function FrameBuilder(formId,appendTo,initialHeight,iframeCode){this.formId=formId;this.initialHeight=initialHeight;this.iframeCode=iframeCode;this.frame=null;this.timeInterval=200;this.appendTo=appendTo||false;this.formSubmitted=0;this.init=function(){this.createFrame();this.addFrameContent(this.iframeCode);};this.createFrame=function(){var tmp_is_ie=!!window.ActiveXObject;var htmlCode="<"+"iframe onload=\"window.parent.scrollTo(0,0)\" src=\"\" allowtransparency=\"true\" frameborder=\"0\" name=\""+this.formId+"\" id=\""+this.formId+"\" style=\"width:100%; height:"+this.initialHeight+"px; border:none;\" scrolling=\"no\"></if"+"rame>";if(this.appendTo===false){document.write(htmlCode);}else{var tmp=document.createElement('div');tmp.innerHTML=htmlCode;var a=this.appendTo;document.getElementById(a).appendChild(tmp.firstChild);}
this.frame=document.getElementById(this.formId);if(tmp_is_ie===true){try{var iframe=this.frame;var doc=iframe.contentDocument?iframe.contentDocument:(iframe.contentWindow.document||iframe.document);doc.open();doc.write("");}
catch(err){this.frame.src="javascript:void((function(){document.open();document.domain=\'"+this.getBaseDomain()+"\';document.close();})())";}}
this.addEvent(this.frame,'load',this.bindMethod(this.setTimer,this));var self=this;if(window.chrome!==undefined){this.frame.onload=function(){try{var doc=this.contentWindow.document;var _jotform=this.contentWindow.JotForm;if(doc!==undefined){var form=doc.getElementById(""+self.formId);self.addEvent(form,"submit",function(){if(_jotform.validateAll()){self.formSubmitted=1;}});}}catch(e){}}}};this.addEvent=function(obj,type,fn){if(obj.attachEvent){obj["e"+type+fn]=fn;obj[type+fn]=function(){obj["e"+type+fn](window.event);};obj.attachEvent("on"+type,obj[type+fn]);}
else{obj.addEventListener(type,fn,false);}};this.addFrameContent=function(string){string=string.replace(new RegExp('src\\=\\"[^"]*captcha.php\"><\/scr'+'ipt>','gim'),'src="http://api.recaptcha.net/js/recaptcha_ajax.js"></scr'+'ipt><'+'div id="recaptcha_div"><'+'/div>'+'<'+'style>#recaptcha_logo{ display:none;} #recaptcha_tagline{display:none;} #recaptcha_table{border:none !important;} .recaptchatable .recaptcha_image_cell, #recaptcha_table{ background-color:transparent !important; } <'+'/style>'+'<'+'script defer="defer"> window.onload = function(){ Recaptcha.create("6Ld9UAgAAAAAAMon8zjt30tEZiGQZ4IIuWXLt1ky", "recaptcha_div", {theme: "clean",tabindex: 0,callback: function (){'+'if (document.getElementById("uword")) { document.getElementById("uword").parentNode.removeChild(document.getElementById("uword")); } if (window["validate"] !== undefined) { if (document.getElementById("recaptcha_response_field")){ document.getElementById("recaptcha_response_field").onblur = function(){ validate(document.getElementById("recaptcha_response_field"), "Required"); } } } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_challenge_field")[0].setAttribute("name", "anum"); } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_response_field")[0].setAttribute("name", "qCap"); }}})'+' }<'+'/script>');string=string.replace(/(type="text\/javascript">)\s+(validate\(\"[^"]*"\);)/,'$1 jTime = setInterval(function(){if("validate" in window){$2clearTimeout(jTime);}}, 1000);');var iframe=this.frame;var doc=iframe.contentDocument?iframe.contentDocument:(iframe.contentWindow.document||iframe.document);doc.open();doc.write(string);setTimeout(function(){doc.close();try{if('JotFormFrameLoaded'in window){JotFormFrameLoaded();}}catch(e){console.log("error on frame loading",e);}},200);};this.setTimer=function(){var self=this;this.interval=setTimeout(function(){self.changeHeight();},this.timeInterval);};this.getBaseDomain=function(){var thn=window.location.hostname;var cc=0;var buff="";for(var i=0;i<thn.length;i++){var chr=thn.charAt(i);if(chr=="."){cc++;}
if(cc==0){buff+=chr;}}
if(cc==2){thn=thn.replace(buff+".","");}
return thn;}
this.changeHeight=function(){var actualHeight=this.getBodyHeight();var currentHeight=this.getViewPortHeight();if(actualHeight===undefined){this.frame.style.height=this.frameHeight;if(!this.frame.style.minHeight){this.frame.style.minHeight="300px";}}else if(Math.abs(actualHeight-currentHeight)>18){this.frame.style.height=(actualHeight)+"px";}
this.setTimer();};this.bindMethod=function(method,scope){return function(){method.apply(scope,arguments);};};this.frameHeight=0;this.getBodyHeight=function(){if(this.formSubmitted===1){return;}
var height;var scrollHeight;var offsetHeight;try{if(this.frame.contentWindow.document.height){height=this.frame.contentWindow.document.height;if(this.frame.contentWindow.document.body.scrollHeight){height=scrollHeight=this.frame.contentWindow.document.body.scrollHeight;}
if(this.frame.contentWindow.document.body.offsetHeight){height=offsetHeight=this.frame.contentWindow.document.body.offsetHeight;}}else if(this.frame.contentWindow.document.body){var isChrome=/Chrome/.test(navigator.userAgent)&&/Google Inc/.test(navigator.vendor);if(this.frame.contentWindow.document.body.scrollHeight){height=scrollHeight=this.frame.contentWindow.document.body.scrollHeight;}
if(isChrome){height=scrollHeight=this.frame.contentWindow.document.height;}
if(this.frame.contentWindow.document.body.offsetHeight){height=offsetHeight=this.frame.contentWindow.document.body.offsetHeight;}
if(scrollHeight&&offsetHeight){height=Math.max(scrollHeight,offsetHeight);}}}catch(e){}
this.frameHeight=height;return height;};this.getViewPortHeight=function(){if(this.formSubmitted===1){return;}
var height=0;try{if(this.frame.contentWindow.window.innerHeight)
{height=this.frame.contentWindow.window.innerHeight-18;}
else if((this.frame.contentWindow.document.documentElement)&&(this.frame.contentWindow.document.documentElement.clientHeight))
{height=this.frame.contentWindow.document.documentElement.clientHeight;}
else if((this.frame.contentWindow.document.body)&&(this.frame.contentWindow.document.body.clientHeight))
{height=this.frame.contentWindow.document.body.clientHeight;}}catch(e){}
return height;};this.init();}
FrameBuilder.get=[];var i10682410622=new FrameBuilder("10682410622",false,"","<!DOCTYPE HTML PUBLIC \"-\/\/W3C\/\/DTD HTML 4.01\/\/EN\" \"http:\/\/www.w3.org\/TR\/html4\/strict.dtd\">\n<html class=\"supernova\"><head>\n<meta http-equiv=\"Content-Type\" content=\"text\/html; charset=utf-8\" \/>\n<link rel=\"alternate\" type=\"application\/json+oembed\" href=\"https:\/\/www.jotform.com\/oembed\/?format=json&amp;url=http%3A%2F%2Fwww.jotform.com%2Fform%2F10682410622\" title=\"oEmbed Form\"><link rel=\"alternate\" type=\"text\/xml+oembed\" href=\"https:\/\/www.jotform.com\/oembed\/?format=xml&amp;url=http%3A%2F%2Fwww.jotform.com%2Fform%2F10682410622\" title=\"oEmbed Form\">\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0, maximum-scale=1.0, user-scalable=0\" \/>\n<meta name=\"HandheldFriendly\" content=\"true\" \/>\n<title>Form<\/title>\n<link href=\"http:\/\/d2g9qbzl5h49rh.cloudfront.net\/static\/formCss.css?3.2.6614\" rel=\"stylesheet\" type=\"text\/css\" \/>\n<link type=\"text\/css\" media=\"print\" rel=\"stylesheet\" href=\"http:\/\/d2g9qbzl5h49rh.cloudfront.net\/css\/printForm.css?3.2.6614\" \/>\n<style type=\"text\/css\">\n    .form-label-left{\n        width:150px !important;\n    }\n    .form-line{\n        padding-top:7px;\n        padding-bottom:7px;\n    }\n    .form-label-right{\n        width:150px !important;\n    }\n    body, html{\n        margin:0;\n        padding:0;\n        background:false;\n    }\n\n    .form-all{\n        margin:0px auto;\n        padding-top:20px;\n        width:690px;\n        color:#555555 !important;\n        font-family:'Verdana';\n        font-size:12px;\n    }\n    .form-radio-item label, .form-checkbox-item label, .form-grading-label, .form-header{\n        color: #555555;\n    }\n\n<\/style>\n\n<style type=\"text\/css\" id=\"form-designer-style\">\n    \/* Injected CSS Code *\/\n.form-all {\n  font-family: \"Verdana\", sans-serif;\n}\n.form-all {\n  width: 690px;\n}\n.form-label-left,\n.form-label-right {\n  width: 150px;\n}\n.form-label {\n  white-space: normal;\n}\n.form-label.form-label-auto {\n  display: inline-block;\n  float: left;\n  text-align: left;\n  width: 150px;\n}\n.form-label-left {\n  display: inline-block;\n  white-space: normal;\n  float: left;\n  text-align: left;\n}\n.form-label-right {\n  display: inline-block;\n  white-space: normal;\n  float: left;\n  text-align: right;\n}\n.form-label-top {\n  white-space: normal;\n  display: block;\n  float: none;\n  text-align: left;\n}\n.form-all {\n  font-size: 12px;\n}\n.form-label {\n  font-weight: bold;\n}\n.form-checkbox-item label,\n.form-radio-item label {\n  font-weight: normal;\n}\n.supernova {\n  background-color: none;\n  background-color: #ffffff;\n}\n.supernova body {\n  background-color: transparent;\n}\n\/*\n@width30: (unit(@formWidth, px) + 60px);\n@width60: (unit(@formWidth, px)+ 120px);\n@width90: (unit(@formWidth, px)+ 180px);\n*\/\n\/* | *\/\n\/* | *\/\n\/* | *\/\n@media screen and (max-width: 480px) {\n  .jotform-form {\n    padding: 10px 0;\n  }\n}\n\/* | *\/\n\/* | *\/\n@media screen and (min-width: 480px) and (max-width: 768px) {\n  .jotform-form {\n    padding: 30px 0;\n  }\n}\n\/* | *\/\n\/* | *\/\n@media screen and (min-width: 768px) and (max-width: 1024px) {\n  .jotform-form {\n    padding: 60px 0;\n  }\n}\n\/* | *\/\n\/* | *\/\n@media screen and (min-width: 1024px) {\n  .jotform-form {\n    padding: 90px 0;\n  }\n}\n\/* | *\/\n.form-all {\n  background-color: none;\n  border: 1px solid transparent;\n}\n.form-all {\n  color: #555555;\n}\n.form-header-group .form-header {\n  color: #555555;\n}\n.form-header-group .form-subHeader {\n  color: #6f6f6f;\n}\n.form-sub-label {\n  color: #6f6f6f;\n}\n.form-label-top,\n.form-label-left,\n.form-label-right {\n  color: #555555;\n}\n.form-checkbox-item label,\n.form-radio-item label {\n  color: #6f6f6f;\n}\n.form-line.form-line-active {\n  -webkit-transition-property: all;\n  -moz-transition-property: all;\n  -ms-transition-property: all;\n  -o-transition-property: all;\n  transition-property: all;\n  -webkit-transition-duration: 0.3s;\n  -moz-transition-duration: 0.3s;\n  -ms-transition-duration: 0.3s;\n  -o-transition-duration: 0.3s;\n  transition-duration: 0.3s;\n  -webkit-transition-timing-function: ease;\n  -moz-transition-timing-function: ease;\n  -ms-transition-timing-function: ease;\n  -o-transition-timing-function: ease;\n  transition-timing-function: ease;\n  background-color: #ffffe0;\n}\n\/* \u00f6mer *\/\n.form-radio-item,\n.form-checkbox-item {\n  padding-bottom: 0px !important;\n}\n.form-radio-item:last-child,\n.form-checkbox-item:last-child {\n  padding-bottom: 0;\n}\n\/* \u00f6mer *\/\n\/*.ctrl-custom-size(@bgSize, @tickSize, @tickOffsetTop, @tickOffsetLeft, @radius) {\n\n\tinput {\n\t\tdisplay: none;\n\t}\n\t\n\tlabel {\n\t\tposition: relative;\n\t\tmargin-left: 0;\n\t}\n\n\tlabel:before {\n\t\tcontent: '';\n\t\tposition: relative;\n\t\tdisplay: inline-block;\n\t\tvertical-align: baseline;\n\t\tmargin-right: 4px;\n\t\t.border-box();\n\t\t.rounded(@radius);\n\n\t\twidth: @bgSize;\n\t\theight: @bgSize;\n\t}\n\n\tlabel:after {\n\t\tcontent: '';\n\t\tposition: absolute;\n\t\tz-index: 10;\t\n\t\tdisplay: inline-block;\n\t\topacity: 0;\n\n\t\ttop:@tickOffsetTop;\n\t\tleft:@tickOffsetLeft;\n\t\twidth: @tickSize;\n\t\theight: @tickSize;\n\t\t.rounded(@radius);\n\t}\n\n\tinput:checked + label:after {\n\t\topacity: 1;\n\t}\n\n}*\/\n.form-single-column .form-checkbox-item,\n.form-single-column .form-radio-item {\n  width: 100%;\n}\n.supernova {\n  background-repeat: no-repeat;\n  background-attachment: scroll;\n  background-position: center top;\n  background-repeat: repeat;\n}\n\/* | *\/\n.form-all {\n  background-repeat: no-repeat;\n  background-attachment: scroll;\n  background-position: center top;\n  background-repeat: repeat;\n}\n.form-header-group {\n  background-repeat: no-repeat;\n  background-attachment: scroll;\n  background-position: center top;\n}\n.form-line {\n  margin-top: 12px;\n  margin-bottom: 12px;\n}\n.form-line {\n  padding: 12px 36px;\n}\n.form-all .qq-upload-button,\n.form-all .form-submit-button,\n.form-all .form-submit-reset,\n.form-all .form-submit-print {\n  font-size: 1em;\n  padding: 9px 15px;\n  font-family: \"Verdana\", sans-serif;\n  font-size: 12px;\n  font-weight: normal;\n}\n.form-all .form-pagebreak-back,\n.form-all .form-pagebreak-next {\n  font-size: 1em;\n  padding: 9px 15px;\n  font-family: \"Verdana\", sans-serif;\n  font-size: 12px;\n  font-weight: normal;\n}\n\/*\n\tTODO: Significant improvement possibility:\n\n\tfollowing import statement is not required in design mode,\n\tbut it should be inside the exported css of current design, in the form itself\n\twhen it is shown to people. Being of this here, causing re-drawn problems.