{"id":246,"date":"2020-12-17T13:33:42","date_gmt":"2020-12-17T13:33:42","guid":{"rendered":"http:\/\/startsmartmodoc.t29dev.com\/?page_id=246"},"modified":"2023-04-20T16:51:54","modified_gmt":"2023-04-20T23:51:54","slug":"get-started","status":"publish","type":"page","link":"https:\/\/smartstartmodoc.org\/espanol\/get-started\/","title":{"rendered":"Empezar"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"246\" class=\"elementor elementor-246\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-6af4e14 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"6af4e14\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-1d444a4\" data-id=\"1d444a4\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-6315d42 elementor-widget elementor-widget-breadcrumbs\" data-id=\"6315d42\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"breadcrumbs.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<p id=\"breadcrumbs\"><span><span><a href=\"https:\/\/smartstartmodoc.org\/\">Home<\/a><\/span><\/span><\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6c75848 eael-gravity-form-button-custom elementor-widget elementor-widget-eael-gravity-form\" data-id=\"6c75848\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"eael-gravity-form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t<div class=\"eael-contact-form eael-gravity-form eael-contact-form-align-default\">\n\t\t        <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_2' style='display:none'><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/espanol\/wp-json\/wp\/v2\/pages\/246#gf_2' data-formid='2' novalidate><input id=\"gpnf_session_hash_2\" type=\"hidden\" name=\"gpnf_session_hash\" value=\"87133b88c179\">\n                        <div class='gform-body gform_body'><div id='gform_page_2_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_2_2\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h1>Tell us about yourself<\/h1><\/li><li id=\"field_2_34\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >A service provider assisted me to enter this information with my permission.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_34'>\n\t\t\t<li class='gchoice gchoice_2_34_0'>\n\t\t\t\t<input name='input_34' type='radio' value='Yes'  id='choice_2_34_0'    \/>\n\t\t\t\t<label for='choice_2_34_0' id='label_2_34_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_34_1'>\n\t\t\t\t<input name='input_34' type='radio' value='No'  id='choice_2_34_1'    \/>\n\t\t\t\t<label for='choice_2_34_1' id='label_2_34_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_45\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_45'>Service Provider Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_2_45' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_46\" class=\"gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_46'>Service Provider Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_46' id='input_2_46' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_47\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_47'>Service Provider Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_47' id='input_2_47' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_42\" class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_42'>Are you receiving out of county services?<\/label><div class='ginput_container ginput_container_select'><select name='input_42' id='input_2_42' class='large gfield_select'     aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/div><\/li><li id=\"field_2_43\" class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_43'>Counties<\/label><div class='ginput_container ginput_container_select'><select name='input_43' id='input_2_43' class='large gfield_select'     aria-invalid=\"false\" ><option value='Shasta' >Shasta<\/option><option value='Lassen County' >Lassen County<\/option><option value='Other (California)' >Other (California)<\/option><option value='Lake County, OR' >Lake County, OR<\/option><option value='Klamath County, OR' >Klamath County, OR<\/option><option value='Douglas County, OR' >Douglas County, OR<\/option><option value='Washoe County, OR' >Washoe County, OR<\/option><\/select><\/div><\/li><li id=\"field_2_41\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_41'>I am a resident of Modoc County<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_41' id='input_2_41' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Yes' selected='selected'>Yes<\/option><\/select><\/div><\/li><li id=\"field_2_44\" class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_44'>Counties<\/label><div class='ginput_container ginput_container_select'><select name='input_44' id='input_2_44' class='large gfield_select'     aria-invalid=\"false\" ><option value='Shasta' >Shasta<\/option><option value='Lassen County' >Lassen County<\/option><option value='Other (California)' >Other (California)<\/option><option value='Lake County, OR' >Lake County, OR<\/option><option value='Klamath County, OR' >Klamath County, OR<\/option><option value='Douglas County, OR' >Douglas County, OR<\/option><option value='Washoe County, OR' >Washoe County, OR<\/option><\/select><\/div><\/li><li id=\"field_2_1\" class=\"gfield gfield--type-name field_sublabel_above gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><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_2_1'>\n                            \n                            <span id='input_2_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_2_1_3' class='gform-field-label gform-field-label--type-sub '>First Name<\/label>\n                                                    <input type='text' name='input_1.3' id='input_2_1_3' value=''   aria-required='false'   placeholder='First Name'  \/>\n                                                <\/span>\n                            \n                            <span id='input_2_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_2_1_6' class='gform-field-label gform-field-label--type-sub '>Last Name<\/label>\n                                                            <input type='text' name='input_1.6' id='input_2_1_6' value=''   aria-required='false'   placeholder='Last Name'  \/>\n                                                        <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_3\" class=\"gfield gfield--type-date gfield--input-type-datedropdown field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Date of Birth<\/label><div id='input_2_3' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_2_3_1_container'><label for='input_2_3_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_3[]' id='input_2_3_1'   aria-required='false'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_2_3_2_container'><label for='input_2_3_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_3[]' id='input_2_3_2'   aria-required='false'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_2_3_3_container'><label for='input_2_3_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_3[]' id='input_2_3_3'   aria-required='false'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_2_4\" class=\"gfield gfield--type-phone gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_4'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_2_4' type='tel' value='' class='medium'  placeholder='Phone'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_5\" class=\"gfield gfield--type-email gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_5'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_2_5' type='email' value='' class='medium'   placeholder='Email'  aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_32\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_32'>ZIP Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_32' id='input_2_32' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='96101' >96101<\/option><option value='96104' >96104<\/option><option value='96108' >96108<\/option><option value='96110' >96110<\/option><option value='96112' >96112<\/option><option value='96115' >96115<\/option><option value='96116' >96116<\/option><option value='96134' >96134 \u2013 Tulelake\/Newell area<\/option><option value='96006' >96006 \u2013 Adin area<\/option><option value='96054' >96054 \u2013 Lookout area<\/option><option value='96056' >96056 \u2013 Day area<\/option><option value='97635' >97635 - New Pine Creek Area<\/option><option value='96123' >96123 - Ravendale\/Termo<\/option><option value='96119' >96119 - Madeline<\/option><\/select><\/div><\/li><li id=\"field_2_15\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_15'>Race \/ Ethnicity<\/label><div class='ginput_container ginput_container_select'><select name='input_15' id='input_2_15' class='medium gfield_select'     aria-invalid=\"false\" ><option value='American Indian\/Alaskan Native' >American Indian\/Alaskan Native<\/option><option value='Asian' >Asian<\/option><option value='Black\/African American' >Black\/African American<\/option><option value='Native Hawaiian\/Other Pacific Islander' >Native Hawaiian\/Other Pacific Islander<\/option><option value='White' >White<\/option><option value='Hispanic\/Latino' >Hispanic\/Latino<\/option><option value='Multiple Races' >Multiple Races<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_2_16\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_16'>Language Preference<\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_2_16' class='medium gfield_select'     aria-invalid=\"false\" ><option value='english' >English<\/option><option value='spanish' >Spanish<\/option><option value='other' >Other<\/option><\/select><\/div><\/li><li id=\"field_2_17\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_17'>Gender<\/label><div class='ginput_container ginput_container_select'><select name='input_17' id='input_2_17' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Female' >Female<\/option><option value='Male' >Male<\/option><option value='Other or Not Disclosed' >Other or Not Disclosed<\/option><\/select><\/div><\/li><li id=\"field_2_18\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Disability Status<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_18'><li class='gchoice gchoice_2_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='disabled'  id='choice_2_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_18_1' id='label_2_18_1' class='gform-field-label gform-field-label--type-inline'>I am disabled<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_19\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_19'>Number of People Living in Household<\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_2_19' class='medium gfield_select'     aria-invalid=\"false\" ><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9+' >9+<\/option><\/select><\/div><\/li><li id=\"field_2_20\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Are you or your partner pregnant?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_20'><li class='gchoice gchoice_2_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='pregnant'  id='choice_2_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_20_1' id='label_2_20_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_21\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_21'>Due Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_21' id='input_2_21' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_21_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_21_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_21' class='gform_hidden' value='https:\/\/smartstartmodoc.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_22\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Are You Experiencing a High Risk Pregnancy?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_22'><li class='gchoice gchoice_2_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='high_risk_pregnancy'  id='choice_2_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_1' id='label_2_22_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_23\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Do you need to travel outside Modoc County for medical appts related to pregnancy?