Online Inquiry
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<ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Resource Foster Parent Application</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col4" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">This is a:</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_41" value="Single Parent Home">Single Parent Home</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_41" value="Two Parent Home">Two Parent Home</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_41" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_41_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 100%;" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Two+Parent+Home" map_to="FH_MaritalStatus"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Household Marital Status (the status between you and your live-in partner):</label><select name="CST_71" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Single">Single</option><option value="Married">Married</option><option value="Widowed">Widowed</option><option value="Divorced">Divorced</option><option value="Engaged">Engaged</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Name_First_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent A First Name:</label><input name="CST_1" type="text" class="er_fld_required" value=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Name_Last_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent A Last Name:</label><input name="CST_2" type="text" class="er_fld_required" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_DOB_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent A Date of Birth:</label><input name="CST_36" type="text" class="er_fld_required" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Phone_Mobile"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent A Mobile Phone:</label><input name="CST_3" type="text" value="" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_EMail"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent A E-Mail:</label><input name="CST_12" type="text" class="er_fld_required" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Parent A Past/ Current Relationships (Select all that apply):</label> <label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_72" value="Married (To Parent B Applicant)">Married (To Parent B Applicant)</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_72" value="Married (Not living together)">Married (Not living together)</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_72" value="Currently Single">Currently Single</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_72" value="Widowed">Widowed</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_72" value="Divorced">Divorced</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required er_fld_desc" type="checkbox" name="CST_72" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_desc" name="CST_72_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" map_to="FH_Name_First_B" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Two+Parent+Home"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent B First Name:</label><input name="CST_4" type="text" class="er_fld_blank er_fld_required" value=""></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" map_to="FH_Name_Last_B" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Two+Parent+Home"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent B Last Name:</label><input name="CST_5" type="text" class="er_fld_blank er_fld_required" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" map_to="FH_DOB_B" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Two+Parent+Home"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent B Date of Birth:</label><input name="CST_37" type="text" value="" class="er_fld_blank er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Phone_Mobile_B"> <i class="fa fa-font"></i><label class="er_fld_label">Parent B Mobile Phone:</label><input name="CST_6" type="text" value="" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" map_to="FH_EMail_2" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Two+Parent+Home"> <i class="fa fa-font"></i><label class="er_fld_label">Parent B E-Mail:</label><input name="CST_13" type="text" class="er_fld_blank" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_showif er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Two+Parent+Home"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Parent B Past/ Current Relationships (Select all that apply):</label> <label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_73" value="Married (To Parent B Applicant)">Married (To Parent B Applicant)</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_73" value="Married (Not living together)">Married (Not living together)</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_73" value="Currently Single">Currently Single</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_73" value="Widowed">Widowed</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_73" value="Divorced">Divorced</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required