\n\twe should find a way to only include this in css send while saving current design\n\n\tsee prepareModel4Save for implementation for @buttonFontType\n*\/\n\/*\n&amp; when ( @buttonFontType = google ) {\n\t@import (css) \"@{buttonFontLink}\";\n}\n*\/\nh2.form-header {\n  line-height: 1.618em;\n  font-size: 1.714em;\n}\nh2 ~ .form-subHeader {\n  line-height: 1.5em;\n  font-size: 1.071em;\n}\n.form-header-group {\n  text-align: left;\n}\n\/*.form-dropdown,\n.form-radio-item,\n.form-checkbox-item,\n.form-radio-other-input,\n.form-checkbox-other-input,*\/\n.form-captcha input,\n.form-spinner input,\n.form-error-message {\n  padding: 4px 3px 2px 3px;\n}\n.form-header-group {\n  font-family: \"Verdana\", sans-serif;\n}\n.form-section {\n  padding: 0px 0px 0px 0px;\n}\n.form-header-group {\n  margin: 12px 36px 12px 36px;\n}\n.form-header-group {\n  padding: 24px 0px 24px 0px;\n}\n.form-textbox,\n.form-textarea {\n  padding: 4px 3px 2px 3px;\n}\n\/*@textInputStyle: \"ti-default\";\n@textInputBorderWidth: -1;\n@textInputBorderStyle: -1;\n@clrTextInputBorder: -1;\n@clrTextInputBg: -1;\n@clrTextInputFont: -1;\n@textInputHeight: -1;\n@textAreaHeight: -1;\n\n&amp; when ( @formControlStyle = ti-default ) {\n\n}*\/\n[data-type=\"control_dropdown\"] .form-input,\n[data-type=\"control_dropdown\"] .form-input-wide {\n  width: 150px;\n}\n.form-label {\n  font-family: \"Verdana\", sans-serif;\n}\nli[data-type=\"control_image\"] div {\n  text-align: left;\n}\nli[data-type=\"control_image\"] img {\n  border: none;\n  border-width: 0px !important;\n  border-style: solid !important;\n  border-color: false !important;\n}\n.form-line-column {\n  width: auto;\n}\n.form-line-error {\n  overflow: hidden;\n  -webkit-transition-property: none;\n  -moz-transition-property: none;\n  -ms-transition-property: none;\n  -o-transition-property: none;\n  transition-property: none;\n  -webkit-transition-duration: 0.3s;\n  -moz-transition-duration: 0.3s;\n  -ms-transition-duration: 0.3s;\n  -o-transition-duration: 0.3s;\n  transition-duration: 0.3s;\n  -webkit-transition-timing-function: ease;\n  -moz-transition-timing-function: ease;\n  -ms-transition-timing-function: ease;\n  -o-transition-timing-function: ease;\n  transition-timing-function: ease;\n  background-color: #fff4f4;\n}\n.form-line-error .form-error-message {\n  background-color: #ff3200;\n  clear: both;\n  float: none;\n}\n.form-line-error .form-error-message .form-error-arrow {\n  border-bottom-color: #ff3200;\n}\n.form-line-error input:not(#coupon-input),\n.form-line-error textarea,\n.form-line-error .form-validation-error {\n  border: 1px solid #ff3200;\n  -webkit-box-shadow: 0 0 3px #ff3200;\n  -moz-box-shadow: 0 0 3px #ff3200;\n  box-shadow: 0 0 3px #ff3200;\n}\n.ie-8 .form-all {\n  margin-top: auto;\n  margin-top: initial;\n}\n.ie-8 .form-all:before {\n  display: none;\n}\n\/* | *\/\n@media screen and (max-width: 768px) {\n  .form-all {\n    border: 0;\n    width: 100%;\n  }\n  .form-sub-label-container {\n    width: 100%;\n    margin: 0;\n  }\n  .form-input {\n    width: 100%;\n  }\n  .form-label {\n    width: 100%!important;\n  }\n  .form-line {\n    padding: 2% 5%;\n    margin: 0;\n  }\n  input[type=text],\n  input[type=email],\n  input[type=tel],\n  textarea {\n    width: 100%;\n    -moz-box-sizing: border-box;\n    -webkit-box-sizing: border-box;\n    box-sizing: border-box;\n  }\n  .form-header-group {\n    padding: 3% 0!important;\n    margin: 5%!important;\n    -moz-box-sizing: border-box;\n    -webkit-box-sizing: border-box;\n    box-sizing: border-box;\n  }\n  .form-buttons-wrapper {\n    margin: 0!important;\n  }\n  .form-buttons-wrapper button {\n    width: 100%;\n  }\n  table {\n    width: 100%!important;\n  }\n  table td + td {\n    padding-left: 3%;\n  }\n  .form-checkbox-item input,\n  .form-radio-item input {\n    width: auto;\n  }\n}\n\/* | *\/\n\n\/*__INSPECT_SEPERATOR__*\/\n\n    \/* Injected CSS Code *\/\n<\/style>\n\n<script src=\"http:\/\/d2g9qbzl5h49rh.cloudfront.net\/static\/prototype.forms.js\" type=\"text\/javascript\"><\/script>\n<script src=\"http:\/\/d2g9qbzl5h49rh.cloudfront.net\/static\/jotform.forms.js?3.2.6614\" type=\"text\/javascript\"><\/script>\n<script type=\"text\/javascript\">\n var jsTime = setInterval(function(){try{\n   JotForm.jsForm = true;\n\n   JotForm.init(function(){\n      setTimeout(function() {\n          $('input_3').hint('ex: myname@example.com');\n       }, 20);\n      setTimeout(function() {\n          $('input_47').hint('ex: 23');\n       }, 20);\n      setTimeout(function() {\n          $('input_48').hint(' ex: 3-6pm');\n       }, 20);\n      setTimeout(function() {\n          $('input_42').hint('ex: myname@example.com');\n       }, 20);\n      setTimeout(function() {\n          $('input_45').hint('ex: myname@example.com');\n       }, 20);\n   });\n\n   clearInterval(jsTime);\n }catch(e){}}, 1000);\n<\/script>\n<\/head>\n<body>\n<form class=\"jotform-form\" action=\"http:\/\/submit.jotform.co\/submit\/10682410622\/\" method=\"post\" name=\"form_10682410622\" id=\"10682410622\" accept-charset=\"utf-8\">\n  <input type=\"hidden\" name=\"formID\" value=\"10682410622\" \/>\n  <div class=\"form-all\">\n    <ul class=\"form-section page-section\">\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_61\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_61\" for=\"input_61\"> Title <\/label>\n        <div id=\"cid_61\" class=\"form-input jf-required\">\n          <select class=\"form-dropdown\" style=\"width:150px\" id=\"input_61\" name=\"q61_title\">\n            <option value=\"\">  <\/option>\n            <option value=\"Mr\"> Mr <\/option>\n            <option value=\"Ms\"> Ms <\/option>\n            <option value=\"Mrs\"> Mrs <\/option>\n            <option value=\"Miss\"> Miss <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_1\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_1\" for=\"input_1\">\n          Name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_1\" class=\"form-input jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <input class=\"form-textbox validate[required]\" type=\"text\" size=\"10\" name=\"q1_name1[first]\" id=\"first_1\" \/>\n            <label class=\"form-sub-label\" for=\"first_1\" id=\"sublabel_first\" style=\"min-height: 13px;\"> First Name <\/label>\n          <\/span>\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <input class=\"form-textbox validate[required]\" type=\"text\" size=\"15\" name=\"q1_name1[last]\" id=\"last_1\" \/>\n            <label class=\"form-sub-label\" for=\"last_1\" id=\"sublabel_last\" style=\"min-height: 13px;\"> Last Name <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_birthdate\" id=\"id_5\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_5\" for=\"input_5\">\n          Date of Birth\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_5\" class=\"form-input jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <select class=\"form-dropdown validate[required]\" name=\"q5_dateOf5[month]\" id=\"input_5_month\">\n              <option>  <\/option>\n              <option value=\"January\"> January <\/option>\n              <option value=\"February\"> February <\/option>\n              <option value=\"March\"> March <\/option>\n              <option value=\"April\"> April <\/option>\n              <option value=\"May\"> May <\/option>\n              <option value=\"June\"> June <\/option>\n              <option value=\"July\"> July <\/option>\n              <option value=\"August\"> August <\/option>\n              <option value=\"September\"> September <\/option>\n              <option value=\"October\"> October <\/option>\n              <option value=\"November\"> November <\/option>\n              <option value=\"December\"> December <\/option>\n            <\/select>\n            <label class=\"form-sub-label\" for=\"input_5_month\" id=\"sublabel_month\" style=\"min-height: 13px;\"> Month <\/label>\n          <\/span>\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <select class=\"form-dropdown validate[required]\" name=\"q5_dateOf5[day]\" id=\"input_5_day\">\n              <option>  <\/option>\n              <option value=\"1\"> 1 <\/option>\n              <option value=\"2\"> 2 <\/option>\n              <option value=\"3\"> 3 <\/option>\n              <option value=\"4\"> 4 <\/option>\n              <option value=\"5\"> 5 <\/option>\n              <option value=\"6\"> 6 <\/option>\n              <option value=\"7\"> 7 <\/option>\n              <option value=\"8\"> 8 <\/option>\n              <option value=\"9\"> 9 <\/option>\n              <option value=\"10\"> 10 <\/option>\n              <option value=\"11\"> 11 <\/option>\n              <option value=\"12\"> 12 <\/option>\n              <option value=\"13\"> 13 <\/option>\n              <option value=\"14\"> 14 <\/option>\n              <option value=\"15\"> 15 <\/option>\n              <option value=\"16\"> 16 <\/option>\n              <option value=\"17\"> 17 <\/option>\n              <option value=\"18\"> 18 <\/option>\n              <option value=\"19\"> 19 <\/option>\n              <option value=\"20\"> 20 <\/option>\n              <option value=\"21\"> 21 <\/option>\n              <option value=\"22\"> 22 <\/option>\n              <option value=\"23\"> 23 <\/option>\n              <option value=\"24\"> 24 <\/option>\n              <option value=\"25\"> 25 <\/option>\n              <option value=\"26\"> 26 <\/option>\n              <option value=\"27\"> 27 <\/option>\n              <option value=\"28\"> 28 <\/option>\n              <option value=\"29\"> 29 <\/option>\n              <option value=\"30\"> 30 <\/option>\n              <option value=\"31\"> 31 <\/option>\n            <\/select>\n            <label class=\"form-sub-label\" for=\"input_5_day\" id=\"sublabel_day\" style=\"min-height: 13px;\"> Day <\/label>\n          <\/span>\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <select class=\"form-dropdown validate[required]\" name=\"q5_dateOf5[year]\" id=\"input_5_year\">\n              <option>  <\/option>\n              <option value=\"2015\"> 2015 <\/option>\n              <option value=\"2014\"> 2014 <\/option>\n              <option value=\"2013\"> 2013 <\/option>\n              <option value=\"2012\"> 2012 <\/option>\n              <option value=\"2011\"> 2011 <\/option>\n              <option value=\"2010\"> 2010 <\/option>\n              <option value=\"2009\"> 2009 <\/option>\n              <option value=\"2008\"> 2008 <\/option>\n              <option value=\"2007\"> 2007 <\/option>\n              <option value=\"2006\"> 2006 <\/option>\n              <option value=\"2005\"> 2005 <\/option>\n              <option value=\"2004\"> 2004 <\/option>\n              <option value=\"2003\"> 2003 <\/option>\n              <option value=\"2002\"> 2002 <\/option>\n              <option value=\"2001\"> 2001 <\/option>\n              <option value=\"2000\"> 2000 <\/option>\n              <option value=\"1999\"> 1999 <\/option>\n              <option value=\"1998\"> 1998 <\/option>\n              <option value=\"1997\"> 1997 <\/option>\n              <option value=\"1996\"> 1996 <\/option>\n              <option value=\"1995\"> 1995 <\/option>\n              <option value=\"1994\"> 1994 <\/option>\n              <option value=\"1993\"> 1993 <\/option>\n              <option value=\"1992\"> 1992 <\/option>\n              <option value=\"1991\"> 1991 <\/option>\n              <option value=\"1990\"> 1990 <\/option>\n              <option value=\"1989\"> 1989 <\/option>\n              <option value=\"1988\"> 1988 <\/option>\n              <option value=\"1987\"> 1987 <\/option>\n              <option value=\"1986\"> 1986 <\/option>\n              <option value=\"1985\"> 1985 <\/option>\n              <option value=\"1984\"> 1984 <\/option>\n              <option value=\"1983\"> 1983 <\/option>\n              <option value=\"1982\"> 1982 <\/option>\n              <option value=\"1981\"> 1981 <\/option>\n              <option value=\"1980\"> 1980 <\/option>\n              <option value=\"1979\"> 1979 <\/option>\n              <option value=\"1978\"> 1978 <\/option>\n              <option value=\"1977\"> 1977 <\/option>\n              <option value=\"1976\"> 1976 <\/option>\n              <option value=\"1975\"> 1975 <\/option>\n              <option value=\"1974\"> 1974 <\/option>\n              <option value=\"1973\"> 1973 <\/option>\n              <option value=\"1972\"> 1972 <\/option>\n              <option value=\"1971\"> 1971 <\/option>\n              <option value=\"1970\"> 1970 <\/option>\n              <option value=\"1969\"> 1969 <\/option>\n              <option value=\"1968\"> 1968 <\/option>\n              <option value=\"1967\"> 1967 <\/option>\n              <option value=\"1966\"> 1966 <\/option>\n              <option value=\"1965\"> 1965 <\/option>\n              <option value=\"1964\"> 1964 <\/option>\n              <option value=\"1963\"> 1963 <\/option>\n              <option value=\"1962\"> 1962 <\/option>\n              <option value=\"1961\"> 1961 <\/option>\n              <option value=\"1960\"> 1960 <\/option>\n              <option value=\"1959\"> 1959 <\/option>\n              <option value=\"1958\"> 1958 <\/option>\n              <option value=\"1957\"> 1957 <\/option>\n              <option value=\"1956\"> 1956 <\/option>\n              <option value=\"1955\"> 1955 <\/option>\n              <option value=\"1954\"> 1954 <\/option>\n              <option value=\"1953\"> 1953 <\/option>\n              <option value=\"1952\"> 1952 <\/option>\n              <option value=\"1951\"> 1951 <\/option>\n              <option value=\"1950\"> 1950 <\/option>\n              <option value=\"1949\"> 1949 <\/option>\n              <option value=\"1948\"> 1948 <\/option>\n              <option value=\"1947\"> 1947 <\/option>\n              <option value=\"1946\"> 1946 <\/option>\n              <option value=\"1945\"> 1945 <\/option>\n              <option value=\"1944\"> 1944 <\/option>\n              <option value=\"1943\"> 1943 <\/option>\n              <option value=\"1942\"> 1942 <\/option>\n              <option value=\"1941\"> 1941 <\/option>\n              <option value=\"1940\"> 1940 <\/option>\n              <option value=\"1939\"> 1939 <\/option>\n              <option value=\"1938\"> 1938 <\/option>\n              <option value=\"1937\"> 1937 <\/option>\n              <option value=\"1936\"> 1936 <\/option>\n              <option value=\"1935\"> 1935 <\/option>\n              <option value=\"1934\"> 1934 <\/option>\n              <option value=\"1933\"> 1933 <\/option>\n              <option value=\"1932\"> 1932 <\/option>\n              <option value=\"1931\"> 1931 <\/option>\n              <option value=\"1930\"> 1930 <\/option>\n              <option value=\"1929\"> 1929 <\/option>\n              <option value=\"1928\"> 1928 <\/option>\n              <option value=\"1927\"> 1927 <\/option>\n              <option value=\"1926\"> 1926 <\/option>\n              <option value=\"1925\"> 1925 <\/option>\n              <option value=\"1924\"> 1924 <\/option>\n              <option value=\"1923\"> 1923 <\/option>\n              <option value=\"1922\"> 1922 <\/option>\n              <option value=\"1921\"> 1921 <\/option>\n              <option value=\"1920\"> 1920 <\/option>\n            <\/select>\n            <label class=\"form-sub-label\" for=\"input_5_year\" id=\"sublabel_year\" style=\"min-height: 13px;\"> Year <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_email\" id=\"id_3\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_3\" for=\"input_3\">\n          E-mail\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_3\" class=\"form-input jf-required\">\n          <input type=\"email\" class=\" form-textbox