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_23'><li class='gchoice gchoice_2_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='travel_outside_county_for_pregnancy_appts'  id='choice_2_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_1' id='label_2_23_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_24\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_24'>Employment Status<\/label><div class='ginput_container ginput_container_select'><select name='input_24' id='input_2_24' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Unemployed Seeking Employment' >Unemployed Seeking Employment<\/option><option value='Unemployed Not Seeking Employment' >Unemployed Not Seeking Employment<\/option><option value='Student' >Student<\/option><option value='Employed Full-Time' >Employed Full-Time<\/option><option value='Employed Part-Time' >Employed Part-Time<\/option><option value='Self-Employed' >Self-Employed<\/option><\/select><\/div><\/li><li id=\"field_2_25\" class=\"gfield gfield--type-select field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_25'>Monthly Household Income Before Taxes<\/label><div class='ginput_container ginput_container_select'><select name='input_25' id='input_2_25' class='medium gfield_select'  aria-describedby=\"gfield_description_2_25\"   aria-invalid=\"false\" ><option value='$0 - $1,810' >$0 - $1,810<\/option><option value='$1,811 - $2,557' >$1,811 - $2,557<\/option><option value='$2,558 - $2,930' >$2,558 - $2,930<\/option><option value='$2,931 - $3,677' >$2,931 - $3,677<\/option><option value='$3,678 - $4,040' >$3,678 - $4,040<\/option><option value='$4,041 - $4,731' >$4,041 - $4,731<\/option><option value='$4,732 - $5,421' >$4,732 - $5,421<\/option><option value='$5,421+' >$5,421+<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_2_25'>*Best Guess<\/div><\/li><li id=\"field_2_26\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_26'>Housing Status<\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_2_26' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Own home' >Own home<\/option><option value='Renting a house \/ apartment \/ room' >Renting a house \/ apartment \/ room<\/option><option value='Living with friend \/ family temporarily' >Living with friend \/ family temporarily<\/option><option value='Living in a hotel \/ motel' >Living in a hotel \/ motel<\/option><option value='Living in car \/ park \/ campground \/ public space' >Living in car \/ park \/ campground \/ public space<\/option><\/select><\/div><\/li><li id=\"field_2_27\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Check all that apply<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_27'><li class='gchoice gchoice_2_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='enrolled_in_medical'  id='choice_2_27_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_1' id='label_2_27_1' class='gform-field-label gform-field-label--type-inline'>Are You Enrolled in Medical (Partnership Health Plan)?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='receive_tanf_or_calworks'  id='choice_2_27_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_2' id='label_2_27_2' class='gform-field-label gform-field-label--type-inline'>Do you Receive TANF or CalWorks?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_27_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.3' type='checkbox'  value='receive_calfresh_or_foodstamps'  id='choice_2_27_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_3' id='label_2_27_3' class='gform-field-label gform-field-label--type-inline'>Do you Receive Calfresh\/Food Stamps?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_27_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.4' type='checkbox'  value='quitting_tobacco_nicotine_info'  id='choice_2_27_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_4' id='label_2_27_4' class='gform-field-label gform-field-label--type-inline'>Do you want information about quitting tobacco\/nicotine?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_27_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.5' type='checkbox'  value='concered_second_hand_smoke'  id='choice_2_27_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_5' id='label_2_27_5' class='gform-field-label gform-field-label--type-inline'>Are you concerned about health effects of second hand smoke, third hand smoke or vaping?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_27_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.6' type='checkbox'  value='receive_wic'  id='choice_2_27_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_6' id='label_2_27_6' class='gform-field-label gform-field-label--type-inline'>Do you receive WIC?<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_31\" class=\"gfield gfield--type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_31' id='input_2_31' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='edf41022b6d7dae1a3d00488' \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_2_8' 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_2_2' class='gform_page' data-js='page-field-id-8' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_2_9\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h1>Dependents <span style=\"color: red; font-size: 30px;\">- Including Babies in Utero<\/span><\/h1><\/li><li id=\"field_2_10\" class=\"gfield gfield--type-form gform-theme__no-reset--children field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_10'>Dependents<\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-1\">\n\t\t\t\t\tName\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f1.label, attr: { 'data-value': f1.label }\"\n\t\t\t\t\tdata-heading=\"Name\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Dependent {0} where Name is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Edit<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Dependent {0} where Name is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Delete<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"2\">\n\t\t\t\tThere are no <span>Entries.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"2\"\n\t\t        data-nestedformid=\"3\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAdd Dependent\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tMaximum number of entries reached.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_10\"\n                id=\"input_2_10\"\n                data-bind=\"value: entryIds\"\n          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