{"id":313,"date":"2022-10-19T12:31:18","date_gmt":"2022-10-19T12:31:18","guid":{"rendered":"https:\/\/honorbus.com\/?page_id=313"},"modified":"2022-10-20T17:32:29","modified_gmt":"2022-10-20T22:32:29","slug":"veteran-applicant","status":"publish","type":"page","link":"https:\/\/honorbus.com\/application\/veteran-applicant\/","title":{"rendered":"Veteran Applicant"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.18.0&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#F4F4F4&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.18.0&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#FFFFFF&#8221; custom_padding=&#8221;50px|30px|50px|30px|true|true&#8221; border_radii=&#8221;on|10px|10px|10px|10px&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#e2e2e2&#8243; box_shadow_style=&#8221;preset3&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.18.0&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_code _builder_version=&#8221;4.18.0&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/wp-json\/wp\/v2\/pages\/313#gf_1' data-formid='1' novalidate>\n        <div id='gf_progressbar_wrapper_1' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>7<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_14' style='width:14%;'><span>14%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_15\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_15\" ><h3 class=\"gsection_title\">Veteran Application<\/h3><div class='gsection_description' id='gfield_description_1_15'>Richland County Honor Trip is provided to each veteran at no cost. Top priority is given to our WWII veterans. A guardian will be provided to assist you on this three-day bus tour to Washington, D.C. This application places you on our list only. Seats on the bus are filled on a first-come, first, served basis. We will contact you regarding your application. We do not accept donations from the veterans participating in the trip prior to their trip. <\/div><\/div><fieldset id=\"field_1_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_1_1'>As it appears on your ID<\/div><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_1_4\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_4\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_4_1_container' >\n                                        <label for='input_1_4_1' id='input_1_4_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_4.1' id='input_1_4_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_4_3_container' >\n                                    <label for='input_1_4_3' id='input_1_4_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_4.3' id='input_1_4_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_4_4_container' >\n                                        <label for='input_1_4_4' id='input_1_4_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                        <input type='text' name='input_4.4' id='input_1_4_4' value=''      aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_4_5_container' >\n                                    <label for='input_1_4_5' id='input_1_4_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                    <input type='text' name='input_4.5' id='input_1_4_5' value=''    aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_1_4_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_3\" class=\"gfield gfield--type-phone gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_3\" ><label class='gfield_label gform-field-label' for='input_1_3'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_1_3' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-email gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\" ><label class='gfield_label gform-field-label' for='input_1_5'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_1_5' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_16\" class=\"gfield gfield--type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_16\" ><label class='gfield_label gform-field-label' for='input_1_16'>Ohio County<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_1_16' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please Choose<\/option><option value='Richland' >Richland<\/option><option value='Ashland' >Ashland<\/option><option value='Knox' >Knox<\/option><\/select><\/div><\/div><div id=\"field_1_17\" class=\"gfield gfield--type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_17\" ><label class='gfield_label gform-field-label' for='input_1_17'>Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_17' id='input_1_17' type='number' step='any'   value='' class='large'    placeholder='How old are you?' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_20\" class=\"gfield gfield--type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_20\" ><label class='gfield_label gform-field-label' for='input_1_20'>Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_20' id='input_1_20' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><\/select><\/div><\/div><div id=\"field_1_39\" class=\"gfield gfield--type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_39\" ><label class='gfield_label gform-field-label' for='input_1_39'>Jacket Size<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_39' id='input_1_39' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Small' >Small<\/option><option value='Medium' >Medium<\/option><option value='Large' >Large<\/option><option value='X-Large' >X-Large<\/option><option value='XX-Large' >XX-Large<\/option><option value='XXX-Large' >XXX-Large<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_32' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-32' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_26\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_26\" ><h3 class=\"gsection_title\">Spouses Information<\/h3><\/div><fieldset id=\"field_1_24\" class=\"gfield gfield--type-name gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_24\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_24'>\n                            \n                            <span id='input_1_24_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.3' id='input_1_24_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_24_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_24_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.6' id='input_1_24_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_24_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_25\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_25\" ><label class='gfield_label gform-field-label' for='input_1_25'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_25' id='input_1_25' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_33\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_33\" ><h3 class=\"gsection_title\">Emergency Contact<\/h3><div class='gsection_description' id='gfield_description_1_33'>Son, daughter, etc. This is the contact for emergencies when you are on the trip. <\/div><\/div><fieldset id=\"field_1_34\" class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_34\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_34'>\n                            \n                            <span id='input_1_34_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_34.3' id='input_1_34_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_34_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_34_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_34.6' id='input_1_34_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_34_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_1_35\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_35\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_1_35' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_35_1_container' >\n                                        <label for='input_1_35_1' id='input_1_35_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_35.1' id='input_1_35_1' value=''    aria-required='false'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_35_2_container' >\n                                        <label for='input_1_35_2' id='input_1_35_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_35.2' id='input_1_35_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_35_3_container' >\n                                    <label for='input_1_35_3' id='input_1_35_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_35.3' id='input_1_35_3' value=''    aria-required='false'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_35_4_container' >\n                                        <label for='input_1_35_4' id='input_1_35_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                        <input type='text' name='input_35.4' id='input_1_35_4' value=''      aria-required='false'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_35_5_container' >\n                                    <label for='input_1_35_5' id='input_1_35_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                    <input type='text' name='input_35.5' id='input_1_35_5' value=''    aria-required='false'    \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_1_35_6_container' >\n                                        <label for='input_1_35_6' id='input_1_35_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                        <select name='input_35.6' id='input_1_35_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option> <\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_36\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_36\" ><label class='gfield_label gform-field-label' for='input_1_36'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_36' id='input_1_36' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_37\" class=\"gfield gfield--type-email gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_37\" ><label class='gfield_label gform-field-label' for='input_1_37'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_37' id='input_1_37' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_38\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_38\" ><label class='gfield_label gform-field-label' for='input_1_38'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_1_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_40\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_40\" ><h3 class=\"gsection_title\">Traveling with another Veteran?