er_fld_desc" type="checkbox" name="CST_73" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_desc" name="CST_73_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Household Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Address_Street_1"> <i class="fa fa-font"></i><label class="er_fld_label required">Address:</label><input name="CST_7" type="text" class="er_fld_required" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Address_Street_2"> <i class="fa fa-font"></i><label class="er_fld_label">Suite/ Apt #:</label><input name="CST_8" type="text" class="er_fld_blank" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 20%;" map_to="FH_Address_County"><i class="fa fa-caret-down"></i><label class="er_fld_label required">City/ County:</label><select name="CST_38" class="er_fld_required er_fld_desc"><option value="Not Listed">Not Listed</option><option value="Abingdon">Abingdon</option><option value="Accomack">Accomack</option><option value="Albemarle">Albemarle</option><option value="Alberta">Alberta</option><option value="Alexandria">Alexandria</option><option value="Alleghany">Alleghany</option><option value="Altavista">Altavista</option><option value="Amelia">Amelia</option><option value="Amherst">Amherst</option><option value="Appalachia">Appalachia</option><option value="Appomattox">Appomattox</option><option value="Arlington">Arlington</option><option value="Ashland">Ashland</option><option value="Atkins">Atkins</option><option value="Augusta">Augusta</option><option value="Bassett">Bassett</option><option value="Bath">Bath</option><option value="Bedford">Bedford</option><option value="Belle Haven">Belle Haven</option><option value="Berryville">Berryville</option><option value="Big Stone Gap">Big Stone Gap</option><option value="Blacksburg">Blacksburg</option><option value="Blackstone">Blackstone</option><option value="Bland">Bland</option><option value="Bloxom">Bloxom</option><option value="Blue Ridge">Blue Ridge</option><option value="Bluefield">Bluefield</option><option value="Boones Mill">Boones Mill</option><option value="Botetourt">Botetourt</option><option value="Bowling Green">Bowling Green</option><option value="Boyce">Boyce</option><option value="Boydton">Boydton</option><option value="Boykins">Boykins</option><option value="Bridgewater">Bridgewater</option><option value="Bristol">Bristol</option><option value="Broadway">Broadway</option><option value="Brodnax">Brodnax</option><option value="Brookneal">Brookneal</option><option value="Brunswick">Brunswick</option><option value="Buchanan">Buchanan</option><option value="Buckingham">Buckingham</option><option value="Buena Vista">Buena Vista</option><option value="Burke">Burke</option><option value="Burkeville">Burkeville</option><option value="Campbell">Campbell</option><option value="Cana">Cana</option><option value="Cape Charles">Cape Charles</option><option value="Caroline">Caroline</option><option value="Carroll">Carroll</option><option value="Castlewood">Castlewood</option><option value="Cedar Bluff">Cedar Bluff</option><option value="Centreville">Centreville</option><option value="Chantilly">Chantilly</option><option value="Charles City">Charles City</option><option value="Charlotte">Charlotte</option><option value="Charlotte Court House">Charlotte Court House</option><option value="Charlottesville">Charlottesville</option><option value="Chase City">Chase City</option><option value="Cheriton">Cheriton</option><option value="Chesapeake">Chesapeake</option><option value="Chester">Chester</option><option value="Chesterfield">Chesterfield</option><option value="Chilhowie">Chilhowie</option><option value="Chincoteague Island">Chincoteague Island</option><option value="Christiansburg">Christiansburg</option><option value="Claremont">Claremont</option><option value="Clarke">Clarke</option><option value="Clarksville">Clarksville</option><option value="Clifton Forge">Clifton Forge</option><option value="Clinchco">Clinchco</option><option value="Clintwood">Clintwood</option><option value="Cloverdale">Cloverdale</option><option value="Coeburn">Coeburn</option><option value="Collinsville">Collinsville</option><option value="Colonial Beach">Colonial Beach</option><option value="Colonial Heights">Colonial Heights</option><option value="Courtland">Courtland</option><option value="Covington">Covington</option><option value="Craig">Craig</option><option value="Craigsville">Craigsville</option><option value="Crewe">Crewe</option><option value="Crimora">Crimora</option><option value="Crozet">Crozet</option><option value="Culpeper">Culpeper</option><option value="Cumberland">Cumberland</option><option value="Dahlgren">Dahlgren</option><option value="Daleville">Daleville</option><option value="Damascus">Damascus</option><option value="Danville">Danville</option><option value="Dayton">Dayton</option><option value="Dendron">Dendron</option><option value="Dickenson">Dickenson</option><option value="Dillwyn">Dillwyn</option><option value="Dinwiddie">Dinwiddie</option><option value="Drakes Branch">Drakes Branch</option><option value="Dryden">Dryden</option><option value="Dublin">Dublin</option><option value="Dumfries">Dumfries</option><option value="Dungannon">Dungannon</option><option value="Dunn Loring">Dunn Loring</option><option value="Eastville">Eastville</option><option value="Edinburg">Edinburg</option><option value="Elkton">Elkton</option><option