{"id":32970,"date":"2022-03-18T07:56:25","date_gmt":"2022-03-18T07:56:25","guid":{"rendered":"https:\/\/alenlewegen.org\/staging\/3913\/?page_id=32970"},"modified":"2022-03-18T09:33:34","modified_gmt":"2022-03-18T09:33:34","slug":"assessment","status":"publish","type":"page","link":"https:\/\/alenlewegen.org\/staging\/3913\/assessment\/","title":{"rendered":"Assessment"},"content":{"rendered":"\n<p><\/p>\n\n\n<div class=\"wpforms-container-save-resume\"><div class=\"wpforms-container wpforms-container-full wpforms-form-abandonment\" id=\"wpforms-32969\"><form id=\"wpforms-form-32969\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"32969\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/staging\/3913\/wp-json\/wp\/v2\/pages\/32970?wpforms_form_id=32969\" data-token=\"0b56934e326a992aea8023c2c718b029\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-page-indicator progress\" data-indicator=\"progress\" data-indicator-color=\"#72b239\" data-scroll=\"1\"><span class=\"wpforms-page-indicator-page-title\" data-page-2-title=\"Agency Information\" data-page-3-title=\"Contact Information\" data-page-4-title=\"Personal Information\" data-page-5-title=\"Household Information\" data-page-6-title=\"List all Household Members\" data-page-7-title=\"Affirmation\"><\/span><span class=\"wpforms-page-indicator-page-title-sep\" style=\"display:none;\"> - <\/span><span class=\"wpforms-page-indicator-steps\">Step <span class=\"wpforms-page-indicator-steps-current\">1<\/span> of 7<\/span><div class=\"wpforms-page-indicator-page-progress-wrap\"><div class=\"wpforms-page-indicator-page-progress\" style=\"width:14.285714285714%;background-color:#72b239\"><\/div><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \"><div id=\"wpforms-32969-field_94-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"94\"><\/div><div id=\"wpforms-32969-field_32-container\" class=\"wpforms-field wpforms-field-name wpforms-one-half wpforms-first\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_32\">Name of Disaster\/Operation <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-32969-field_32\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][32]\" required><\/div><div id=\"wpforms-32969-field_29-container\" class=\"wpforms-field wpforms-field-date-time wpforms-one-half\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_29\">Date<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-32969-field_29\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][29][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-32969-field_98-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"98\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"1\" data-formid=\"32969\" disabled>Next<\/button><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Resume Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  \" style=\"display:none;\"><div id=\"wpforms-32969-field_31-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"31\"><h3 id=\"wpforms-32969-field_31\" name=\"wpforms[fields][31]\">1. Assessing Agency Information<\/h3><\/div><div id=\"wpforms-32969-field_28-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_28\">Organization doing the assessment (and collaborating organization):<\/label><input type=\"text\" id=\"wpforms-32969-field_28\" class=\"wpforms-field-medium\" name=\"wpforms[fields][28]\" ><\/div><div id=\"wpforms-32969-field_33-container\" class=\"wpforms-field wpforms-field-name wpforms-one-third wpforms-first\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_33\">Name of the Staff\/Intake Person <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-32969-field_33\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][33]\" required><\/div><div id=\"wpforms-32969-field_34-container\" class=\"wpforms-field wpforms-field-name wpforms-one-third\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_34\">Role in the community <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-32969-field_34\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][34]\" required><\/div><div id=\"wpforms-32969-field_35-container\" class=\"wpforms-field wpforms-field-name wpforms-one-third\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_35\">Contact information <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-32969-field_35\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][35]\" required><\/div><div id=\"wpforms-32969-field_93-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"93\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev\" data-action=\"prev\" data-page=\"2\" data-formid=\"32969\" disabled>Previous<\/button><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"2\" data-formid=\"32969\" disabled>Next<\/button><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Resume Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3  \" style=\"display:none;\"><div id=\"wpforms-32969-field_36-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"36\"><h3 id=\"wpforms-32969-field_36\" name=\"wpforms[fields][36]\">2. Contact Information<\/h3><\/div><div id=\"wpforms-32969-field_37-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third wpforms-first\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_37\">Province\/Region<\/label><input type=\"text\" id=\"wpforms-32969-field_37\" class=\"wpforms-field-large\" name=\"wpforms[fields][37]\" ><\/div><div