{"id":1979,"date":"2025-08-31T16:01:24","date_gmt":"2025-08-31T16:01:24","guid":{"rendered":"https:\/\/agelesspatientportal.com\/?page_id=1979"},"modified":"2025-12-11T17:11:10","modified_gmt":"2025-12-11T17:11:10","slug":"employment-application","status":"publish","type":"page","link":"https:\/\/agelesspatientportal.com\/?page_id=1979","title":{"rendered":"Employment Application"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1979\" class=\"elementor elementor-1979\">\n\t\t\t\t<div class=\"elementor-element elementor-element-833d3ee e-flex e-con-boxed e-con e-parent\" data-id=\"833d3ee\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-f773f0a e-con-full e-flex e-con e-child\" data-id=\"f773f0a\" data-element_type=\"container\" data-e-type=\"container\" 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    <h2 class=\"gform_title\">Employment Application<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_10'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F1979#gf_10' data-formid='10' novalidate>\n        <div id='gf_progressbar_wrapper_10' 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'>4<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_10_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_10' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_10_24\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h4>Onboarding Memorandum<\/h4>\n<strrong>Nursing License for maryland:\nDocuments required with this application (All) Check if attached<\/strong><\/div><fieldset id=\"field_10_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_23'><div class='gchoice gchoice_10_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Thoroughly completed employment application'  id='choice_10_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_23_1' id='label_10_23_1' class='gform-field-label gform-field-label--type-inline'>Thoroughly completed employment application<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='Current Professional License (Signed), if any'  id='choice_10_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_23_2' id='label_10_23_2' class='gform-field-label gform-field-label--type-inline'>Current Professional License (Signed), if any<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_23_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.3' type='checkbox'  value='Current CPR card\/First Aid (Signed)'  id='choice_10_23_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_23_3' id='label_10_23_3' class='gform-field-label gform-field-label--type-inline'>Current CPR card\/First Aid (Signed)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_23_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.4' type='checkbox'  value='PPD\/Chest X-Ray \/Medical'  id='choice_10_23_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_23_4' id='label_10_23_4' class='gform-field-label gform-field-label--type-inline'>PPD\/Chest X-Ray \/Medical<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_25\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_25'><div class='gchoice gchoice_10_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='Employment Eligibility Verification (Form I-9)'  id='choice_10_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_25_1' id='label_10_25_1' class='gform-field-label gform-field-label--type-inline'>Employment Eligibility Verification (Form I-9)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='Driver\u2019s License\/ State Issue ID card (Signed)'  id='choice_10_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_25_2' id='label_10_25_2' class='gform-field-label gform-field-label--type-inline'>Driver\u2019s License\/ State Issue ID card (Signed)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_25_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.3' type='checkbox'  value='Two employment reference forms or letter (phone # included)'  id='choice_10_25_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_25_3' id='label_10_25_3' class='gform-field-label gform-field-label--type-inline'>Two employment reference forms or letter (phone # included)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_25_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.4' type='checkbox'  value='One personal reference form or letter (phone # included)'  id='choice_10_25_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_25_4' id='label_10_25_4' class='gform-field-label gform-field-label--type-inline'>One personal reference form or letter (phone # included)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_26\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_26'><div class='gchoice gchoice_10_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='Copy of Social Security Card (Bring original signed copy to interview)'  id='choice_10_26_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_26_1' id='label_10_26_1' class='gform-field-label gform-field-label--type-inline'>Copy of Social Security Card (Bring original signed copy to interview)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='One year of experience working in the field'  id='choice_10_26_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_26_2' id='label_10_26_2' class='gform-field-label gform-field-label--type-inline'>One year of experience working in the field<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_26_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.3' type='checkbox'  value='Background Check (a must)'  id='choice_10_26_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_26_3' id='label_10_26_3' class='gform-field-label gform-field-label--type-inline'>Background Check (a must)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_26_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.4' type='checkbox'  value='Any other information you have for employment'  id='choice_10_26_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_26_4' id='label_10_26_4' class='gform-field-label gform-field-label--type-inline'>Any other information you have for employment<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_27'>If you do not have all the documents above, please tell us when it will be available:<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_10_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_8\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Your Personal Information<\/h3><\/div><div id=\"field_10_177\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_177'>Date of Application<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_177' id='input_10_177' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_177_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_177_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_177' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_10_35\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><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 has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_10_35'>\n                            \n                            <span id='input_10_35_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_10_35_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_35.3' id='input_10_35_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            <span id='input_10_35_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_10_35_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                    <input type='text' name='input_35.4' id='input_10_35_4' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            <span id='input_10_35_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_10_35_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_35.6' id='input_10_35_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_10_21\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><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 ginput_container_address gform-grid-row' id='input_10_21' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_10_21_1_container' >\n                                        <label for='input_10_21_1' id='input_10_21_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_21.1' id='input_10_21_1' value=''    aria-required='false'   autocomplete=\"address-line1\" \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_10_21_2_container' >\n                                        <label for='input_10_21_2' id='input_10_21_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_21.2' id='input_10_21_2' value=''    autocomplete=\"address-line2\" aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_10_21_3_container' >\n                                    <label for='input_10_21_3' id='input_10_21_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_21.3' id='input_10_21_3' value=''    aria-required='false'   autocomplete=\"address-level2\" \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_10_21_4_container' >\n                                        <label for='input_10_21_4' id='input_10_21_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                        <select name='input_21.4' id='input_10_21_4'     aria-required='false'   autocomplete=\"address-level1\" ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' selected='selected'>Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_10_21_5_container' >\n                                    <label for='input_10_21_5' id='input_10_21_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                    <input type='text' name='input_21.5' id='input_10_21_5' value=''    aria-required='false'   