<\/h3><div class='gsection_description' id='gfield_description_1_40'>If you would like to travel with another veteran, please provide their name below. <\/div><\/div><fieldset id=\"field_1_41\" class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_41\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_41'>\n                            \n                            <span id='input_1_41_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_41.3' id='input_1_41_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_41_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_41_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_41.6' id='input_1_41_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_41_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_6' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"1\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"1\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_6' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-6' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_31\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_31\" ><h3 class=\"gsection_title\">Military Service<\/h3><\/div><div id=\"field_1_19\" class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_19\" ><label class='gfield_label gform-field-label' for='input_1_19'>In what conflict did you serve?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_1_19' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='WWII' >WWII<\/option><option value='Korean War' >Korean War<\/option><option value='Vietnam' >Vietnam<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_1_21\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_21\" ><label class='gfield_label gform-field-label' for='input_1_21'>Branch of Service<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_1_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_22\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_22\" ><label class='gfield_label gform-field-label' for='input_1_22'>Highest Rank at end of service<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_1_22' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_30\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_30\" ><label class='gfield_label gform-field-label' for='input_1_30'>Dates of Service<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_1_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_29\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_29\" ><label class='gfield_label gform-field-label' for='input_1_29'>Military Activity<\/label><div class='gfield_description' id='gfield_description_1_29'>Years of Service, Decorations, War and Items of Special Interest. <\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_29' id='input_1_29' class='textarea large'  aria-describedby=\"gfield_description_1_29\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_18' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_18' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-18' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_10\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\" ><h3 class=\"gsection_title\">Medical Information<\/h3><div class='gsection_description' id='gfield_description_1_10'>The information provided will not disqualify you. It permits us to assess the support we need during the trip. Information is for Seneca County Honor Bus personnel only. Please note that you will be required to climb up and down short flights of steps to enter and exit the bus. Your physician must be aware of your planned participation of this three day trip. <\/div><\/div><fieldset id=\"field_1_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_53\" ><legend class='gfield_label gform-field-label' >I have motion sickness<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_53'>\n\t\t\t<div class='gchoice gchoice_1_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Yes'  id='choice_1_53_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_53_0' id='label_1_53_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='No'  id='choice_1_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_53_1' id='label_1_53_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_44\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_44\" ><label class='gfield_label gform-field-label' for='input_1_44'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_1_44' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_58\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_58\" ><hr><\/div><fieldset id=\"field_1_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_55\" ><legend class='gfield_label gform-field-label' >I have breathing problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_55'>\n\t\t\t<div class='gchoice gchoice_1_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Yes'  id='choice_1_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_55_0' id='label_1_55_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='No'  id='choice_1_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_55_1' id='label_1_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_46\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_46\" ><label class='gfield_label gform-field-label' for='input_1_46'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_1_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_60\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_60\" ><hr><\/div><fieldset id=\"field_1_54\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_54\" ><legend class='gfield_label gform-field-label' >I use a home nebulizer machine or CPAP<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_54'>\n\t\t\t<div class='gchoice gchoice_1_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Yes'  id='choice_1_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_54_0' id='label_1_54_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='No'  id='choice_1_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_54_1' id='label_1_54_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_48\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_48\" ><label class='gfield_label gform-field-label' for='input_1_48'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_1_48' type='text' value='' class='large'    placeholder='Discuss the use of hand-held nebulizers before the trip with your physician.'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_59\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_59\" ><hr><\/div><fieldset id=\"field_1_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_56\" ><legend class='gfield_label gform-field-label' >I use Oxygen<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_56'>\n\t\t\t<div class='gchoice gchoice_1_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Yes'  id='choice_1_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_56_0' id='label_1_56_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='No'  id='choice_1_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_56_1' id='label_1_56_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_50\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_50\" ><label class='gfield_label gform-field-label' for='input_1_50'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_1_50' type='text' value='' class='large'    placeholder='Perscription is required'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_61\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_61\" ><hr><\/div><fieldset id=\"field_1_57\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_57\" ><legend class='gfield_label gform-field-label' >Diagnosed Alzheimer&#039;s?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_57'>\n\t\t\t<div class='gchoice gchoice_1_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Yes'  id='choice_1_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_57_0' id='label_1_57_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='No'  id='choice_1_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_57_1' id='label_1_57_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_52\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_52\" ><label class='gfield_label gform-field-label' for='input_1_52'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_1_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_62\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_62\" ><hr><\/div><fieldset id=\"field_1_66\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_66\" ><legend class='gfield_label gform-field-label' >I use a colostomy or urostomy bag<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_66'>\n\t\t\t<div class='gchoice gchoice_1_66_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Yes'  id='choice_1_66_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_66_0' id='label_1_66_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_66_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='No'  id='choice_1_66_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_66_1' id='label_1_66_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_67\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_67\" ><label class='gfield_label gform-field-label' for='input_1_67'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_1_67' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_65\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_65\" ><hr><\/div><fieldset id=\"field_1_69\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_69\" ><legend class='gfield_label gform-field-label' >I am a diabetic<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_69'>\n\t\t\t<div class='gchoice gchoice_1_69_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Yes'  id='choice_1_69_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_69_0' id='label_1_69_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_69_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='No'  id='choice_1_69_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_69_1' id='label_1_69_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_64\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_64\" ><label