value="Emory">Emory</option><option value="Emporia">Emporia</option><option value="Essex">Essex</option><option value="Ewing">Ewing</option><option value="Exmore">Exmore</option><option value="Fairfax">Fairfax</option><option value="Falls Church">Falls Church</option><option value="Fancy Gap">Fancy Gap</option><option value="Farmville">Farmville</option><option value="Fauquier">Fauquier</option><option value="Ferrum">Ferrum</option><option value="Fieldale">Fieldale</option><option value="Fincastle">Fincastle</option><option value="Fishersville">Fishersville</option><option value="Floyd">Floyd</option><option value="Fluvanna">Fluvanna</option><option value="Forest">Forest</option><option value="Fort Belvoir">Fort Belvoir</option><option value="Franconia">Franconia</option><option value="Franklin">Franklin</option><option value="Frederick">Frederick</option><option value="Fredericksburg">Fredericksburg</option><option value="Fries">Fries</option><option value="Front Royal">Front Royal</option><option value="Galax">Galax</option><option value="Gate City">Gate City</option><option value="Giles">Giles</option><option value="Glade Spring">Glade Spring</option><option value="Glasgow">Glasgow</option><option value="Glen Allen">Glen Allen</option><option value="Glen Lyn">Glen Lyn</option><option value="Gloucester">Gloucester</option><option value="Gloucester Courthouse">Gloucester Courthouse</option><option value="Gloucester Point">Gloucester Point</option><option value="Goochland">Goochland</option><option value="Gordonsville">Gordonsville</option><option value="Goshen">Goshen</option><option value="Grayson">Grayson</option><option value="Great Falls">Great Falls</option><option value="Greene">Greene</option><option value="Greensville">Greensville</option><option value="Gretna">Gretna</option><option value="Grottoes">Grottoes</option><option value="Grundy">Grundy</option><option value="Halifax">Halifax</option><option value="Hamilton">Hamilton</option><option value="Hampton">Hampton</option><option value="Hanover">Hanover</option><option value="Harrisonburg">Harrisonburg</option><option value="Haymarket">Haymarket</option><option value="Haysi">Haysi</option><option value="Henrico">Henrico</option><option value="Henry">Henry</option><option value="Herndon">Herndon</option><option value="Highland">Highland</option><option value="Highland Springs">Highland Springs</option><option value="Hillsboro">Hillsboro</option><option value="Hillsville">Hillsville</option><option value="Honaker">Honaker</option><option value="Hopewell">Hopewell</option><option value="Huntington">Huntington</option><option value="Hurt">Hurt</option><option value="Hybla Valley">Hybla Valley</option><option value="Independence">Independence</option><option value="Iron Gate">Iron Gate</option><option value="Irvington">Irvington</option><option value="Ivor">Ivor</option><option value="Isle of Wight">Isle of Wight</option><option value="James City">James City</option><option value="Jarratt">Jarratt</option><option value="Jefferson">Jefferson</option><option value="Jolivue">Jolivue</option><option value="Jonesville">Jonesville</option><option value="Keller">Keller</option><option value="Kenbridge">Kenbridge</option><option value="Keokee">Keokee</option><option value="Keysville">Keysville</option><option value="Kilmarnock">Kilmarnock</option><option value="King and Queen">King and Queen</option><option value="King George">King George</option><option value="King William">King William</option><option value="La Crosse">La Crosse</option><option value="Lake Monticello">Lake Monticello</option><option value="Lakeside">Lakeside</option><option value="Lancaster">Lancaster</option><option value="Lawrenceville">Lawrenceville</option><option value="Lebanon">Lebanon</option><option value="Lee">Lee</option><option value="Leesburg">Leesburg</option><option value="Lexington">Lexington</option><option value="Lorton">Lorton</option><option value="Loudoun">Loudoun</option><option value="Louisa">Louisa</option><option value="Lovettsville">Lovettsville</option><option value="Lunenburg">Lunenburg</option><option value="Luray">Luray</option><option value="Lynchburg">Lynchburg</option><option value="Madison">Madison</option><option value="Madison Heights">Madison Heights</option><option value="Manassas">Manassas</option><option value="Manassas Park">Manassas Park</option><option value="Marion">Marion</option><option value="Martinsville">Martinsville</option><option value="Matthews">Matthews</option><option value="Mechanicsville">Mechanicsville</option><option value="Middlesex">Middlesex</option><option value="Middletown">Middletown</option><option value="Midlothian">Midlothian</option><option value="Mineral">Mineral</option><option value="Monterey">Monterey</option><option value="Montgomery">Montgomery</option><option value="Montross">Montross</option><option value="Narrows">Narrows</option><option value="Nelson">Nelson</option><option value="New Kent">New Kent</option><option value="Newport News">Newport News</option><option value="Norfolk">Norfolk</option><option value="Northampton">Northampton</option><option value="Northumberland">Northumberland</option><option value="Norton">Norton</option><option value="Nottoway">Nottoway</option><option