autocomplete=\"postal-code\" \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_21.6' id='input_10_21_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_10_2\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_2'>Email Address<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_10_2' type='email' value='' class='medium'     aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                        <\/div><\/div><div id=\"field_10_10\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_10'>Your Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_10_10' type='tel' value='' class='medium'    aria-invalid=\"false\"  autocomplete=\"tel\" \/><\/div><\/div><div id=\"field_10_178\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_178'>SSN<\/label><div class='ginput_container ginput_container_text'><input name='input_178' id='input_10_178' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_179\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_179'>Date of birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_179' id='input_10_179' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_179_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_179_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_179' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_10_180\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-five-twelfths field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you a citizen of the United States<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_180'>\n\t\t\t<div class='gchoice gchoice_10_180_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_180' type='radio' value='No'  id='choice_10_180_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_180_0' id='label_10_180_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_180_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_180' type='radio' value='Yes'  id='choice_10_180_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_180_1' id='label_10_180_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_181\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-seven-twelfths field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you eligible to work in the United States<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_181'>\n\t\t\t<div class='gchoice gchoice_10_181_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_181' type='radio' value='Yes'  id='choice_10_181_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_181_0' id='label_10_181_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_10_181_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_181' type='radio' value='No'  id='choice_10_181_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_181_1' id='label_10_181_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_182\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-five-twelfths field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If you are under age 18, do you have an employment\/age certificate?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_182'>\n\t\t\t<div class='gchoice gchoice_10_182_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_182' type='radio' value='No'  id='choice_10_182_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_182_0' id='label_10_182_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_182_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_182' type='radio' value='Yes'  id='choice_10_182_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_182_1' id='label_10_182_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_183\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-seven-twelfths field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever been convicted of a misdemeanor or felony?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_183'>\n\t\t\t<div class='gchoice gchoice_10_183_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_183' type='radio' value='No'  id='choice_10_183_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_183_0' id='label_10_183_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_183_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_183' type='radio' value='Yes'  id='choice_10_183_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_183_1' id='label_10_183_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_184\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_184'>If yes, please explain the circumstances of the conviction:<\/label><div class='ginput_container ginput_container_text'><input name='input_184' id='input_10_184' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_10_18' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_10_2' class='gform_page' data-js='page-field-id-18' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_10_2' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_10_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Position You&#039;re Applying For<\/h3><\/div><fieldset id=\"field_10_3\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gf_list_2col field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Position You&#039;re Applying For<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_3'>\n\t\t\t<div class='gchoice gchoice_10_3_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Registered Nurse'  id='choice_10_3_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_3_0' id='label_10_3_0' class='gform-field-label gform-field-label--type-inline'>Registered Nurse<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_3_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Licensed Practical Nursing (LPN)'  id='choice_10_3_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_3_1' id='label_10_3_1' class='gform-field-label gform-field-label--type-inline'>Licensed Practical Nursing (LPN)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_3_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Certified Medical Technician'  id='choice_10_3_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_3_2' id='label_10_3_2' class='gform-field-label gform-field-label--type-inline'>Certified Medical Technician<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_3_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Certified Nursing Assistant (CNA)'  id='choice_10_3_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_3_3' id='label_10_3_3' class='gform-field-label gform-field-label--type-inline'>Certified Nursing Assistant (CNA)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_3_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Geriartic Nursing Assistant (GNA)'  id='choice_10_3_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_3_4' id='label_10_3_4' class='gform-field-label gform-field-label--type-inline'>Geriartic Nursing Assistant (GNA)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_3_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='UA\/CCA'  id='choice_10_3_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_3_5' id='label_10_3_5' class='gform-field-label gform-field-label--type-inline'>UA\/CCA<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_6\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Previous Employment<\/h3><\/div><div id=\"field_10_94\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_94'>Employer 1<\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_10_94' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_97\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_97'>Start Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_97' id='input_10_97' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_97_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_97_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_97' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_96\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_96'>End Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_96' id='input_10_96' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_96_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_96_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_96' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_99\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_99'>Positioned held<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_10_99' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_119\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_119'>Employer Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_119' id='input_10_119' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_104\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_104'>Reason for leaving<\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_10_104' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_107\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_107'>May We Contact This Employer?