validate[required, Email]\" id=\"input_3\" name=\"q3_email\" size=\"30\" value=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_phone\" id=\"id_68\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_68\" for=\"input_68\"> Home Phone <\/label>\n        <div id=\"cid_68\" class=\"form-input jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <input class=\"form-textbox\" type=\"tel\" name=\"q68_homePhone[area]\" id=\"input_68_area\" size=\"3\">\n            <span class=\"phone-separate\">\n              &nbsp;-\n            <\/span>\n            <label class=\"form-sub-label\" for=\"input_68_area\" id=\"sublabel_area\" style=\"min-height: 13px;\"> Area Code <\/label>\n          <\/span>\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <input class=\"form-textbox\" type=\"tel\" name=\"q68_homePhone[phone]\" id=\"input_68_phone\" size=\"8\">\n            <label class=\"form-sub-label\" for=\"input_68_phone\" id=\"sublabel_phone\" style=\"min-height: 13px;\"> Phone Number <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_phone\" id=\"id_69\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_69\" for=\"input_69\"> Cell Phone <\/label>\n        <div id=\"cid_69\" class=\"form-input jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <input class=\"form-textbox\" type=\"tel\" name=\"q69_cellPhone[area]\" id=\"input_69_area\" size=\"3\">\n            <span class=\"phone-separate\">\n              &nbsp;-\n            <\/span>\n            <label class=\"form-sub-label\" for=\"input_69_area\" id=\"sublabel_area\" style=\"min-height: 13px;\"> Area Code <\/label>\n          <\/span>\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <input class=\"form-textbox\" type=\"tel\" name=\"q69_cellPhone[phone]\" id=\"input_69_phone\" size=\"8\">\n            <label class=\"form-sub-label\" for=\"input_69_phone\" id=\"sublabel_phone\" style=\"min-height: 13px;\"> Phone Number <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_phone\" id=\"id_70\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_70\" for=\"input_70\"> Work Phone <\/label>\n        <div id=\"cid_70\" class=\"form-input jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <input class=\"form-textbox\" type=\"tel\" name=\"q70_workPhone[area]\" id=\"input_70_area\" size=\"3\">\n            <span class=\"phone-separate\">\n              &nbsp;-\n            <\/span>\n            <label class=\"form-sub-label\" for=\"input_70_area\" id=\"sublabel_area\" style=\"min-height: 13px;\"> Area Code <\/label>\n          <\/span>\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <input class=\"form-textbox\" type=\"tel\" name=\"q70_workPhone[phone]\" id=\"input_70_phone\" size=\"8\">\n            <label class=\"form-sub-label\" for=\"input_70_phone\" id=\"sublabel_phone\" style=\"min-height: 13px;\"> Phone Number <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_address\" id=\"id_71\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_71\" for=\"input_71\">\n          Address\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_71\" class=\"form-input jf-required\">\n          <table summary=\"\" undefined class=\"form-address-table\" border=\"0\" cellpadding=\"0\" cellspacing=\"0\">\n            <tr>\n              <td colspan=\"2\">\n                <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n                  <input class=\"form-textbox validate[required] form-address-line\" type=\"text\" name=\"q71_address71[addr_line1]\" id=\"input_71_addr_line1\" \/>\n                  <label class=\"form-sub-label\" for=\"input_71_addr_line1\" id=\"sublabel_71_addr_line1\" style=\"min-height: 13px;\"> Street Address <\/label>\n                <\/span>\n              <\/td>\n            <\/tr>\n            <tr>\n              <td colspan=\"2\">\n                <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n                  <input class=\"form-textbox form-address-line\" type=\"text\" name=\"q71_address71[addr_line2]\" id=\"input_71_addr_line2\" size=\"46\" \/>\n                  <label class=\"form-sub-label\" for=\"input_71_addr_line2\" id=\"sublabel_71_addr_line2\" style=\"min-height: 13px;\"> Street Address Line 2 <\/label>\n                <\/span>\n              <\/td>\n            <\/tr>\n            <tr>\n              <td width=\"50%\">\n                <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n                  <input class=\"form-textbox validate[required] form-address-city\" type=\"text\" name=\"q71_address71[city]\" id=\"input_71_city\" size=\"21\" \/>\n                  <label class=\"form-sub-label\" for=\"input_71_city\" id=\"sublabel_71_city\" style=\"min-height: 13px;\"> City <\/label>\n                <\/span>\n              <\/td>\n              <td>\n                <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n                  <input class=\"form-textbox validate[required] form-address-state\" type=\"text\" name=\"q71_address71[state]\" id=\"input_71_state\" size=\"22\" \/>\n                  <label class=\"form-sub-label\" for=\"input_71_state\" id=\"sublabel_71_state\" style=\"min-height: 13px;\"> State \/ Province <\/label>\n                <\/span>\n              <\/td>\n            <\/tr>\n            <tr>\n              <td width=\"50%\">\n                <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n                  <input class=\"form-textbox validate[required] form-address-postal\" type=\"text\" name=\"q71_address71[postal]\" id=\"input_71_postal\" size=\"10\" \/>\n                  <label class=\"form-sub-label\" for=\"input_71_postal\" id=\"sublabel_71_postal\" style=\"min-height: 13px;\"> Postal \/ Zip Code <\/label>\n                <\/span>\n              <\/td>\n              <td>\n                <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n                  <select class=\"form-dropdown validate[required] form-address-country\" defaultcountry=\"United States\" name=\"q71_address71[country]\" id=\"input_71_country\">\n                    <option value=\"\" selected> Please Select <\/option>\n                    <option selected=\"selected\" value=\"United States\"> United States <\/option>\n                    <option value=\"Afghanistan\"> Afghanistan <\/option>\n                    <option value=\"Albania\"> Albania <\/option>\n                    <option value=\"Algeria\"> Algeria <\/option>\n                    <option value=\"American Samoa\"> American Samoa <\/option>\n                    <option value=\"Andorra\"> Andorra <\/option>\n                    <option value=\"Angola\"> Angola <\/option>\n                    <option value=\"Anguilla\"> Anguilla <\/option>\n                    <option value=\"Antigua and Barbuda\"> Antigua and Barbuda <\/option>\n                    <option value=\"Argentina\"> Argentina <\/option>\n                    <option value=\"Armenia\"> Armenia <\/option>\n                    <option value=\"Aruba\"> Aruba <\/option>\n                    <option value=\"Australia\"> Australia <\/option>\n                    <option value=\"Austria\"> Austria <\/option>\n                    <option value=\"Azerbaijan\"> Azerbaijan <\/option>\n                    <option value=\"The Bahamas\"> The Bahamas <\/option>\n                    <option value=\"Bahrain\"> Bahrain <\/option>\n                    <option value=\"Bangladesh\"> Bangladesh <\/option>\n                    <option value=\"Barbados\"> Barbados <\/option>\n                    <option value=\"Belarus\"> Belarus <\/option>\n                    <option value=\"Belgium\"> Belgium <\/option>\n                    <option value=\"Belize\"> Belize <\/option>\n                    <option value=\"Benin\"> Benin <\/option>\n                    <option value=\"Bermuda\"> Bermuda <\/option>\n                    <option value=\"Bhutan\"> Bhutan <\/option>\n                    <option value=\"Bolivia\"> Bolivia <\/option>\n                    <option value=\"Bosnia and Herzegovina\"> Bosnia and Herzegovina <\/option>\n                    <option value=\"Botswana\"> Botswana <\/option>\n                    <option value=\"Brazil\"> Brazil <\/option>\n                    <option value=\"Brunei\"> Brunei <\/option>\n                    <option value=\"Bulgaria\"> Bulgaria <\/option>\n                    <option value=\"Burkina Faso\"> Burkina Faso <\/option>\n                    <option value=\"Burundi\"> Burundi <\/option>\n                    <option value=\"Cambodia\"> Cambodia <\/option>\n                    <option value=\"Cameroon\"> Cameroon <\/option>\n                    <option value=\"Canada\"> Canada <\/option>\n                    <option value=\"Cape Verde\"> Cape Verde <\/option>\n                    <option value=\"Cayman Islands\"> Cayman Islands <\/option>\n                    <option value=\"Central African Republic\"> Central African Republic <\/option>\n                    <option value=\"Chad\"> Chad <\/option>\n                    <option value=\"Chile\"> Chile <\/option>\n                    <option value=\"People's Republic of China\"> People's Republic of China <\/option>\n                    <option value=\"Republic of China\"> Republic of China <\/option>\n                    <option value=\"Christmas Island\"> Christmas Island <\/option>\n                    <option value=\"Cocos (Keeling) Islands\"> Cocos (Keeling) Islands <\/option>\n                    <option value=\"Colombia\"> Colombia <\/option>\n                    <option value=\"Comoros\"> Comoros <\/option>\n                    <option value=\"Congo\"> Congo <\/option>\n                    <option value=\"Cook Islands\"> Cook Islands <\/option>\n                    <option value=\"Costa Rica\"> Costa Rica <\/option>\n                    <option value=\"Cote d'Ivoire\"> Cote d'Ivoire <\/option>\n                    <option value=\"Croatia\"> Croatia <\/option>\n                    <option value=\"Cuba\"> Cuba <\/option>\n                    <option value=\"Cyprus\"> Cyprus <\/option>\n                    <option value=\"Czech Republic\"> Czech Republic <\/option>\n                    <option value=\"Denmark\"> Denmark <\/option>\n                    <option value=\"Djibouti\"> Djibouti <\/option>\n                    <option value=\"Dominica\"> Dominica <\/option>\n                    <option value=\"Dominican Republic\"> Dominican Republic <\/option>\n                    <option value=\"Ecuador\"> Ecuador <\/option>\n                    <option value=\"Egypt\"> Egypt <\/option>\n                    <option value=\"El Salvador\"> El Salvador <\/option>\n                    <option value=\"Equatorial Guinea\"> Equatorial Guinea <\/option>\n                    <option value=\"Eritrea\"> Eritrea <\/option>\n                    <option value=\"Estonia\"> Estonia <\/option>\n                    <option value=\"Ethiopia\"> Ethiopia <\/option>\n                    <option value=\"Falkland Islands\"> Falkland Islands <\/option>\n                    <option value=\"Faroe Islands\"> Faroe Islands <\/option>\n                    <option value=\"Fiji\"> Fiji <\/option>\n                    <option value=\"Finland\"> Finland <\/option>\n                    <option value=\"France\"> France <\/option>\n                    <option value=\"French Polynesia\"> French Polynesia <\/option>\n                    <option value=\"Gabon\"> Gabon <\/option>\n                    <option value=\"The Gambia\"> The Gambia <\/option>\n                    <option value=\"Georgia\"> Georgia <\/option>\n                    <option value=\"Germany\"> Germany <\/option>\n                    <option value=\"Ghana\"> Ghana <\/option>\n                    <option value=\"Gibraltar\"> Gibraltar <\/option>\n                    <option value=\"Greece\"> Greece <\/option>\n                    <option value=\"Greenland\"> Greenland <\/option>\n                    <option value=\"Grenada\"> Grenada <\/option>\n                    <option value=\"Guadeloupe\"> Guadeloupe <\/option>\n                    <option value=\"Guam\"> Guam <\/option>\n                    <option value=\"Guatemala\"> Guatemala <\/option>\n                    <option value=\"Guernsey\"> Guernsey <\/option>\n                    <option value=\"Guinea\"> Guinea <\/option>\n                    <option value=\"Guinea-Bissau\"> Guinea-Bissau <\/option>\n                    <option value=\"Guyana\"> Guyana <\/option>\n                    <option value=\"Haiti\"> Haiti <\/option>\n                    <option value=\"Honduras\"> Honduras <\/option>\n                    <option value=\"Hong Kong\"> Hong Kong <\/option>\n                    <option value=\"Hungary\"> Hungary <\/option>\n                    <option value=\"Iceland\"> Iceland <\/option>\n                    <option value=\"India\"> India <\/option>\n                    <option value=\"Indonesia\"> Indonesia <\/option>\n                    <option value=\"Iran\"> Iran <\/option>\n                    <option value=\"Iraq\"> Iraq <\/option>\n                    <option value=\"Ireland\"> Ireland <\/option>\n                    <option value=\"Israel\"> Israel <\/option>\n                    <option value=\"Italy\"> Italy <\/option>\n                    <option value=\"Jamaica\"> Jamaica <\/option>\n                    <option value=\"Japan\"> Japan <\/option>\n                    <option value=\"Jersey\"> Jersey <\/option>\n                    <option value=\"Jordan\"> Jordan <\/option>\n                    <option value=\"Kazakhstan\"> Kazakhstan <\/option>\n                    <option value=\"Kenya\"> Kenya <\/option>\n                    <option value=\"Kiribati\"> Kiribati <\/option>\n                    <option value=\"North Korea\"> North Korea <\/option>\n                    <option value=\"South Korea\"> South Korea <\/option>\n                    <option value=\"Kosovo\"> Kosovo <\/option>\n                    <option value=\"Kuwait\"> Kuwait <\/option>\n                    <option value=\"Kyrgyzstan\"> Kyrgyzstan <\/option>\n                    <option value=\"Laos\"> Laos <\/option>\n                    <option value=\"Latvia\"> Latvia <\/option>\n                    <option value=\"Lebanon\"> Lebanon <\/option>\n                    <option value=\"Lesotho\"> Lesotho <\/option>\n                    <option value=\"Liberia\"> Liberia <\/option>\n                    <option value=\"Libya\"> Libya <\/option>\n                    <option value=\"Liechtenstein\"> Liechtenstein <\/option>\n                    <option value=\"Lithuania\"> Lithuania <\/option>\n                    <option value=\"Luxembourg\"> Luxembourg <\/option>\n                    <option value=\"Macau\"> Macau <\/option>\n                    <option value=\"Macedonia\"> Macedonia <\/option>\n                    <option value=\"Madagascar\"> Madagascar <\/option>\n                    <option value=\"Malawi\"> Malawi <\/option>\n                    <option value=\"Malaysia\"> Malaysia <\/option>\n                    <option value=\"Maldives\"> Maldives <\/option>\n                    <option value=\"Mali\"> Mali <\/option>\n                    <option value=\"Malta\"> Malta <\/option>\n                    <option value=\"Marshall Islands\"> Marshall Islands <\/option>\n                    <option value=\"Martinique\"> Martinique <\/option>\n                    <option value=\"Mauritania\"> Mauritania <\/option>\n                    <option value=\"Mauritius\"> Mauritius <\/option>\n                    <option value=\"Mayotte\"> Mayotte <\/option>\n                    <option value=\"Mexico\"> Mexico <\/option>\n                    <option value=\"Micronesia\"> Micronesia <\/option>\n                    <option value=\"Moldova\"> Moldova <\/option>\n                    <option value=\"Monaco\"> Monaco <\/option>\n                    <option value=\"Mongolia\"> Mongolia <\/option>\n                    <option value=\"Montenegro\"> Montenegro <\/option>\n                    <option value=\"Montserrat\"> Montserrat <\/option>\n                    <option value=\"Morocco\"> Morocco <\/option>\n                    <option value=\"Mozambique\"> Mozambique <\/option>\n                    <option value=\"Myanmar\"> Myanmar <\/option>\n                    <option value=\"Nagorno-Karabakh\"> Nagorno-Karabakh <\/option>\n                    <option value=\"Namibia\"> Namibia <\/option>\n                    <option value=\"Nauru\"> Nauru <\/option>\n                    <option value=\"Nepal\"> Nepal <\/option>\n                    <option value=\"Netherlands\"> Netherlands <\/option>\n                    <option value=\"Netherlands Antilles\"> Netherlands Antilles <\/option>\n                    <option value=\"New Caledonia\"> New Caledonia <\/option>\n                    <option value=\"New Zealand\"> New Zealand <\/option>\n                    <option value=\"Nicaragua\"> Nicaragua <\/option>\n                    <option value=\"Niger\"> Niger <\/option>\n                    <option value=\"Nigeria\"> Nigeria <\/option>\n                    <option value=\"Niue\"> Niue <\/option>\n                    <option value=\"Norfolk Island\"> Norfolk Island <\/option>\n                    <option value=\"Turkish Republic of Northern Cyprus\"> Turkish Republic of Northern Cyprus <\/option>\n                    <option value=\"Northern Mariana\"> Northern Mariana <\/option>\n                    <option value=\"Norway\"> Norway <\/option>\n                    <option value=\"Oman\"> Oman <\/option>\n                    <option value=\"Pakistan\"> Pakistan <\/option>\n                    <option value=\"Palau\"> Palau <\/option>\n                    <option value=\"Palestine\"> Palestine <\/option>\n                    <option value=\"Panama\"> Panama <\/option>\n                    <option value=\"Papua New Guinea\"> Papua New Guinea <\/option>\n                    <option value=\"Paraguay\"> Paraguay <\/option>\n                    <option value=\"Peru\"> Peru <\/option>\n                    <option value=\"Philippines\"> Philippines <\/option>\n                    <option value=\"Pitcairn Islands\"> Pitcairn Islands <\/option>\n                    <option value=\"Poland\"> Poland <\/option>\n                    <option value=\"Portugal\"> Portugal <\/option>\n                    <option value=\"Puerto Rico\"> Puerto Rico <\/option>\n                    <option value=\"Qatar\"> Qatar <\/option>\n                    <option value=\"Romania\"> Romania <\/option>\n                    <option value=\"Russia\"> Russia <\/option>\n                    <option value=\"Rwanda\"> Rwanda <\/option>\n                    <option value=\"Saint Barthelemy\"> Saint Barthelemy <\/option>\n                    <option value=\"Saint Helena\"> Saint Helena <\/option>\n                    <option value=\"Saint Kitts and Nevis\"> Saint Kitts and Nevis <\/option>\n                    <option value=\"Saint Lucia\"> Saint Lucia <\/option>\n                    <option value=\"Saint Martin\"> Saint Martin <\/option>\n                    <option value=\"Saint Pierre and Miquelon\"> Saint Pierre and Miquelon <\/option>\n                    <option value=\"Saint Vincent and the Grenadines\"> Saint Vincent and the Grenadines <\/option>\n                    <option value=\"Samoa\"> Samoa <\/option>\n                    <option value=\"San Marino\"> San Marino <\/option>\n                    <option value=\"Sao Tome and Principe\"> Sao Tome and Principe <\/option>\n                    <option value=\"Saudi Arabia\"> Saudi Arabia <\/option>\n                    <option value=\"Senegal\"> Senegal <\/option>\n                    <option value=\"Serbia\"> Serbia <\/option>\n                    <option value=\"Seychelles\"> Seychelles <\/option>\n                    <option value=\"Sierra Leone\"> Sierra Leone <\/option>\n                    <option value=\"Singapore\"> Singapore <\/option>\n                    <option value=\"Slovakia\"> Slovakia <\/option>\n                    <option value=\"Slovenia\"> Slovenia <\/option>\n                    <option value=\"Solomon Islands\"> Solomon Islands <\/option>\n                    <option value=\"Somalia\"> Somalia <\/option>\n                    <option value=\"Somaliland\"> Somaliland <\/option>\n                    <option value=\"South Africa\"> South Africa <\/option>\n                    <option value=\"South Ossetia\"> South Ossetia <\/option>\n                    <option value=\"Spain\"> Spain <\/option>\n                    <option value=\"Sri Lanka\"> Sri Lanka <\/option>\n                    <option value=\"Sudan\"> Sudan <\/option>\n                    <option value=\"Suriname\"> Suriname <\/option>\n                    <option value=\"Svalbard\"> Svalbard <\/option>\n                    <option value=\"Swaziland\"> Swaziland <\/option>\n                    <option value=\"Sweden\"> Sweden <\/option>\n                    <option value=\"Switzerland\"> Switzerland <\/option>\n                    <option value=\"Syria\"> Syria <\/option>\n                    <option value=\"Taiwan\"> Taiwan <\/option>\n                    <option value=\"Tajikistan\"> Tajikistan <\/option>\n                    <option value=\"Tanzania\"> Tanzania <\/option>\n                    <option value=\"Thailand\"> Thailand <\/option>\n                    <option value=\"Timor-Leste\"> Timor-Leste <\/option>\n                    <option value=\"Togo\"> Togo <\/option>\n                    <option value=\"Tokelau\"> Tokelau <\/option>\n                    <option value=\"Tonga\"> Tonga <\/option>\n                    <option value=\"Transnistria Pridnestrovie\"> Transnistria Pridnestrovie <\/option>\n                    <option value=\"Trinidad and Tobago\"> Trinidad and Tobago <\/option>\n                    <option value=\"Tristan da Cunha\"> Tristan da Cunha <\/option>\n                    <option value=\"Tunisia\"> Tunisia <\/option>\n                    <option value=\"Turkey\"> Turkey <\/option>\n                    <option value=\"Turkmenistan\"> Turkmenistan <\/option>\n                    <option value=\"Turks and Caicos Islands\"> Turks and Caicos Islands <\/option>\n                    <option value=\"Tuvalu\"> Tuvalu <\/option>\n                    <option value=\"Uganda\"> Uganda <\/option>\n                    <option value=\"Ukraine\"> Ukraine <\/option>\n                    <option value=\"United Arab Emirates\"> United Arab Emirates <\/option>\n                    <option value=\"United Kingdom\"> United Kingdom <\/option>\n                    <option value=\"Uruguay\"> Uruguay <\/option>\n                    <option value=\"Uzbekistan\"> Uzbekistan <\/option>\n                    <option value=\"Vanuatu\"> Vanuatu <\/option>\n                    <option value=\"Vatican City\"> Vatican City <\/option>\n                    <option value=\"Venezuela\"> Venezuela <\/option>\n                    <option value=\"Vietnam\"> Vietnam <\/option>\n                    <option value=\"British Virgin Islands\"> British Virgin Islands <\/option>\n                    <option value=\"Isle of Man\"> Isle of Man <\/option>\n                    <option value=\"US Virgin Islands\"> US Virgin Islands <\/option>\n                    <option value=\"Wallis and Futuna\"> Wallis and Futuna <\/option>\n                    <option value=\"Western Sahara\"> Western Sahara <\/option>\n                    <option value=\"Yemen\"> Yemen <\/option>\n                    <option value=\"Zambia\"> Zambia <\/option>\n                    <option value=\"Zimbabwe\"> Zimbabwe <\/option>\n                    <option value=\"other\"> Other <\/option>\n                  <\/select>\n                  <label class=\"form-sub-label\" for=\"input_71_country\" id=\"sublabel_71_country\" style=\"min-height: 13px;\"> Country <\/label>\n                <\/span>\n              <\/td>\n            <\/tr>\n          <\/table>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_8\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_8\" for=\"input_8\">\n          How did you hear about Raphael House?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_8\" class=\"form-input jf-required\">\n          <input type=\"text\" class=\" form-textbox validate[required]\" data-type=\"input-textbox\" id=\"input_8\" name=\"q8_howDid8\" size=\"20\" value=\"\" \/>\n        <\/div>\n      <\/li>\n      <li id=\"cid_95\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group\">\n          <div class=\"header-text httal\">\n            <h2 id=\"header_95\" class=\"form-header\">\n              Areas of Interest\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_dropdown\" id=\"id_73\">\n        <label class=\"form-label form-label-top\" id=\"label_73\" for=\"input_73\">\n          Position you're applying for\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_73\" class=\"form-input-wide jf-required\">\n          <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_73\" name=\"q73_positionYoure73\">\n            <option value=\"\">  <\/option>\n            <option value=\"Afterschool Tutor (3:00-5:45)\"> Afterschool Tutor (3:00-5:45) <\/option>\n            <option value=\"Kitchen Assist (3:30-7pm)\"> Kitchen Assist (3:30-7pm) <\/option>\n            <option value=\"Kitchen Assist (5:00-7pm)\"> Kitchen Assist (5:00-7pm) <\/option>\n            <option value=\"Children's Evening Program Vol(6-8:30pm)\"> Children's Evening Program Vol(6-8:30pm) <\/option>\n            <option value=\"General\/Unspecified\"> General\/Unspecified <\/option>\n            <option value=\"Workforce Development Volunteer (M-F)\"> Workforce Development Volunteer (M-F) <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_102\">\n        <div id=\"cid_102\" class=\"form-input-wide\">\n          <div id=\"text_102\" class=\"form-html\">\n            <p><strong><span style=\"font-size:small;color:#000000;font-family:arial, helvetica, sans-serif;\">Please also select any areas below in which you would be willing to donate your time or skills<\/span><\/strong><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_15\">\n        <label class=\"form-label form-label-top\" id=\"label_15\" for=\"input_15\"> Education\/Leadership Roles: <\/label>\n        <div id=\"cid_15\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\">\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_15_0\" name=\"q15_educationleadershipRoles15[]\" value=\"Academic Tutoring (afterschool or Saturday mornings)\" \/>\n              <label for=\"input_15_0\"> Academic Tutoring (afterschool or Saturday mornings) <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_15_1\" name=\"q15_educationleadershipRoles15[]\" value=\"Activities Facilitation (art, crafts, fitness, etc.)