value="Occoquan">Occoquan</option><option value="Onancock">Onancock</option><option value="Orange">Orange</option><option value="Page">Page</option><option value="Patrick">Patrick</option><option value="Petersburg">Petersburg</option><option value="Pittsylvania">Pittsylvania</option><option value="Poquoson">Poquoson</option><option value="Portsmouth">Portsmouth</option><option value="Powhatan">Powhatan</option><option value="Prince Edward">Prince Edward</option><option value="Prince George">Prince George</option><option value="Prince William">Prince William</option><option value="Pulaski">Pulaski</option><option value="Radford">Radford</option><option value="Rappahannock">Rappahannock</option><option value="Richmond">Richmond</option><option value="Richmond City">Richmond City</option><option value="Roanoke">Roanoke</option><option value="Roanoke City">Roanoke City</option><option value="Rockbridge">Rockbridge</option><option value="Rockingham">Rockingham</option><option value="Rocky Mount">Rocky Mount</option><option value="Russell">Russell</option><option value="Salem">Salem</option><option value="Scott">Scott</option><option value="Shenandoah">Shenandoah</option><option value="Smithfield">Smithfield</option><option value="Smyth">Smyth</option><option value="Southampton">Southampton</option><option value="South Boston">South Boston</option><option value="South Hill">South Hill</option><option value="Spotsylvania">Spotsylvania</option><option value="Spotsylvania Courthouse">Spotsylvania Courthouse</option><option value="Springfield">Springfield</option><option value="Stafford">Stafford</option><option value="Staunton">Staunton</option><option value="Stephens City">Stephens City</option><option value="Strasburg">Strasburg</option><option value="Stuart">Stuart</option><option value="Suffolk">Suffolk</option><option value="Surry">Surry</option><option value="Sussex">Sussex</option><option value="Tappahannock">Tappahannock</option><option value="Tazewell">Tazewell</option><option value="Timberville">Timberville</option><option value="Toms Brook">Toms Brook</option><option value="Triangle">Triangle</option><option value="Troutville">Troutville</option><option value="Urbanna">Urbanna</option><option value="Victoria">Victoria</option><option value="Vienna">Vienna</option><option value="Vinton">Vinton</option><option value="Virginia Beach">Virginia Beach</option><option value="Warren">Warren</option><option value="Warrenton">Warrenton</option><option value="Warsaw">Warsaw</option><option value="Washington">Washington</option><option value="Waynesboro">Waynesboro</option><option value="Westmoreland">Westmoreland</option><option value="West Point">West Point</option><option value="Williamsburg">Williamsburg</option><option value="Winchester">Winchester</option><option value="Windsor">Windsor</option><option value="Wise">Wise</option><option value="Woodstock">Woodstock</option><option value="Wythe">Wythe</option><option value="Wytheville">Wytheville</option><option value="York">York</option><option value="Yorktown">Yorktown</option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" er_fld_condfld="CST_38" er_fld_condvals="er_fld_showif_values=Not+Listed" style="width: 20%;" map_to="FH_Address_County"> <i class="fa fa-font"></i><label class="er_fld_label required">City/ County:</label><input name="CST_70" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_Address_State"> <i class="fa fa-font"></i><label class="er_fld_label">State:</label><input name="CST_10" type="text" class="" value="Virginia"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_Address_Zip"> <i class="fa fa-font"></i><label class="er_fld_label required">Zipcode:</label><input name="CST_11" type="text" class="er_fld_required" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Length of Time at Current Address:</label><select name="CST_44" class="er_fld_required"><option value="Less Than 1 Year">Less Than 1 Year</option><option value="1 Year">1 Year</option><option value="2 Years">2 Years</option><option value="3 Years">3 Years</option><option value="4 Years">4 Years</option><option value="5 Years">5 Years</option><option value="6+ Years">6+ Years</option></select></li><li class="er_fld_type_radio er_fld_type_radio_col4" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Has anyone living in the home lived in another state (or states) in the past 5 years?</label> <label class="er_option"><input class="type_radio er_fld_required er_fld_desc" type="radio" name="CST_46" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required er_fld_desc" type="radio" name="CST_46" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required er_fld_desc" type="radio" name="CST_46" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_desc" name="CST_46_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Do you have weapons/firearms in your home?</label><select name="CST_76" class="er_fld_required er_fld_desc"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Do you have a pool or hot tub on your property?</label><select name="CST_77" class="er_fld_required er_fld_desc"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Do you have a trampoline on your property?