<\/label><div class='ginput_container ginput_container_select'><select name='input_107' id='input_10_107' class='large gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_10_195\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_195'>Employer Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_195' id='input_10_195' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_10_196\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr\/><\/div><div id=\"field_10_100\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_100'>Employer 2<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_10_100' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_101\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_101'>Start Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_101' id='input_10_101' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_101_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_101_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_101' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_102\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_102'>End Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_102' id='input_10_102' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_102_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_102_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_102' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_103\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_103'>Positioned held<\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_10_103' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_120\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_120'>Employer Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_120' id='input_10_120' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_110\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_110'>Reason for leaving<\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_10_110' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_111\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_111'>May We Contact This Employer?<\/label><div class='ginput_container ginput_container_select'><select name='input_111' id='input_10_111' class='large gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_10_197\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_197'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_197' id='input_10_197' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_10_198\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr\/><\/div><div id=\"field_10_113\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_113'>Employer 3<\/label><div class='ginput_container ginput_container_text'><input name='input_113' id='input_10_113' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_115\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_115'>Start Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_115' id='input_10_115' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_115_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_115_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_115' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_116\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_116'>End Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_116' id='input_10_116' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_116_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_116_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_116' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_123\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_123'>Position held<\/label><div class='ginput_container ginput_container_text'><input name='input_123' id='input_10_123' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_124\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_124'>Employer Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_124' id='input_10_124' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_125\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_125'>May we contact ths employer<\/label><div class='ginput_container ginput_container_select'><select name='input_125' id='input_10_125' class='large gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_10_126\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_126'>Reason for leaving<\/label><div class='ginput_container ginput_container_text'><input name='input_126' id='input_10_126' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_199\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_199'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_199' id='input_10_199' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_10_128\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_128'>Please indicate all relevant experience, skills and work history that relate to the job description of which you have applied.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_128' id='input_10_128' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_60\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr\/>\n<br\/>\n<h4>Available  Days\/Times (in HH:MM format)\n<\/h4><\/div><fieldset id=\"field_10_38\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Day<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_38'><div class='gchoice gchoice_10_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='Sunday'  id='choice_10_38_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_38_1' id='label_10_38_1' class='gform-field-label gform-field-label--type-inline'>Sunday<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_37\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_37'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_37' id='input_10_37' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_37_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_37_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_37' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_10_40\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Day<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_40'><div class='gchoice gchoice_10_40_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.1' type='checkbox'  value='Monday'  id='choice_10_40_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_40_1' id='label_10_40_1' class='gform-field-label gform-field-label--type-inline'>Monday<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_41\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_41'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_41' id='input_10_41' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_41_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_41_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_41' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_10_43\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Day<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_43'><div class='gchoice gchoice_10_43_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.1' type='checkbox'  value='Tuesday'  id='choice_10_43_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_43_1' id='label_10_43_1' class='gform-field-label gform-field-label--type-inline'>Tuesday<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_44\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_44'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_44' id='input_10_44' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_44_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_44_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_44' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_10_46\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Day<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_46'><div class='gchoice gchoice_10_46_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.1' type='checkbox'  value='Wednesday'  id='choice_10_46_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_46_1' id='label_10_46_1' class='gform-field-label gform-field-label--type-inline'>Wednesday<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_47\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_47'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_47' id='input_10_47' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_47_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_47_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_47' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_10_49\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Day<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_49'><div class='gchoice gchoice_10_49_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.1' type='checkbox'  value='Thursday'  id='choice_10_49_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_49_1' id='label_10_49_1' class='gform-field-label gform-field-label--type-inline'>Thursday<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_50\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_50'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_50' id='input_10_50' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_50_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_50_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_50' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_10_52\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Day<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_52'><div class='gchoice gchoice_10_52_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.1' type='checkbox'  value='Friday'  id='choice_10_52_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_52_1' id='label_10_52_1' class='gform-field-label gform-field-label--type-inline'>Friday<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_53\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_53'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_53' id='input_10_53' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_53_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_53_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_53' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_10_59\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Day<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_59'><div class='gchoice gchoice_10_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='Saturday'  id='choice_10_59_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_59_1' id='label_10_59_1' class='gform-field-label