\/option><option  value=\"Cook Islands\" data-code=\"CK\">Cook Islands<\/option><option  value=\"Costa Rica\" data-code=\"CR\">Costa Rica<\/option><option  value=\"Croatia\" data-code=\"HR\">Croatia<\/option><option  value=\"Cuba\" data-code=\"CU\">Cuba<\/option><option  value=\"Curacao\" data-code=\"CW\">Curacao<\/option><option  value=\"Cyprus\" data-code=\"CY\">Cyprus<\/option><option  value=\"Czech Republic\" data-code=\"CZ\">Czech Republic<\/option><option  value=\"Denmark\" data-code=\"DK\">Denmark<\/option><option  value=\"Djibouti\" data-code=\"DJ\">Djibouti<\/option><option  value=\"Dominica\" data-code=\"DM\">Dominica<\/option><option  value=\"Dominican Republic\" data-code=\"DO\">Dominican Republic<\/option><option  value=\"East Timor\" data-code=\"TL\">East Timor<\/option><option  value=\"Ecuador\" data-code=\"EC\">Ecuador<\/option><option  value=\"Egypt\" data-code=\"EG\">Egypt<\/option><option  value=\"El Salvador\" data-code=\"SV\">El Salvador<\/option><option  value=\"Equatorial Guinea\" data-code=\"GQ\">Equatorial Guinea<\/option><option  value=\"Eritrea\" data-code=\"ER\">Eritrea<\/option><option  value=\"Estonia\" data-code=\"EE\">Estonia<\/option><option  value=\"Ethiopia\" data-code=\"ET\">Ethiopia<\/option><option  value=\"Falkland Islands (Malvinas)\">Falkland Islands (Malvinas)<\/option><option  value=\"Faroe Islands\" data-code=\"FO\">Faroe Islands<\/option><option  value=\"Fiji\" data-code=\"FJ\">Fiji<\/option><option  value=\"Finland\" data-code=\"FI\">Finland<\/option><option  value=\"France\" data-code=\"FR\">France<\/option><option  value=\"French Guiana\" data-code=\"GF\">French Guiana<\/option><option  value=\"French Polynesia\" data-code=\"PF\">French Polynesia<\/option><option  value=\"French Southern Territories\" data-code=\"TF\">French Southern Territories<\/option><option  value=\"Gabon\" data-code=\"GA\">Gabon<\/option><option  value=\"Gambia\" data-code=\"GM\">Gambia<\/option><option  value=\"Georgia\" data-code=\"GE\">Georgia<\/option><option  value=\"Germany\" data-code=\"DE\">Germany<\/option><option  value=\"Ghana\" data-code=\"GH\">Ghana<\/option><option  value=\"Gibraltar\" data-code=\"GI\">Gibraltar<\/option><option  value=\"Greece\" data-code=\"GR\">Greece<\/option><option  value=\"Greenland\" data-code=\"GL\">Greenland<\/option><option  value=\"Grenada\" data-code=\"GD\">Grenada<\/option><option  value=\"Guadeloupe\" data-code=\"GP\">Guadeloupe<\/option><option  value=\"Guam\" data-code=\"GU\">Guam<\/option><option  value=\"Guatemala\" data-code=\"GT\">Guatemala<\/option><option  value=\"Guernsey\" data-code=\"GG\">Guernsey<\/option><option  value=\"Guinea\" data-code=\"GN\">Guinea<\/option><option  value=\"Guinea-Bissau\" data-code=\"GW\">Guinea-Bissau<\/option><option  value=\"Guyana\" data-code=\"GY\">Guyana<\/option><option  value=\"Haiti\" data-code=\"HT\">Haiti<\/option><option  value=\"Heard Island and McDonald Islands\" data-code=\"HM\">Heard Island and McDonald Islands<\/option><option  value=\"Holy See\">Holy See<\/option><option  value=\"Honduras\" data-code=\"HN\">Honduras<\/option><option  value=\"Hong Kong\" data-code=\"HK\">Hong Kong<\/option><option  value=\"Hungary\" data-code=\"HU\">Hungary<\/option><option  value=\"Iceland\" data-code=\"IS\">Iceland<\/option><option  value=\"India\" data-code=\"IN\">India<\/option><option  value=\"Indonesia\" data-code=\"ID\">Indonesia<\/option><option  value=\"Iran\" data-code=\"IR\">Iran<\/option><option  value=\"Iraq\" data-code=\"IQ\">Iraq<\/option><option  value=\"Ireland\" data-code=\"IE\">Ireland<\/option><option  value=\"Isle of Man\" data-code=\"IM\">Isle of Man<\/option><option  value=\"Israel\" data-code=\"IL\">Israel<\/option><option  value=\"Italy\" data-code=\"IT\">Italy<\/option><option  value=\"Jamaica\" data-code=\"JM\">Jamaica<\/option><option  value=\"Japan\" data-code=\"JP\">Japan<\/option><option  value=\"Jersey\" data-code=\"JE\">Jersey<\/option><option  value=\"Jordan\" data-code=\"JO\">Jordan<\/option><option  value=\"Kazakhstan\" data-code=\"KZ\">Kazakhstan<\/option><option  value=\"Kenya\" data-code=\"KE\">Kenya<\/option><option  value=\"Kiribati\" data-code=\"KI\">Kiribati<\/option><option  value=\"Kosovo\" data-code=\"XK\">Kosovo<\/option><option  value=\"Kuwait\" data-code=\"KW\">Kuwait<\/option><option  value=\"Kyrgyzstan\" data-code=\"KG\">Kyrgyzstan<\/option><option  value=\"Laos\" data-code=\"LA\">Laos<\/option><option  value=\"Latvia\" data-code=\"LV\">Latvia<\/option><option  value=\"Lebanon\" data-code=\"LB\">Lebanon<\/option><option  value=\"Lesotho\" data-code=\"LS\">Lesotho<\/option><option  value=\"Liberia\" data-code=\"LR\">Liberia<\/option><option  value=\"Libya\" data-code=\"LY\">Libya<\/option><option  value=\"Liechtenstein\" data-code=\"LI\">Liechtenstein<\/option><option  value=\"Lithuania\" data-code=\"LT\">Lithuania<\/option><option  value=\"Luxembourg\" data-code=\"LU\">Luxembourg<\/option><option  value=\"Macao\" data-code=\"MO\">Macao<\/option><option  value=\"Macedonia\" data-code=\"MK\">Macedonia<\/option><option  value=\"Madagascar\" data-code=\"MG\">Madagascar<\/option><option  value=\"Malawi\" data-code=\"MW\">Malawi<\/option><option  value=\"Malaysia\" data-code=\"MY\">Malaysia<\/option><option  value=\"Maldives\" data-code=\"MV\">Maldives<\/option><option  value=\"Mali\" data-code=\"ML\">Mali<\/option><option  value=\"Malta\" data-code=\"MT\">Malta<\/option><option  value=\"Marshall Islands\" data-code=\"MH\">Marshall Islands<\/option><option  value=\"Martinique\" data-code=\"MQ\">Martinique<\/option><option  value=\"Mauritania\" data-code=\"MR\">Mauritania<\/option><option  value=\"Mauritius\" data-code=\"MU\">Mauritius<\/option><option  value=\"Mayotte\" data-code=\"YT\">Mayotte<\/option><option  value=\"Mexico\" data-code=\"MX\">Mexico<\/option><option  value=\"Micronesia\" data-code=\"FM\">Micronesia<\/option><option  value=\"Moldova\" data-code=\"MD\">Moldova<\/option><option  value=\"Monaco\" data-code=\"MC\">Monaco<\/option><option  value=\"Mongolia\" data-code=\"MN\">Mongolia<\/option><option  value=\"Montenegro\" data-code=\"ME\">Montenegro<\/option><option  value=\"Montserrat\" data-code=\"MS\">Montserrat<\/option><option  value=\"Morocco\" data-code=\"MA\">Morocco<\/option><option  value=\"Mozambique\" data-code=\"MZ\">Mozambique<\/option><option  value=\"Myanmar\" data-code=\"MM\">Myanmar<\/option><option  value=\"Namibia\" data-code=\"NA\">Namibia<\/option><option  value=\"Nauru\" data-code=\"NR\">Nauru<\/option><option  value=\"Nepal\" data-code=\"NP\">Nepal<\/option><option  value=\"Netherlands\" data-code=\"NL\">Netherlands<\/option><option  value=\"New Caledonia\" data-code=\"NC\">New Caledonia<\/option><option  value=\"New Zealand\" data-code=\"NZ\">New Zealand<\/option><option  value=\"Nicaragua\" data-code=\"NI\">Nicaragua<\/option><option  value=\"Niger\" data-code=\"NE\">Niger<\/option><option  value=\"Nigeria\" data-code=\"NG\">Nigeria<\/option><option  value=\"Niue\" data-code=\"NU\">Niue<\/option><option  value=\"Norfolk Island\" data-code=\"NF\">Norfolk Island<\/option><option  value=\"North Korea\" data-code=\"KP\">North Korea<\/option><option  value=\"Northern Mariana Islands\" data-code=\"MP\">Northern Mariana Islands<\/option><option  value=\"Norway\" data-code=\"NO\">Norway<\/option><option  value=\"Oman\" data-code=\"OM\">Oman<\/option><option  value=\"Pakistan\" data-code=\"PK\">Pakistan<\/option><option  value=\"Palau\" data-code=\"PW\">Palau<\/option><option  value=\"Palestine\">Palestine<\/option><option  value=\"Panama\" data-code=\"PA\">Panama<\/option><option  value=\"Papua New Guinea\" data-code=\"PG\">Papua New Guinea<\/option><option  value=\"Paraguay\" data-code=\"PY\">Paraguay<\/option><option  value=\"Peru\" data-code=\"PE\">Peru<\/option><option  value=\"Philippines\" data-code=\"PH\">Philippines<\/option><option  value=\"Pitcairn\" data-code=\"PN\">Pitcairn<\/option><option  value=\"Poland\" data-code=\"PL\">Poland<\/option><option  value=\"Portugal\" data-code=\"PT\">Portugal<\/option><option  value=\"Puerto Rico\" data-code=\"PR\">Puerto Rico<\/option><option  value=\"Qatar\" data-code=\"QA\">Qatar<\/option><option  value=\"Reunion\" data-code=\"RE\">Reunion<\/option><option  value=\"Romania\" data-code=\"RO\">Romania<\/option><option  value=\"Russia\" data-code=\"RU\">Russia<\/option><option  value=\"Rwanda\" data-code=\"RW\">Rwanda<\/option><option  value=\"Saint Barthelemy\" data-code=\"BL\">Saint Barthelemy<\/option><option  value=\"Saint Helena, Ascension and Tristan da Cunha\">Saint Helena, Ascension and Tristan da Cunha<\/option><option  value=\"Saint Kitts and Nevis\" data-code=\"KN\">Saint Kitts and Nevis<\/option><option  value=\"Saint Lucia\" data-code=\"LC\">Saint Lucia<\/option><option  value=\"Saint Martin (French part)\">Saint Martin (French part)<\/option><option  value=\"Saint Pierre and Miquelon\" data-code=\"PM\">Saint Pierre and Miquelon<\/option><option  value=\"Saint Vincent and the Grenadines\" data-code=\"VC\">Saint Vincent and the Grenadines<\/option><option  value=\"Samoa\" data-code=\"WS\">Samoa<\/option><option  value=\"San Marino\" data-code=\"SM\">San Marino<\/option><option  value=\"Sao Tome and Principe\" data-code=\"ST\">Sao Tome and Principe<\/option><option  value=\"Saudi Arabia\" data-code=\"SA\">Saudi Arabia<\/option><option  value=\"Senegal\" data-code=\"SN\">Senegal<\/option><option  value=\"Serbia\" data-code=\"RS\">Serbia<\/option><option  value=\"Seychelles\" data-code=\"SC\">Seychelles<\/option><option  value=\"Sierra Leone\" data-code=\"SL\">Sierra Leone<\/option><option  value=\"Singapore\" data-code=\"SG\">Singapore<\/option><option  value=\"Sint Maarten (Dutch part)\">Sint Maarten (Dutch part)<\/option><option  value=\"Slovakia\" data-code=\"SK\">Slovakia<\/option><option  value=\"Slovenia\" data-code=\"SI\">Slovenia<\/option><option  value=\"Solomon Islands\" data-code=\"SB\">Solomon Islands<\/option><option  value=\"Somalia\" data-code=\"SO\">Somalia<\/option><option  value=\"South Africa\" data-code=\"ZA\">South Africa<\/option><option  value=\"South Georgia and the South Sandwich Islands\" data-code=\"GS\">South Georgia and the South Sandwich Islands<\/option><option  