</label><select name="CST_97" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Pets</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col4" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Do you have any pets?</label> <label class="er_option"><input class="type_radio er_fld_desc er_fld_required" type="radio" name="CST_78" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_desc er_fld_required" type="radio" name="CST_78" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_desc er_fld_required" type="radio" name="CST_78" value="Other:">Other:<input class="cst_Other er_fld_desc er_fld_required" name="CST_78_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_78" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Please list their names, species, breed, and age:</label><textarea name="CST_79" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Vehicles</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">How many vehicles are kept on your property?</label><select name="CST_80" class="er_fld_required er_fld_desc"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="0 - I/we use public transportation">0 - I/we use public transportation</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></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_80" er_fld_condvals="er_fld_showif_values=1&er_fld_showif_values=2&er_fld_showif_values=3&er_fld_showif_values=4&er_fld_showif_values=5%2B"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Year:</label><input name="CST_81" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_80" er_fld_condvals="er_fld_showif_values=1&er_fld_showif_values=2&er_fld_showif_values=3&er_fld_showif_values=4&er_fld_showif_values=5%2B"> <i class="fa fa-font"></i><label class="er_fld_label required">Make:</label><input name="CST_82" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_80" er_fld_condvals="er_fld_showif_values=1&er_fld_showif_values=2&er_fld_showif_values=3&er_fld_showif_values=4&er_fld_showif_values=5%2B"> <i class="fa fa-font"></i><label class="er_fld_label required">Model:</label><input name="CST_83" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_80" er_fld_condvals="er_fld_showif_values=2&er_fld_showif_values=3&er_fld_showif_values=4&er_fld_showif_values=5%2B"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Year:</label><input name="CST_84" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_80" er_fld_condvals="er_fld_showif_values=2&er_fld_showif_values=3&er_fld_showif_values=4&er_fld_showif_values=5%2B"> <i class="fa fa-font"></i><label class="er_fld_label required">Make:</label><input name="CST_85" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_80" er_fld_condvals="er_fld_showif_values=2&er_fld_showif_values=3&er_fld_showif_values=4&er_fld_showif_values=5%2B"> <i class="fa fa-font"></i><label class="er_fld_label required">Model:</label><input name="CST_86" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_80" er_fld_condvals="er_fld_showif_values=3&er_fld_showif_values=4&er_fld_showif_values=5%2B"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Year:</label><input name="CST_87" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_80" er_fld_condvals="er_fld_showif_values=3&er_fld_showif_values=4&er_fld_showif_values=5%2B"> <i class="fa fa-font"></i><label class="er_fld_label required">Make:</label><input name="CST_88" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_80" er_fld_condvals="er_fld_showif_values=3&er_fld_showif_values=4&er_fld_showif_values=5%2B"> <i class="fa fa-font"></i><label class="er_fld_label required">Model:</label><input name="CST_89" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_80" er_fld_condvals="er_fld_showif_values=4&er_fld_showif_values=5%2B"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Year:</label><input name="CST_90" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_80" er_fld_condvals="er_fld_showif_values=4&er_fld_showif_values=5%2B"> <i class="fa fa-font"></i><label class="er_fld_label required">Make:</label><input name="CST_91" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_80" er_fld_condvals="er_fld_showif_values=4&er_fld_showif_values=5%2B"> <i class="fa fa-font"></i><label class="er_fld_label required">Model:</label><input name="CST_92" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_80" er_fld_condvals="er_fld_showif_values=5%2B"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Please list the year, make, and model of any additional vehicles in the space below:</label><textarea name="CST_93" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Household Members</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_showif er_fld_type_radio_col4" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_46" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Please select each state that any member of the household (including yourselves) has resided in over the past 5 years outside of