gform-field-label--type-inline'>Saturday<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_56\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_56'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_56' id='input_10_56' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_56_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_56_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_56' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_10_20' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_10_20' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_10_3' class='gform_page' data-js='page-field-id-20' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_10_3' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_10_61\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >\n<h4>Education And Training<\/h4><\/div><div id=\"field_10_62\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_62'>High School Name:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_62' id='input_10_62' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_63\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_63'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_63' id='input_10_63' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_63_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_63_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_63' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_10_64\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Diploma received<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_64'>\n\t\t\t<div class='gchoice gchoice_10_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Yes'  id='choice_10_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_64_0' id='label_10_64_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_10_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='No'  id='choice_10_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_64_1' id='label_10_64_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_65\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_65'>College\/Training School<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_65' id='input_10_65' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_66\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_66'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_66' id='input_10_66' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_66_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_66_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_66' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_10_67\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Diploma received<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_67'>\n\t\t\t<div class='gchoice gchoice_10_67_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Yes'  id='choice_10_67_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_67_0' id='label_10_67_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_10_67_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='No'  id='choice_10_67_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_67_1' id='label_10_67_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_68\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_68'>Professional Training\/Qualifications with dates and levels obtained:<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_10_68' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_69\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_69'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_69' id='input_10_69' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_69_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_69_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_69' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_70\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_70'>Cerification\/License Obtained<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_10_70' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_71\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><strong>Skills<\/strong>\n<\/div><fieldset id=\"field_10_150\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Can you do vital signs?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_150'>\n\t\t\t<div class='gchoice gchoice_10_150_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_150' type='radio' value='Yes'  id='choice_10_150_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_150_0' id='label_10_150_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_10_150_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_150' type='radio' value='No'  id='choice_10_150_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_150_1' id='label_10_150_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_151\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Can you do a neurological assessment?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_151'>\n\t\t\t<div class='gchoice gchoice_10_151_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_151' type='radio' value='Yes'  id='choice_10_151_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_151_0' id='label_10_151_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_10_151_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_151' type='radio' value='No'  id='choice_10_151_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_151_1' id='label_10_151_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_153\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Can you chart nurses\u2019 notes? ?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_153'>\n\t\t\t<div class='gchoice gchoice_10_153_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_153' type='radio' value='Yes'  id='choice_10_153_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_153_0' id='label_10_153_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_10_153_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_153' type='radio' value='No'  id='choice_10_153_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_153_1' id='label_10_153_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_154\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Can you give intramuscular medications?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_154'>\n\t\t\t<div class='gchoice gchoice_10_154_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Yes'  id='choice_10_154_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_154_0' id='label_10_154_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_10_154_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='No'  id='choice_10_154_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_154_1' id='label_10_154_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_155\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Can you do catheter care?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_155'>\n\t\t\t<div class='gchoice gchoice_10_155_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_155' type='radio' value='Yes'  id='choice_10_155_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_155_0' id='label_10_155_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_10_155_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_155' type='radio' value='No'  id='choice_10_155_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_155_1' id='label_10_155_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_156\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Can you give IV medications?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_156'>\n\t\t\t<div class='gchoice gchoice_10_156_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_156' type='radio' value='Yes'  id='choice_10_156_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_156_0' id='label_10_156_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_10_156_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_156' type='radio' value='No'  id='choice_10_156_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_156_1' id='label_10_156_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_157\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Can you start IV\u2019s?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_157'>\n\t\t\t<div class='gchoice gchoice_10_157_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_157' type='radio' value='Yes'  id='choice_10_157_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_157_0' id='label_10_157_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_10_157_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_157' type='radio' value='No'  id='choice_10_157_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_157_1' id='label_10_157_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_158\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Can you access patients for admission? ?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_158'>\n\t\t\t<div class='gchoice gchoice_10_158_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_158' type='radio' value='Yes'  id='choice_10_158_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_158_0' id='label_10_158_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_10_158_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_158' type='radio' value='No'  id='choice_10_158_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_158_1' id='label_10_158_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_159\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Can you discharge patients?