value=\"South Korea\" data-code=\"KR\">South Korea<\/option><option  value=\"South Sudan\" data-code=\"SS\">South Sudan<\/option><option  value=\"Spain\" data-code=\"ES\">Spain<\/option><option  value=\"Sri Lanka\" data-code=\"LK\">Sri Lanka<\/option><option  value=\"Sudan\" data-code=\"SD\">Sudan<\/option><option  value=\"Suriname\" data-code=\"SR\">Suriname<\/option><option  value=\"Svalbard and Jan Mayen\" data-code=\"SJ\">Svalbard and Jan Mayen<\/option><option  value=\"Swaziland\" data-code=\"SZ\">Swaziland<\/option><option  value=\"Sweden\" data-code=\"SE\">Sweden<\/option><option  value=\"Switzerland\" data-code=\"CH\">Switzerland<\/option><option  value=\"Syria\" data-code=\"SY\">Syria<\/option><option  value=\"Taiwan\" data-code=\"TW\">Taiwan<\/option><option  value=\"Tajikistan\" data-code=\"TJ\">Tajikistan<\/option><option  value=\"Tanzania\" data-code=\"TZ\">Tanzania<\/option><option  value=\"Thailand\" data-code=\"TH\">Thailand<\/option><option  value=\"Timor-Leste\">Timor-Leste<\/option><option  value=\"Togo\" data-code=\"TG\">Togo<\/option><option  value=\"Tokelau\" data-code=\"TK\">Tokelau<\/option><option  value=\"Tonga\" data-code=\"TO\">Tonga<\/option><option  value=\"Trinidad and Tobago\" data-code=\"TT\">Trinidad and Tobago<\/option><option  value=\"Tunisia\" data-code=\"TN\">Tunisia<\/option><option  value=\"Turkey\" data-code=\"TR\">Turkey<\/option><option  value=\"Turkmenistan\" data-code=\"TM\">Turkmenistan<\/option><option  value=\"Turks and Caicos Islands\" data-code=\"TC\">Turks and Caicos Islands<\/option><option  value=\"Tuvalu\" data-code=\"TV\">Tuvalu<\/option><option  value=\"Uganda\" data-code=\"UG\">Uganda<\/option><option  value=\"Ukraine\" data-code=\"UA\">Ukraine<\/option><option  value=\"United Arab Emirates\" data-code=\"AE\">United Arab Emirates<\/option><option  value=\"United Kingdom\" data-code=\"GB\">United Kingdom<\/option><option  value=\"United States\" data-code=\"US\">United States<\/option><option  value=\"United States Minor Outlying Islands\" data-code=\"UM\">United States Minor Outlying Islands<\/option><option  value=\"Uruguay\" data-code=\"UY\">Uruguay<\/option><option  value=\"Uzbekistan\" data-code=\"UZ\">Uzbekistan<\/option><option  value=\"Vanuatu\" data-code=\"VU\">Vanuatu<\/option><option  value=\"Vatican City\">Vatican City<\/option><option  value=\"Venezuela\" data-code=\"VE\">Venezuela<\/option><option  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custom_padding=&#8221;50px|25px|15px|25px|false|true&#8221;][\/et_pb_number_counter][\/et_pb_column][et_pb_column type=&#8221;1_2&#8243; _builder_version=&#8221;3.0.47&#8243; parallax=&#8221;off&#8221; parallax_method=&#8221;on&#8221;][et_pb_cta title=&#8221;Get In Touch&#8221; button_url=&#8221;mailto:debbie.weissenburger@aimint.org&#8221; button_text=&#8221;Contact Us&#8221; _builder_version=&#8221;3.9&#8243; header_font=&#8221;Rubik|700|||||||&#8221; header_font_size=&#8221;40px&#8221; header_font_size_phone=&#8221;30px&#8221; header_font_size_last_edited=&#8221;on|phone&#8221; header_line_height=&#8221;1.4em&#8221; body_font=&#8221;Rubik||||||||&#8221; body_line_height=&#8221;2em&#8221; body_line_height_last_edited=&#8221;off|desktop&#8221; background_color=&#8221;#ffffff&#8221; border_radii=&#8221;on|10px|10px|10px|10px&#8221; custom_button=&#8221;on&#8221; button_text_size=&#8221;16px&#8221; button_text_color=&#8221;#ffffff&#8221; button_bg_color=&#8221;#7f5aff&#8221; button_border_width=&#8221;10px&#8221; button_border_color=&#8221;rgba(65,65,144,0)&#8221; button_border_radius=&#8221;70px&#8221; button_font=&#8221;Rubik|700|||||||&#8221; button_use_icon=&#8221;off&#8221; button_text_color_hover=&#8221;#ffffff&#8221; button_bg_color_hover=&#8221;#9577ff&#8221; button_border_radius_hover=&#8221;70px&#8221; text_orientation=&#8221;left&#8221; background_layout=&#8221;light&#8221; max_width_last_edited=&#8221;off|desktop&#8221; module_alignment=&#8221;right&#8221; custom_margin=&#8221;|||&#8221; custom_padding=&#8221;64px|60px|64px|60px|true&#8221;]<\/p>\n<p><strong>Location:<\/strong> N&#8217;Djamena, Chad<\/p>\n<p><strong>Email:\u00a0<\/strong><a href=\"mailto:debbie.weissenburger@aimint.org\">Debbie Weissenburger<\/a><\/p>\n<p><strong>School Hours:<\/strong> M-F: 7:30am &#8211; 12:50pm<\/p>\n<p>\u00a0<\/p>\n<p>\u00a0<\/p>\n<p>[\/et_pb_cta][\/et_pb_column][\/et_pb_row][et_pb_row disabled_on=&#8221;off|off|off&#8221; _builder_version=&#8221;3.5&#8243;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;3.0.47&#8243; parallax=&#8221;off&#8221; parallax_method=&#8221;on&#8221;][et_pb_text _builder_version=&#8221;3.9&#8243; text_font=&#8221;Rubik||||||||&#8221; text_line_height=&#8221;2em&#8221; text_line_height_last_edited=&#8221;off|desktop&#8221; header_font=&#8221;||||||||&#8221; header_2_font=&#8221;Rubik|700||on|||||&#8221; header_2_font_size=&#8221;12px&#8221; header_2_letter_spacing=&#8221;3px&#8221; header_2_line_height=&#8221;1.5em&#8221; header_5_font=&#8221;Rubik|700||on|||||&#8221; header_5_font_size=&#8221;12px&#8221; header_5_letter_spacing=&#8221;3px&#8221; header_5_line_height=&#8221;1.5em&#8221; max_width=&#8221;700px&#8221; module_alignment=&#8221;center&#8221; custom_margin=&#8221;50px||||false&#8221; custom_margin_tablet=&#8221;0px|||&#8221; custom_margin_last_edited=&#8221;off|desktop&#8221;]<\/p>\n<h5>Wellspring Policies<\/h5>\n<p><span style=\"font-size: 14px\">To view our current policies and procedures please visit the <a href=\"https:\/\/aimint.org\/wellspring\/policies\">Policies and Procedures<\/a> page.<br \/> <\/span><\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;3.9&#8243; background_image=&#8221;https:\/\/aimint.org\/wellspring\/wp-content\/uploads\/sites\/37\/2018\/07\/shapes-bg-color.png&#8221; global_module=&#8221;764&#8243; saved_tabs=&#8221;all&#8221;][et_pb_row _builder_version=&#8221;3.9&#8243;][et_pb_column type=&#8221;1_4&#8243; _builder_version=&#8221;3.9&#8243; parallax=&#8221;off&#8221; parallax_method=&#8221;on&#8221;][et_pb_cta button_url=&#8221;https:\/\/aimint.org\/wellspring\/about\/&#8221; button_text=&#8221;ABOUT&#8221; _builder_version=&#8221;3.9&#8243; header_font=&#8221;||||||||&#8221; header_font_size=&#8221;26px&#8221; use_background_color=&#8221;off&#8221; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; border_radii=&#8221;on|10px|10px|10px|10px&#8221; custom_button=&#8221;on&#8221; button_bg_color=&#8221;#2b76df&#8221; button_border_radius=&#8221;10px&#8221; button_letter_spacing=&#8221;5px&#8221; button_font=&#8221;Cabin Sketch|700|||||||&#8221; button_bg_color_hover=&#8221;#2b76df&#8221; button_border_radius_hover=&#8221;10px&#8221; button_letter_spacing_hover=&#8221;6px&#8221; button_alignment=&#8221;center&#8221; custom_margin=&#8221;|||&#8221; custom_padding=&#8221;|||&#8221;][\/et_pb_cta][\/et_pb_column][et_pb_column type=&#8221;1_4&#8243; _builder_version=&#8221;3.9&#8243; parallax=&#8221;off&#8221; parallax_method=&#8221;on&#8221;][et_pb_cta button_url=&#8221;http:\/\/usgiving.aimint.org\/project\/chad-missionary-kids-school&#8221; button_text=&#8221;GIVE&#8221; _builder_version=&#8221;3.9&#8243; header_font=&#8221;||||||||&#8221; header_font_size=&#8221;26px&#8221; use_background_color=&#8221;off&#8221; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; border_radii=&#8221;on|10px|10px|10px|10px&#8221; custom_button=&#8221;on&#8221; button_bg_color=&#8221;#ff7355&#8243; button_border_radius=&#8221;10px&#8221; button_letter_spacing=&#8221;5px&#8221; button_font=&#8221;Cabin Sketch|700|||||||&#8221; button_bg_color_hover=&#8221;#ff7355&#8243; button_border_radius_hover=&#8221;10px&#8221; button_letter_spacing_hover=&#8221;6px&#8221; button_alignment=&#8221;center&#8221;][\/et_pb_cta][\/et_pb_column][et_pb_column type=&#8221;1_4&#8243; _builder_version=&#8221;3.9&#8243; parallax=&#8221;off&#8221; parallax_method=&#8221;on&#8221;][et_pb_cta button_url=&#8221;https:\/\/aimint.org\/wellspring\/application\/&#8221; button_text=&#8221;APPLY&#8221; _builder_version=&#8221;3.9&#8243; header_font=&#8221;||||||||&#8221; header_font_size=&#8221;26px&#8221; use_background_color=&#8221;off&#8221; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; border_radii=&#8221;on|10px|10px|10px|10px&#8221; custom_button=&#8221;on&#8221; button_bg_color=&#8221;#ff9c02&#8243; button_border_radius=&#8221;10px&#8221; button_letter_spacing=&#8221;5px&#8221; button_font=&#8221;Cabin Sketch|700|||||||&#8221; button_bg_color_hover=&#8221;#ff9c02&#8243; button_border_radius_hover=&#8221;10px&#8221; button_letter_spacing_hover=&#8221;6px&#8221; button_alignment=&#8221;center&#8221;][\/et_pb_cta][\/et_pb_column][et_pb_column type=&#8221;1_4&#8243; _builder_version=&#8221;3.9&#8243; parallax=&#8221;off&#8221; parallax_method=&#8221;on&#8221;][et_pb_cta button_url=&#8221;https:\/\/aimint.org\/wellspring\/gallery&#8221; button_text=&#8221;GALLERY&#8221; _builder_version=&#8221;3.9&#8243; header_font=&#8221;||||||||&#8221; header_font_size=&#8221;26px&#8221; use_background_color=&#8221;off&#8221; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; border_radii=&#8221;on|10px|10px|10px|10px&#8221; custom_button=&#8221;on&#8221; button_bg_color=&#8221;#74bc19&#8243; button_border_radius=&#8221;10px&#8221; button_letter_spacing=&#8221;5px&#8221; button_font=&#8221;Cabin Sketch|700|||||||&#8221; button_bg_color_hover=&#8221;#74bc19&#8243; button_border_radius_hover=&#8221;10px&#8221; button_letter_spacing_hover=&#8221;6px&#8221; button_alignment=&#8221;center&#8221;][\/et_pb_cta][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Welcome to the Wellspring Academy application form. Please take the time to carefully fill out each section\u00a0to provide us with the information we need to best serve you and your family. <div class=\"frm_forms  with_frm_style frm_style_formidable-style-2\" id=\"frm_form_5_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_namlb\" >\n<div class=\"frm_form_fields  frm_page_num_1\">\n<fieldset>\n<legend class=\"frm_hidden\">Application Form<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"5\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_5\" id=\"frm_hide_fields_5\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"namlb\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_5\" name=\"frm_submit_entry_5\" value=\"5712b82180\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wellspring\/wp-json\/wp\/v2\/pages\/181\" \/><div id=\"frm_field_64_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_we3zy\" class=\"frm_primary_label\">Student First Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_we3zy\" name=\"item_meta[64]\" value=\"\"  data-reqmsg=\"Student First Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Student First Name is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_65_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_yvpwl\" class=\"frm_primary_label\">Last Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_yvpwl\" name=\"item_meta[65]\" value=\"\"  data-reqmsg=\"Last Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last Name is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_66_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_8kqff\" class=\"frm_primary_label\">Age\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"number\" id=\"field_8kqff\" name=\"item_meta[66]\" value=\"\" data-reqmsg=\"Age cannot be blank.