\" \/>\n              <label for=\"input_15_1\"> Activities Facilitation (art, crafts, fitness, etc.) <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_15_2\" name=\"q15_educationleadershipRoles15[]\" value=\"Child Care (field-trip chaperone, story-telling, supervised child\u2019s play)\" \/>\n              <label for=\"input_15_2\"> Child Care (field-trip chaperone, story-telling, supervised child\u2019s play) <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_15_3\" name=\"q15_educationleadershipRoles15[]\" value=\"ESL Tutoring\" \/>\n              <label for=\"input_15_3\"> ESL Tutoring <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_15_4\" name=\"q15_educationleadershipRoles15[]\" value=\"Training (career\/college prep, technology, financial literacy, parenting)\" \/>\n              <label for=\"input_15_4\"> Training (career\/college prep, technology, financial literacy, parenting) <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_16\">\n        <label class=\"form-label form-label-top\" id=\"label_16\" for=\"input_16\"> Support Roles: <\/label>\n        <div id=\"cid_16\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\">\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_16_0\" name=\"q16_supportRoles[]\" value=\"Clerical (copying, filing, stuffing envelopes)\" \/>\n              <label for=\"input_16_0\"> Clerical (copying, filing, stuffing envelopes) <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_16_1\" name=\"q16_supportRoles[]\" value=\"Facilities\/Grounds (cleaning, gardening, general maintenance, painting)\" \/>\n              <label for=\"input_16_1\"> Facilities\/Grounds (cleaning, gardening, general maintenance, painting) <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_16_2\" name=\"q16_supportRoles[]\" value=\"Kitchen (cooking, dishes, food prep, food service)\" \/>\n              <label for=\"input_16_2\"> Kitchen (cooking, dishes, food prep, food service) <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_17\">\n        <label class=\"form-label form-label-top\" id=\"label_17\" for=\"input_17\"> Professional Services: <\/label>\n        <div id=\"cid_17\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\">\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_17_0\" name=\"q17_professionalServices17[]\" value=\"Accounting\/Finance\" \/>\n              <label for=\"input_17_0\"> Accounting\/Finance <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_17_1\" name=\"q17_professionalServices17[]\" value=\"Graphic Design\" \/>\n              <label for=\"input_17_1\"> Graphic Design <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_17_2\" name=\"q17_professionalServices17[]\" value=\"Information Technology\/Web Development\" \/>\n              <label for=\"input_17_2\"> Information Technology\/Web Development <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_17_3\" name=\"q17_professionalServices17[]\" value=\"Marketing\/Public Relations\" \/>\n              <label for=\"input_17_3\"> Marketing\/Public Relations <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_17_4\" name=\"q17_professionalServices17[]\" value=\"Writing\/Editing\" \/>\n              <label for=\"input_17_4\"> Writing\/Editing <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_17_5\" name=\"q17_professionalServices17[]\" value=\"Other\" \/>\n              <label for=\"input_17_5\"> Other <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_19\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group\">\n          <div class=\"header-text httal\">\n            <h2 id=\"header_19\" class=\"form-header\">\n              Experience &amp; Skills\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_4\">\n        <label class=\"form-label form-label-top\" id=\"label_4\" for=\"input_4\"> Occupation <\/label>\n        <div id=\"cid_4\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" class=\" form-textbox\" data-type=\"input-textbox\" id=\"input_4\" name=\"q4_occupation4\" size=\"20\" value=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_20\">\n        <label class=\"form-label form-label-top\" id=\"label_20\" for=\"input_20\">\n          Are you currently employed?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_20\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\">\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_20_0\" name=\"q20_areYou\" value=\"Yes\" \/>\n              <label for=\"input_20_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_20_1\" name=\"q20_areYou\" value=\"No\" \/>\n              <label for=\"input_20_1\"> No <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_21\">\n        <label class=\"form-label form-label-top\" id=\"label_21\" for=\"input_21\">\n          Name of Your Present or Most Recent Employer\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_21\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" class=\" form-textbox validate[required]\" data-type=\"input-textbox\" id=\"input_21\" name=\"q21_nameOf\" size=\"20\" value=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_23\">\n        <label class=\"form-label form-label-top\" id=\"label_23\" for=\"input_23\"> Job Title <\/label>\n        <div id=\"cid_23\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" class=\" form-textbox\" data-type=\"input-textbox\" id=\"input_23\" name=\"q23_jobTitle\" size=\"20\" value=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_address\" id=\"id_98\">\n        <label class=\"form-label form-label-top\" id=\"label_98\" for=\"input_98\"> Address of Your Present or Most Recent Employer <\/label>\n        <div id=\"cid_98\" class=\"form-input-wide jf-required\">\n          <table summary=\"\" undefined class=\"form-address-table\" border=\"0\" cellpadding=\"0\" cellspacing=\"0\">\n            <tr>\n              <td colspan=\"2\">\n                <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n                  <input class=\"form-textbox form-address-line\" type=\"text\" name=\"q98_addressOf98[addr_line1]\" id=\"input_98_addr_line1\" \/>\n                  <label class=\"form-sub-label\" for=\"input_98_addr_line1\" id=\"sublabel_98_addr_line1\" style=\"min-height: 13px;\"> Street Address <\/label>\n                <\/span>\n              <\/td>\n            <\/tr>\n            <tr>\n              <td colspan=\"2\">\n                <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n                  <input class=\"form-textbox form-address-line\" type=\"text\" name=\"q98_addressOf98[addr_line2]\" id=\"input_98_addr_line2\" size=\"46\" \/>\n                  <label class=\"form-sub-label\" for=\"input_98_addr_line2\" id=\"sublabel_98_addr_line2\" style=\"min-height: 13px;\"> Street Address Line 2 <\/label>\n                <\/span>\n              <\/td>\n            <\/tr>\n            <tr>\n              <td width=\"50%\">\n                <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n                  <input class=\"form-textbox form-address-city\" type=\"text\" name=\"q98_addressOf98[city]\" id=\"input_98_city\" size=\"21\" \/>\n                  <label class=\"form-sub-label\" for=\"input_98_city\" id=\"sublabel_98_city\" style=\"min-height: 13px;\"> City <\/label>\n                <\/span>\n              <\/td>\n              <td>\n                <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n                  <input class=\"form-textbox form-address-state\" type=\"text\" name=\"q98_addressOf98[state]\" id=\"input_98_state\" size=\"22\" \/>\n                  <label class=\"form-sub-label\" for=\"input_98_state\" id=\"sublabel_98_state\" style=\"min-height: 13px;\"> State \/ Province <\/label>\n                <\/span>\n              <\/td>\n            <\/tr>\n            <tr>\n              <td width=\"50%\">\n                <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n                  <input class=\"form-textbox form-address-postal\" type=\"text\" name=\"q98_addressOf98[postal]\" id=\"input_98_postal\" size=\"10\" \/>\n                  <label class=\"form-sub-label\" for=\"input_98_postal\" id=\"sublabel_98_postal\" style=\"min-height: 13px;\"> Postal \/ Zip Code <\/label>\n                <\/span>\n              <\/td>\n              <td>\n                <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n                  <select class=\"form-dropdown form-address-country\" defaultcountry=\"United States\" name=\"q98_addressOf98[country]\" id=\"input_98_country\">\n                    <option value=\"\" selected> Please Select <\/option>\n                    <option selected=\"selected\" value=\"United States\"> United States <\/option>\n                    <option value=\"Afghanistan\"> Afghanistan <\/option>\n                    <option value=\"Albania\"> Albania <\/option>\n                    <option value=\"Algeria\"> Algeria <\/option>\n                    <option value=\"American Samoa\"> American Samoa <\/option>\n                    <option value=\"Andorra\"> Andorra <\/option>\n                    <option value=\"Angola\"> Angola <\/option>\n                    <option value=\"Anguilla\"> Anguilla <\/option>\n                    <option value=\"Antigua and Barbuda\"> Antigua and Barbuda <\/option>\n                    <option value=\"Argentina\"> Argentina <\/option>\n                    <option value=\"Armenia\"> Armenia <\/option>\n                    <option value=\"Aruba\"> Aruba <\/option>\n                    <option value=\"Australia\"> Australia <\/option>\n                    <option value=\"Austria\"> Austria <\/option>\n                    <option value=\"Azerbaijan\"> Azerbaijan <\/option>\n                    <option value=\"The Bahamas\"> The Bahamas <\/option>\n                    <option value=\"Bahrain\"> Bahrain <\/option>\n                    <option value=\"Bangladesh\"> Bangladesh <\/option>\n                    <option value=\"Barbados\"> Barbados <\/option>\n                    <option value=\"Belarus\"> Belarus <\/option>\n                    <option value=\"Belgium\"> Belgium <\/option>\n                    <option value=\"Belize\"> Belize <\/option>\n                    <option value=\"Benin\"> Benin <\/option>\n                    <option value=\"Bermuda\"> Bermuda <\/option>\n                    <option value=\"Bhutan\"> Bhutan <\/option>\n                    <option value=\"Bolivia\"> Bolivia <\/option>\n                    <option value=\"Bosnia and Herzegovina\"> Bosnia and Herzegovina <\/option>\n                    <option value=\"Botswana\"> Botswana <\/option>\n                    <option value=\"Brazil\"> Brazil <\/option>\n                    <option value=\"Brunei\"> Brunei <\/option>\n                    <option value=\"Bulgaria\"> Bulgaria <\/option>\n                    <option value=\"Burkina Faso\"> Burkina Faso <\/option>\n                    <option value=\"Burundi\"> Burundi <\/option>\n                    <option value=\"Cambodia\"> Cambodia <\/option>\n                    <option value=\"Cameroon\"> Cameroon <\/option>\n                    <option value=\"Canada\"> Canada <\/option>\n                    <option value=\"Cape Verde\"> Cape Verde <\/option>\n                    <option value=\"Cayman Islands\"> Cayman Islands <\/option>\n                    <option value=\"Central African Republic\"> Central African Republic <\/option>\n                    <option value=\"Chad\"> Chad <\/option>\n                    <option value=\"Chile\"> Chile <\/option>\n                    <option value=\"People's Republic of China\"> People's Republic of China <\/option>\n                    <option value=\"Republic of China\"> Republic of China <\/option>\n                    <option value=\"Christmas Island\"> Christmas Island <\/option>\n                    <option value=\"Cocos (Keeling) Islands\"> Cocos (Keeling) Islands <\/option>\n                    <option value=\"Colombia\"> Colombia <\/option>\n                    <option value=\"Comoros\"> Comoros <\/option>\n                    <option value=\"Congo\"> Congo <\/option>\n                    <option value=\"Cook Islands\"> Cook Islands <\/option>\n                    <option value=\"Costa Rica\"> Costa Rica <\/option>\n                    <option value=\"Cote d'Ivoire\"> Cote d'Ivoire <\/option>\n                    <option value=\"Croatia\"> Croatia <\/option>\n                    <option value=\"Cuba\"> Cuba <\/option>\n                    <option value=\"Cyprus\"> Cyprus <\/option>\n                    <option value=\"Czech Republic\"> Czech Republic <\/option>\n                    <option value=\"Denmark\"> Denmark <\/option>\n                    <option value=\"Djibouti\"> Djibouti <\/option>\n                    <option value=\"Dominica\"> Dominica <\/option>\n                    <option value=\"Dominican Republic\"> Dominican Republic <\/option>\n                    <option value=\"Ecuador\"> Ecuador <\/option>\n                    <option value=\"Egypt\"> Egypt <\/option>\n                    <option value=\"El Salvador\"> El Salvador <\/option>\n                    <option value=\"Equatorial Guinea\"> Equatorial Guinea <\/option>\n                    <option value=\"Eritrea\"> Eritrea <\/option>\n                    <option value=\"Estonia\"> Estonia <\/option>\n                    <option value=\"Ethiopia\"> Ethiopia <\/option>\n                    <option value=\"Falkland Islands\"> Falkland Islands <\/option>\n                    <option value=\"Faroe Islands\"> Faroe Islands <\/option>\n                    <option value=\"Fiji\"> Fiji <\/option>\n                    <option value=\"Finland\"> Finland <\/option>\n                    <option value=\"France\"> France <\/option>\n                    <option value=\"French Polynesia\"> French Polynesia <\/option>\n                    <option value=\"Gabon\"> Gabon <\/option>\n                    <option value=\"The Gambia\"> The Gambia <\/option>\n                    <option value=\"Georgia\"> Georgia <\/option>\n                    <option value=\"Germany\"> Germany <\/option>\n                    <option value=\"Ghana\"> Ghana <\/option>\n                    <option value=\"Gibraltar\"> Gibraltar <\/option>\n                    <option value=\"Greece\"> Greece <\/option>\n                    <option value=\"Greenland\"> Greenland <\/option>\n                    <option value=\"Grenada\"> Grenada <\/option>\n                    <option value=\"Guadeloupe\"> Guadeloupe <\/option>\n                    <option value=\"Guam\"> Guam <\/option>\n                    <option value=\"Guatemala\"> Guatemala <\/option>\n                    <option value=\"Guernsey\"> Guernsey <\/option>\n                    <option value=\"Guinea\"> Guinea <\/option>\n                    <option value=\"Guinea-Bissau\"> Guinea-Bissau <\/option>\n                    <option value=\"Guyana\"> Guyana <\/option>\n                    <option value=\"Haiti\"> Haiti <\/option>\n                    <option value=\"Honduras\"> Honduras <\/option>\n                    <option value=\"Hong Kong\"> Hong Kong <\/option>\n                    <option value=\"Hungary\"> Hungary <\/option>\n                    <option value=\"Iceland\"> Iceland <\/option>\n                    <option value=\"India\"> India <\/option>\n                    <option value=\"Indonesia\"> Indonesia <\/option>\n                    <option value=\"Iran\"> Iran <\/option>\n                    <option value=\"Iraq\"> Iraq <\/option>\n                    <option value=\"Ireland\"> Ireland <\/option>\n                    <option value=\"Israel\"> Israel <\/option>\n                    <option value=\"Italy\"> Italy <\/option>\n                    <option value=\"Jamaica\"> Jamaica <\/option>\n                    <option value=\"Japan\"> Japan <\/option>\n                    <option value=\"Jersey\"> Jersey <\/option>\n                    <option value=\"Jordan\"> Jordan <\/option>\n                    <option value=\"Kazakhstan\"> Kazakhstan <\/option>\n                    <option value=\"Kenya\"> Kenya <\/option>\n                    <option value=\"Kiribati\"> Kiribati <\/option>\n                    <option value=\"North Korea\"> North Korea <\/option>\n                    <option