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_159'>\n\t\t\t<div class='gchoice gchoice_10_159_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_159' type='radio' value='Yes'  id='choice_10_159_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_159_0' id='label_10_159_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_10_159_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_159' type='radio' value='No'  id='choice_10_159_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_159_1' id='label_10_159_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_160\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Can you set up oxygen for patients?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_160'>\n\t\t\t<div class='gchoice gchoice_10_160_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_160' type='radio' value='Yes'  id='choice_10_160_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_160_0' id='label_10_160_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_10_160_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_160' type='radio' value='No'  id='choice_10_160_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_160_1' id='label_10_160_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_161\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you had CPR?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_161'>\n\t\t\t<div class='gchoice gchoice_10_161_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_161' type='radio' value='Yes'  id='choice_10_161_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_161_0' id='label_10_161_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_10_161_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_161' type='radio' value='No'  id='choice_10_161_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_161_1' id='label_10_161_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_162\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have intensive care experience??<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_162'>\n\t\t\t<div class='gchoice gchoice_10_162_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_162' type='radio' value='Yes'  id='choice_10_162_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_162_0' id='label_10_162_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_10_162_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_162' type='radio' value='No'  id='choice_10_162_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_162_1' id='label_10_162_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_145\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><strong>Preference<\/strong><\/div><fieldset id=\"field_10_163\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you a licensed driver?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_163'>\n\t\t\t<div class='gchoice gchoice_10_163_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_163' type='radio' value='Yes'  id='choice_10_163_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_163_0' id='label_10_163_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_10_163_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_163' type='radio' value='No'  id='choice_10_163_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_163_1' id='label_10_163_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_164\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Will you work shifts at a hospital?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_164'>\n\t\t\t<div class='gchoice gchoice_10_164_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_164' type='radio' value='Yes'  id='choice_10_164_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_164_0' id='label_10_164_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_10_164_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_164' type='radio' value='No'  id='choice_10_164_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_164_1' id='label_10_164_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_165\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Will you travel 30 minutes one way?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_165'>\n\t\t\t<div class='gchoice gchoice_10_165_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_165' type='radio' value='Yes'  id='choice_10_165_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_165_0' id='label_10_165_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_10_165_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_165' type='radio' value='No'  id='choice_10_165_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_165_1' id='label_10_165_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_166\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Will you work shifts at a nursing home?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_166'>\n\t\t\t<div class='gchoice gchoice_10_166_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_166' type='radio' value='Yes'  id='choice_10_166_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_166_0' id='label_10_166_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_10_166_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_166' type='radio' value='No'  id='choice_10_166_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_166_1' id='label_10_166_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_167\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Will you work every other weekend?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_167'>\n\t\t\t<div class='gchoice gchoice_10_167_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='Yes'  id='choice_10_167_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_167_0' id='label_10_167_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_10_167_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='No'  id='choice_10_167_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_167_1' id='label_10_167_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_168\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Will you work private duty cases?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_168'>\n\t\t\t<div class='gchoice gchoice_10_168_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_168' type='radio' value='Yes'  id='choice_10_168_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_168_0' id='label_10_168_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_10_168_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_168' type='radio' value='No'  id='choice_10_168_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_168_1' id='label_10_168_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_169\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-five-twelfths field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >In which areas have you had experience?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_169'><div class='gchoice gchoice_10_169_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_169.1' type='checkbox'  value='Medical Surgery'  id='choice_10_169_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_169_1' id='label_10_169_1' class='gform-field-label gform-field-label--type-inline'>Medical Surgery<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_169_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_169.2' type='checkbox'  value='OB\/GYN'  id='choice_10_169_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_169_2' id='label_10_169_2' class='gform-field-label gform-field-label--type-inline'>OB\/GYN<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_169_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_169.3' type='checkbox'  value='Oncolology'  id='choice_10_169_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_169_3' id='label_10_169_3' class='gform-field-label gform-field-label--type-inline'>Oncolology<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_169_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_169.4' type='checkbox'  value='Geriatric'  id='choice_10_169_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_169_4' id='label_10_169_4' class='gform-field-label gform-field-label--type-inline'>Geriatric<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_169_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_169.5' type='checkbox'  value='Emergency Room'  id='choice_10_169_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_169_5' id='label_10_169_5' class='gform-field-label gform-field-label--type-inline'>Emergency Room<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_129\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr>\n<br>\n<h4>Medical History<\/h4>\n<br\/>\n<strong>Skills<\/strong>\n<\/div><div id=\"field_10_72\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_72'>What absences due to illness have you had from work for the past two years<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_10_72' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_73\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-two-thirds field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_73'>Do you have any illness that will prevent you from performing the duties of the position of which you have applied?<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_10_73' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Can you lift or push a weight of seventy pounds?