Virginia:</label> <label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Alabama">Alabama</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Alaska">Alaska</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Arizona">Arizona</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Arkansas">Arkansas</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="California">California</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Colorado">Colorado</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Connecticut">Connecticut</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Delaware">Delaware</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Florida">Florida</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Georgia">Georgia</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Hawaii">Hawaii</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Idaho">Idaho</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Illinois">Illinois</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Indiana">Indiana</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Iowa">Iowa</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Kansas">Kansas</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Kentucky">Kentucky</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Louisiana">Louisiana</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Maine">Maine</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Maryland">Maryland</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Massachusetts">Massachusetts</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Michigan">Michigan</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Minnesota">Minnesota</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Mississippi">Mississippi</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Missouri">Missouri</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Montana">Montana</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Nebraska">Nebraska</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Nevada">Nevada</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="New Hampshire">New Hampshire</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="New Jersey">New Jersey</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="New Mexico">New Mexico</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="New York">New York</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="North Carolina">North Carolina</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="North Dakota">North Dakota</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Ohio">Ohio</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Oklahoma">Oklahoma</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Oregon">Oregon</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Pennsylvania">Pennsylvania</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Rhode Island">Rhode Island</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="South Carolina">South Carolina</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="South Dakota">South Dakota</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Tennessee">Tennessee</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Texas">Texas</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Utah">Utah</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Vermont">Vermont</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Washington">Washington</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="West Virginia">West Virginia</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Wisconsin">Wisconsin</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_45" value="Wyoming">Wyoming</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required er_fld_desc" type="checkbox" name="CST_45" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_desc" name="CST_45_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">In addition to yourselves (Parents A and B), how many more people live in your home?</label><select name="CST_57" class="er_fld_required er_fld_desc"><option value="No One">No One</option><option value="1" selected="">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></select></li><li class="er_fld_type_radio er_fld_type_radio_col4 er_fld_showif" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=1&er_fld_showif_values=2&er_fld_showif_values=3&er_fld_showif_values=4&er_fld_showif_values=5&er_fld_showif_values=6%2B"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Has anyone over the age of 14 lived out of state in the past 5 years?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_58" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_58" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_58" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_58_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=1&er_fld_showif_values=2&er_fld_showif_values=3&er_fld_showif_values=4&er_fld_showif_values=5&er_fld_showif_values=6%2B"> <i class="fa fa-font"></i><label class="er_fld_label required">Household Member 1 Name:</label><input name="CST_59" type="text" class="er_fld_required"></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=1&er_fld_showif_values=2&er_fld_showif_values=3&er_fld_showif_values=4&er_fld_showif_values=5&er_fld_showif_values=6%2B"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Household Member 1 Date of Birth:</label><input class="cst_datepicker er_fld_required" name="CST_60" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=1"> <i class="fa fa-font"></i><label class="er_fld_label required">Relationship: son/daughter, relative (what type) Roomate etc.