id=\"wpforms-32969-field_38-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"38\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_38\">Sub city\/Zone<\/label><input type=\"text\" id=\"wpforms-32969-field_38\" class=\"wpforms-field-large\" name=\"wpforms[fields][38]\" ><\/div><div id=\"wpforms-32969-field_39-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_39\">Woreda\/Kebele<\/label><input type=\"text\" id=\"wpforms-32969-field_39\" class=\"wpforms-field-large\" name=\"wpforms[fields][39]\" ><\/div><div id=\"wpforms-32969-field_40-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third wpforms-first\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_40\">House Number #<\/label><input type=\"text\" id=\"wpforms-32969-field_40\" class=\"wpforms-field-large\" name=\"wpforms[fields][40]\" ><\/div><div id=\"wpforms-32969-field_41-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_41\">Village Name<\/label><input type=\"text\" id=\"wpforms-32969-field_41\" class=\"wpforms-field-large\" name=\"wpforms[fields][41]\" ><\/div><div id=\"wpforms-32969-field_42-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_42\">Mailbox\/Additional Description:<\/label><input type=\"text\" id=\"wpforms-32969-field_42\" class=\"wpforms-field-large\" name=\"wpforms[fields][42]\" ><\/div><div id=\"wpforms-32969-field_43-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-one-half wpforms-first wpforms-list-2-columns\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_43\">Where are you currently residing?<\/label><ul id=\"wpforms-32969-field_43\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-32969-field_43_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][43][]\" value=\"Own Home\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_43_1\">Own Home<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-32969-field_43_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][43][]\" value=\"Transitional Housing \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_43_2\">Transitional Housing <\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-32969-field_43_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][43][]\" value=\"In Someone else\u2019s Home\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_43_3\">In Someone else\u2019s Home<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-32969-field_43_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][43][]\" value=\"Emergency Shelter\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_43_4\">Emergency Shelter<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-32969-field_43_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][43][]\" value=\"Campsites\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_43_5\">Campsites<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-32969-field_43_6\" data-rule-check-limit=\"true\" name=\"wpforms[fields][43][]\" value=\"Others\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_43_6\">Others<\/label><\/li><\/ul><\/div><div id=\"wpforms-32969-field_44-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-half wpforms-one-third wpforms-first\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_44\">Phone(Primary)<\/label><input type=\"tel\" id=\"wpforms-32969-field_44\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][44]\" ><\/div><div id=\"wpforms-32969-field_45-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-third\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_45\">Alternative contact Person\/Phone<\/label><input type=\"tel\" id=\"wpforms-32969-field_45\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][45]\" ><\/div><div id=\"wpforms-32969-field_47-container\" class=\"wpforms-field wpforms-field-email wpforms-one-third\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_47\">Email<\/label><input type=\"email\" id=\"wpforms-32969-field_47\" class=\"wpforms-field-large\" name=\"wpforms[fields][47]\" ><\/div><div id=\"wpforms-32969-field_96-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"96\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev\" data-action=\"prev\" data-page=\"3\" data-formid=\"32969\" disabled>Previous<\/button><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"3\" data-formid=\"32969\" disabled>Next<\/button><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Resume Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-4  \" style=\"display:none;\"><div id=\"wpforms-32969-field_48-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"48\"><h3 id=\"wpforms-32969-field_48\" name=\"wpforms[fields][48]\">3. Personal  Information<\/h3><\/div><div id=\"wpforms-32969-field_50-container\" class=\"wpforms-field wpforms-field-name wpforms-one-fourth wpforms-first\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_50\">Caregiver&#039;s Name(Adult who is the parent\/guardian) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-32969-field_50\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][50]\" required><\/div><div id=\"wpforms-32969-field_51-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth wpforms-list-inline\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_51\">Gender<\/label><ul id=\"wpforms-32969-field_51\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_51_1\" name=\"wpforms[fields][51]\" value=\"Male\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_51_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_51_2\" name=\"wpforms[fields][51]\" value=\"Female\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_51_2\">Female<\/label><\/li><\/ul><\/div><div