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_74'>\n\t\t\t<div class='gchoice gchoice_10_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Yes'  id='choice_10_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_74_0' id='label_10_74_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_10_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='No'  id='choice_10_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_74_1' id='label_10_74_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_170\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_170'>Have you had any special training<\/label><div class='gfield_description' id='gfield_description_10_170'>list special training and or certifications<\/div><div class='ginput_container ginput_container_text'><input name='input_170' id='input_10_170' type='text' value='' class='large'  aria-describedby=\"gfield_description_10_170\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_171\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_171'>Do you have any handicaps?. If so explain<\/label><div class='ginput_container ginput_container_text'><input name='input_171' id='input_10_171' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_172\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_172'>How many hours a week do you wish to work?<\/label><div class='ginput_container ginput_container_text'><input name='input_172' id='input_10_172' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_75\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h4>Character References<\/h4>\n<strong>Please list three references of which we may contact<\/strong><\/div><div id=\"field_10_76\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_76'>Name<\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_10_76' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_77\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_77'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_10_77' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_78\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_78'>Years of Affiliation<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_10_78' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_80\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_80'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_80' id='input_10_80' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_187\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_187'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_187' id='input_10_187' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_10_188\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_188'>Comments<\/label><div class='ginput_container ginput_container_text'><input name='input_188' id='input_10_188' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_189\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr\/><\/div><div id=\"field_10_81\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_81'>Name<\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_10_81' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_82\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_82'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_10_82' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_83\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_83'>Years of Affiliation<\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_10_83' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_84\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_84'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_84' id='input_10_84' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_190\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_190'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_190' id='input_10_190' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_10_191\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_191'>Comments<\/label><div class='ginput_container ginput_container_text'><input name='input_191' id='input_10_191' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_192\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr\/><\/div><div id=\"field_10_85\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_85'>Name<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_10_85' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_87\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_87'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_10_87' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_88\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_88'>Years of Affiliation<\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_10_88' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_89\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_89'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_89' id='input_10_89' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_193\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_193'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_193' id='input_10_193' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_10_194\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_194'>Comments<\/label><div class='ginput_container ginput_container_text'><input name='input_194' id='input_10_194' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_90\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h4>Declaration<\/h4>\n<p>By signing below, I, , hereby certify that all information included in the above\napplication is true and valid to the best of my knowledge. I also understand that misrepresentation or\nfalsification of the information provided above will result in my immediate disqualification from the selection\nprocess and dismissal from any position appointed to by the Agency after discovery.\n<\/p><\/div><div id=\"field_10_185\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-two-thirds field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_185'>Signature<\/label><input type='hidden' value='' name='input_185' id='input_10_185_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_10_185_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_10_185' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_10_185_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_10_185_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_10_185_data' name='input_10_185_data' value=''><\/div><\/div><div id=\"field_10_186\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_186'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_186' id='input_10_186' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_186_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_186_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_186' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_11\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">More About You<\/h3><\/div><fieldset id=\"field_10_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you are a US citizen?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_30'>\n\t\t\t<div class='gchoice gchoice_10_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_10_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_30_0' id='label_10_30_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_10_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_10_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_30_1' id='label_10_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you eligible to work in the United States?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_31'>\n\t\t\t<div class='gchoice gchoice_10_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_10_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_31_0' id='label_10_31_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_10_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_10_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_31_1' id='label_10_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If you are under age 18, do you have an employment\/age certificate?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_32'>\n\t\t\t<div class='gchoice gchoice_10_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Yes'  id='choice_10_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_32_0' id='label_10_32_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_10_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='No'  id='choice_10_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_32_1' id='label_10_32_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever been convicted of a misdemeanor or felony?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_33'>\n\t\t\t<div class='gchoice gchoice_10_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Yes'  id='choice_10_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_33_0' id='label_10_33_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_10_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='No'  id='choice_10_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_33_1' id='label_10_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_200\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h4>Employee Emergency Information <\/h4>\n<hr\/><\/div><fieldset id=\"field_10_201\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Emergency Contact 1<\/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_10_201'>\n                            \n                            <span id='input_10_201_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_10_201_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_201.3' id='input_10_201_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_10_201_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_10_201_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_201.6' id='input_10_201_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_10_203\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_203'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_203' id='input_10_203' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_10_204\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_204'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_204' id='input_10_204' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_208\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_208'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_208' id='input_10_208' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_205\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Emergency