</label><input name="CST_99" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=2&er_fld_showif_values=3&er_fld_showif_values=4&er_fld_showif_values=5&er_fld_showif_values=6%2B"> <i class="fa fa-font"></i><label class="er_fld_label required">Household Member 2 Name:</label><input name="CST_61" type="text" class="er_fld_required"></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=2&er_fld_showif_values=3&er_fld_showif_values=4&er_fld_showif_values=5&er_fld_showif_values=6%2B"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Household Member 2 Date of Birth:</label><input class="cst_datepicker er_fld_required" name="CST_62" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=1&er_fld_showif_values=2&er_fld_showif_values=3&er_fld_showif_values=4&er_fld_showif_values=5&er_fld_showif_values=6%2B"> <i class="fa fa-font"></i><label class="er_fld_label required">Relationship: son/daughter, relative (what type) Roomate etc.</label><input name="CST_100" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=3&er_fld_showif_values=4&er_fld_showif_values=5&er_fld_showif_values=6%2B"> <i class="fa fa-font"></i><label class="er_fld_label required">Household Member 3 Name:</label><input name="CST_63" type="text" class="er_fld_required"></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=3&er_fld_showif_values=4&er_fld_showif_values=5&er_fld_showif_values=6%2B"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Household Member 3 Date of Birth:</label><input class="cst_datepicker er_fld_required" name="CST_64" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=1&er_fld_showif_values=2&er_fld_showif_values=3&er_fld_showif_values=4&er_fld_showif_values=5&er_fld_showif_values=6%2B"> <i class="fa fa-font"></i><label class="er_fld_label required">Relationship: son/daughter, relative (what type) Roomate etc.</label><input name="CST_101" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=4&er_fld_showif_values=5&er_fld_showif_values=6%2B"> <i class="fa fa-font"></i><label class="er_fld_label required">Household Member 4 Name:</label><input name="CST_65" type="text" class="er_fld_required"></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=4&er_fld_showif_values=5&er_fld_showif_values=6%2B"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Household Member 4 Date of Birth:</label><input class="cst_datepicker er_fld_required" name="CST_66" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=1&er_fld_showif_values=2&er_fld_showif_values=3&er_fld_showif_values=4&er_fld_showif_values=5&er_fld_showif_values=6%2B"> <i class="fa fa-font"></i><label class="er_fld_label required">Relationship: son/daughter, relative (what type) Roomate etc.</label><input name="CST_102" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=5&er_fld_showif_values=6%2B"> <i class="fa fa-font"></i><label class="er_fld_label required">Household Member 5 Name:</label><input name="CST_67" type="text" class="er_fld_required"></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=5&er_fld_showif_values=6%2B"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Household Member 5 Date of Birth:</label><input class="cst_datepicker er_fld_required" name="CST_68" type="text"></li><li class="er_fld_type_text er_fld_selected er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=1&er_fld_showif_values=2&er_fld_showif_values=3&er_fld_showif_values=4&er_fld_showif_values=5&er_fld_showif_values=6%2B"> <i class="fa fa-font"></i><label class="er_fld_label required">Relationship: son/daughter, relative (what type) Roomate etc.</label><input name="CST_103" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=6%2B" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">If there are more than 5 additional household members, please include their names and dates of birth below:</label><textarea name="CST_69" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Employment Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Employer_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent A Employer:</label><input name="CST_47" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Occupation_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent A Title/ Position:</label><input name="CST_48" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent A Schedule:</label><input name="CST_49" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent A Monthly Income:</label><input name="CST_50" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent A Length of Employment:</label><input name="CST_51" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Two+Parent+Home"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent B Employer:</label><input name="CST_52" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Two+Parent+Home"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent B Ttile/ Position:</label><input name="CST_53" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Two+Parent+Home"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent B Schedule:</label><input name="CST_54" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Two+Parent+Home"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent B Monthly Income:</label><input name="CST_55" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Two+Parent+Home"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent B Length of Employment:</label><input name="CST_56" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Fostering Questions</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col4" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Have you ever applied to be a foster parent with any other private or public agency?