id=\"wpforms-32969-field_52-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth\" data-field-id=\"52\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_52\">Date of Birth<\/label><input type=\"text\" id=\"wpforms-32969-field_52\" class=\"wpforms-field-medium\" name=\"wpforms[fields][52]\" ><\/div><div id=\"wpforms-32969-field_55-container\" class=\"wpforms-field wpforms-field-number wpforms-one-fourth\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_55\">Age<\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-32969-field_55\" class=\"wpforms-field-medium\" name=\"wpforms[fields][55]\" ><\/div><div id=\"wpforms-32969-field_56-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_56\">Primary Language<\/label><input type=\"text\" id=\"wpforms-32969-field_56\" class=\"wpforms-field-medium\" name=\"wpforms[fields][56]\" ><\/div><div id=\"wpforms-32969-field_57-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half wpforms-list-inline\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_57\">Do you have an active Bank Account?<\/label><ul id=\"wpforms-32969-field_57\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_57_1\" name=\"wpforms[fields][57]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_57_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_57_2\" name=\"wpforms[fields][57]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_57_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-32969-field_97-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"97\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev\" data-action=\"prev\" data-page=\"4\" data-formid=\"32969\" disabled>Previous<\/button><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"4\" data-formid=\"32969\" disabled>Next<\/button><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Resume Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-5  \" style=\"display:none;\"><div id=\"wpforms-32969-field_58-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"58\"><h3 id=\"wpforms-32969-field_58\" name=\"wpforms[fields][58]\">4. Household  Information<\/h3><\/div><div id=\"wpforms-32969-field_59-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-third wpforms-first wpforms-list-inline\" data-field-id=\"59\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_59\">Did the child(ren)\/ parent(s) served in military ? <\/label><ul id=\"wpforms-32969-field_59\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_59_1\" name=\"wpforms[fields][59]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_59_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_59_2\" name=\"wpforms[fields][59]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_59_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-32969-field_61-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"61\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_61\">Which Branch?  e.g Defense, Fano, Militia, Liyu Hayle<\/label><input type=\"text\" id=\"wpforms-32969-field_61\" class=\"wpforms-field-medium\" name=\"wpforms[fields][61]\" ><\/div><div id=\"wpforms-32969-field_60-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-one-third wpforms-list-inline\" data-field-id=\"60\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_60\">Parent(s) death<\/label><ul id=\"wpforms-32969-field_60\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-32969-field_60_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][60][]\" value=\"Father\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_60_1\">Father<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-32969-field_60_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][60][]\" value=\"Mother \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_60_2\">Mother <\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-32969-field_60_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][60][]\" value=\"Both\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_60_3\">Both<\/label><\/li><\/ul><\/div><div id=\"wpforms-32969-field_62-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third wpforms-first\" data-field-id=\"62\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_62\">Full Name of Deceased Parent(s)<\/label><input type=\"text\" id=\"wpforms-32969-field_62\" class=\"wpforms-field-large\" name=\"wpforms[fields][62]\" ><\/div><div id=\"wpforms-32969-field_63-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-third wpforms-list-inline\" data-field-id=\"63\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_63\">Do you have a proof of death certificate?<\/label><ul id=\"wpforms-32969-field_63\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_63_1\" name=\"wpforms[fields][63]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_63_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_63_2\" name=\"wpforms[fields][63]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_63_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-32969-field_64-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"64\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_64\">Issued by:<\/label><input type=\"text\" id=\"wpforms-32969-field_64\" class=\"wpforms-field-medium\" name=\"wpforms[fields][64]\" ><\/div><div id=\"wpforms-32969-field_65-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-third wpforms-first\" data-field-id=\"65\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_65\">If Child(ren) death, how old are the parent(s)?