\" aria-required=\"true\" data-invmsg=\"Age is invalid\" aria-invalid=\"false\"   min=\"0\" max=\"100\" step=\"any\" \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_67_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_f0vf0\" class=\"frm_primary_label\">Birth Date\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_f0vf0\" name=\"item_meta[67]\" value=\"\"  maxlength=\"10\" data-reqmsg=\"Birth Date cannot be blank.\" aria-required=\"true\" data-invmsg=\"Birth Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_68_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_49q7g\" class=\"frm_primary_label\">Nationality\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[68]\" id=\"field_49q7g\"  data-placeholder=\"Please Select One\"  placeholder=\"Please Select One\" data-reqmsg=\"Nationality cannot be blank.\" aria-required=\"true\" data-invmsg=\"Nationality is invalid\" class=\"auto_width\" aria-invalid=\"false\"  >\n\t\t<option  class=\"frm-select-placeholder\" value=\"\" data-placeholder=\"true\">Please Select One<\/option><option  value=\"Afghan\">Afghan<\/option><option  value=\"Albanian\">Albanian<\/option><option  value=\"Algerian\">Algerian<\/option><option  value=\"American\">American<\/option><option  value=\"Andorran\">Andorran<\/option><option  value=\"Angolan\">Angolan<\/option><option  value=\"Antiguans\">Antiguans<\/option><option  value=\"Argentinean\">Argentinean<\/option><option  value=\"Armenian\">Armenian<\/option><option  value=\"Australian\">Australian<\/option><option  value=\"Austrian\">Austrian<\/option><option  value=\"Azerbaijani\">Azerbaijani<\/option><option  value=\"Bahamian\">Bahamian<\/option><option  value=\"Bahraini\">Bahraini<\/option><option  value=\"Bangladeshi\">Bangladeshi<\/option><option  value=\"Barbadian\">Barbadian<\/option><option  value=\"Barbudans\">Barbudans<\/option><option  value=\"Batswana\">Batswana<\/option><option  value=\"Belarusian\">Belarusian<\/option><option  value=\"Belgian\">Belgian<\/option><option  value=\"Belizean\">Belizean<\/option><option  value=\"Beninese\">Beninese<\/option><option  value=\"Bhutanese\">Bhutanese<\/option><option  value=\"Bolivian\">Bolivian<\/option><option  value=\"Bosnian\">Bosnian<\/option><option  value=\"Brazilian\">Brazilian<\/option><option  value=\"British\">British<\/option><option  value=\"Bruneian\">Bruneian<\/option><option  value=\"Bulgarian\">Bulgarian<\/option><option  value=\"Burkinabe\">Burkinabe<\/option><option  value=\"Burmese\">Burmese<\/option><option  value=\"Burundian\">Burundian<\/option><option  value=\"Cambodian\">Cambodian<\/option><option  value=\"Cameroonian\">Cameroonian<\/option><option  value=\"Canadian\">Canadian<\/option><option  value=\"Cape Verdean\">Cape Verdean<\/option><option  value=\"Central African\">Central African<\/option><option  value=\"Chadian\">Chadian<\/option><option  value=\"Chilean\">Chilean<\/option><option  value=\"Chinese\">Chinese<\/option><option  value=\"Colombian\">Colombian<\/option><option  value=\"Comoran\">Comoran<\/option><option  value=\"Congolese\">Congolese<\/option><option  value=\"Congolese\">Congolese<\/option><option  value=\"Costa Rican\">Costa Rican<\/option><option  value=\"Croatian\">Croatian<\/option><option  value=\"Cuban\">Cuban<\/option><option  value=\"Cypriot\">Cypriot<\/option><option  value=\"Czech\">Czech<\/option><option  value=\"Danish\">Danish<\/option><option  value=\"Djibouti\">Djibouti<\/option><option  value=\"Dominican\">Dominican<\/option><option  value=\"Dominican\">Dominican<\/option><option  value=\"Dutch\">Dutch<\/option><option  value=\"Dutchman\">Dutchman<\/option><option  value=\"Dutchwoman\">Dutchwoman<\/option><option  value=\"East Timorese\">East Timorese<\/option><option  value=\"Ecuadorean\">Ecuadorean<\/option><option  value=\"Egyptian\">Egyptian<\/option><option  value=\"Emirian\">Emirian<\/option><option  value=\"Equatorial Guinean\">Equatorial Guinean<\/option><option  value=\"Eritrean\">Eritrean<\/option><option  value=\"Estonian\">Estonian<\/option><option  value=\"Ethiopian\">Ethiopian<\/option><option  value=\"Fijian\">Fijian<\/option><option  value=\"Filipino\">Filipino<\/option><option  value=\"Finnish\">Finnish<\/option><option  value=\"French\">French<\/option><option  value=\"Gabonese\">Gabonese<\/option><option  value=\"Gambian\">Gambian<\/option><option  value=\"Georgian\">Georgian<\/option><option  value=\"German\">German<\/option><option  value=\"Ghanaian\">Ghanaian<\/option><option  value=\"Greek\">Greek<\/option><option  value=\"Grenadian\">Grenadian<\/option><option  value=\"Guatemalan\">Guatemalan<\/option><option  value=\"Guinea-Bissauan\">Guinea-Bissauan<\/option><option  value=\"Guinean\">Guinean<\/option><option  value=\"Guyanese\">Guyanese<\/option><option  value=\"Haitian\">Haitian<\/option><option  value=\"Herzegovinian\">Herzegovinian<\/option><option  value=\"Honduran\">Honduran<\/option><option  value=\"Hungarian\">Hungarian<\/option><option  value=\"I-Kiribati\">I-Kiribati<\/option><option  value=\"Icelander\">Icelander<\/option><option  value=\"Indian\">Indian<\/option><option  value=\"Indonesian\">Indonesian<\/option><option  value=\"Iranian\">Iranian<\/option><option  value=\"Iraqi\">Iraqi<\/option><option  value=\"Irish\">Irish<\/option><option  value=\"Irish\">Irish<\/option><option  value=\"Israeli\">Israeli<\/option><option  value=\"Italian\">Italian<\/option><option  value=\"Ivorian\">Ivorian<\/option><option  value=\"Jamaican\">Jamaican<\/option><option  value=\"Japanese\">Japanese<\/option><option  value=\"Jordanian\">Jordanian<\/option><option  value=\"Kazakhstani\">Kazakhstani<\/option><option  value=\"Kenyan\">Kenyan<\/option><option  value=\"Kittian and Nevisian\">Kittian and Nevisian<\/option><option  value=\"Kuwaiti\">Kuwaiti<\/option><option  value=\"Kyrgyz\">Kyrgyz<\/option><option  value=\"Laotian\">Laotian<\/option><option  value=\"Latvian\">Latvian<\/option><option  value=\"Lebanese\">Lebanese<\/option><option  value=\"Liberian\">Liberian<\/option><option  value=\"Libyan\">Libyan<\/option><option  value=\"Liechtensteiner\">Liechtensteiner<\/option><option  value=\"Lithuanian\">Lithuanian<\/option><option  value=\"Luxembourger\">Luxembourger<\/option><option  value=\"Macedonian\">Macedonian<\/option><option  value=\"Malagasy\">Malagasy<\/option><option  value=\"Malawian\">Malawian<\/option><option  value=\"Malaysian\">Malaysian<\/option><option  value=\"Maldivan\">Maldivan<\/option><option  value=\"Malian\">Malian<\/option><option  value=\"Maltese\">Maltese<\/option><option  value=\"Marshallese\">Marshallese<\/option><option  value=\"Mauritanian\">Mauritanian<\/option><option  value=\"Mauritian\">Mauritian<\/option><option  value=\"Mexican\">Mexican<\/option><option  value=\"Micronesian\">Micronesian<\/option><option  value=\"Moldovan\">Moldovan<\/option><option  value=\"Monacan\">Monacan<\/option><option  value=\"Mongolian\">Mongolian<\/option><option  value=\"Moroccan\">Moroccan<\/option><option  value=\"Mosotho\">Mosotho<\/option><option  value=\"Motswana\">Motswana<\/option><option  value=\"Mozambican\">Mozambican<\/option><option  value=\"Namibian\">Namibian<\/option><option  value=\"Nauruan\">Nauruan<\/option><option  value=\"Nepalese\">Nepalese<\/option><option  value=\"Netherlander\">Netherlander<\/option><option  value=\"New Zealander\">New Zealander<\/option><option  value=\"Ni-Vanuatu\">Ni-Vanuatu<\/option><option  value=\"Nicaraguan\">Nicaraguan<\/option><option  value=\"Nigerian\">Nigerian<\/option><option  value=\"Nigerien\">Nigerien<\/option><option  value=\"North Korean\">North Korean<\/option><option  value=\"Northern Irish\">Northern Irish<\/option><option  value=\"Norwegian\">Norwegian<\/option><option  value=\"Omani\">Omani<\/option><option  value=\"Pakistani\">Pakistani<\/option><option  value=\"Palauan\">Palauan<\/option><option  value=\"Panamanian\">Panamanian<\/option><option  value=\"Papua New Guinean\">Papua New Guinean<\/option><option  value=\"Paraguayan\">Paraguayan<\/option><option  value=\"Peruvian\">Peruvian<\/option><option  value=\"Polish\">Polish<\/option><option  value=\"Portuguese\">Portuguese<\/option><option  value=\"Qatari\">Qatari<\/option><option  value=\"Romanian\">Romanian<\/option><option  value=\"Russian\">Russian<\/option><option  value=\"Rwandan\">Rwandan<\/option><option  value=\"Saint Lucian\">Saint Lucian<\/option><option  value=\"Salvadoran\">Salvadoran<\/option><option  value=\"Samoan\">Samoan<\/option><option  value=\"San Marinese\">San Marinese<\/option><option  value=\"Sao Tomean\">Sao Tomean<\/option><option  value=\"Saudi\">Saudi<\/option><option  value=\"Scottish\">Scottish<\/option><option  value=\"Senegalese\">Senegalese<\/option><option  value=\"Serbian\">Serbian<\/option><option  value=\"Seychellois\">Seychellois<\/option><option  value=\"Sierra Leonean\">Sierra Leonean<\/option><option  value=\"Singaporean\">Singaporean<\/option><option  value=\"Slovakian\">Slovakian<\/option><option  value=\"Slovenian\">Slovenian<\/option><option  