Contact 2<\/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_10_205'>\n                            \n                            <span id='input_10_205_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_10_205_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_205.3' id='input_10_205_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_10_205_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_10_205_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_205.6' id='input_10_205_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_10_206\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_206'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_206' id='input_10_206' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_10_207\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_207'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_207' id='input_10_207' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_209\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_209'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_209' id='input_10_209' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_210\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Emergency Contact 3<\/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_10_210'>\n                            \n                            <span id='input_10_210_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_10_210_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_210.3' id='input_10_210_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_10_210_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_10_210_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_210.6' id='input_10_210_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_10_211\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_211'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_211' id='input_10_211' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_10_212\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_212'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_212' id='input_10_212' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_213\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_213'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_213' id='input_10_213' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_12\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_12'>Tell Us About Yourself<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_10_12' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_13\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_10_13'>Upload Your Resume<\/label><div class='gfield_description' id='gfield_description_10_13'>Please upload multiple documents including any certifications and your resume in pdf, doc or .docx format. <\/div><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_10_13' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_10_13&quot;,&quot;container&quot;:&quot;gform_multifile_upload_10_13&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_10_13&quot;,&quot;filelist&quot;:&quot;gform_preview_10_13&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/agelesspatientportal.com\\\/?gf_page=e6472e0a7100eee&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/agelesspatientportal.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/agelesspatientportal.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;pdf,doc,docx&quot;}],&quot;max_file_size&quot;:&quot;26214400b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:10,&quot;field_id&quot;:13,&quot;_gform_file_upload_nonce_10_13&quot;:&quot;e8726a04ae&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_10_13&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_10_13' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_10_13' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_10_13 gfield_description_10_13\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_10_13'>Accepted file types: pdf, doc, docx, Max. file size: 25 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_10_13'><\/ul> <div id='gform_preview_10_13' class='ginput_preview_list'><\/div><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_10_176' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_10_176' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_10_4' class='gform_page' data-js='page-field-id-176' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_10_4' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_10_214\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h4>Hepatitis B Immunization Consent\/Refusal<\/h4><\/div><fieldset id=\"field_10_215\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Yes I want to receive the Hepatitis B vaccine<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_215'><div class='gchoice gchoice_10_215_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.1' type='checkbox'  value='Yes I want to receive the Hepatitis B vaccine'  id='choice_10_215_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_215_1' id='label_10_215_1' class='gform-field-label gform-field-label--type-inline'>Yes I want to receive the Hepatitis B vaccine<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_216\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p>I read the information given to me about Hepatitis B virus and Hepatitis B vaccine and I had the opportunity to ask questions. My questions were answered.  \nI want to participate in the vaccination program. I understand this includes three injections \nat prescribed intervals over a 6-month period. I understand  that there is no guarantee that \nI will become immune to Hepatitis B and that I might experience an adverse side effect as \nthe result of the vaccination.<\/p><\/div><div id=\"field_10_217\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><strong>1st Dose<\/strong><\/div><div id=\"field_10_219\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_219'>Date given<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_219' id='input_10_219' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_219_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_219_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_219' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_220\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_220'>Lot # administered By<\/label><div class='ginput_container ginput_container_text'><input name='input_220' id='input_10_220' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_221\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_221'>Next  due date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_221' id='input_10_221' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_221_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_221_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_221' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_222\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><strong>2nd Dose<\/strong><\/div><div id=\"field_10_224\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_224'>Date given<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_224' id='input_10_224' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_224_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_224_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_224' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_225\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_225'>Lot # administered By<\/label><div class='ginput_container ginput_container_text'><input name='input_225' id='input_10_225' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_226\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_226'>Next  due date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_226' id='input_10_226' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_226_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_226_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_226' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_227\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><strong>3nd Dose<\/strong><\/div><div id=\"field_10_228\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_228'>Date given<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_228' id='input_10_228' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_228_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_228_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_228' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_229\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_229'>Lot # administered By<\/label><div class='ginput_container ginput_container_text'><input name='input_229' id='input_10_229' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_230\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_230'>Next  due date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_230' id='input_10_230' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_230_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_230_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_230' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_10_231\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_231'><div class='gchoice gchoice_10_231_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_231.1' type='checkbox'  value='No, I do not want to receive the Hepatitis B vaccine.'  