</label> <label class="er_option"><input class="type_checkbox er_fld_required er_fld_desc" type="checkbox" name="CST_27" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required er_fld_desc" type="checkbox" name="CST_27" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required er_fld_desc" type="checkbox" name="CST_27" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_desc" name="CST_27_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">If Yes Please list the names of the agencies you applied to below. If you are currently or previously licensed by an agency, in addition to their name, please provide their address, the date you began as a licensed home for them, and the date you closed your home (or state you're still licensed with them).</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Agency Information:</label><textarea name="CST_28" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_showif er_fld_type_paragraph_large" draggable="false" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Yes" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">If you were licensed with your previous or current foster and/or adoptive agency, please describe your experience below (if you've never been licensed, type NA):</label><textarea name="CST_43" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">If you have applied to be a foster parent with another agency but were not approved, please describe why (e.g., you chose not to continue, circumstances at the time prevented your approval, etc.):</label><textarea name="CST_29" style="width:100%;" class=""></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large" draggable="false" style="width: 50%;" map_to="FH_Inquiry_Why_Parents"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Describe your motivation for becoming a foster parent:</label><textarea name="CST_30" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">What supports do you have in your life that you feel will assist you in being successful as a foster family?</label><textarea name="CST_42" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Foster Home References</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Please give the contact information for three (3) persons who have knowledge about your character, your applicable experience with children and your experience with caretaking of others. Each family must provide 3 references; however, the references must be knowledgeable about both parents. At least ONE reference must be someone NOT related to your family. Using the spaces below, please provide the following for all three references: Name Address Phone number Email address</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large" draggable="false" style="width: 33.3333%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Reference #1:</label><textarea name="CST_32" style="width:100%;" class="er_fld_required"></textarea></li><li class="er_fld_type_paragraph er_fld_type_paragraph_large" draggable="false" style="width: 33.3333%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Reference #2:</label><textarea name="CST_33" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large" draggable="false" style="width: 33.3333%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Reference #3:</label><textarea name="CST_39" style="width:100%;" class="er_fld_required"></textarea></li><li class="er_fld_type_radio er_fld_type_radio_col4" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">I have provided the name, address, phone number, and email address for all 3 of my references:</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_40" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_40" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_40" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_40_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" er_fld_condfld="CST_40" er_fld_condvals="er_fld_showif_values=No" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">In order for us to accept your reference, we MUST have the following: Name Address Phone Number E-Mail Address</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature" draggable="false" style="width: 50%;"> <i class="fa fa-pencil"></i><label class="er_fld_label required">Signature</label><div class="cst_signaturepad"></div><input name="CST_34" type="text" class="er_fld_required"><button class="type_button" disabled="">Clear Signature</button></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Two+Parent+Home"> <i class="fa fa-pencil"></i><label class="er_fld_label required">Signature</label><div class="cst_signaturepad"></div><input name="CST_35" type="text" class="er_fld_blank er_fld_required"><button class="type_button" disabled="">Clear Signature</button></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false"> <i class="fa fa-font"></i><label class="er_fld_label">Single Line Text</label><input name="CST_98" type="text"></li></ul>
Submit