value=\"Solomon Islander\">Solomon Islander<\/option><option  value=\"Somali\">Somali<\/option><option  value=\"South African\">South African<\/option><option  value=\"South Korean\">South Korean<\/option><option  value=\"Spanish\">Spanish<\/option><option  value=\"Sri Lankan\">Sri Lankan<\/option><option  value=\"Sudanese\">Sudanese<\/option><option  value=\"Surinamer\">Surinamer<\/option><option  value=\"Swazi\">Swazi<\/option><option  value=\"Swedish\">Swedish<\/option><option  value=\"Swiss\">Swiss<\/option><option  value=\"Syrian\">Syrian<\/option><option  value=\"Taiwanese\">Taiwanese<\/option><option  value=\"Tajik\">Tajik<\/option><option  value=\"Tanzanian\">Tanzanian<\/option><option  value=\"Thai\">Thai<\/option><option  value=\"Togolese\">Togolese<\/option><option  value=\"Tongan\">Tongan<\/option><option  value=\"Trinidadian or Tobagonian\">Trinidadian or Tobagonian<\/option><option  value=\"Tunisian\">Tunisian<\/option><option  value=\"Turkish\">Turkish<\/option><option  value=\"Tuvaluan\">Tuvaluan<\/option><option  value=\"Ugandan\">Ugandan<\/option><option  value=\"Ukrainian\">Ukrainian<\/option><option  value=\"Uruguayan\">Uruguayan<\/option><option  value=\"Uzbekistani\">Uzbekistani<\/option><option  value=\"Venezuelan\">Venezuelan<\/option><option  value=\"Vietnamese\">Vietnamese<\/option><option  value=\"Welsh\">Welsh<\/option><option  value=\"Welsh\">Welsh<\/option><option  value=\"Yemenite\">Yemenite<\/option><option  value=\"Zambian\">Zambian<\/option><option  value=\"Zimbabwean\">Zimbabwean<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_69_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_rglq3\" class=\"frm_primary_label\">Passport #\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_rglq3\" name=\"item_meta[69]\" value=\"\"  data-reqmsg=\"Passport # cannot be blank.\" aria-required=\"true\" data-invmsg=\"Passport # is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_70_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_md2tc\" class=\"frm_primary_label\">Male\/Female\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[70]\" id=\"field_md2tc\"  data-placeholder=\"Please Select One\"  placeholder=\"Please Select One\" data-reqmsg=\"Male\/Female cannot be blank.\" aria-required=\"true\" data-invmsg=\"Male\/Female is invalid\" class=\"auto_width\" aria-invalid=\"false\"  >\n\t\t<option  class=\"frm-select-placeholder\" value=\"\" data-placeholder=\"true\">Please Select One<\/option><option  value=\"Male\">Male<\/option><option  value=\"Female\">Female<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_71_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_vat7k\" class=\"frm_primary_label\">Grade currently Completing\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[71]\" id=\"field_vat7k\"  data-placeholder=\"Please Select One\"  placeholder=\"Please Select One\" data-reqmsg=\"Grade currently Completing cannot be blank.\" aria-required=\"true\" data-invmsg=\"Grade currently Completing is invalid\" class=\"auto_width\" aria-invalid=\"false\"  >\n\t\t<option  class=\"frm-select-placeholder\" value=\"\" data-placeholder=\"true\">Please Select One<\/option><option  value=\"Kindergarten\">Kindergarten<\/option><option  value=\"First Grade\">First Grade<\/option><option  value=\"Second Grade\">Second Grade<\/option><option  value=\"Third Grade\">Third Grade<\/option><option  value=\"Fourth Grade\">Fourth Grade<\/option><option  value=\"Fifth Grade\">Fifth Grade<\/option><option  value=\"Sixth Grade\">Sixth Grade<\/option><option  value=\"Seventh Grade\">Seventh Grade<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_72_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_na3zs\" class=\"frm_primary_label\">Please list previous schools or schooling\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[72]\" id=\"field_na3zs\" rows=\"5\"  data-reqmsg=\"Please list previous schools or schooling cannot be blank.\" aria-required=\"true\" data-invmsg=\"Please list previous schools or schooling is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_73_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_ns92z\" class=\"frm_primary_label\">Grade student is applying to join\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_ns92z\" name=\"item_meta[73]\" value=\"\"  data-reqmsg=\"Grade student is applying to join cannot be blank.\" aria-required=\"true\" data-invmsg=\"Grade student is applying to join is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_74_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_f7dwf\" class=\"frm_primary_label\">All languages the student speaks, reads, or writes\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_f7dwf\" name=\"item_meta[74]\" value=\"\"  data-reqmsg=\"All languages the student speaks, reads, or writes cannot be blank.\" aria-required=\"true\" data-invmsg=\"All languages the student speaks, reads, or writes is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_75_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_7gjbs\" class=\"frm_primary_label\">Language spoken at home\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_7gjbs\" name=\"item_meta[75]\" value=\"\"  data-reqmsg=\"Language spoken at home cannot be blank.\" aria-required=\"true\" data-invmsg=\"Language spoken at home is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_76_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_r3twg\" class=\"frm_primary_label\">Parent's first language(s)\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_r3twg\" name=\"item_meta[76]\" value=\"\"  data-reqmsg=\"Parent&#039;s first language(s) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Parent&#039;s first language(s) is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_77_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_7aj2q\" class=\"frm_primary_label\">Parent 1's First Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_7aj2q\" name=\"item_meta[77]\" value=\"\"  data-reqmsg=\"Parent 1&#039;s First Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Parent 1&#039;s First Name is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_78_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_ly5x2\" class=\"frm_primary_label\">Last Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_ly5x2\" name=\"item_meta[78]\" value=\"\"  data-reqmsg=\"Last Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last Name is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_79_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_6xiut\" class=\"frm_primary_label\">Email Address\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_6xiut\" name=\"item_meta[79]\" value=\"\"  data-reqmsg=\"Email Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email Address is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_80_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_xjq7\" class=\"frm_primary_label\">Cell Phone Number\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_xjq7\" name=\"item_meta[80]\" value=\"\"  style=\"width:115px\" data-reqmsg=\"Cell Phone Number cannot be blank.\" aria-required=\"true\" data-invmsg=\"Cell Phone Number is invalid\" class=\"auto_width\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_81_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_r2g49\" class=\"frm_primary_label\">Parent 2's First Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_r2g49\" name=\"item_meta[81]\" value=\"\"  data-reqmsg=\"Parent 2&#039;s First Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Parent 2&#039;s First Name is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_82_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_ql066\" class=\"frm_primary_label\">Last Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_ql066\" name=\"item_meta[82]\" value=\"\"  data-reqmsg=\"Last Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last Name is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_83_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_cs2m9\" class=\"frm_primary_label\">Email Address\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_cs2m9\" name=\"item_meta[83]\" value=\"\"  data-reqmsg=\"Email Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email Address is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_84_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_dfzzn\" class=\"frm_primary_label\">Cell Phone Number\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_dfzzn\" name=\"item_meta[84]\" value=\"\"  style=\"width:115px\" data-reqmsg=\"Cell Phone Number cannot be blank.\" aria-required=\"true\" data-invmsg=\"Cell Phone Number is invalid\" class=\"auto_width\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_85_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_oaq9\" class=\"frm_primary_label\">Organization Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_oaq9\" name=\"item_meta[85]\" value=\"\"  data-reqmsg=\"Organization Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Organization Name is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_86_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_6a9fw\" class=\"frm_primary_label\">Address\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <fieldset aria-labelledby=\"field_6a9fw_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tAddress<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_86-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_6a9fw_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress\t<\/label>\n\t\t<input type=\"text\" id=\"field_6a9fw_line1\" value=\"\" name=\"item_meta[86][line1]\"  data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_86-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_6a9fw_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress\t<\/label>\n\t\t<input type=\"text\" id=\"field_6a9fw_line2\" value=\"\" name=\"item_meta[86][line2]\"  data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_86-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_6a9fw_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_6a9fw_city\" value=\"\" name=\"item_meta[86][city]\"  data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_86-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_6a9fw_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\r\n\r\n(put