class='gfield_label gform-field-label' for='input_1_64'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_1_64' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_68\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_68\" ><hr><\/div><fieldset id=\"field_1_63\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_63\" ><legend class='gfield_label gform-field-label' >I have a pacemaker<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_63'>\n\t\t\t<div class='gchoice gchoice_1_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Yes'  id='choice_1_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_63_0' id='label_1_63_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='No'  id='choice_1_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_63_1' id='label_1_63_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_70\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_70\" ><label class='gfield_label gform-field-label' for='input_1_70'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_1_70' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_71\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_71\" ><hr><\/div><fieldset id=\"field_1_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_72\" ><legend class='gfield_label gform-field-label' >Previous heart conditions<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_72'>\n\t\t\t<div class='gchoice gchoice_1_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Yes'  id='choice_1_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_72_0' id='label_1_72_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='No'  id='choice_1_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_72_1' id='label_1_72_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_75\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_75\" ><label class='gfield_label gform-field-label' for='input_1_75'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_1_75' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_74\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_74\" ><hr><\/div><fieldset id=\"field_1_76\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_76\" ><legend class='gfield_label gform-field-label' >I use a cane, walker, wheelchair<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_76'>\n\t\t\t<div class='gchoice gchoice_1_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Yes'  id='choice_1_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_76_0' id='label_1_76_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='No'  id='choice_1_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_76_1' id='label_1_76_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_73\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_73\" ><label class='gfield_label gform-field-label' for='input_1_73'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_1_73' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_77\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_77\" ><hr><\/div><fieldset id=\"field_1_78\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_78\" ><legend class='gfield_label gform-field-label' >History of Epilepsy or Seizures<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_78'>\n\t\t\t<div class='gchoice gchoice_1_78_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Yes'  id='choice_1_78_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_78_0' id='label_1_78_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_78_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='No'  id='choice_1_78_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_78_1' id='label_1_78_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_79\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_79\" ><label class='gfield_label gform-field-label' for='input_1_79'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_1_79' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_80\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_80\" ><hr><\/div><fieldset id=\"field_1_81\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_81\" ><legend class='gfield_label gform-field-label' >Can you walk the length of a football field?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_81'>\n\t\t\t<div class='gchoice gchoice_1_81_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Yes'  id='choice_1_81_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_81_0' id='label_1_81_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_81_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='No'  id='choice_1_81_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_81_1' id='label_1_81_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_82\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_82\" ><label class='gfield_label gform-field-label' for='input_1_82'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_1_82' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_83\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_83\" ><hr><\/div><fieldset id=\"field_1_84\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_84\" ><legend class='gfield_label gform-field-label' >Do you sleepwalk?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_84'>\n\t\t\t<div class='gchoice gchoice_1_84_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Yes'  id='choice_1_84_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_84_0' id='label_1_84_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_84_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='No'  id='choice_1_84_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_84_1' id='label_1_84_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_85\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_85\" ><label class='gfield_label gform-field-label' for='input_1_85'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_1_85' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_86\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_86\" ><hr><\/div><fieldset id=\"field_1_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_87\" ><legend class='gfield_label gform-field-label' >Do you wear depends or similar products?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_87'>\n\t\t\t<div class='gchoice gchoice_1_87_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='Yes'  id='choice_1_87_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_87_0' id='label_1_87_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_87_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='No'  id='choice_1_87_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_87_1' id='label_1_87_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_88\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_88\" ><label class='gfield_label gform-field-label' for='input_1_88'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_1_88' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_89\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_89\" ><hr><\/div><fieldset id=\"field_1_90\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_90\" ><legend class='gfield_label gform-field-label' >Other Medical Issues<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_90'>\n\t\t\t<div class='gchoice gchoice_1_90_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='Yes'  id='choice_1_90_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_90_0' id='label_1_90_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_90_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='No'  id='choice_1_90_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_90_1' id='label_1_90_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_91\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_91\" ><label class='gfield_label gform-field-label' for='input_1_91'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_91' id='input_1_91' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_93\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_93\" ><hr><\/div><div id=\"field_1_94\" class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_94\" ><label class='gfield_label gform-field-label' for='input_1_94'>Weight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_94'>In lbs<\/div><div class='ginput_container ginput_container_number'><input name='input_94' id='input_1_94' type='number' step='any'   value='' class='large'    placeholder='Enter weight value' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_1_94\" \/><\/div><\/div><div id=\"field_1_95\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_95\" ><label class='gfield_label gform-field-label' for='input_1_95'>Please list any special diet needs<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_95' id='input_1_95' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_92' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_92' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_5' class='gform_page' data-js='page-field-id-92' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_5' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_103\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_103\" ><h3 class=\"gsection_title\">Additional Medical Information<\/h3><\/div><fieldset id=\"field_1_7\" class=\"gfield gfield--type-list gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_7\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Drug and\/or Food Allergies<\/legend><div class='gfield_description' id='gfield_description_1_7'>Please list any drug and\/or food allergies you may have<\/div><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Allergy<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_7_cell1 gform-grid-col' data-label='Allergy'><input aria-invalid='false'  aria-describedby=\"gfield_description_1_7\" aria-label='Allergy, Row 1' data-aria-label-template='Allergy, Row {0}' type='text' name='input_7[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_97\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_97\" ><legend class='gfield_label gform-field-label' >I have checked with my Dr regarding this trip &amp; time away<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_97'>\n\t\t\t<div class='gchoice gchoice_1_97_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_97' type='radio' value='Yes'  id='choice_1_97_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_97_0' id='label_1_97_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_97_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_97' type='radio' value='No'  id='choice_1_97_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_97_1' id='label_1_97_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_98\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_98\" ><label class='gfield_label gform-field-label' for='input_1_98'>Additional Medical History<\/label><div class='gfield_description' id='gfield_description_1_98'>Any other significant medical history we should know, including operations in the last two years?