value=\"South Korea\"> South Korea <\/option>\n                    <option value=\"Kosovo\"> Kosovo <\/option>\n                    <option value=\"Kuwait\"> Kuwait <\/option>\n                    <option value=\"Kyrgyzstan\"> Kyrgyzstan <\/option>\n                    <option value=\"Laos\"> Laos <\/option>\n                    <option value=\"Latvia\"> Latvia <\/option>\n                    <option value=\"Lebanon\"> Lebanon <\/option>\n                    <option value=\"Lesotho\"> Lesotho <\/option>\n                    <option value=\"Liberia\"> Liberia <\/option>\n                    <option value=\"Libya\"> Libya <\/option>\n                    <option value=\"Liechtenstein\"> Liechtenstein <\/option>\n                    <option value=\"Lithuania\"> Lithuania <\/option>\n                    <option value=\"Luxembourg\"> Luxembourg <\/option>\n                    <option value=\"Macau\"> Macau <\/option>\n                    <option value=\"Macedonia\"> Macedonia <\/option>\n                    <option value=\"Madagascar\"> Madagascar <\/option>\n                    <option value=\"Malawi\"> Malawi <\/option>\n                    <option value=\"Malaysia\"> Malaysia <\/option>\n                    <option value=\"Maldives\"> Maldives <\/option>\n                    <option value=\"Mali\"> Mali <\/option>\n                    <option value=\"Malta\"> Malta <\/option>\n                    <option value=\"Marshall Islands\"> Marshall Islands <\/option>\n                    <option value=\"Martinique\"> Martinique <\/option>\n                    <option value=\"Mauritania\"> Mauritania <\/option>\n                    <option value=\"Mauritius\"> Mauritius <\/option>\n                    <option value=\"Mayotte\"> Mayotte <\/option>\n                    <option value=\"Mexico\"> Mexico <\/option>\n                    <option value=\"Micronesia\"> Micronesia <\/option>\n                    <option value=\"Moldova\"> Moldova <\/option>\n                    <option value=\"Monaco\"> Monaco <\/option>\n                    <option value=\"Mongolia\"> Mongolia <\/option>\n                    <option value=\"Montenegro\"> Montenegro <\/option>\n                    <option value=\"Montserrat\"> Montserrat <\/option>\n                    <option value=\"Morocco\"> Morocco <\/option>\n                    <option value=\"Mozambique\"> Mozambique <\/option>\n                    <option value=\"Myanmar\"> Myanmar <\/option>\n                    <option value=\"Nagorno-Karabakh\"> Nagorno-Karabakh <\/option>\n                    <option value=\"Namibia\"> Namibia <\/option>\n                    <option value=\"Nauru\"> Nauru <\/option>\n                    <option value=\"Nepal\"> Nepal <\/option>\n                    <option value=\"Netherlands\"> Netherlands <\/option>\n                    <option value=\"Netherlands Antilles\"> Netherlands Antilles <\/option>\n                    <option value=\"New Caledonia\"> New Caledonia <\/option>\n                    <option value=\"New Zealand\"> New Zealand <\/option>\n                    <option value=\"Nicaragua\"> Nicaragua <\/option>\n                    <option value=\"Niger\"> Niger <\/option>\n                    <option value=\"Nigeria\"> Nigeria <\/option>\n                    <option value=\"Niue\"> Niue <\/option>\n                    <option value=\"Norfolk Island\"> Norfolk Island <\/option>\n                    <option value=\"Turkish Republic of Northern Cyprus\"> Turkish Republic of Northern Cyprus <\/option>\n                    <option value=\"Northern Mariana\"> Northern Mariana <\/option>\n                    <option value=\"Norway\"> Norway <\/option>\n                    <option value=\"Oman\"> Oman <\/option>\n                    <option value=\"Pakistan\"> Pakistan <\/option>\n                    <option value=\"Palau\"> Palau <\/option>\n                    <option value=\"Palestine\"> Palestine <\/option>\n                    <option value=\"Panama\"> Panama <\/option>\n                    <option value=\"Papua New Guinea\"> Papua New Guinea <\/option>\n                    <option value=\"Paraguay\"> Paraguay <\/option>\n                    <option value=\"Peru\"> Peru <\/option>\n                    <option value=\"Philippines\"> Philippines <\/option>\n                    <option value=\"Pitcairn Islands\"> Pitcairn Islands <\/option>\n                    <option value=\"Poland\"> Poland <\/option>\n                    <option value=\"Portugal\"> Portugal <\/option>\n                    <option value=\"Puerto Rico\"> Puerto Rico <\/option>\n                    <option value=\"Qatar\"> Qatar <\/option>\n                    <option value=\"Romania\"> Romania <\/option>\n                    <option value=\"Russia\"> Russia <\/option>\n                    <option value=\"Rwanda\"> Rwanda <\/option>\n                    <option value=\"Saint Barthelemy\"> Saint Barthelemy <\/option>\n                    <option value=\"Saint Helena\"> Saint Helena <\/option>\n                    <option value=\"Saint Kitts and Nevis\"> Saint Kitts and Nevis <\/option>\n                    <option value=\"Saint Lucia\"> Saint Lucia <\/option>\n                    <option value=\"Saint Martin\"> Saint Martin <\/option>\n                    <option value=\"Saint Pierre and Miquelon\"> Saint Pierre and Miquelon <\/option>\n                    <option value=\"Saint Vincent and the Grenadines\"> Saint Vincent and the Grenadines <\/option>\n                    <option value=\"Samoa\"> Samoa <\/option>\n                    <option value=\"San Marino\"> San Marino <\/option>\n                    <option value=\"Sao Tome and Principe\"> Sao Tome and Principe <\/option>\n                    <option value=\"Saudi Arabia\"> Saudi Arabia <\/option>\n                    <option value=\"Senegal\"> Senegal <\/option>\n                    <option value=\"Serbia\"> Serbia <\/option>\n                    <option value=\"Seychelles\"> Seychelles <\/option>\n                    <option value=\"Sierra Leone\"> Sierra Leone <\/option>\n                    <option value=\"Singapore\"> Singapore <\/option>\n                    <option value=\"Slovakia\"> Slovakia <\/option>\n                    <option value=\"Slovenia\"> Slovenia <\/option>\n                    <option value=\"Solomon Islands\"> Solomon Islands <\/option>\n                    <option value=\"Somalia\"> Somalia <\/option>\n                    <option value=\"Somaliland\"> Somaliland <\/option>\n                    <option value=\"South Africa\"> South Africa <\/option>\n                    <option value=\"South Ossetia\"> South Ossetia <\/option>\n                    <option value=\"Spain\"> Spain <\/option>\n                    <option value=\"Sri Lanka\"> Sri Lanka <\/option>\n                    <option value=\"Sudan\"> Sudan <\/option>\n                    <option value=\"Suriname\"> Suriname <\/option>\n                    <option value=\"Svalbard\"> Svalbard <\/option>\n                    <option value=\"Swaziland\"> Swaziland <\/option>\n                    <option value=\"Sweden\"> Sweden <\/option>\n                    <option value=\"Switzerland\"> Switzerland <\/option>\n                    <option value=\"Syria\"> Syria <\/option>\n                    <option value=\"Taiwan\"> Taiwan <\/option>\n                    <option value=\"Tajikistan\"> Tajikistan <\/option>\n                    <option value=\"Tanzania\"> Tanzania <\/option>\n                    <option value=\"Thailand\"> Thailand <\/option>\n                    <option value=\"Timor-Leste\"> Timor-Leste <\/option>\n                    <option value=\"Togo\"> Togo <\/option>\n                    <option value=\"Tokelau\"> Tokelau <\/option>\n                    <option value=\"Tonga\"> Tonga <\/option>\n                    <option value=\"Transnistria Pridnestrovie\"> Transnistria Pridnestrovie <\/option>\n                    <option value=\"Trinidad and Tobago\"> Trinidad and Tobago <\/option>\n                    <option value=\"Tristan da Cunha\"> Tristan da Cunha <\/option>\n                    <option value=\"Tunisia\"> Tunisia <\/option>\n                    <option value=\"Turkey\"> Turkey <\/option>\n                    <option value=\"Turkmenistan\"> Turkmenistan <\/option>\n                    <option value=\"Turks and Caicos Islands\"> Turks and Caicos Islands <\/option>\n                    <option value=\"Tuvalu\"> Tuvalu <\/option>\n                    <option value=\"Uganda\"> Uganda <\/option>\n                    <option value=\"Ukraine\"> Ukraine <\/option>\n                    <option value=\"United Arab Emirates\"> United Arab Emirates <\/option>\n                    <option value=\"United Kingdom\"> United Kingdom <\/option>\n                    <option value=\"Uruguay\"> Uruguay <\/option>\n                    <option value=\"Uzbekistan\"> Uzbekistan <\/option>\n                    <option value=\"Vanuatu\"> Vanuatu <\/option>\n                    <option value=\"Vatican City\"> Vatican City <\/option>\n                    <option value=\"Venezuela\"> Venezuela <\/option>\n                    <option value=\"Vietnam\"> Vietnam <\/option>\n                    <option value=\"British Virgin Islands\"> British Virgin Islands <\/option>\n                    <option value=\"Isle of Man\"> Isle of Man <\/option>\n                    <option value=\"US Virgin Islands\"> US Virgin Islands <\/option>\n                    <option value=\"Wallis and Futuna\"> Wallis and Futuna <\/option>\n                    <option value=\"Western Sahara\"> Western Sahara <\/option>\n                    <option value=\"Yemen\"> Yemen <\/option>\n                    <option value=\"Zambia\"> Zambia <\/option>\n                    <option value=\"Zimbabwe\"> Zimbabwe <\/option>\n                    <option value=\"other\"> Other <\/option>\n                  <\/select>\n                  <label class=\"form-sub-label\" for=\"input_98_country\" id=\"sublabel_98_country\" style=\"min-height: 13px;\"> Country <\/label>\n                <\/span>\n              <\/td>\n            <\/tr>\n          <\/table>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_24\">\n        <label class=\"form-label form-label-top\" id=\"label_24\" for=\"input_24\">\n          Are you a student?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_24\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\">\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_24_0\" name=\"q24_areYou24\" value=\"Yes\" \/>\n              <label for=\"input_24_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_24_1\" name=\"q24_areYou24\" value=\"No\" \/>\n              <label for=\"input_24_1\"> No <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_25\">\n        <label class=\"form-label form-label-top\" id=\"label_25\" for=\"input_25\"> Name of school <\/label>\n        <div id=\"cid_25\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" class=\" form-textbox\" data-type=\"input-textbox\" id=\"input_25\" name=\"q25_nameOf25\" size=\"20\" value=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_26\">\n        <label class=\"form-label form-label-top\" id=\"label_26\" for=\"input_26\"> Major <\/label>\n        <div id=\"cid_26\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" class=\" form-textbox\" data-type=\"input-textbox\" id=\"input_26\" name=\"q26_major26\" size=\"20\" value=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_27\">\n        <label class=\"form-label form-label-top\" id=\"label_27\" for=\"input_27\">\n          Have you done other volunteer work?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_27\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\">\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_27_0\" name=\"q27_haveYou\" value=\"Yes\" \/>\n              <label for=\"input_27_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_27_1\" name=\"q27_haveYou\" value=\"No\" \/>\n              <label for=\"input_27_1\"> No <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_29\">\n        <label class=\"form-label form-label-top\" id=\"label_29\" for=\"input_29\"> If so, please describe: <\/label>\n        <div id=\"cid_29\" class=\"form-input-wide jf-required\">\n          <textarea id=\"input_29\" class=\"form-textarea\" name=\"q29_ifSo\" cols=\"40\" rows=\"6\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textarea\" id=\"id_30\">\n        <label class=\"form-label form-label-top\" id=\"label_30\" for=\"input_30\">\n          What motivated you to want to volunteer at Raphael House?