N\/A if this does not apply)\t<\/label>\n\t\t<input type=\"text\" id=\"field_6a9fw_state\" value=\"\" name=\"item_meta[86][state]\"  data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\" \/>\n\t<div class=\"frm_description\">State\/Province\r\n\r\n(put N\/A if this does not apply)<\/div><\/div>\n<div id=\"frm_field_86-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_6a9fw_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\r\n(put N\/A if this does not apply)\t<\/label>\n\t\t<input type=\"text\" id=\"field_6a9fw_zip\" value=\"\" name=\"item_meta[86][zip]\"  data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal\r\n(put N\/A if this does not apply)<\/div><\/div>\n<div id=\"frm_field_86-country_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_6a9fw_country\" class=\"frm_screen_reader frm_hidden\">\n\t\tCountry\t<\/label>\n\t\t\t<select name=\"item_meta[86][country]\" id=\"field_6a9fw_country\"  data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"country-name\">\n\t\t\t<option value=\"\" class=\"\">\n\t\t\t\t \t\t\t<\/option>\n\t\t\t<option  value=\"Afghanistan\" data-code=\"AF\">Afghanistan<\/option><option  value=\"Aland Islands\" data-code=\"AX\">Aland Islands<\/option><option  value=\"Albania\" data-code=\"AL\">Albania<\/option><option  value=\"Algeria\" data-code=\"DZ\">Algeria<\/option><option  value=\"American Samoa\" data-code=\"AS\">American Samoa<\/option><option  value=\"Andorra\" data-code=\"AD\">Andorra<\/option><option  value=\"Angola\" data-code=\"AO\">Angola<\/option><option  value=\"Anguilla\" data-code=\"AI\">Anguilla<\/option><option  value=\"Antarctica\" data-code=\"AQ\">Antarctica<\/option><option  value=\"Antigua and Barbuda\" data-code=\"AG\">Antigua and Barbuda<\/option><option  value=\"Argentina\" data-code=\"AR\">Argentina<\/option><option  value=\"Armenia\" data-code=\"AM\">Armenia<\/option><option  value=\"Aruba\" data-code=\"AW\">Aruba<\/option><option  value=\"Australia\" data-code=\"AU\">Australia<\/option><option  value=\"Austria\" data-code=\"AT\">Austria<\/option><option  value=\"Azerbaijan\" data-code=\"AZ\">Azerbaijan<\/option><option  value=\"Bahamas\" data-code=\"BS\">Bahamas<\/option><option  value=\"Bahrain\" data-code=\"BH\">Bahrain<\/option><option  value=\"Bangladesh\" data-code=\"BD\">Bangladesh<\/option><option  value=\"Barbados\" data-code=\"BB\">Barbados<\/option><option  value=\"Belarus\" data-code=\"BY\">Belarus<\/option><option  value=\"Belgium\" data-code=\"BE\">Belgium<\/option><option  value=\"Belize\" data-code=\"BZ\">Belize<\/option><option  value=\"Benin\" data-code=\"BJ\">Benin<\/option><option  value=\"Bermuda\" data-code=\"BM\">Bermuda<\/option><option  value=\"Bhutan\" data-code=\"BT\">Bhutan<\/option><option  value=\"Bolivia\" data-code=\"BO\">Bolivia<\/option><option  value=\"Bonaire, Sint Eustatius and Saba\">Bonaire, Sint Eustatius and Saba<\/option><option  value=\"Bosnia and Herzegovina\" data-code=\"BA\">Bosnia and Herzegovina<\/option><option  value=\"Botswana\" data-code=\"BW\">Botswana<\/option><option  value=\"Bouvet Island\" data-code=\"BV\">Bouvet Island<\/option><option  value=\"Brazil\" data-code=\"BR\">Brazil<\/option><option  value=\"British Indian Ocean Territory\" data-code=\"IO\">British Indian Ocean Territory<\/option><option  value=\"Brunei\" data-code=\"BN\">Brunei<\/option><option  value=\"Bulgaria\" data-code=\"BG\">Bulgaria<\/option><option  value=\"Burkina Faso\" data-code=\"BF\">Burkina Faso<\/option><option  value=\"Burundi\" data-code=\"BI\">Burundi<\/option><option  value=\"C&ocirc;te d&#039;Ivoire\">C&ocirc;te d&#039;Ivoire<\/option><option  value=\"Cambodia\" data-code=\"KH\">Cambodia<\/option><option  value=\"Cameroon\" data-code=\"CM\">Cameroon<\/option><option  value=\"Canada\" data-code=\"CA\">Canada<\/option><option  value=\"Cape Verde\" data-code=\"CV\">Cape Verde<\/option><option  value=\"Cayman Islands\" data-code=\"KY\">Cayman Islands<\/option><option  value=\"Central African Republic\" data-code=\"CF\">Central African Republic<\/option><option  value=\"Chad\" data-code=\"TD\">Chad<\/option><option  value=\"Chile\" data-code=\"CL\">Chile<\/option><option  value=\"China\" data-code=\"CN\">China<\/option><option  value=\"Christmas Island\" data-code=\"CX\">Christmas Island<\/option><option  value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option  value=\"Colombia\" data-code=\"CO\">Colombia<\/option><option  value=\"Comoros\" data-code=\"KM\">Comoros<\/option><option  value=\"Congo\">Congo<\/option><option  value=\"Cook Islands\" data-code=\"CK\">Cook Islands<\/option><option  value=\"Costa Rica\" data-code=\"CR\">Costa Rica<\/option><option  value=\"Croatia\" data-code=\"HR\">Croatia<\/option><option  value=\"Cuba\" data-code=\"CU\">Cuba<\/option><option  value=\"Curacao\" data-code=\"CW\">Curacao<\/option><option  value=\"Cyprus\" data-code=\"CY\">Cyprus<\/option><option  value=\"Czech Republic\" data-code=\"CZ\">Czech Republic<\/option><option  value=\"Denmark\" data-code=\"DK\">Denmark<\/option><option  value=\"Djibouti\" data-code=\"DJ\">Djibouti<\/option><option  value=\"Dominica\" data-code=\"DM\">Dominica<\/option><option  value=\"Dominican Republic\" data-code=\"DO\">Dominican Republic<\/option><option  value=\"East Timor\" data-code=\"TL\">East Timor<\/option><option  value=\"Ecuador\" data-code=\"EC\">Ecuador<\/option><option  value=\"Egypt\" data-code=\"EG\">Egypt<\/option><option  value=\"El Salvador\" data-code=\"SV\">El Salvador<\/option><option  value=\"Equatorial Guinea\" data-code=\"GQ\">Equatorial Guinea<\/option><option  value=\"Eritrea\" data-code=\"ER\">Eritrea<\/option><option  value=\"Estonia\" data-code=\"EE\">Estonia<\/option><option  value=\"Ethiopia\" data-code=\"ET\">Ethiopia<\/option><option  value=\"Falkland Islands (Malvinas)\">Falkland Islands (Malvinas)<\/option><option  value=\"Faroe Islands\" data-code=\"FO\">Faroe Islands<\/option><option  value=\"Fiji\" data-code=\"FJ\">Fiji<\/option><option  value=\"Finland\" data-code=\"FI\">Finland<\/option><option  value=\"France\" data-code=\"FR\">France<\/option><option  value=\"French Guiana\" data-code=\"GF\">French Guiana<\/option><option  value=\"French Polynesia\" data-code=\"PF\">French Polynesia<\/option><option  value=\"French Southern Territories\" data-code=\"TF\">French Southern Territories<\/option><option  value=\"Gabon\" data-code=\"GA\">Gabon<\/option><option  value=\"Gambia\" data-code=\"GM\">Gambia<\/option><option  value=\"Georgia\" data-code=\"GE\">Georgia<\/option><option  value=\"Germany\" data-code=\"DE\">Germany<\/option><option  value=\"Ghana\" data-code=\"GH\">Ghana<\/option><option  value=\"Gibraltar\" data-code=\"GI\">Gibraltar<\/option><option  value=\"Greece\" data-code=\"GR\">Greece<\/option><option  value=\"Greenland\" data-code=\"GL\">Greenland<\/option><option  value=\"Grenada\" data-code=\"GD\">Grenada<\/option><option  value=\"Guadeloupe\" data-code=\"GP\">Guadeloupe<\/option><option  value=\"Guam\" data-code=\"GU\">Guam<\/option><option  value=\"Guatemala\" data-code=\"GT\">Guatemala<\/option><option  value=\"Guernsey\" data-code=\"GG\">Guernsey<\/option><option  value=\"Guinea\" data-code=\"GN\">Guinea<\/option><option  value=\"Guinea-Bissau\" data-code=\"GW\">Guinea-Bissau<\/option><option  value=\"Guyana\" data-code=\"GY\">Guyana<\/option><option  value=\"Haiti\" data-code=\"HT\">Haiti<\/option><option  value=\"Heard Island and McDonald Islands\" data-code=\"HM\">Heard Island and McDonald Islands<\/option><option  value=\"Holy See\">Holy See<\/option><option  value=\"Honduras\" data-code=\"HN\">Honduras<\/option><option  value=\"Hong Kong\" data-code=\"HK\">Hong Kong<\/option><option  value=\"Hungary\" data-code=\"HU\">Hungary<\/option><option  value=\"Iceland\" data-code=\"IS\">Iceland<\/option><option  value=\"India\" data-code=\"IN\">India<\/option><option  value=\"Indonesia\" data-code=\"ID\">Indonesia<\/option><option  value=\"Iran\" data-code=\"IR\">Iran<\/option><option  value=\"Iraq\" data-code=\"IQ\">Iraq<\/option><option  value=\"Ireland\" data-code=\"IE\">Ireland<\/option><option  value=\"Isle of Man\" data-code=\"IM\">Isle of Man<\/option><option  value=\"Israel\" data-code=\"IL\">Israel<\/option><option  value=\"Italy\" data-code=\"IT\">Italy<\/option><option  value=\"Jamaica\" data-code=\"JM\">Jamaica<\/option><option  value=\"Japan\" data-code=\"JP\">Japan<\/option><option  value=\"Jersey\" data-code=\"JE\">Jersey<\/option><option  value=\"Jordan\" data-code=\"JO\">Jordan<\/option><option  value=\"Kazakhstan\" data-code=\"KZ\">Kazakhstan<\/option><option  value=\"Kenya\" data-code=\"KE\">Kenya<\/option><option  value=\"Kiribati\" data-code=\"KI\">Kiribati<\/option><option  value=\"Kosovo\" data-code=\"XK\">Kosovo<\/option><option  value=\"Kuwait\" data-code=\"KW\">Kuwait<\/option><option  value=\"Kyrgyzstan\" data-code=\"KG\">Kyrgyzstan<\/option><option  value=\"Laos\" data-code=\"LA\">Laos<\/option><option  value=\"Latvia\" data-code=\"LV\">Latvia<\/option><option  value=\"Lebanon\" data-code=\"LB\">Lebanon<\/option><option  value=\"Lesotho\" data-code=\"LS\">Lesotho<\/option><option  value=\"Liberia\" data-code=\"LR\">Liberia<\/option><option  value=\"Libya\" data-code=\"LY\">Libya<\/option><option  value=\"Liechtenstein\" data-code=\"LI\">Liechtenstein<\/option><option  value=\"Lithuania\" data-code=\"LT\">Lithuania<\/option><option  value=\"Luxembourg\" data-code=\"LU\">Luxembourg<\/option><option  value=\"Macao\" data-code=\"MO\">Macao<\/option><option  value=\"Macedonia\" data-code=\"MK\">Macedonia<\/option><option  value=\"Madagascar\" data-code=\"MG\">Madagascar<\/option><option  value=\"Malawi\" data-code=\"MW\">Malawi<\/option><option  value=\"Malaysia\" data-code=\"MY\">Malaysia<\/option><option  value=\"Maldives\" data-code=\"MV\">Maldives<\/option><option  value=\"Mali\" data-code=\"ML\">Mali<\/option><option  value=\"Malta\" data-code=\"MT\">Malta<\/option><option  value=\"Marshall Islands\" data-code=\"MH\">Marshall Islands<\/option><option  value=\"Martinique\" data-code=\"MQ\">Martinique<\/option><option  value=\"Mauritania\" data-code=\"MR\">Mauritania<\/option><option  