<\/label><ul id=\"wpforms-32969-field_65\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_65_1\" name=\"wpforms[fields][65]\" value=\"Over the age of 60 (60&amp; 60+)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_65_1\">Over the age of 60 (60&amp; 60+)<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_65_3\" name=\"wpforms[fields][65]\" value=\"Age 55 and disability with Disability \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_65_3\">Age 55 and disability with Disability <\/label><\/li><\/ul><\/div><div id=\"wpforms-32969-field_69-container\" class=\"wpforms-field wpforms-field-number wpforms-one-third\" data-field-id=\"69\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_69\">How many child(ren) do you have 18 and over?<\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-32969-field_69\" class=\"wpforms-field-medium\" name=\"wpforms[fields][69]\" ><\/div><div id=\"wpforms-32969-field_70-container\" class=\"wpforms-field wpforms-field-number wpforms-one-third\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_70\">How many child(ren) do you have under the age of 18?<\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-32969-field_70\" class=\"wpforms-field-medium\" name=\"wpforms[fields][70]\" ><\/div><div id=\"wpforms-32969-field_67-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-third wpforms-first wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"67\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_67\">Do you care for a child with special needs (disability )? <\/label><ul id=\"wpforms-32969-field_67\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_67_1\" name=\"wpforms[fields][67]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_67_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_67_2\" name=\"wpforms[fields][67]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_67_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-32969-field_68-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"68\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_68\">If yes, how many?<\/label><input type=\"text\" id=\"wpforms-32969-field_68\" class=\"wpforms-field-medium\" name=\"wpforms[fields][68]\" ><\/div><div id=\"wpforms-32969-field_71-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-one-third wpforms-list-inline\" data-field-id=\"71\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_71\">Did the person who service in military<\/label><ul id=\"wpforms-32969-field_71\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-32969-field_71_1\" name=\"wpforms[fields][71][]\" value=\"wounded \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_71_1\">wounded <\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-32969-field_71_2\" name=\"wpforms[fields][71][]\" value=\"ill (Critical health Condition)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_71_2\">ill (Critical health Condition)<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-32969-field_71_3\" name=\"wpforms[fields][71][]\" value=\"injured\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_71_3\">injured<\/label><\/li><\/ul><\/div><div id=\"wpforms-32969-field_72-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth wpforms-first\" data-field-id=\"72\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_72\">Describe the injury<\/label><input type=\"text\" id=\"wpforms-32969-field_72\" class=\"wpforms-field-medium\" name=\"wpforms[fields][72]\" ><\/div><div id=\"wpforms-32969-field_73-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth wpforms-list-inline\" data-field-id=\"73\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_73\">Availability of medicines\/medical supplies<\/label><ul id=\"wpforms-32969-field_73\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_73_1\" name=\"wpforms[fields][73]\" value=\"Adequate\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_73_1\">Adequate<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_73_2\" name=\"wpforms[fields][73]\" value=\"Basic\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_73_2\">Basic<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_73_3\" name=\"wpforms[fields][73]\" value=\"Inadequate\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_73_3\">Inadequate<\/label><\/li><\/ul><\/div><div id=\"wpforms-32969-field_74-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth wpforms-list-inline\" data-field-id=\"74\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_74\">Does the person pay for medical treatment?<\/label><ul id=\"wpforms-32969-field_74\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_74_1\" name=\"wpforms[fields][74]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_74_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_74_2\" name=\"wpforms[fields][74]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_74_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-32969-field_75-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth wpforms-list-inline\" data-field-id=\"75\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_75\">Is treatment completed?