<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_98' id='input_1_98' class='textarea large'  aria-describedby=\"gfield_description_1_98\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_101' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_101' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"6\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"6\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_6' class='gform_page' data-js='page-field-id-101' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_6' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_102\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_102\" ><h3 class=\"gsection_title\">Medication &amp; Pharmacy Information<\/h3><\/div><div id=\"field_1_99\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_99\" ><label class='gfield_label gform-field-label' for='input_1_99'>Your Pharmacy&#039;s Name<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_1_99' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_100\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_100\" ><label class='gfield_label gform-field-label' for='input_1_100'>Your Pharmacy&#039;s Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_100' id='input_1_100' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_109\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_109\" ><hr><\/div><fieldset id=\"field_1_96\" class=\"gfield gfield--type-list gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_96\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Medications<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Medication Name<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">How Often<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Dose &amp; Time of Day<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">RX #<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_96_cell1 gform-grid-col' data-label='Medication Name'><input aria-invalid='false'   aria-label='Medication Name, Row 1' data-aria-label-template='Medication Name, Row {0}' type='text' name='input_96[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_96_cell2 gform-grid-col' data-label='How Often'><input aria-invalid='false'   aria-label='How Often, Row 1' data-aria-label-template='How Often, Row {0}' type='text' name='input_96[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_96_cell3 gform-grid-col' data-label='Dose &amp; Time of Day'><input aria-invalid='false'   aria-label='Dose &amp; Time of Day, Row 1' data-aria-label-template='Dose &amp; Time of Day, Row {0}' type='text' name='input_96[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_96_cell4 gform-grid-col' data-label='RX #'><input aria-invalid='false'   aria-label='RX #, Row 1' data-aria-label-template='RX #, Row {0}' type='text' name='input_96[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_105' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_105' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"7\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"7\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_7' class='gform_page' data-js='page-field-id-105' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_7' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_106\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_106\" ><h3 class=\"gsection_title\">Review &amp; Submit Application<\/h3><\/div><div id=\"field_1_107\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_107\" >As photographic and video equipment are frequently used to memorialize and document Richland County Honor Trip and events, my image may appear in a public forum, such as the media or website, to acknowledge, promote or advance the work of the Richland County Honor Trip program. I hereby release the photographer and Richland Country Honor Trip from all claims and liability relating to said photographs. I hereby give permission for my images captured during Richland Country Honor Trip activities through video, photo, or other media, to med used solely for the purpose of Richland County Honor Trip promotional materials and publications, and wave any rights or compensation or ownership thereto. \n<\/div><div id=\"field_1_108\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_108\" >I understand and acknowledge that medical insurance is the responsibility of me, the veteran, and that Richland County Honor Trip does not provide medical care. I accept all risks associated with travel and other Richland County Honor Trip activities and will not hold Richland County Honor Trip responsible for any injuries incurred by me while participating in the Richland County Honor Trip. \n<\/div><div id=\"field_1_110\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_110\" >I acknowledge that I have reviewed this application and that the information provided is true and accurate, Further, the undersigned does release and hold harmless Richland County Honor Trip, organization sponsors, committee members, agents successors and assigns from any and all actions, claims or damages for any personal injuries or property damages which may occur in the course of or during this trip or any of its activities. <\/div><div id=\"field_1_111\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_111\" >I also attest that I have never been convicted of a felony nor under investigation for a felony offense. <\/div><div id=\"field_1_113\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_113\" ><label class='gfield_label gform-field-label' for='input_1_113'>Your Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_113' id='input_1_113' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_114\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_114\" ><label class='gfield_label gform-field-label' for='input_1_114'>Todays Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_114' id='input_1_114' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_114_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_114_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_114' class='gform_hidden' value='https:\/\/honorbus.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_115\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_115\" >This application will be sent to: <\/br>\n<\/br>\n<b>AMVETS Post #26<\/b><\/br>\n1100 Fourth St.<\/br>\nMansfield, OH 44906<\/br>\n<i>ATTN: Richland County Veterans Honor Bus<\/i><\/br>\n419-565-3769<\/div><\/div><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_1' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Submit Application'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='WyJ7XCI1M1wiOltcIjRlMWVmYzgyMzRjYjBhNjMzYjk5NDYwNjc1MDFhNGNmXCIsXCI0M2JmYTM2MTc5YTZjYTA0NzhiZjgxMGY2NTJmYjhmM1wiXSxcIjU1XCI6W1wiNGUxZWZjODIzNGNiMGE2MzNiOTk0NjA2NzUwMWE0Y2ZcIixcIjQzYmZhMzYxNzlhNmNhMDQ3OGJmODEwZjY1MmZiOGYzXCJdLFwiNTRcIjpbXCI0ZTFlZmM4MjM0Y2IwYTYzM2I5OTQ2MDY3NTAxYTRjZlwiLFwiNDNiZmEzNjE3OWE2Y2EwNDc4YmY4MTBmNjUyZmI4ZjNcIl0sXCI1NlwiOltcIjRlMWVmYzgyMzRjYjBhNjMzYjk5NDYwNjc1MDFhNGNmXCIsXCI0M2JmYTM2MTc5YTZjYTA0NzhiZjgxMGY2NTJmYjhmM1wiXSxcIjU3XCI6W1wiNGUxZWZjODIzNGNiMGE2MzNiOTk0NjA2NzUwMWE0Y2ZcIixcIjQzYmZhMzYxNzlhNmNhMDQ3OGJmODEwZjY1MmZiOGYzXCJdLFwiNjZcIjpbXCI0ZTFlZmM4MjM0Y2IwYTYzM2I5OTQ2MDY3NTAxYTRjZlwiLFwiNDNiZmEzNjE3OWE2Y2EwNDc4YmY4MTBmNjUyZmI4ZjNcIl0sXCI2OVwiOltcIjRlMWVmYzgyMzRjYjBhNjMzYjk5NDYwNjc1MDFhNGNmXCIsXCI0M2JmYTM2MTc5YTZjYTA0NzhiZjgxMGY2NTJmYjhmM1wiXSxcIjYzXCI6W1wiNGUxZWZjODIzNGNiMGE2MzNiOTk0NjA2NzUwMWE0Y2ZcIixcIjQzYmZhMzYxNzlhNmNhMDQ3OGJmODEwZjY1MmZiOGYzXCJdLFwiNzJcIjpbXCI0ZTFlZmM4MjM0Y2IwYTYzM2I5OTQ2MDY3NTAxYTRjZlwiLFwiNDNiZmEzNjE3OWE2Y2EwNDc4YmY4MTBmNjUyZmI4ZjNcIl0sXCI3NlwiOltcIjRlMWVmYzgyMzRjYjBhNjMzYjk5NDYwNjc1MDFhNGNmXCIsXCI0M2JmYTM2MTc5YTZjYTA0NzhiZjgxMGY2NTJmYjhmM1wiXSxcIjc4XCI6W1wiNGUxZWZjODIzNGNiMGE2MzNiOTk0NjA2NzUwMWE0Y2ZcIixcIjQzYmZhMzYxNzlhNmNhMDQ3OGJmODEwZjY1MmZiOGYzXCJdLFwiODFcIjpbXCI0ZTFlZmM4MjM0Y2IwYTYzM2I5OTQ2MDY3NTAxYTRjZlwiLFwiNDNiZmEzNjE3OWE2Y2EwNDc4YmY4MTBmNjUyZmI4ZjNcIl0sXCI4NFwiOltcIjRlMWVmYzgyMzRjYjBhNjMzYjk5NDYwNjc1MDFhNGNmXCIsXCI0M2JmYTM2MTc5YTZjYTA0NzhiZjgxMGY2NTJmYjhmM1wiXSxcIjg3XCI6W1wiNGUxZWZjODIzNGNiMGE2MzNiOTk0NjA2NzUwMWE0Y2ZcIixcIjQzYmZhMzYxNzlhNmNhMDQ3OGJmODEwZjY1MmZiOGYzXCJdLFwiOTBcIjpbXCI0ZTFlZmM4MjM0Y2IwYTYzM2I5OTQ2MDY3NTAxYTRjZlwiLFwiNDNiZmEzNjE3OWE2Y2EwNDc4YmY4MTBmNjUyZmI4ZjNcIl0sXCI5N1wiOltcIjRlMWVmYzgyMzRjYjBhNjMzYjk5NDYwNjc1MDFhNGNmXCIsXCI0M2JmYTM2MTc5YTZjYTA0NzhiZjgxMGY2NTJmYjhmM1wiXX0iLCI4NThkZDllZjkxY2MwNDBhODJiYTQ5ZDg2NmUxOTE3NyJd' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='2' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/div><\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 1, 'https:\/\/honorbus.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_1').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_1');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_1').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_1').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_1').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_1').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_1').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_1').val();gformInitSpinner( 1, 'https:\/\/honorbus.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [1, current_page]);window['gf_submitting_1'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_1').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_1').