value=\"Mauritius\" data-code=\"MU\">Mauritius<\/option><option  value=\"Mayotte\" data-code=\"YT\">Mayotte<\/option><option  value=\"Mexico\" data-code=\"MX\">Mexico<\/option><option  value=\"Micronesia\" data-code=\"FM\">Micronesia<\/option><option  value=\"Moldova\" data-code=\"MD\">Moldova<\/option><option  value=\"Monaco\" data-code=\"MC\">Monaco<\/option><option  value=\"Mongolia\" data-code=\"MN\">Mongolia<\/option><option  value=\"Montenegro\" data-code=\"ME\">Montenegro<\/option><option  value=\"Montserrat\" data-code=\"MS\">Montserrat<\/option><option  value=\"Morocco\" data-code=\"MA\">Morocco<\/option><option  value=\"Mozambique\" data-code=\"MZ\">Mozambique<\/option><option  value=\"Myanmar\" data-code=\"MM\">Myanmar<\/option><option  value=\"Namibia\" data-code=\"NA\">Namibia<\/option><option  value=\"Nauru\" data-code=\"NR\">Nauru<\/option><option  value=\"Nepal\" data-code=\"NP\">Nepal<\/option><option  value=\"Netherlands\" data-code=\"NL\">Netherlands<\/option><option  value=\"New Caledonia\" data-code=\"NC\">New Caledonia<\/option><option  value=\"New Zealand\" data-code=\"NZ\">New Zealand<\/option><option  value=\"Nicaragua\" data-code=\"NI\">Nicaragua<\/option><option  value=\"Niger\" data-code=\"NE\">Niger<\/option><option  value=\"Nigeria\" data-code=\"NG\">Nigeria<\/option><option  value=\"Niue\" data-code=\"NU\">Niue<\/option><option  value=\"Norfolk Island\" data-code=\"NF\">Norfolk Island<\/option><option  value=\"North Korea\" data-code=\"KP\">North Korea<\/option><option  value=\"Northern Mariana Islands\" data-code=\"MP\">Northern Mariana Islands<\/option><option  value=\"Norway\" data-code=\"NO\">Norway<\/option><option  value=\"Oman\" data-code=\"OM\">Oman<\/option><option  value=\"Pakistan\" data-code=\"PK\">Pakistan<\/option><option  value=\"Palau\" data-code=\"PW\">Palau<\/option><option  value=\"Palestine\">Palestine<\/option><option  value=\"Panama\" data-code=\"PA\">Panama<\/option><option  value=\"Papua New Guinea\" data-code=\"PG\">Papua New Guinea<\/option><option  value=\"Paraguay\" data-code=\"PY\">Paraguay<\/option><option  value=\"Peru\" data-code=\"PE\">Peru<\/option><option  value=\"Philippines\" data-code=\"PH\">Philippines<\/option><option  value=\"Pitcairn\" data-code=\"PN\">Pitcairn<\/option><option  value=\"Poland\" data-code=\"PL\">Poland<\/option><option  value=\"Portugal\" data-code=\"PT\">Portugal<\/option><option  value=\"Puerto Rico\" data-code=\"PR\">Puerto Rico<\/option><option  value=\"Qatar\" data-code=\"QA\">Qatar<\/option><option  value=\"Reunion\" data-code=\"RE\">Reunion<\/option><option  value=\"Romania\" data-code=\"RO\">Romania<\/option><option  value=\"Russia\" data-code=\"RU\">Russia<\/option><option  value=\"Rwanda\" data-code=\"RW\">Rwanda<\/option><option  value=\"Saint Barthelemy\" data-code=\"BL\">Saint Barthelemy<\/option><option  value=\"Saint Helena, Ascension and Tristan da Cunha\">Saint Helena, Ascension and Tristan da Cunha<\/option><option  value=\"Saint Kitts and Nevis\" data-code=\"KN\">Saint Kitts and Nevis<\/option><option  value=\"Saint Lucia\" data-code=\"LC\">Saint Lucia<\/option><option  value=\"Saint Martin (French part)\">Saint Martin (French part)<\/option><option  value=\"Saint Pierre and Miquelon\" data-code=\"PM\">Saint Pierre and Miquelon<\/option><option  value=\"Saint Vincent and the Grenadines\" data-code=\"VC\">Saint Vincent and the Grenadines<\/option><option  value=\"Samoa\" data-code=\"WS\">Samoa<\/option><option  value=\"San Marino\" data-code=\"SM\">San Marino<\/option><option  value=\"Sao Tome and Principe\" data-code=\"ST\">Sao Tome and Principe<\/option><option  value=\"Saudi Arabia\" data-code=\"SA\">Saudi Arabia<\/option><option  value=\"Senegal\" data-code=\"SN\">Senegal<\/option><option  value=\"Serbia\" data-code=\"RS\">Serbia<\/option><option  value=\"Seychelles\" data-code=\"SC\">Seychelles<\/option><option  value=\"Sierra Leone\" data-code=\"SL\">Sierra Leone<\/option><option  value=\"Singapore\" data-code=\"SG\">Singapore<\/option><option  value=\"Sint Maarten (Dutch part)\">Sint Maarten (Dutch part)<\/option><option  value=\"Slovakia\" data-code=\"SK\">Slovakia<\/option><option  value=\"Slovenia\" data-code=\"SI\">Slovenia<\/option><option  value=\"Solomon Islands\" data-code=\"SB\">Solomon Islands<\/option><option  value=\"Somalia\" data-code=\"SO\">Somalia<\/option><option  value=\"South Africa\" data-code=\"ZA\">South Africa<\/option><option  value=\"South Georgia and the South Sandwich Islands\" data-code=\"GS\">South Georgia and the South Sandwich Islands<\/option><option  value=\"South Korea\" data-code=\"KR\">South Korea<\/option><option  value=\"South Sudan\" data-code=\"SS\">South Sudan<\/option><option  value=\"Spain\" data-code=\"ES\">Spain<\/option><option  value=\"Sri Lanka\" data-code=\"LK\">Sri Lanka<\/option><option  value=\"Sudan\" data-code=\"SD\">Sudan<\/option><option  value=\"Suriname\" data-code=\"SR\">Suriname<\/option><option  value=\"Svalbard and Jan Mayen\" data-code=\"SJ\">Svalbard and Jan Mayen<\/option><option  value=\"Swaziland\" data-code=\"SZ\">Swaziland<\/option><option  value=\"Sweden\" data-code=\"SE\">Sweden<\/option><option  value=\"Switzerland\" data-code=\"CH\">Switzerland<\/option><option  value=\"Syria\" data-code=\"SY\">Syria<\/option><option  value=\"Taiwan\" data-code=\"TW\">Taiwan<\/option><option  value=\"Tajikistan\" data-code=\"TJ\">Tajikistan<\/option><option  value=\"Tanzania\" data-code=\"TZ\">Tanzania<\/option><option  value=\"Thailand\" data-code=\"TH\">Thailand<\/option><option  value=\"Timor-Leste\">Timor-Leste<\/option><option  value=\"Togo\" data-code=\"TG\">Togo<\/option><option  value=\"Tokelau\" data-code=\"TK\">Tokelau<\/option><option  value=\"Tonga\" data-code=\"TO\">Tonga<\/option><option  value=\"Trinidad and Tobago\" data-code=\"TT\">Trinidad and Tobago<\/option><option  value=\"Tunisia\" data-code=\"TN\">Tunisia<\/option><option  value=\"Turkey\" data-code=\"TR\">Turkey<\/option><option  value=\"Turkmenistan\" data-code=\"TM\">Turkmenistan<\/option><option  value=\"Turks and Caicos Islands\" data-code=\"TC\">Turks and Caicos Islands<\/option><option  value=\"Tuvalu\" data-code=\"TV\">Tuvalu<\/option><option  value=\"Uganda\" data-code=\"UG\">Uganda<\/option><option  value=\"Ukraine\" data-code=\"UA\">Ukraine<\/option><option  value=\"United Arab Emirates\" data-code=\"AE\">United Arab Emirates<\/option><option  value=\"United Kingdom\" data-code=\"GB\">United Kingdom<\/option><option  value=\"United States\" data-code=\"US\">United States<\/option><option  value=\"United States Minor Outlying Islands\" data-code=\"UM\">United States Minor Outlying Islands<\/option><option  value=\"Uruguay\" data-code=\"UY\">Uruguay<\/option><option  value=\"Uzbekistan\" data-code=\"UZ\">Uzbekistan<\/option><option  value=\"Vanuatu\" data-code=\"VU\">Vanuatu<\/option><option  value=\"Vatican City\">Vatican City<\/option><option  value=\"Venezuela\" data-code=\"VE\">Venezuela<\/option><option  value=\"Vietnam\" data-code=\"VN\">Vietnam<\/option><option  value=\"Virgin Islands, British\">Virgin Islands, British<\/option><option  value=\"Virgin Islands, U.S.\">Virgin Islands, U.S.<\/option><option  value=\"Wallis and Futuna\" data-code=\"WF\">Wallis and Futuna<\/option><option  value=\"Western Sahara\" data-code=\"EH\">Western Sahara<\/option><option  value=\"Yemen\" data-code=\"YE\">Yemen<\/option><option  value=\"Zambia\" data-code=\"ZM\">Zambia<\/option><option  value=\"Zimbabwe\" data-code=\"ZW\">Zimbabwe<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">Country<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_87_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_wmze7\" class=\"frm_primary_label\">Email Contact\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_wmze7\" name=\"item_meta[87]\" value=\"\"  data-reqmsg=\"Email Contact cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email Contact is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_88_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_sbs53\" class=\"frm_primary_label\">Cellphone Contact\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_sbs53\" name=\"item_meta[88]\" value=\"\"  style=\"width:115px\" data-reqmsg=\"Cellphone Contact cannot be blank.\" aria-required=\"true\" data-invmsg=\"Cellphone Contact is invalid\" class=\"auto_width\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_89_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_op5iu\" class=\"frm_primary_label\">Family Address\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <fieldset aria-labelledby=\"field_op5iu_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tFamily Address<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_89-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_op5iu_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tFamily Address\t<\/label>\n\t\t<input type=\"text\" id=\"field_op5iu_line1\" value=\"\" name=\"item_meta[89][line1]\"  data-reqmsg=\"Family Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Family Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_89-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_op5iu_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tFamily Address\t<\/label>\n\t\t<input type=\"text\" id=\"field_op5iu_line2\" value=\"\" name=\"item_meta[89][line2]\"  data-reqmsg=\"Family Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Family Address is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_89-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_op5iu_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_op5iu_city\" value=\"\" name=\"item_meta[89][city]\"  data-reqmsg=\"Family Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Family Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_89-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_op5iu_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\t<\/label>\n\t\t<input type=\"text\" id=\"field_op5iu_state\" value=\"\" name=\"item_meta[89][state]\"  data-reqmsg=\"Family Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Family Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\" \/>\n\t<div class=\"frm_description\">State\/Province<\/div><\/div>\n<div