<\/label><ul id=\"wpforms-32969-field_75\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_75_1\" name=\"wpforms[fields][75]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_75_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_75_2\" name=\"wpforms[fields][75]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_75_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-32969-field_99-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"99\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev\" data-action=\"prev\" data-page=\"5\" data-formid=\"32969\" disabled>Previous<\/button><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"5\" data-formid=\"32969\" disabled>Next<\/button><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Resume Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-6  \" style=\"display:none;\"><div id=\"wpforms-32969-field_76-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"76\"><h3 id=\"wpforms-32969-field_76\" name=\"wpforms[fields][76]\">5. List All Household Members (important to include child(ren) caring for)<\/h3><\/div><div id=\"wpforms-32969-field_79-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth wpforms-first\" data-field-id=\"79\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_79\">Full Name<\/label><input type=\"text\" id=\"wpforms-32969-field_79\" class=\"wpforms-field-medium\" name=\"wpforms[fields][79]\" ><\/div><div id=\"wpforms-32969-field_80-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth wpforms-list-inline\" data-field-id=\"80\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_80\">Gender<\/label><ul id=\"wpforms-32969-field_80\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_80_1\" name=\"wpforms[fields][80]\" value=\"Male\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_80_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-32969-field_80_2\" name=\"wpforms[fields][80]\" value=\"Female\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-32969-field_80_2\">Female<\/label><\/li><\/ul><\/div><div id=\"wpforms-32969-field_82-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth\" data-field-id=\"82\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_82\">Date of Birth<\/label><input type=\"text\" id=\"wpforms-32969-field_82\" class=\"wpforms-field-medium\" name=\"wpforms[fields][82]\" ><\/div><div id=\"wpforms-32969-field_83-container\" class=\"wpforms-field wpforms-field-number wpforms-one-fourth\" data-field-id=\"83\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_83\">Age<\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-32969-field_83\" class=\"wpforms-field-medium\" name=\"wpforms[fields][83]\" ><\/div><div id=\"wpforms-32969-field_92-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"92\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_92\">Relationship to Caregiver<\/label><input type=\"text\" id=\"wpforms-32969-field_92\" class=\"wpforms-field-medium\" name=\"wpforms[fields][92]\" ><\/div><div id=\"wpforms-32969-field_100-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"100\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev\" data-action=\"prev\" data-page=\"6\" data-formid=\"32969\" disabled>Previous<\/button><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"6\" data-formid=\"32969\" disabled>Next<\/button><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Resume Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-7 last \" style=\"display:none;\"><div id=\"wpforms-32969-field_84-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"84\"><h3 id=\"wpforms-32969-field_84\" name=\"wpforms[fields][84]\">6. Affirmation<\/h3><\/div><div id=\"wpforms-32969-field_85-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"85\"><div id=\"wpforms-32969-field_85\"><p>  I affirm that the information on this application is accurate. I affirm that the documentations provided is true and accurate. I acknowledge that approval is contingent upon the availability of resources. You are aware of this referral, and your information will be only shared with others to coordinate services, to make referrals to programs and benefits, and payment. <\/p><\/div><\/div><div id=\"wpforms-32969-field_86-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"86\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_86\">Signature of Staff\/Intake Person<\/label><div class=\"wpforms-signature-wrap wpforms-field-medium\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-32969-field_86-signature\" data-color=\"#000000\"><\/canvas><button class=\"wpforms-signature-clear\" title=\"Clear Signature\">Clear Signature<\/button><\/div><input type=\"text\" id=\"wpforms-32969-field_86\" class=\"wpforms-signature-input wpforms-screen-reader-element\" name=\"wpforms[fields][86]\" ><\/div><div id=\"wpforms-32969-field_87-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"87\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_87\">Caregiver (Caregiver Representative) Signature <\/label><div class=\"wpforms-signature-wrap wpforms-field-medium\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-32969-field_87-signature\" data-color=\"#000000\"><\/canvas><button class=\"wpforms-signature-clear\" title=\"Clear Signature\">Clear Signature<\/button><\/div><input type=\"text\" id=\"wpforms-32969-field_87\" class=\"wpforms-signature-input wpforms-screen-reader-element\" name=\"wpforms[fields][87]\" ><\/div><div id=\"wpforms-32969-field_89-container\" class=\"wpforms-field wpforms-field-name wpforms-one-half wpforms-first\" data-field-id=\"89\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_89\">Name