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [1]);window['gf_submitting_1'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_1').text());}, 50);}else{jQuery('#gform_1').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"1\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);                if (event.defaultPrevented) {                return;         }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_1\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_1\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_1\" );        let postRenderFired = false;                function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            jQuery( document ).trigger( 'gform_post_render', [1, current_page] );            gform.utils.trigger( { event: 'gform\/postRender', native: false, data: { formId: 1, currentPage: current_page } } );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n[\/et_pb_code][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='1' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/wp-json\/wp\/v2\/pages\/313#gf_1' data-formid='1' novalidate>\n        <div id='gf_progressbar_wrapper_1' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>7<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_14' style='width:14%;'><span>14%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_15\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_15\" ><h3 class=\"gsection_title\">Veteran Application<\/h3><div class='gsection_description' id='gfield_description_1_15'>Richland County Honor Trip is provided to each veteran at no cost. Top priority is given to our WWII veterans. A guardian will be provided to assist you on this three-day bus tour to Washington, D.C. This application places you on our list only. Seats on the bus are filled on a first-come, first, served basis. We will contact you regarding your application. We do not accept donations from the veterans participating in the trip prior to their trip. <\/div><\/div><fieldset id=\"field_1_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_1_1'>As it appears on your ID<\/div><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_1_4\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_4\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_4_1_container' >\n                                        <label for='input_1_4_1' id='input_1_4_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_4.1' id='input_1_4_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_4_3_container' >\n                                    <label for='input_1_4_3' id='input_1_4_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_4.3' id='input_1_4_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_4_4_container' >\n                                        <label for='input_1_4_4' id='input_1_4_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                        <input type='text' name='input_4.4' id='input_1_4_4' value=''      aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_4_5_container' >\n                                    <label for='input_1_4_5' id='input_1_4_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                    <input type='text' name='input_4.5' id='input_1_4_5' value=''    aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_1_4_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_3\" class=\"gfield gfield--type-phone gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_3\" ><label class='gfield_label gform-field-label' for='input_1_3'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_1_3' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-email gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\" ><label class='gfield_label gform-field-label' for='input_1_5'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_1_5' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_16\" class=\"gfield gfield--type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_16\" ><label class='gfield_label gform-field-label' for='input_1_16'>Ohio County<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_1_16' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please Choose<\/option><option value='Richland' >Richland<\/option><option value='Ashland' >Ashland<\/option><option value='Knox' >Knox<\/option><\/select><\/div><\/div><div id=\"field_1_17\" class=\"gfield gfield--type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_17\" ><label class='gfield_label gform-field-label' for='input_1_17'>Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_17' id='input_1_17' type='number' step='any'   value='' class='large'    placeholder='How old are you?' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_20\" class=\"gfield gfield--type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_20\" ><label class='gfield_label gform-field-label' for='input_1_20'>Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_20' id='input_1_20' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><\/select><\/div><\/div><div id=\"field_1_39\" class=\"gfield gfield--type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_39\" ><label class='gfield_label gform-field-label' for='input_1_39'>Jacket Size<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_39' id='input_1_39' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Small' >Small<\/option><option value='Medium' >Medium<\/option><option value='Large' >Large<\/option><option value='X-Large' >X-Large<\/option><option value='XX-Large' >XX-Large<\/option><option value='XXX-Large' >XXX-Large<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_32' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-32' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_26\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_26\" ><h3 class=\"gsection_title\">Spouses Information<\/h3><\/div><fieldset id=\"field_1_24\" class=\"gfield gfield--type-name gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_24\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_24'>\n                            \n                            <span id='input_1_24_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.3' id='input_1_24_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_24_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_24_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.6' id='input_1_24_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_24_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_25\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_25\" ><label class='gfield_label gform-field-label' for='input_1_25'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_25' id='input_1_25' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_33\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_33\" ><h3 class=\"gsection_title\">Emergency Contact<\/h3><div class='gsection_description' id='gfield_description_1_33'>Son, daughter, etc. This is the contact for emergencies when you are on the trip. <\/div><\/div><fieldset id=\"field_1_34\" class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_34\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_34'>\n                            \n                            <span id='input_1_34_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_34.3' id='input_1_34_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_34_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_34_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_34.6' id='input_1_34_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_34_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_1_35\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_35\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_1_35' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_35_1_container' >\n                                        <label for='input_1_35_1' id='input_1_35_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_35.1' id='input_1_35_1' value=''    aria-required='false'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_35_2_container' >\n                                        <label for='input_1_35_2' id='input_1_35_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_35.2' id='input_1_35_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_35_3_container' >\n                                    <label for='input_1_35_3' id='input_1_35_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_35.3' id='input_1_35_3' value=''    aria-required='false'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_35_4_container' >\n                                        <label for='input_1_35_4' id='input_1_35_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                        <input type='text' name='input_35.4' id='input_1_35_4' value=''      aria-required='false'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_35_5_container' >\n                                    <label for='input_1_35_5' id='input_1_35_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                    <input type='text' name='input_35.5' id='input_1_35_5' value=''    aria-required='false'    \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_1_35_6_container' >\n                                        <label for='input_1_35_6' id='input_1_35_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                        <select name='input_35.6' id='input_1_35_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option> <\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_36\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_36\" ><label class='gfield_label gform-field-label' for='input_1_36'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_36' id='input_1_36' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_37\" class=\"gfield gfield--type-email gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_37\" ><label class='gfield_label gform-field-label' for='input_1_37'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_37' id='input_1_37' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_38\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_38\" ><label class='gfield_label gform-field-label' for='input_1_38'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_1_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_40\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_40\" ><h3 class=\"gsection_title\">Traveling with another Veteran?