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_30\" class=\"form-input-wide jf-required\">\n          <textarea id=\"input_30\" class=\"form-textarea validate[required]\" name=\"q30_whatMotivated\" cols=\"40\" rows=\"6\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_32\">\n        <label class=\"form-label form-label-top\" id=\"label_32\" for=\"input_32\"> Do you have special interests or life experiences that would contribute to the work we do? <\/label>\n        <div id=\"cid_32\" class=\"form-input-wide jf-required\">\n          <textarea id=\"input_32\" class=\"form-textarea\" name=\"q32_doYou\" cols=\"40\" rows=\"6\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_33\">\n        <label class=\"form-label form-label-top\" id=\"label_33\" for=\"input_33\"> Do you know any crafts or have skills that you could teach others? <\/label>\n        <div id=\"cid_33\" class=\"form-input-wide jf-required\">\n          <textarea id=\"input_33\" class=\"form-textarea\" name=\"q33_doYou33\" cols=\"40\" rows=\"6\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_34\">\n        <label class=\"form-label form-label-top\" id=\"label_34\" for=\"input_34\"> Are there any languages other than English that you speak fluently? <\/label>\n        <div id=\"cid_34\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" class=\" form-textbox\" data-type=\"input-textbox\" id=\"input_34\" name=\"q34_areThere\" size=\"20\" value=\"\" \/>\n        <\/div>\n      <\/li>\n      <li id=\"cid_85\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group\">\n          <div class=\"header-text httal\">\n            <h2 id=\"header_85\" class=\"form-header\">\n              Emergency Contact Info\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_64\">\n        <label class=\"form-label form-label-top\" id=\"label_64\" for=\"input_64\">\n          Person to contact in case of emergency\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_64\" class=\"form-input-wide jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <input type=\"text\" class=\" form-textbox validate[required]\" data-type=\"input-textbox\" id=\"input_64\" name=\"q64_personTo\" size=\"20\" value=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_64\" style=\"min-height: 13px;\"> Name <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_107\">\n        <label class=\"form-label form-label-top\" id=\"label_107\" for=\"input_107\">\n          Relationship of emergency contact\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_107\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" class=\" form-textbox validate[required]\" data-type=\"input-textbox\" id=\"input_107\" name=\"q107_relationshipOf107\" size=\"20\" value=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_phone\" id=\"id_7\">\n        <label class=\"form-label form-label-top\" id=\"label_7\" for=\"input_7\">\n          Emergency Contact Phone\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_7\" class=\"form-input-wide jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <input class=\"form-textbox validate[required]\" type=\"tel\" name=\"q7_emergencyContact7[area]\" id=\"input_7_area\" size=\"3\">\n            <span class=\"phone-separate\">\n              &nbsp;-\n            <\/span>\n            <label class=\"form-sub-label\" for=\"input_7_area\" id=\"sublabel_area\" style=\"min-height: 13px;\"> Area Code <\/label>\n          <\/span>\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <input class=\"form-textbox validate[required]\" type=\"tel\" name=\"q7_emergencyContact7[phone]\" id=\"input_7_phone\" size=\"8\">\n            <label class=\"form-sub-label\" for=\"input_7_phone\" id=\"sublabel_phone\" style=\"min-height: 13px;\"> Phone Number <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li id=\"cid_46\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group\">\n          <div class=\"header-text httal\">\n            <h2 id=\"header_46\" class=\"form-header\">\n              Availability\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_55\">\n        <label class=\"form-label form-label-top\" id=\"label_55\" for=\"input_55\">\n          Please check all that apply:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_55\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\">\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_55_0\" name=\"q55_pleaseCheck[]\" value=\"I can commit one year.\" \/>\n              <label for=\"input_55_0\"> I can commit one year. <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_55_1\" name=\"q55_pleaseCheck[]\" value=\"I can commit 6 months.\" \/>\n              <label for=\"input_55_1\"> I can commit 6 months. <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_55_2\" name=\"q55_pleaseCheck[]\" value=\"I am available for ongoing volunteer opportunities that do not require a commitment.\" \/>\n              <label for=\"input_55_2\"> I am available for ongoing volunteer opportunities that do not require a commitment. <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_56\">\n        <label class=\"form-label form-label-top\" id=\"label_56\" for=\"input_56\">\n          When can you start?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_56\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" class=\" form-textbox validate[required]\" data-type=\"input-textbox\" id=\"input_56\" name=\"q56_whenCan\" size=\"20\" value=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_number\" id=\"id_47\">\n        <label class=\"form-label form-label-top\" id=\"label_47\" for=\"input_47\">\n          Approximately how many hours per week can you contribute?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_47\" class=\"form-input-wide jf-required\">\n          <input type=\"number\" class=\"form-number-input  form-textbox validate[required, Numeric]\" id=\"input_47\" name=\"q47_approximatelyHow47\" style=\"width:60px\" size=\"5\" value=\"\" data-type=\"input-number\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_99\">\n        <div id=\"cid_99\" class=\"form-input-wide\">\n          <div id=\"text_99\" class=\"form-html\">\n            <p style=\"text-align:left;\"><strong><span style=\"font-family:arial, helvetica, sans-serif;font-size:small;\">Please specify the times during which you are available for each of the days listed below:<\/span><br \/><\/strong><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_48\">\n        <label class=\"form-label form-label-top\" id=\"label_48\" for=\"input_48\"> Monday <\/label>\n        <div id=\"cid_48\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" class=\" form-textbox\" data-type=\"input-textbox\" id=\"input_48\" name=\"q48_monday48\" size=\"20\" value=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_49\">\n        <label class=\"form-label form-label-top\" id=\"label_49\" for=\"input_49\"> Tuesday <\/label>\n        <div id=\"cid_49\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" class=\" form-textbox\" data-type=\"input-textbox\" id=\"input_49\" name=\"q49_tuesday\" size=\"20\" value=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_50\">\n        <label class=\"form-label form-label-top\" id=\"label_50\" for=\"input_50\"> Wednesday <\/label>\n        <div id=\"cid_50\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" class=\" form-textbox\" data-type=\"input-textbox\" id=\"input_50\" name=\"q50_wednesday\" size=\"20\" value=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_51\">\n        <label class=\"form-label form-label-top\" id=\"label_51\" for=\"input_51\"> Thursday <\/label>\n        <div id=\"cid_51\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" class=\" form-textbox\" data-type=\"input-textbox\" id=\"input_51\" name=\"q51_thursday\" size=\"20\" value=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_52\">\n        <label class=\"form-label form-label-top\" id=\"label_52\" for=\"input_52\"> Friday <\/label>\n        <div id=\"cid_52\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" class=\" form-textbox\" data-type=\"input-textbox\" id=\"input_52\" name=\"q52_friday\" size=\"20\" value=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_53\">\n        <label class=\"form-label form-label-top\" id=\"label_53\" for=\"input_53\"> Saturday <\/label>\n        <div id=\"cid_53\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" class=\" form-textbox\" data-type=\"input-textbox\" id=\"input_53\" name=\"q53_saturday\" size=\"20\" value=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_54\">\n        <label class=\"form-label form-label-top\" id=\"label_54\" for=\"input_54\"> Sunday <\/label>\n        <div id=\"cid_54\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" class=\" form-textbox\" data-type=\"input-textbox\" id=\"input_54\" name=\"q54_sunday\" size=\"20\" value=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_72\">\n        <label class=\"form-label form-label-top\" id=\"label_72\" for=\"input_72\"> Additional Comments <\/label>\n        <div id=\"cid_72\" class=\"form-input-wide jf-required\">\n          <textarea id=\"input_72\" class=\"form-textarea\" name=\"q72_additionalComments72\" cols=\"40\" rows=\"6\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li id=\"cid_35\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group\">\n          <div class=\"header-text httal\">\n            <h2 id=\"header_35\" class=\"form-header\">\n              Background\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_36\">\n        <label class=\"form-label form-label-top\" id=\"label_36\" for=\"input_36\">\n          Have you ever been convicted of, or pleaded guilty to, a crime?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_36\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\">\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_36_0\" name=\"q36_haveYou36\" value=\"Yes\" \/>\n              <label for=\"input_36_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_36_1\" name=\"q36_haveYou36\" value=\"No\" \/>\n              <label for=\"input_36_1\"> No <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_37\">\n        <label class=\"form-label form-label-top\" id=\"label_37\" for=\"input_37\">\n          Are you currently under arrest, or released on bond or on your own recognizance, pending trial for a criminal offense?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_37\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\">\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_37_0\" name=\"q37_areYou37\" value=\"Yes\" \/>\n              <label for=\"input_37_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_37_1\" name=\"q37_areYou37\" value=\"No\" \/>\n              <label for=\"input_37_1\"> No <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_38\">\n        <label class=\"form-label form-label-top\" id=\"label_38\" for=\"input_38\"> If you answered yes to either of the above, please state the circumstances: <\/label>\n        <div id=\"cid_38\" class=\"form-input-wide jf-required\">\n          <textarea id=\"input_38\" class=\"form-textarea\" name=\"q38_ifYou\" cols=\"40\" rows=\"6\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li id=\"cid_39\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group\">\n          <div class=\"header-text httal\">\n            <h2 id=\"header_39\" class=\"form-header\">\n              References\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_65\">\n        <label class=\"form-label form-label-top\" id=\"label_65\" for=\"input_65\">\n          Reference 1\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_65\" class=\"form-input-wide jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <input type=\"text\" class=\" form-textbox validate[required]\" data-type=\"input-textbox\" id=\"input_65\" name=\"q65_reference1\" size=\"20\" value=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_65\" style=\"min-height: 13px;\"> Name <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_phone\" id=\"id_41\">\n        <label class=\"form-label form-label-top\" id=\"label_41\" for=\"input_41\">\n          Reference 1\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_41\" class=\"form-input-wide jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <input class=\"form-textbox validate[required]\" type=\"tel\" name=\"q41_reference141[area]\" id=\"input_41_area\" size=\"3\">\n            <span class=\"phone-separate\">\n              &nbsp;-\n            <\/span>\n            <label class=\"form-sub-label\" for=\"input_41_area\" id=\"sublabel_area\" style=\"min-height: 13px;\"> Area Code <\/label>\n          <\/span>\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <input class=\"form-textbox validate[required]\" type=\"tel\" name=\"q41_reference141[phone]\" id=\"input_41_phone\" size=\"8\">\n            <label class=\"form-sub-label\" for=\"input_41_phone\" id=\"sublabel_phone\" style=\"min-height: 13px;\"> Phone Number <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_email\" id=\"id_42\">\n        <label class=\"form-label form-label-top\" id=\"label_42\" for=\"input_42\"> Reference 1 <\/label>\n        <div id=\"cid_42\" class=\"form-input-wide jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <input type=\"email\" class=\" form-textbox validate[Email]\" id=\"input_42\" name=\"q42_reference142\" size=\"30\" value=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_42\" style=\"min-height: 13px;\"> E-mail <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_67\">\n        <label class=\"form-label form-label-top\" id=\"label_67\" for=\"input_67\">\n          Reference 2\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_67\" class=\"form-input-wide jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <input type=\"text\" class=\" form-textbox validate[required]\" data-type=\"input-textbox\" id=\"input_67\" name=\"q67_reference2\" size=\"20\" value=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_67\" style=\"min-height: 13px;\"> Name <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_phone\" id=\"id_44\">\n        <label class=\"form-label form-label-top\" id=\"label_44\" for=\"input_44\">\n          Reference 2\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_44\" class=\"form-input-wide jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <input class=\"form-textbox validate[required]\" type=\"tel\" name=\"q44_reference244[area]\" id=\"input_44_area\" size=\"3\">\n            <span class=\"phone-separate\">\n              &nbsp;-\n            <\/span>\n            <label class=\"form-sub-label\" for=\"input_44_area\" id=\"sublabel_area\" style=\"min-height: 13px;\"> Area Code <\/label>\n          <\/span>\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <input class=\"form-textbox validate[required]\" type=\"tel\" name=\"q44_reference244[phone]\" id=\"input_44_phone\" size=\"8\">\n            <label class=\"form-sub-label\" for=\"input_44_phone\" id=\"sublabel_phone\" style=\"min-height: 13px;\"> Phone Number <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_email\" id=\"id_45\">\n        <label class=\"form-label form-label-top\" id=\"label_45\" for=\"input_45\"> Reference 2 <\/label>\n        <div id=\"cid_45\" class=\"form-input-wide jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align: top\">\n            <input type=\"email\" class=\" form-textbox validate[Email]\" id=\"input_45\" name=\"q45_reference245\" size=\"30\" value=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_45\" style=\"min-height: 13px;\"> E-mail <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li id=\"cid_59\" class=\"form-input-wide\" data-type=\"control_pagebreak\">\n        <div class=\"form-pagebreak\">\n          <div class=\"form-pagebreak-back-container\">\n            <button type=\"button\" class=\"form-pagebreak-back \" id=\"form-pagebreak-back_59\">\n              Back\n            <\/button>\n          <\/div>\n          <div class=\"form-pagebreak-next-container\">\n            <button type=\"button\" class=\"form-pagebreak-next \" id=\"form-pagebreak-next_59\">\n              Next\n            <\/button>\n          <\/div>\n        <\/div>\n      <\/li>\n    <\/ul>\n    <ul class=\"form-section page-section\" style=\"display:none;\">\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_83\">\n        <div id=\"cid_83\" class=\"form-input-wide\">\n          <div id=\"text_83\" class=\"form-html\">\n            <p><span style=\"font-family:arial, helvetica, sans-serif;font-size:small;\">The information in this application is correct to the best of my knowledge. I authorize any references, past employers and past volunteer programs listed in this application to give you any information (including opinions) that they may have regarding my character and fitness for volunteer work in a shelter for homeless families. In consideration of the receipt and evaluation of this application by Raphael House, I hereby release any individual, church, youth organization, charity, employer, reference, or any other person or organization, including record custodians, both collectively and individually, from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs, or family, on account of compliance or any attempts to comply with this authorization. I waive any right that I may have to inspect any information provided about me by any person or organization identified by me in this application. I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement which I have read and understand.