id=\"frm_field_89-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_op5iu_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_op5iu_zip\" value=\"\" name=\"item_meta[89][zip]\"  data-reqmsg=\"Family Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Family Address is invalid\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal<\/div><\/div>\n<div id=\"frm_field_89-country_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_op5iu_country\" class=\"frm_screen_reader frm_hidden\">\n\t\tCountry\t<\/label>\n\t\t\t<select name=\"item_meta[89][country]\" id=\"field_op5iu_country\"  data-reqmsg=\"Family Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Family Address is invalid\" aria-invalid=\"false\"   autocomplete=\"country-name\">\n\t\t\t<option value=\"\" class=\"\">\n\t\t\t\t \t\t\t<\/option>\n\t\t\t<option  value=\"Afghanistan\" data-code=\"AF\">Afghanistan<\/option><option  value=\"Aland Islands\" data-code=\"AX\">Aland Islands<\/option><option  value=\"Albania\" data-code=\"AL\">Albania<\/option><option  value=\"Algeria\" data-code=\"DZ\">Algeria<\/option><option  value=\"American Samoa\" data-code=\"AS\">American Samoa<\/option><option  value=\"Andorra\" data-code=\"AD\">Andorra<\/option><option  value=\"Angola\" data-code=\"AO\">Angola<\/option><option  value=\"Anguilla\" data-code=\"AI\">Anguilla<\/option><option  value=\"Antarctica\" data-code=\"AQ\">Antarctica<\/option><option  value=\"Antigua and Barbuda\" data-code=\"AG\">Antigua and Barbuda<\/option><option  value=\"Argentina\" data-code=\"AR\">Argentina<\/option><option  value=\"Armenia\" data-code=\"AM\">Armenia<\/option><option  value=\"Aruba\" data-code=\"AW\">Aruba<\/option><option  value=\"Australia\" data-code=\"AU\">Australia<\/option><option  value=\"Austria\" data-code=\"AT\">Austria<\/option><option  value=\"Azerbaijan\" data-code=\"AZ\">Azerbaijan<\/option><option  value=\"Bahamas\" data-code=\"BS\">Bahamas<\/option><option  value=\"Bahrain\" data-code=\"BH\">Bahrain<\/option><option  value=\"Bangladesh\" data-code=\"BD\">Bangladesh<\/option><option  value=\"Barbados\" data-code=\"BB\">Barbados<\/option><option  value=\"Belarus\" data-code=\"BY\">Belarus<\/option><option  value=\"Belgium\" data-code=\"BE\">Belgium<\/option><option  value=\"Belize\" data-code=\"BZ\">Belize<\/option><option  value=\"Benin\" data-code=\"BJ\">Benin<\/option><option  value=\"Bermuda\" data-code=\"BM\">Bermuda<\/option><option  value=\"Bhutan\" data-code=\"BT\">Bhutan<\/option><option  value=\"Bolivia\" data-code=\"BO\">Bolivia<\/option><option  value=\"Bonaire, Sint Eustatius and Saba\">Bonaire, Sint Eustatius and Saba<\/option><option  value=\"Bosnia and Herzegovina\" data-code=\"BA\">Bosnia and Herzegovina<\/option><option  value=\"Botswana\" data-code=\"BW\">Botswana<\/option><option  value=\"Bouvet Island\" data-code=\"BV\">Bouvet Island<\/option><option  value=\"Brazil\" data-code=\"BR\">Brazil<\/option><option  value=\"British Indian Ocean Territory\" data-code=\"IO\">British Indian Ocean Territory<\/option><option  value=\"Brunei\" data-code=\"BN\">Brunei<\/option><option  value=\"Bulgaria\" data-code=\"BG\">Bulgaria<\/option><option  value=\"Burkina Faso\" data-code=\"BF\">Burkina Faso<\/option><option  value=\"Burundi\" data-code=\"BI\">Burundi<\/option><option  value=\"C&ocirc;te d&#039;Ivoire\">C&ocirc;te d&#039;Ivoire<\/option><option  value=\"Cambodia\" data-code=\"KH\">Cambodia<\/option><option  value=\"Cameroon\" data-code=\"CM\">Cameroon<\/option><option  value=\"Canada\" data-code=\"CA\">Canada<\/option><option  value=\"Cape Verde\" data-code=\"CV\">Cape Verde<\/option><option  value=\"Cayman Islands\" data-code=\"KY\">Cayman Islands<\/option><option  value=\"Central African Republic\" data-code=\"CF\">Central African Republic<\/option><option  value=\"Chad\" data-code=\"TD\">Chad<\/option><option  value=\"Chile\" data-code=\"CL\">Chile<\/option><option  value=\"China\" data-code=\"CN\">China<\/option><option  value=\"Christmas Island\" data-code=\"CX\">Christmas Island<\/option><option  value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option  value=\"Colombia\" data-code=\"CO\">Colombia<\/option><option  value=\"Comoros\" data-code=\"KM\">Comoros<\/option><option  value=\"Congo\">Congo<\/option><option  value=\"Cook Islands\" data-code=\"CK\">Cook Islands<\/option><option  value=\"Costa Rica\" data-code=\"CR\">Costa Rica<\/option><option  value=\"Croatia\" data-code=\"HR\">Croatia<\/option><option  value=\"Cuba\" data-code=\"CU\">Cuba<\/option><option  value=\"Curacao\" data-code=\"CW\">Curacao<\/option><option  value=\"Cyprus\" data-code=\"CY\">Cyprus<\/option><option  value=\"Czech Republic\" data-code=\"CZ\">Czech Republic<\/option><option  value=\"Denmark\" data-code=\"DK\">Denmark<\/option><option  value=\"Djibouti\" data-code=\"DJ\">Djibouti<\/option><option  value=\"Dominica\" data-code=\"DM\">Dominica<\/option><option  value=\"Dominican Republic\" data-code=\"DO\">Dominican Republic<\/option><option  value=\"East Timor\" data-code=\"TL\">East Timor<\/option><option  value=\"Ecuador\" data-code=\"EC\">Ecuador<\/option><option  value=\"Egypt\" data-code=\"EG\">Egypt<\/option><option  value=\"El Salvador\" data-code=\"SV\">El Salvador<\/option><option  value=\"Equatorial Guinea\" data-code=\"GQ\">Equatorial Guinea<\/option><option  value=\"Eritrea\" data-code=\"ER\">Eritrea<\/option><option  value=\"Estonia\" data-code=\"EE\">Estonia<\/option><option  value=\"Ethiopia\" data-code=\"ET\">Ethiopia<\/option><option  value=\"Falkland Islands (Malvinas)\">Falkland Islands (Malvinas)<\/option><option  value=\"Faroe Islands\" data-code=\"FO\">Faroe Islands<\/option><option  value=\"Fiji\" data-code=\"FJ\">Fiji<\/option><option  value=\"Finland\" data-code=\"FI\">Finland<\/option><option  value=\"France\" data-code=\"FR\">France<\/option><option  value=\"French Guiana\" data-code=\"GF\">French Guiana<\/option><option  value=\"French Polynesia\" data-code=\"PF\">French Polynesia<\/option><option  value=\"French Southern Territories\" data-code=\"TF\">French Southern Territories<\/option><option  value=\"Gabon\" data-code=\"GA\">Gabon<\/option><option  value=\"Gambia\" data-code=\"GM\">Gambia<\/option><option  value=\"Georgia\" data-code=\"GE\">Georgia<\/option><option  value=\"Germany\" data-code=\"DE\">Germany<\/option><option  value=\"Ghana\" data-code=\"GH\">Ghana<\/option><option  value=\"Gibraltar\" data-code=\"GI\">Gibraltar<\/option><option  value=\"Greece\" data-code=\"GR\">Greece<\/option><option  value=\"Greenland\" data-code=\"GL\">Greenland<\/option><option  value=\"Grenada\" data-code=\"GD\">Grenada<\/option><option  value=\"Guadeloupe\" data-code=\"GP\">Guadeloupe<\/option><option  value=\"Guam\" data-code=\"GU\">Guam<\/option><option  value=\"Guatemala\" data-code=\"GT\">Guatemala<\/option><option  value=\"Guernsey\" data-code=\"GG\">Guernsey<\/option><option  value=\"Guinea\" data-code=\"GN\">Guinea<\/option><option  value=\"Guinea-Bissau\" data-code=\"GW\">Guinea-Bissau<\/option><option  value=\"Guyana\" data-code=\"GY\">Guyana<\/option><option  value=\"Haiti\" data-code=\"HT\">Haiti<\/option><option  value=\"Heard Island and McDonald Islands\" data-code=\"HM\">Heard Island and McDonald Islands<\/option><option  value=\"Holy See\">Holy See<\/option><option  value=\"Honduras\" data-code=\"HN\">Honduras<\/option><option  value=\"Hong Kong\" data-code=\"HK\">Hong Kong<\/option><option  value=\"Hungary\" data-code=\"HU\">Hungary<\/option><option  value=\"Iceland\" data-code=\"IS\">Iceland<\/option><option  value=\"India\" data-code=\"IN\">India<\/option><option  value=\"Indonesia\" data-code=\"ID\">Indonesia<\/option><option  value=\"Iran\" data-code=\"IR\">Iran<\/option><option  value=\"Iraq\" data-code=\"IQ\">Iraq<\/option><option  value=\"Ireland\" data-code=\"IE\">Ireland<\/option><option  value=\"Isle of Man\" data-code=\"IM\">Isle of Man<\/option><option  value=\"Israel\" data-code=\"IL\">Israel<\/option><option  value=\"Italy\" data-code=\"IT\">Italy<\/option><option  value=\"Jamaica\" data-code=\"JM\">Jamaica<\/option><option  value=\"Japan\" data-code=\"JP\">Japan<\/option><option  value=\"Jersey\" data-code=\"JE\">Jersey<\/option><option  value=\"Jordan\" data-code=\"JO\">Jordan<\/option><option  value=\"Kazakhstan\" data-code=\"KZ\">Kazakhstan<\/option><option  value=\"Kenya\" data-code=\"KE\">Kenya<\/option><option  value=\"Kiribati\" data-code=\"KI\">Kiribati<\/option><option  value=\"Kosovo\" data-code=\"XK\">Kosovo<\/option><option  value=\"Kuwait\" data-code=\"KW\">Kuwait<\/option><option  value=\"Kyrgyzstan\" data-code=\"KG\">Kyrgyzstan<\/option><option  value=\"Laos\" data-code=\"LA\">Laos<\/option><option  value=\"Latvia\" data-code=\"LV\">Latvia<\/option><option  value=\"Lebanon\" data-code=\"LB\">Lebanon<\/option><option  value=\"Lesotho\" data-code=\"LS\">Lesotho<\/option><option  value=\"Liberia\" data-code=\"LR\">Liberia<\/option><option  value=\"Libya\" data-code=\"LY\">Libya<\/option><option  value=\"Liechtenstein\" data-code=\"LI\">Liechtenstein<\/option><option  value=\"Lithuania\" data-code=\"LT\">Lithuania<\/option><option  value=\"Luxembourg\" data-code=\"LU\">Luxembourg<\/option><option  value=\"Macao\" data-code=\"MO\">Macao<\/option><option  value=\"Macedonia\" data-code=\"MK\">Macedonia<\/option><option  value=\"Madagascar\" data-code=\"MG\">Madagascar<\/option><option  value=\"Malawi\" data-code=\"MW\">Malawi<\/option><option  value=\"Malaysia\" data-code=\"MY\">Malaysia<\/option><option  value=\"Maldives\" data-code=\"MV\">Maldives<\/option><option  value=\"Mali\" data-code=\"ML\">Mali<\/option><option  value=\"Malta\" data-code=\"MT\">Malta<\/option><option  value=\"Marshall Islands\" data-code=\"MH\">Marshall Islands<\/option><option  value=\"Martinique\" data-code=\"MQ\">Martinique<\/option><option  value=\"Mauritania\" data-code=\"MR\">Mauritania<\/option><option  value=\"Mauritius\" data-code=\"MU\">Mauritius<\/option><option  value=\"Mayotte\" data-code=\"YT\">Mayotte<\/option><option  value=\"Mexico\" data-code=\"MX\">Mexico<\/option><option  value=\"Micronesia\" data-code=\"FM\">Micronesia<\/option><option  value=\"Moldova\" data-code=\"MD\">Moldova<\/option><option  