of Caregiver Representative <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-32969-field_89\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][89]\" required><\/div><div id=\"wpforms-32969-field_90-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-half\" data-field-id=\"90\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_90\">Phone<\/label><input type=\"tel\" id=\"wpforms-32969-field_90\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][90]\" ><\/div><div id=\"wpforms-32969-field_22-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_22\">Parents\/Children Photo<\/label><div\n\t\tclass=\"wpforms-uploader\"\n\t\tdata-field-id=\"22\"\n\t\tdata-form-id=\"32969\"\n\t\tdata-input-name=\"wpforms_32969_22\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages,ttf,eot,woff,svg,json\"\n\t\tdata-max-size=\"536870912\"\n\t\tdata-max-file-number=\"12\"\n\t\tdata-post-max-size=\"536870912\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg viewBox=\"0 0 1024 1024\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"#b1b1b1\" aria-hidden=\"true\">\n\t\t\t<path d=\"M885.2 446.3l-.2-.8-112.2-285.1c-5-16.1-19.9-27.2-36.8-27.2H281.2c-17 0-32.1 11.3-36.9 27.6L139.4 443l-.3.7-.2.8c-1.3 4.9-1.7 9.9-1 14.8-.1 1.6-.2 3.2-.2 4.8V830a60.9 60.9 0 0 0 60.8 60.8h627.2c33.5 0 60.8-27.3 60.9-60.8V464.1c0-1.3 0-2.6-.1-3.7.4-4.9 0-9.6-1.3-14.1zm-295.8-43l-.3 15.7c-.8 44.9-31.8 75.1-77.1 75.1-22.1 0-41.1-7.1-54.8-20.6S436 441.2 435.6 419l-.3-15.7H229.5L309 210h399.2l81.7 193.3H589.4zm-375 76.8h157.3c24.3 57.1 76 90.8 140.4 90.8 33.7 0 65-9.4 90.3-27.2 22.2-15.6 39.5-37.4 50.7-63.6h156.5V814H214.4V480.1z\"><\/path>\n\t\t<\/svg>\n\t\t<span class=\"modern-title\">Click or drag files to this area to upload.<\/span>\n\n\t\t\t\t\t<span class=\"modern-hint\">You can upload up to 12 files.<\/span>\n\t\t\t<\/div>\n<\/div>\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-32969-field_22\"\n\t\tname=\"wpforms_32969_22\" \t\tvalue=\"\">\n<\/div><div id=\"wpforms-32969-field_3-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-32969-field_3\">Your Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-32969-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" required><\/div><div id=\"wpforms-32969-field_95-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"95\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><\/div><\/div><\/div><\/div><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"32969\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-32969\" class=\"wpforms-submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/alenlewegen.org\/staging\/3913\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"\"><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Resume Later<\/span><\/a><\/div><\/form><\/div>  <!-- .wpforms-container -->\n\t\t<div class=\"wpforms-save-resume-confirmation\" style=\"display: none\">\n\t\t\t<div class=\"message\"><p>Your form entry has been saved and a unique link has been created which you can access to resume this form.<\/p>\n<p>Enter your email address to receive the link via email. Alternately, you can copy and save the link below.<\/p>\n<p>Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.<\/p>\n<\/div>\n\t\t\t<div class=\"wpforms-save-resume-actions\">\n\t\t\t\t\t\t\t\t\t<div class=\"wpforms-field\">\n\t\t\t\t\t<label class=\"wpforms-field-label wpforms-save-resume-label\">\n\t\t\t\t\t\tCopy Link\t\t\t\t\t<\/label>\n\t\t\t\t\t<div class=\"wpforms-save-resume-shortcode-container\">\n\t\t\t\t\t\t<input type=\"text\" class=\"wpforms-save-resume-shortcode\" value=\"\" disabled \/>\n\t\t\t\t\t\t<span class=\"wpforms-save-resume-shortcode-copy\" title=\"Copy resume link to clipboard\">\n\t\t\t\t\t\t\t<span class=\"copy-icon\"><\/span>\n\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<form class=\"wpforms-validate wpforms-form wpforms-save-resume-email-notification\" method=\"post\" action=\"\/staging\/3913\/wp-json\/wp\/v2\/pages\/32970\">\n\t\t\t\t\t\t<div class=\"wpforms-field wpforms-field-email\">\n\t\t\t\t\t\t\t<label class=\"wpforms-field-label wpforms-save-resume-label\">\n\t\t\t\t\t\t\t\tEmail\t\t\t\t\t\t\t\t<span class=\"wpforms-required-label\">*<\/span>\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<input type=\"email\" name=\"wpforms[save_resume_email]\" required>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"wpforms-submit-container\">\n\t\t\t\t\t\t\t<input type=\"hidden\" id=\"_wpnonce\" name=\"_wpnonce\" value=\"5fa02c8bd0\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/staging\/3913\/wp-json\/wp\/v2\/pages\/32970\" \/>\t\t\t\t\t\t\t<input type=\"hidden\" name=\"wpforms[form_id]\" value=\"32969\">\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"wpforms[entry_id]\" class=\"wpforms-save-resume-entry-id\" value=\"\">\n\t\t\t\t\t\t\t<button type=\"submit\" name=\"wpforms[save-resume]\" class=\"wpforms-submit\" value=\"wpforms-submit\">\n\t\t\t\t\t\t\t\tSend Link\t\t\t\t\t\t\t<\/button>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/form>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\n\t\t<\/div>","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"nf_dc_page":"","om_disable_all_campaigns":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-32970","page","type-page","status-publish"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - 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