<\/span><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_62\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_62\" for=\"input_62\">\n          Applicant's Signature:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_62\" class=\"form-input jf-required\">\n          <input type=\"text\" class=\" form-textbox validate[required]\" data-type=\"input-textbox\" id=\"input_62\" name=\"q62_applicantsSignature\" size=\"20\" value=\"\" \/>\n        <\/div>\n      <\/li>\n      <li id=\"cid_75\" class=\"form-input-wide\" data-type=\"control_pagebreak\">\n        <div class=\"form-pagebreak\">\n          <div class=\"form-pagebreak-back-container\">\n            <button type=\"button\" class=\"form-pagebreak-back \" id=\"form-pagebreak-back_75\">\n              Back\n            <\/button>\n          <\/div>\n          <div class=\"form-pagebreak-next-container\">\n            <button type=\"button\" class=\"form-pagebreak-next \" id=\"form-pagebreak-next_75\">\n              Next\n            <\/button>\n          <\/div>\n        <\/div>\n      <\/li>\n    <\/ul>\n    <ul class=\"form-section page-section\" style=\"display:none;\">\n      <li id=\"cid_77\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group\">\n          <div class=\"header-text httal\">\n            <h2 id=\"header_77\" class=\"form-header\">\n              Raphael House Volunteer Agreement\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_76\">\n        <div id=\"cid_76\" class=\"form-input-wide\">\n          <div id=\"text_76\" class=\"form-html\">\n            <p class=\"MsoNormal\" style=\"text-align:justify;\"><span style=\"font-size:small;\">Raphael House exists to provide a safe and secure environment for homeless families where they can work out the difficulties that led to or have been caused by their homelessness. While on duty, Raphael House volunteers are regarded as staff and are required to behave in a professional manner. Residents are to be treated with respect and dignity. Inappropriate behavior may result in immediate dismissal from volunteer responsibilities.<\/span><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_87\" class=\"form-input-wide\" data-type=\"control_pagebreak\">\n        <div class=\"form-pagebreak\">\n          <div class=\"form-pagebreak-back-container\">\n            <button type=\"button\" class=\"form-pagebreak-back \" id=\"form-pagebreak-back_87\">\n              Back\n            <\/button>\n          <\/div>\n          <div class=\"form-pagebreak-next-container\">\n            <button type=\"button\" class=\"form-pagebreak-next \" id=\"form-pagebreak-next_87\">\n              Next\n            <\/button>\n          <\/div>\n        <\/div>\n      <\/li>\n    <\/ul>\n    <ul class=\"form-section page-section\" style=\"display:none;\">\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_105\">\n        <label class=\"form-label form-label-top\" id=\"label_105\" for=\"input_105\">\n          As a Raphael House volunteer:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_105\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\">\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_105_0\" name=\"q105_asA105[]\" value=\"I will report for my shifts as expected. If unable to do so, I will try to find an appropriate replacement from the list of volunteers supplied to me. I will also notify my supervisor as soon as I am aware I will be unable to attend.\" \/>\n              <label for=\"input_105_0\"> I will report for my shifts as expected. If unable to do so, I will try to find an appropriate replacement from the list of volunteers supplied to me. I will also notify my supervisor as soon as I am aware I will be unable to attend. <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_105_1\" name=\"q105_asA105[]\" value=\"I will refrain from the use of alcoholic beverages for at least two hours before coming in for my shift.\" \/>\n              <label for=\"input_105_1\"> I will refrain from the use of alcoholic beverages for at least two hours before coming in for my shift. <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_105_2\" name=\"q105_asA105[]\" value=\"I will not discuss the private affairs of the residents with non-staff members, nor will I disclose their names or any other information to strangers.\" \/>\n              <label for=\"input_105_2\"> I will not discuss the private affairs of the residents with non-staff members, nor will I disclose their names or any other information to strangers. <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_105_3\" name=\"q105_asA105[]\" value=\"I will not pursue a relationship with any current or former Raphael House resident outside of Raphael House unless it is with the full knowledge of his\/her caseworker or is coordinated through the Raphael House Aftercare Program.\" \/>\n              <label for=\"input_105_3\"> I will not pursue a relationship with any current or former Raphael House resident outside of Raphael House unless it is with the full knowledge of his\/her caseworker or is coordinated through the Raphael House Aftercare Program. <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_90\" class=\"form-input-wide\" data-type=\"control_pagebreak\">\n        <div class=\"form-pagebreak\">\n          <div class=\"form-pagebreak-back-container\">\n            <button type=\"button\" class=\"form-pagebreak-back \" id=\"form-pagebreak-back_90\">\n              Back\n            <\/button>\n          <\/div>\n          <div class=\"form-pagebreak-next-container\">\n            <button type=\"button\" class=\"form-pagebreak-next \" id=\"form-pagebreak-next_90\">\n              Next\n            <\/button>\n          <\/div>\n        <\/div>\n      <\/li>\n    <\/ul>\n    <ul class=\"form-section page-section\" style=\"display:none;\">\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_89\">\n        <div id=\"cid_89\" class=\"form-input-wide\">\n          <div id=\"text_89\" class=\"form-html\">\n            <p class=\"MsoBodyText\" style=\"text-align:left;\"><span style=\"font-family:Arial;font-size:small;\">When  working with children, it is important to be aware of the disturbing  and traumatic rise of child physical and sexual abuse. The following  policies reflect our commitment to provide protective care of all  children, youth, volunteers, and staff who participate in the Raphael  House program.<\/span><\/p>\n            <p class=\"MsoNormal\"><span style=\"font-size:small;font-family:Arial;\">Adults  who have been convicted of either child sexual or physical abuse are not eligible for volunteer placement.<\/span><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_94\" class=\"form-input-wide\" data-type=\"control_pagebreak\">\n        <div class=\"form-pagebreak\">\n          <div class=\"form-pagebreak-back-container\">\n            <button type=\"button\" class=\"form-pagebreak-back \" id=\"form-pagebreak-back_94\">\n              Back\n            <\/button>\n          <\/div>\n          <div class=\"form-pagebreak-next-container\">\n            <button type=\"button\" class=\"form-pagebreak-next \" id=\"form-pagebreak-next_94\">\n              Next\n            <\/button>\n          <\/div>\n        <\/div>\n      <\/li>\n    <\/ul>\n    <ul class=\"form-section page-section\" style=\"display:none;\">\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_92\">\n        <label class=\"form-label form-label-top\" id=\"label_92\" for=\"input_92\">\n          As a Raphael House volunteer:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_92\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\">\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_92_0\" name=\"q92_asA92[]\" value=\"I will observe the &quot;two adult&quot; rule. This requires that adults are never alone with children or youth without an adult partner.\" \/>\n              <label for=\"input_92_0\"> I will observe the \"two adult\" rule. This requires that adults are never alone with children or youth without an adult partner. <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_92_1\" name=\"q92_asA92[]\" value=\"I will immediately report any behaviors which seem abusive or inappropriate to my supervisor.\" \/>\n              <label for=\"input_92_1\"> I will immediately report any behaviors which seem abusive or inappropriate to my supervisor. <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_93\">\n        <div id=\"cid_93\" class=\"form-input-wide\">\n          <div id=\"text_93\" class=\"form-html\">\n            <p><span style=\"font-family:arial, helvetica, sans-serif;\"><strong><span style=\"font-size:small;\">Please answer the following questions. Your responses will be kept confidential:<\/span><\/strong><\/span><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_78\">\n        <label class=\"form-label form-label-top\" id=\"label_78\" for=\"input_78\">\n          Do you agree to observe all Raphael House policies regarding working with families, children, and youth?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_78\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\">\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_78_0\" name=\"q78_doYou78\" value=\"Yes\" \/>\n              <label for=\"input_78_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_78_1\" name=\"q78_doYou78\" value=\"No\" \/>\n              <label for=\"input_78_1\"> No <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_79\">\n        <label class=\"form-label form-label-top\" id=\"label_79\" for=\"input_79\">\n          Have you ever been convicted of or pleaded guilty to a crime involving children or youth?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_79\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\">\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_79_0\" name=\"q79_haveYou79\" value=\"Yes\" \/>\n              <label for=\"input_79_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_79_1\" name=\"q79_haveYou79\" value=\"No\" \/>\n              <label for=\"input_79_1\"> No <\/label>\n            <\/span>\n            <span class=\"clearfix\">\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_100\" class=\"form-input-wide\" data-type=\"control_pagebreak\">\n        <div class=\"form-pagebreak\">\n          <div class=\"form-pagebreak-back-container\">\n            <button type=\"button\" class=\"form-pagebreak-back \" id=\"form-pagebreak-back_100\">\n              Back\n            <\/button>\n          <\/div>\n          <div class=\"form-pagebreak-next-container\">\n            <button type=\"button\" class=\"form-pagebreak-next \" id=\"form-pagebreak-next_100\">\n              Next\n            <\/button>\n          <\/div>\n        <\/div>\n      <\/li>\n    <\/ul>\n    <ul class=\"form-section page-section\" style=\"display:none;\">\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_101\">\n        <div id=\"cid_101\" class=\"form-input-wide\">\n          <div id=\"text_101\" class=\"form-html\">\n            <p>I have read the preceding volunteer agreement in its entirety, and I understand and agree to observe the guidelines and safeguards listed:<\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_86\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_86\" for=\"input_86\">\n          Signature:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_86\" class=\"form-input jf-required\">\n          <input type=\"text\" class=\" form-textbox validate[required]\" data-type=\"input-textbox\" id=\"input_86\" name=\"q86_signature\" size=\"20\" value=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_button\" id=\"id_63\">\n        <div id=\"cid_63\" class=\"form-input-wide\">\n          <div style=\"margin-left:156px\" class=\"form-buttons-wrapper\">\n            <button id=\"input_63\" type=\"submit\" class=\"form-submit-button\">\n              Submit Form\n            <\/button>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li style=\"display:none\">\n        Should be Empty:\n        <input type=\"text\" name=\"website\" value=\"\" \/>\n      <\/li>\n    <\/ul>\n  <\/div>\n  <input type=\"hidden\" id=\"simple_spc\" name=\"simple_spc\" value=\"10682410622\" \/>\n  <script type=\"text\/javascript\">\n  document.getElementById(\"si\" + \"mple\" + \"_spc\").value = \"10682410622-10682410622\";\n  <\/script>\n  <input type=\"hidden\" class=\"form-hidden\" value=\"\" id=\"input_106\" name=\"q106_officialUse\" \/>\n<\/form><\/body>\n<\/html>\n");(function(){window.handleIFrameMessage=function(e){var args=e.data.split(":");var iframe=document.getElementById("10682410622");if(!iframe){return};switch(args[0]){case"scrollIntoView":if(!("nojump"in FrameBuilder.get)){iframe.scrollIntoView();}
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