id='choice_10_231_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_231_1' id='label_10_231_1' class='gform-field-label gform-field-label--type-inline'>No, I do not want to receive the Hepatitis B vaccine.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_232\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p>I understand that due to my occupational exposure to blood or other potentially infectious \nmaterial, I may be at risk of acquiring Hepatitis B virus (HBV). I was given the opportunity to \nbe vaccinated with Hepatitis B vaccine at no charge to me. However, I declined Hepatitis B \nvaccination at this time. I understand that by declining this vaccine, I continue to be at an \nincreased risk of acquiring Hepatitis B, a serious disease. If in the future I want to be \nvaccinated with the hepatitis B vaccine, I understand that I can receive the vaccine series at no charge to me.<\/p><\/div><fieldset id=\"field_10_22\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Confidential Agreement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_10_22' tabindex='0'>READ CAREFULLY AND SIGN BELOW IF YOU AGREE TO THESE TERMS OF EMPLOYMENT<br \/>\nI agree that except at the request and for the benefit of Ageless Healthcare LLC I will not disclose to anyone or use for my own purposes any of Ageless Healthcare, LLC confidential or proprietary information, either during or after my employment. I understand and agree that Ageless Healthcare, LLC bidding, costs, pricing and marketing information and techniques, customer names and information, and employee name and information are confidential and proprietary to Home Health Care, LLC. I certify that this application contains no willful misrepresentation or falsifications and that this information given by me is true and complete to the best of my knowledge and belief. I authorized Ageless Healthcare, LLC to contact all sources to verify the information on<br \/>\nthis application. I understand that any falsification, misrepresentation or fraudulent information provided by me in connection with my application for employment is sufficient grounds for withdrawal of an employment offer or immediate discharge.I understand that this application is not a contract of employment.<br \/>\nI authorize and request my former employers, references, and educational institutions which have information about me, to give Ageless Healthcare, LLC any and all information and opinions about me in their possession and which may lawfully be disclosed. I hereby waive written notice of such release of information and opinions, and release such former employers, references, and educational institutions from any liability or claim relating to such release of information and opinions. I also authorized and requested federal, state, and local governmental agencies to release to Ageless Healthcare, LLC any information requested, concerning any criminal convictions on my record. A photocopy of this signed authorization and waiver shall be valid as an original.<\/div><div class='ginput_container ginput_container_consent'><input name='input_22.1' id='input_10_22_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_10_22\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_10_22_1' ><strong>I agree to the terms and conditions.<\/strong><\/label><input type='hidden' name='input_22.2' value='&lt;strong&gt;I agree to the terms and conditions.&lt;\/strong&gt;' class='gform_hidden' \/><input type='hidden' name='input_22.3' value='5' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_10_173\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><strong>Conflict of Interest<\/strong><br\/>\nI acknowledge that I have read the company policy statement concerning conflict of interest and I hereby declare that neither I, nor any other business to which I may be associated, nor, to the best of my knowledge, any member of my immediate family has any conflict between our personal affairs or interests and the proper performance of my responsibilities for the company that would constitute a violation of that company policy. Furthermore, I declare that during my employment, I shall continue to maintain my affairs in accordance with the requirements of said policy.<\/div><div id=\"field_10_174\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-two-thirds gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_174'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><input type='hidden' value='' name='input_174' id='input_10_174_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_10_174_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><canvas id='input_10_174' width='600' height='180' style='border-style: dashed; border-width: 2px; border-color: #707070; background-color:#FFFFFF; cursor: url(https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_10_174_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_10_174_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_10_174_data' name='input_10_174_data' value=''><\/div><\/div><div id=\"field_10_175\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_175'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_175' id='input_10_175' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_175_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_175_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_175' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_234\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr\/>\n<br\/>\n<h5><strong>Caregiver Consent Form<\/strong><\/h5><\/div><fieldset id=\"field_10_236\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><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_10_236'>\n                            \n                            <span id='input_10_236_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_10_236_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_236.3' id='input_10_236_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_10_236_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_10_236_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_236.6' id='input_10_236_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_10_237\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_237'>Date of birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_237' id='input_10_237' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_237_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_237_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_237' class='gform_hidden' value='https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_238\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-five-twelfths field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_238'>Social Security #<\/label><div class='ginput_container ginput_container_text'><input name='input_238' id='input_10_238' type='password' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_239\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_239'>Telephone<\/label><div class='ginput_container ginput_container_text'><input name='input_239' id='input_10_239' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_240\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >I hereby consent to provide care for clients of Ageless Healthcare, LLC. and I hereby acknowledge that \nsuch consent will remain in effect unless and until I cancel such consent writing. I hereby acknowledge \nand confirm that I am mentally capable of giving informed consent to the provision of the care and am \nnot subject to duress or undue influence. \nI HEREBY ACKNOWLEDGE AND UNDERSTAND THAT, BY SIGNING THIS VOLUNTARY CAREGIVER  CONSENT FORM, I AM GIVING INFORMED CONSENT TO PROVIDE Ageless Healthcare, LLC AND CANNOT \nBRING A TORT OR OTHER SIMILAR ACTION AGAINST Ageless Healthcare, LLC UNLESS THE ACTION OR \nOMISSION OF Ageless Healthcare, LLC CONSTITUTES WILLFUL OR WANTON MISCONDUCT.  \nUpon signing this agreement, I agree that I                               \nwill not employ any client from \nAgeless Healthcare, LLC. without the due consent of Ageless Healthcare, LLC. Ageless Healthcare, LLC preserves the right to sue the caregiver for up to $10,000.00 if the caregiver is employed directly or indirectly by the client. \n\n<\/div><div id=\"field_10_241\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-three-quarter gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_241'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><input type='hidden' value='' name='input_241' id='input_10_241_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_10_241_Container' class='gfield_signature_container ginput_container' style='height:180px; width:650px; ' ><canvas id='input_10_241' width='650' height='180' style='border-style: dashed; border-width: 1px; border-color: #7d7d7d; background-color:#FFFFFF; cursor: url(https:\/\/agelesspatientportal.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_10_241_toolbar' style='margin:5px 0;position:relative;height:20px;width:650px;max-width:100%;'><img id = 'input_10_241_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_10_241_data' name='input_10_241_data' value=''><\/div><\/div><div id=\"field_10_242\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_242'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_242' id='input_10_242' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_242_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_242_date_format' class='screen-reader-text'>MM slash 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