<\/h3><div class='gsection_description' id='gfield_description_1_40'>If you would like to travel with another veteran, please provide their name below. <\/div><\/div><fieldset id=\"field_1_41\" class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_41\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_41'>\n                            \n                            <span id='input_1_41_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_41.3' id='input_1_41_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_41_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_41_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_41.6' id='input_1_41_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_41_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_6' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"1\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"1\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_6' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-6' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_31\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_31\" ><h3 class=\"gsection_title\">Military Service<\/h3><\/div><div id=\"field_1_19\" class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_19\" ><label class='gfield_label gform-field-label' for='input_1_19'>In what conflict did you serve?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_1_19' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='WWII' >WWII<\/option><option value='Korean War' >Korean War<\/option><option value='Vietnam' >Vietnam<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_1_21\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_21\" ><label class='gfield_label gform-field-label' for='input_1_21'>Branch of Service<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_1_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_22\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_22\" ><label class='gfield_label gform-field-label' for='input_1_22'>Highest Rank at end of service<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_1_22' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_30\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_30\" ><label class='gfield_label gform-field-label' for='input_1_30'>Dates of Service<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_1_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_29\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_29\" ><label class='gfield_label gform-field-label' for='input_1_29'>Military Activity<\/label><div class='gfield_description' id='gfield_description_1_29'>Years of Service, Decorations, War and Items of Special Interest. <\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_29' id='input_1_29' class='textarea large'  aria-describedby=\"gfield_description_1_29\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_18' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_18' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-18' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_10\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\" ><h3 class=\"gsection_title\">Medical Information<\/h3><div class='gsection_description' id='gfield_description_1_10'>The information provided will not disqualify you. It permits us to assess the support we need during the trip. Information is for Seneca County Honor Bus personnel only. Please note that you will be required to climb up and down short flights of steps to enter and exit the bus. Your physician must be aware of your planned participation of this three day trip. <\/div><\/div><fieldset id=\"field_1_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_53\" ><legend class='gfield_label gform-field-label' >I have motion sickness<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_53'>\n\t\t\t<div class='gchoice gchoice_1_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Yes'  id='choice_1_53_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_53_0' id='label_1_53_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='No'  id='choice_1_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_53_1' id='label_1_53_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_44\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_44\" ><label class='gfield_label gform-field-label' for='input_1_44'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_1_44' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_58\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_58\" ><hr><\/div><fieldset id=\"field_1_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_55\" ><legend class='gfield_label gform-field-label' >I have breathing problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_55'>\n\t\t\t<div class='gchoice gchoice_1_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Yes'  id='choice_1_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_55_0' id='label_1_55_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='No'  id='choice_1_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_55_1' id='label_1_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_46\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_46\" ><label class='gfield_label gform-field-label' for='input_1_46'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_1_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_60\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_60\" ><hr><\/div><fieldset id=\"field_1_54\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_54\" ><legend class='gfield_label gform-field-label' >I use a home nebulizer machine or CPAP<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_54'>\n\t\t\t<div class='gchoice gchoice_1_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Yes'  id='choice_1_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_54_0' id='label_1_54_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='No'  id='choice_1_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_54_1' id='label_1_54_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_48\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_48\" ><label class='gfield_label gform-field-label' for='input_1_48'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_1_48' type='text' value='' class='large'    placeholder='Discuss the use of hand-held nebulizers before the trip with your physician.'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_59\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_59\" ><hr><\/div><fieldset id=\"field_1_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_56\" ><legend class='gfield_label gform-field-label' >I use Oxygen<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_56'>\n\t\t\t<div class='gchoice gchoice_1_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Yes'  id='choice_1_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_56_0' id='label_1_56_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='No'  id='choice_1_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_56_1' id='label_1_56_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_50\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_50\" ><label class='gfield_label gform-field-label' for='input_1_50'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_1_50' type='text' value='' class='large'    placeholder='Perscription is required'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_61\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_61\" ><hr><\/div><fieldset id=\"field_1_57\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_57\" ><legend class='gfield_label gform-field-label' >Diagnosed Alzheimer&#039;s?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_57'>\n\t\t\t<div class='gchoice gchoice_1_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Yes'  id='choice_1_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_57_0' id='label_1_57_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='No'  id='choice_1_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_57_1' id='label_1_57_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_52\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_52\" ><label class='gfield_label gform-field-label' for='input_1_52'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_1_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_62\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_62\" ><hr><\/div><fieldset id=\"field_1_66\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_66\" ><legend class='gfield_label gform-field-label' >I use a colostomy or urostomy bag<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_66'>\n\t\t\t<div class='gchoice gchoice_1_66_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Yes'  id='choice_1_66_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_66_0' id='label_1_66_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_66_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='No'  id='choice_1_66_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_66_1' id='label_1_66_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_67\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_67\" ><label class='gfield_label gform-field-label' for='input_1_67'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_1_67' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_65\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_65\" ><hr><\/div><fieldset id=\"field_1_69\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_69\" ><legend class='gfield_label gform-field-label' >I am a diabetic<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_69'>\n\t\t\t<div class='gchoice gchoice_1_69_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Yes'  id='choice_1_69_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_69_0' id='label_1_69_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_69_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='No'  id='choice_1_69_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_69_1' id='label_1_69_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_64\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_64\" ><label