Online Inquiry
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Click the 'Generate Form' link to pre-populate the form when you are ready.
<ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 50%;"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date</label><input class="cst_datepicker" name="CST_3" type="text"></li><li class="er_fld_type_radio er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false" map_to="FH_MaritalStatus"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Marital Status</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_6" value="Single">Single</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_6" value="Married">Married</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_6" value="Widowed ">Widowed </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_6" value="Divorced">Divorced</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_6" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_6_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Name_First_A"> <i class="fa fa-font"></i><label class="er_fld_label required">First Name</label><input name="CST_2" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Name_Last_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name</label><input name="CST_12" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" map_to="FH_Name_First_B" er_fld_condfld="CST_6" er_fld_condvals="er_fld_showif_values=Married"> <i class="fa fa-font"></i><label class="er_fld_label required">Spouse's First Name</label><input name="CST_4" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" map_to="FH_Name_Last_B" er_fld_condfld="CST_6" er_fld_condvals="er_fld_showif_values=Married"> <i class="fa fa-font"></i><label class="er_fld_label required">Spouse's Last Name</label><input name="CST_13" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Address:</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Address_Street_1"> <i class="fa fa-font"></i><label class="er_fld_label required">Street</label><input name="CST_8" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Address_City"> <i class="fa fa-font"></i><label class="er_fld_label required">City</label><input name="CST_7" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Address_County"> <i class="fa fa-font"></i><label class="er_fld_label required">County</label><input name="CST_9" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Address_Zip"> <i class="fa fa-font"></i><label class="er_fld_label required">Zip Code</label><input name="CST_11" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="FH_EMail"> <i class="fa fa-font"></i><label class="er_fld_label required">Email</label><input name="CST_14" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Phone_Home"> <i class="fa fa-font"></i><label class="er_fld_label required">Main Phone #</label><input name="CST_16" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Phone_Other"> <i class="fa fa-font"></i><label class="er_fld_label">Other Phone #</label><input name="CST_15" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1" style="white-space: normal; width: 50%;" draggable="false" map_to="FH_Inquiry_Comments"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Do you have children?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_17" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_17" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_17" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_17_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_showif er_fld_type_paragraph_medium" draggable="false" map_to="FH_Inquiry_Comments" er_fld_condfld="CST_17" er_fld_condvals="er_fld_showif_values=Yes" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Age and Gender of Each Child</label><textarea name="CST_18" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_number er_fld_showif" draggable="false" map_to="FH_Inquiry_Comments" er_fld_condfld="CST_17" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">How many children live in the home?</label><input name="CST_19" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal;" draggable="false" map_to="FH_Inquiry_Comments"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Are there any other adults living in the home?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_20" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_20" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_20" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_20_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false" map_to="FH_Inquiry_Comments"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Previous Foster Parent? </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_21" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_21" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_21" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_21_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_showif er_fld_type_paragraph_medium" draggable="false" style="width: 50%;" er_fld_condfld="CST_21" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Foster parent with whom and when?</label><textarea name="CST_22" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col3" style="white-space:normal;" draggable="false" map_to="FH_Inquiry_Comments"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Do you currently have any of the following trainings?</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_23" value="IMPACT">IMPACT</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_23" value="TRPT">TRPT</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_23" value="MAPP ">MAPP </label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_23" value="CPI">CPI</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_23" value="TACT2/TBM">TACT2/TBM</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_23" value="First Aid/CPR ">First Aid/CPR </label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_23" value="None">None</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_23" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_23_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" map_to="FH_ReferralSource"><i class="fa fa-caret-down"></i><label class="er_fld_label required">How did you hear about Elks Aidmore? </label><select name="CST_24" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Billboard">Billboard</option><option value="Church/Pastor">Church/Pastor</option><option value="Display Table at Event">Display Table at Event</option><option value="Employee">Employee</option><option value="Foster Parent">Foster Parent</option><option value="Other Agency">Other Agency</option><option value="Other Agency Foster Parent">Other Agency Foster Parent</option><option value="Protective Services">Protective Services</option><option value="Radio/TV Ad">Radio/TV Ad</option><option value="Website">Website</option><option value="Social Media">Social Media</option><option value="Other">Other</option></select></li></ul><ul id="er_row_last" class="er_fld_row"><li class="er_fld_type_text er_fld_selected er_fld_showif" draggable="false" map_to="FH_ReferredByName" er_fld_condfld="CST_24" er_fld_condvals="er_fld_showif_values=Foster+Parent"> <i class="fa fa-font"></i><label class="er_fld_label">If referred by an Elks Aidmore Inc. Foster Parent, Who?</label><input name="CST_25" type="text"></li></ul>
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