value=\"Monaco\" data-code=\"MC\">Monaco<\/option><option  value=\"Mongolia\" data-code=\"MN\">Mongolia<\/option><option  value=\"Montenegro\" data-code=\"ME\">Montenegro<\/option><option  value=\"Montserrat\" data-code=\"MS\">Montserrat<\/option><option  value=\"Morocco\" data-code=\"MA\">Morocco<\/option><option  value=\"Mozambique\" data-code=\"MZ\">Mozambique<\/option><option  value=\"Myanmar\" data-code=\"MM\">Myanmar<\/option><option  value=\"Namibia\" data-code=\"NA\">Namibia<\/option><option  value=\"Nauru\" data-code=\"NR\">Nauru<\/option><option  value=\"Nepal\" data-code=\"NP\">Nepal<\/option><option  value=\"Netherlands\" data-code=\"NL\">Netherlands<\/option><option  value=\"New Caledonia\" data-code=\"NC\">New Caledonia<\/option><option  value=\"New Zealand\" data-code=\"NZ\">New Zealand<\/option><option  value=\"Nicaragua\" data-code=\"NI\">Nicaragua<\/option><option  value=\"Niger\" data-code=\"NE\">Niger<\/option><option  value=\"Nigeria\" data-code=\"NG\">Nigeria<\/option><option  value=\"Niue\" data-code=\"NU\">Niue<\/option><option  value=\"Norfolk Island\" data-code=\"NF\">Norfolk Island<\/option><option  value=\"North Korea\" data-code=\"KP\">North Korea<\/option><option  value=\"Northern Mariana Islands\" data-code=\"MP\">Northern Mariana Islands<\/option><option  value=\"Norway\" data-code=\"NO\">Norway<\/option><option  value=\"Oman\" data-code=\"OM\">Oman<\/option><option  value=\"Pakistan\" data-code=\"PK\">Pakistan<\/option><option  value=\"Palau\" data-code=\"PW\">Palau<\/option><option  value=\"Palestine\">Palestine<\/option><option  value=\"Panama\" data-code=\"PA\">Panama<\/option><option  value=\"Papua New Guinea\" data-code=\"PG\">Papua New Guinea<\/option><option  value=\"Paraguay\" data-code=\"PY\">Paraguay<\/option><option  value=\"Peru\" data-code=\"PE\">Peru<\/option><option  value=\"Philippines\" data-code=\"PH\">Philippines<\/option><option  value=\"Pitcairn\" data-code=\"PN\">Pitcairn<\/option><option  value=\"Poland\" data-code=\"PL\">Poland<\/option><option  value=\"Portugal\" data-code=\"PT\">Portugal<\/option><option  value=\"Puerto Rico\" data-code=\"PR\">Puerto Rico<\/option><option  value=\"Qatar\" data-code=\"QA\">Qatar<\/option><option  value=\"Reunion\" data-code=\"RE\">Reunion<\/option><option  value=\"Romania\" data-code=\"RO\">Romania<\/option><option  value=\"Russia\" data-code=\"RU\">Russia<\/option><option  value=\"Rwanda\" data-code=\"RW\">Rwanda<\/option><option  value=\"Saint Barthelemy\" data-code=\"BL\">Saint Barthelemy<\/option><option  value=\"Saint Helena, Ascension and Tristan da Cunha\">Saint Helena, Ascension and Tristan da Cunha<\/option><option  value=\"Saint Kitts and Nevis\" data-code=\"KN\">Saint Kitts and Nevis<\/option><option  value=\"Saint Lucia\" data-code=\"LC\">Saint Lucia<\/option><option  value=\"Saint Martin (French part)\">Saint Martin (French part)<\/option><option  value=\"Saint Pierre and Miquelon\" data-code=\"PM\">Saint Pierre and Miquelon<\/option><option  value=\"Saint Vincent and the Grenadines\" data-code=\"VC\">Saint Vincent and the Grenadines<\/option><option  value=\"Samoa\" data-code=\"WS\">Samoa<\/option><option  value=\"San Marino\" data-code=\"SM\">San Marino<\/option><option  value=\"Sao Tome and Principe\" data-code=\"ST\">Sao Tome and Principe<\/option><option  value=\"Saudi Arabia\" data-code=\"SA\">Saudi Arabia<\/option><option  value=\"Senegal\" data-code=\"SN\">Senegal<\/option><option  value=\"Serbia\" data-code=\"RS\">Serbia<\/option><option  value=\"Seychelles\" data-code=\"SC\">Seychelles<\/option><option  value=\"Sierra Leone\" data-code=\"SL\">Sierra Leone<\/option><option  value=\"Singapore\" data-code=\"SG\">Singapore<\/option><option  value=\"Sint Maarten (Dutch part)\">Sint Maarten (Dutch part)<\/option><option  value=\"Slovakia\" data-code=\"SK\">Slovakia<\/option><option  value=\"Slovenia\" data-code=\"SI\">Slovenia<\/option><option  value=\"Solomon Islands\" data-code=\"SB\">Solomon Islands<\/option><option  value=\"Somalia\" data-code=\"SO\">Somalia<\/option><option  value=\"South Africa\" data-code=\"ZA\">South Africa<\/option><option  value=\"South Georgia and the South Sandwich Islands\" data-code=\"GS\">South Georgia and the South Sandwich Islands<\/option><option  value=\"South Korea\" data-code=\"KR\">South Korea<\/option><option  value=\"South Sudan\" data-code=\"SS\">South Sudan<\/option><option  value=\"Spain\" data-code=\"ES\">Spain<\/option><option  value=\"Sri Lanka\" data-code=\"LK\">Sri Lanka<\/option><option  value=\"Sudan\" data-code=\"SD\">Sudan<\/option><option  value=\"Suriname\" data-code=\"SR\">Suriname<\/option><option  value=\"Svalbard and Jan Mayen\" data-code=\"SJ\">Svalbard and Jan Mayen<\/option><option  value=\"Swaziland\" data-code=\"SZ\">Swaziland<\/option><option  value=\"Sweden\" data-code=\"SE\">Sweden<\/option><option  value=\"Switzerland\" data-code=\"CH\">Switzerland<\/option><option  value=\"Syria\" data-code=\"SY\">Syria<\/option><option  value=\"Taiwan\" data-code=\"TW\">Taiwan<\/option><option  value=\"Tajikistan\" data-code=\"TJ\">Tajikistan<\/option><option  value=\"Tanzania\" data-code=\"TZ\">Tanzania<\/option><option  value=\"Thailand\" data-code=\"TH\">Thailand<\/option><option  value=\"Timor-Leste\">Timor-Leste<\/option><option  value=\"Togo\" data-code=\"TG\">Togo<\/option><option  value=\"Tokelau\" data-code=\"TK\">Tokelau<\/option><option  value=\"Tonga\" data-code=\"TO\">Tonga<\/option><option  value=\"Trinidad and Tobago\" data-code=\"TT\">Trinidad and Tobago<\/option><option  value=\"Tunisia\" data-code=\"TN\">Tunisia<\/option><option  value=\"Turkey\" data-code=\"TR\">Turkey<\/option><option  value=\"Turkmenistan\" data-code=\"TM\">Turkmenistan<\/option><option  value=\"Turks and Caicos Islands\" data-code=\"TC\">Turks and Caicos Islands<\/option><option  value=\"Tuvalu\" data-code=\"TV\">Tuvalu<\/option><option  value=\"Uganda\" data-code=\"UG\">Uganda<\/option><option  value=\"Ukraine\" data-code=\"UA\">Ukraine<\/option><option  value=\"United Arab Emirates\" data-code=\"AE\">United Arab Emirates<\/option><option  value=\"United Kingdom\" data-code=\"GB\">United Kingdom<\/option><option  value=\"United States\" data-code=\"US\">United States<\/option><option  value=\"United States Minor Outlying Islands\" data-code=\"UM\">United States Minor Outlying Islands<\/option><option  value=\"Uruguay\" data-code=\"UY\">Uruguay<\/option><option  value=\"Uzbekistan\" data-code=\"UZ\">Uzbekistan<\/option><option  value=\"Vanuatu\" data-code=\"VU\">Vanuatu<\/option><option  value=\"Vatican City\">Vatican City<\/option><option  value=\"Venezuela\" data-code=\"VE\">Venezuela<\/option><option  value=\"Vietnam\" data-code=\"VN\">Vietnam<\/option><option  value=\"Virgin Islands, British\">Virgin Islands, British<\/option><option  value=\"Virgin Islands, U.S.\">Virgin Islands, U.S.<\/option><option  value=\"Wallis and Futuna\" data-code=\"WF\">Wallis and Futuna<\/option><option  value=\"Western Sahara\" data-code=\"EH\">Western Sahara<\/option><option  value=\"Yemen\" data-code=\"YE\">Yemen<\/option><option  value=\"Zambia\" data-code=\"ZM\">Zambia<\/option><option  value=\"Zimbabwe\" data-code=\"ZW\">Zimbabwe<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">Country<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_90_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_mx94j\" class=\"frm_primary_label\">Emergency Contact\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_mx94j\" name=\"item_meta[90]\" value=\"\"  data-reqmsg=\"Emergency Contact cannot be blank.\" aria-required=\"true\" data-invmsg=\"Emergency Contact is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_91_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_ohx8z\" class=\"frm_primary_label\">Phone Number\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_ohx8z\" name=\"item_meta[91]\" value=\"\"  style=\"width:115px\" data-reqmsg=\"Phone Number cannot be blank.\" aria-required=\"true\" data-invmsg=\"Phone Number is invalid\" class=\"auto_width\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<input type=\"hidden\" name=\"frm_page_order_5\" id=\"frm_page_order_5\" value=\"28\" \/>\t\t<input  type=\"hidden\" name=\"item_meta[92]\" id=\"field_eiwqd\" value=\"\"  data-placeholder=\"Please Select One\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[94]\" id=\"field_48da1\" value=\"\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[95]\" id=\"field_ww8tc\" value=\"\"  data-placeholder=\"Please Select One\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[96]\" id=\"field_km9fs\" value=\"\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[97]\" id=\"field_bf4\" value=\"\"  data-placeholder=\"Please Select One\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[98]\" id=\"field_jrb31\" value=\"\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[99]\" id=\"field_nf76b\" value=\"\"  data-placeholder=\"Please Select One\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[100]\" id=\"field_6djn1\" value=\"\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[101]\" id=\"field_m83cn\" value=\"\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[102]\" id=\"field_o059r\" value=\"\"     \/>\n\t\t\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_108_container\">\n\t\t\t<label for=\"field_jf4i2\" >\n\t\t\t\tIf you are human, leave this field blank.\t\t\t<\/label>\n\t\t\t<input  id=\"field_jf4i2\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[108]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"YyCPgknKdoHsqwVaJP94b2NufkCJaEVyEvBOHjRETd8+Vtw6caZf1RRM07mriozk\" \/><div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit\" type=\"submit\"   formnovalidate=\"formnovalidate\">Next<\/button>\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\nLocation: N&#8217;Djamena, ChadEmail:\u00a0Debbie WeissenburgerSchool Hours: M-F: 7:30am &#8211; 12:50pm\u00a0\u00a0Wellspring Policies To view our current policies and procedures please visit the Policies and Procedures [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-181","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - 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