class='gfield_label gform-field-label' for='input_1_64'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_1_64' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_68\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_68\" ><hr><\/div><fieldset id=\"field_1_63\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_63\" ><legend class='gfield_label gform-field-label' >I have a pacemaker<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_63'>\n\t\t\t<div class='gchoice gchoice_1_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Yes'  id='choice_1_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_63_0' id='label_1_63_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='No'  id='choice_1_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_63_1' id='label_1_63_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_70\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_70\" ><label class='gfield_label gform-field-label' for='input_1_70'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_1_70' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_71\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_71\" ><hr><\/div><fieldset id=\"field_1_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_72\" ><legend class='gfield_label gform-field-label' >Previous heart conditions<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_72'>\n\t\t\t<div class='gchoice gchoice_1_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Yes'  id='choice_1_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_72_0' id='label_1_72_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='No'  id='choice_1_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_72_1' id='label_1_72_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_75\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_75\" ><label class='gfield_label gform-field-label' for='input_1_75'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_1_75' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_74\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_74\" ><hr><\/div><fieldset id=\"field_1_76\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_76\" ><legend class='gfield_label gform-field-label' >I use a cane, walker, wheelchair<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_76'>\n\t\t\t<div class='gchoice gchoice_1_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Yes'  id='choice_1_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_76_0' id='label_1_76_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='No'  id='choice_1_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_76_1' id='label_1_76_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_73\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_73\" ><label class='gfield_label gform-field-label' for='input_1_73'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_1_73' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_77\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_77\" ><hr><\/div><fieldset id=\"field_1_78\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_78\" ><legend class='gfield_label gform-field-label' >History of Epilepsy or Seizures<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_78'>\n\t\t\t<div class='gchoice gchoice_1_78_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Yes'  id='choice_1_78_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_78_0' id='label_1_78_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_78_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='No'  id='choice_1_78_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_78_1' id='label_1_78_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_79\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_79\" ><label class='gfield_label gform-field-label' for='input_1_79'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_1_79' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_80\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_80\" ><hr><\/div><fieldset id=\"field_1_81\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_81\" ><legend class='gfield_label gform-field-label' >Can you walk the length of a football field?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_81'>\n\t\t\t<div class='gchoice gchoice_1_81_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Yes'  id='choice_1_81_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_81_0' id='label_1_81_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_81_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='No'  id='choice_1_81_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_81_1' id='label_1_81_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_82\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_82\" ><label class='gfield_label gform-field-label' for='input_1_82'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_1_82' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_83\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_83\" ><hr><\/div><fieldset id=\"field_1_84\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_84\" ><legend class='gfield_label gform-field-label' >Do you sleepwalk?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_84'>\n\t\t\t<div class='gchoice gchoice_1_84_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Yes'  id='choice_1_84_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_84_0' id='label_1_84_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_84_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='No'  id='choice_1_84_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_84_1' id='label_1_84_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_85\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_85\" ><label class='gfield_label gform-field-label' for='input_1_85'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_1_85' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_86\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_86\" ><hr><\/div><fieldset id=\"field_1_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_87\" ><legend class='gfield_label gform-field-label' >Do you wear depends or similar products?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_87'>\n\t\t\t<div class='gchoice gchoice_1_87_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='Yes'  id='choice_1_87_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_87_0' id='label_1_87_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_87_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='No'  id='choice_1_87_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_87_1' id='label_1_87_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_88\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_88\" ><label class='gfield_label gform-field-label' for='input_1_88'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_1_88' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_89\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_89\" ><hr><\/div><fieldset id=\"field_1_90\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_90\" ><legend class='gfield_label gform-field-label' >Other Medical Issues<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_90'>\n\t\t\t<div class='gchoice gchoice_1_90_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='Yes'  id='choice_1_90_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_90_0' id='label_1_90_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_90_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='No'  id='choice_1_90_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_90_1' id='label_1_90_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_91\" class=\"gfield gfield--type-text gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_91\" ><label class='gfield_label gform-field-label' for='input_1_91'>Please Explain<\/label><div class='ginput_container ginput_container_text'><input name='input_91' id='input_1_91' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_93\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_93\" ><hr><\/div><div id=\"field_1_94\" class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_94\" ><label class='gfield_label gform-field-label' for='input_1_94'>Weight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_94'>In lbs<\/div><div class='ginput_container ginput_container_number'><input name='input_94' id='input_1_94' type='number' step='any'   value='' class='large'    placeholder='Enter weight value' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_1_94\" \/><\/div><\/div><div id=\"field_1_95\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_95\" ><label class='gfield_label gform-field-label' for='input_1_95'>Please list any special diet needs<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_95' id='input_1_95' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_92' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_92' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_5' class='gform_page' data-js='page-field-id-92' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_5' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_103\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_103\" ><h3 class=\"gsection_title\">Additional Medical Information<\/h3><\/div><fieldset id=\"field_1_7\" class=\"gfield gfield--type-list gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_7\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Drug and\/or Food Allergies<\/legend><div class='gfield_description' id='gfield_description_1_7'>Please list any drug and\/or food allergies you may have<\/div><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Allergy<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_7_cell1 gform-grid-col' data-label='Allergy'><input aria-invalid='false'  aria-describedby=\"gfield_description_1_7\" aria-label='Allergy, Row 1' data-aria-label-template='Allergy, Row {0}' type='text' name='input_7[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_97\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_97\" ><legend class='gfield_label gform-field-label' >I have checked with my Dr regarding this trip &amp; time away<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_97'>\n\t\t\t<div class='gchoice gchoice_1_97_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_97' type='radio' value='Yes'  id='choice_1_97_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_97_0' id='label_1_97_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_97_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_97' type='radio' value='No'  id='choice_1_97_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_97_1' id='label_1_97_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_98\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_98\" ><label class='gfield_label gform-field-label' for='input_1_98'>Additional Medical History<\/label><div class='gfield_description' id='gfield_description_1_98'>Any other significant medical history we should know, including operations in the last two years?<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_98' id='input_1_98' class='textarea large'  aria-describedby=\"gfield_description_1_98\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_101' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_101' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"6\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"6\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_6' class='gform_page' data-js='page-field-id-101' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_6' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_102\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_102\" ><h3 class=\"gsection_title\">Medication &amp; Pharmacy Information<\/h3><\/div><div id=\"field_1_99\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_99\" ><label class='gfield_label gform-field-label' for='input_1_99'>Your Pharmacy&#039;s Name<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_1_99' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_100\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_100\" ><label class='gfield_label gform-field-label' for='input_1_100'>Your Pharmacy&#039;s Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_100' id='input_1_100' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_109\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_109\" ><hr><\/div><fieldset id=\"field_1_96\" class=\"gfield gfield--type-list gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_96\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Medications<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Medication Name<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">How Often<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Dose &amp; Time of Day<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">RX #<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_96_cell1 gform-grid-col' data-label='Medication Name'><input aria-invalid='false'   aria-label='Medication Name, Row 1' data-aria-label-template='Medication Name, Row {0}' type='text' name='input_96[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_96_cell2 gform-grid-col' data-label='How Often'><input aria-invalid='false'   aria-label='How Often, Row 1' data-aria-label-template='How Often, Row {0}' type='text' name='input_96[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_96_cell3 gform-grid-col' data-label='Dose &amp; Time of Day'><input aria-invalid='false'   aria-label='Dose &amp; Time of Day, Row 1' data-aria-label-template='Dose &amp; Time of Day, Row {0}' type='text' name='input_96[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_96_cell4 gform-grid-col' data-label='RX #'><input aria-invalid='false'   aria-label='RX #, Row 1' data-aria-label-template='RX #, Row {0}' type='text' name='input_96[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_105' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_105' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"7\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"7\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_7' class='gform_page' data-js='page-field-id-105' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_7' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_106\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_106\" ><h3 class=\"gsection_title\">Review &amp; Submit Application<\/h3><\/div><div id=\"field_1_107\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_107\" >As photographic and video equipment are frequently used to memorialize and document Richland County Honor Trip and events, my image may appear in a public forum, such as the media or website, to acknowledge, promote or advance the work of the Richland County Honor Trip program. I hereby release the photographer and Richland Country Honor Trip from all claims and liability relating to said photographs. I hereby give permission for my images captured during Richland Country Honor Trip activities through video, photo, or other media, to med used solely for the purpose of Richland County Honor Trip promotional materials and publications, and wave any rights or compensation or ownership thereto. \n<\/div><div id=\"field_1_108\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_108\" >I understand and acknowledge that medical insurance is the responsibility of me, the veteran, and that Richland County Honor Trip does not provide medical care. I accept all risks associated with travel and other Richland County Honor Trip activities and will not hold Richland County Honor Trip responsible for any injuries incurred by me while participating in the Richland County Honor Trip. \n<\/div><div id=\"field_1_110\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_110\" >I acknowledge that I have reviewed this application and that the information provided is true and accurate, Further, the undersigned does release and hold harmless Richland County Honor Trip, organization sponsors, committee members, agents successors and assigns from any and all actions, claims or damages for any personal injuries or property damages which may occur in the course of or during this trip or any of its activities. <\/div><div id=\"field_1_111\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_111\" >I also attest that I have never been convicted of a felony nor under investigation for a felony offense. <\/div><div id=\"field_1_113\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_113\" ><label class='gfield_label gform-field-label' for='input_1_113'>Your Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_113' id='input_1_113' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_114\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_114\" ><label class='gfield_label gform-field-label' for='input_1_114'>Todays Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_114' id='input_1_114' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_114_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_114_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_114' class='gform_hidden' value='https:\/\/honorbus.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_115\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_115\" >This application will be sent to: <\/br>\n<\/br>\n<b>AMVETS Post #26<\/b><\/br>\n1100 Fourth St.<\/br>\nMansfield, OH 44906<\/br>\n<i>ATTN: Richland County Veterans Honor Bus<\/i><\/br>\n419-565-3769<\/div><\/div><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_1' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Submit Application'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='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' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='2' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/div><\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 1, 'https:\/\/honorbus.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_1').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_1');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_1').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_1').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_1').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_1').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_1').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_1').val();gformInitSpinner( 1, 'https:\/\/honorbus.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [1, current_page]);window['gf_submitting_1'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_1').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_1').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [1]);window['gf_submitting_1'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_1').text());}, 50);}else{jQuery('#gform_1').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"1\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);                if (event.defaultPrevented) {                return;         }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_1\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_1\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_1\" );        let postRenderFired = false;                function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            jQuery( document ).trigger( 'gform_post_render', [1, current_page] );            gform.utils.trigger( { event: 'gform\/postRender', native: false, data: { formId: 1, currentPage: current_page } } );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n\n","protected":false},"author":1,"featured_media":0,"parent":11,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":""},"_links":{"self":[{"href":"https:\/\/honorbus.com\/wp-json\/wp\/v2\/pages\/313"}],"collection":[{"href":"https:\/\/honorbus.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/honorbus.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/honorbus.com\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/honorbus.com\/wp-json\/wp\/v2\/comments?post=313"}],"version-history":[{"count":6,"href":"https:\/\/honorbus.com\/wp-json\/wp\/v2\/pages\/313\/revisions"}],"predecessor-version":[{"id":448,"href":"https:\/\/honorbus.com\/wp-json\/wp\/v2\/pages\/313\/revisions\/448"}],"up":[{"embeddable":true,"href":"https:\/\/honorbus.com\/wp-json\/wp\/v2\/pages\/11"}],"wp:attachment":[{"href":"https:\/\/honorbus.com\/wp-json\/wp\/v2\/media?parent=313"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}