{"id":202,"date":"2015-02-08T14:24:27","date_gmt":"2015-02-08T22:24:27","guid":{"rendered":"http:\/\/sofn6.org\/arv\/?page_id=202"},"modified":"2025-02-23T14:32:25","modified_gmt":"2025-02-23T22:32:25","slug":"camperstudent-health","status":"publish","type":"page","link":"https:\/\/sofn6.org\/arv\/camperstudent-health\/","title":{"rendered":"Camper\/Student Health"},"content":{"rendered":"<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 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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 gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_13' style='display:none'><div id='gf_13' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Camper\/Student Health History<\/h2>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_13' id='gform_13'  action='\/arv\/wp-json\/wp\/v2\/pages\/202#gf_13' data-formid='13' novalidate><div id='gf_page_steps_13' class='gf_page_steps'><div id='gf_step_13_1' class='gf_step gf_step_active gf_step_first'><span class='gf_step_number'>1<\/span><span class='gf_step_label'>Camper\/Student<\/span><\/div><div id='gf_step_13_2' class='gf_step gf_step_next gf_step_pending'><span class='gf_step_number'>2<\/span><span class='gf_step_label'>Parent\/Guardian<\/span><\/div><div id='gf_step_13_3' class='gf_step gf_step_pending'><span class='gf_step_number'>3<\/span><span class='gf_step_label'>Emergency Contacts<\/span><\/div><div id='gf_step_13_4' class='gf_step gf_step_pending'><span class='gf_step_number'>4<\/span><span class='gf_step_label'>Health Providers<\/span><\/div><div id='gf_step_13_5' class='gf_step gf_step_pending'><span class='gf_step_number'>5<\/span><span class='gf_step_label'>Immunizations<\/span><\/div><div id='gf_step_13_6' class='gf_step gf_step_pending'><span class='gf_step_number'>6<\/span><span class='gf_step_label'>General Health History<\/span><\/div><div id='gf_step_13_7' class='gf_step gf_step_pending'><span class='gf_step_number'>7<\/span><span class='gf_step_label'>Medications<\/span><\/div><div id='gf_step_13_8' class='gf_step gf_step_last gf_step_pending'><span class='gf_step_number'>8<\/span><span class='gf_step_label'>Allergies<\/span><\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_13_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_13' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_1\" class=\"gfield gfield--type-hidden gfield--input-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_1' id='input_13_1' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='04\/27\/2026' \/><\/div><\/div><fieldset id=\"field_13_2\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Camper\/Student Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_13_2'>\n                            \n                            <span id='input_13_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_13_2_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_13_2_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_13_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_13_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_13_2_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_13_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_6'>\n\t\t\t<div class='gchoice gchoice_13_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Male'  id='choice_13_6_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_6_0' id='label_13_6_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Female'  id='choice_13_6_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_6_1' id='label_13_6_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_6_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Non-binary'  id='choice_13_6_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_6_2' id='label_13_6_2' class='gform-field-label gform-field-label--type-inline'>Non-binary<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_6_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Other'  id='choice_13_6_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_6_3' id='label_13_6_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_4\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half 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_13_4'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_4' id='input_13_4' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_13_4_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_13_4_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_13_4' class='gform_hidden' value='https:\/\/sofn6.org\/arv\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_13_95\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_13_95' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_13_95_1_container' >\n                                        <input type='text' name='input_95.1' id='input_13_95_1' value=''    aria-required='true'    \/>\n                                        <label for='input_13_95_1' id='input_13_95_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_13_95_2_container' >\n                                        <input type='text' name='input_95.2' id='input_13_95_2' value=''     aria-required='false'   \/>\n                                        <label for='input_13_95_2' id='input_13_95_2_label' class='gform-field-label gform-field-label--type-sub '>Apt \/ Spc #<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_13_95_3_container' >\n                                    <input type='text' name='input_95.3' id='input_13_95_3' value=''    aria-required='true'    \/>\n                                    <label for='input_13_95_3' id='input_13_95_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_13_95_4_container' >\n                                        <input type='text' name='input_95.4' id='input_13_95_4' value=''      aria-required='true'    \/>\n                                        <label for='input_13_95_4' id='input_13_95_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_13_95_5_container' >\n                                    <input type='text' name='input_95.5' id='input_13_95_5' value=''    aria-required='true'    \/>\n                                    <label for='input_13_95_5' id='input_13_95_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_13_95_6_container' >\n                                        <select name='input_95.6' id='input_13_95_6'   aria-required='true'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' selected='selected'>United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_13_95_6' id='input_13_95_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_13_97\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_97'>Please tell us about your camper so that we can appropriately interact with them:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_97' id='input_13_97' class='textarea large'  aria-describedby=\"gfield_description_13_97\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_13_97'>Tell us if there are medical considerations that we need to know about.<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_13_5' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_13_2_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_2' class='gform_page' data-js='page-field-id-5' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_13_7\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Parent\/Guardian Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_13_7'>\n                            \n                            <span id='input_13_7_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.3' id='input_13_7_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_13_7_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_13_7_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.6' id='input_13_7_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_13_7_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_13_9\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half 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_13_9'>Best Emergency Contact Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_13_9' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_10\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-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_13_10'>Alternate Emergency Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_13_10' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_11\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_11'>Parent\/Guardian 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_11' id='input_13_11' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_13_11\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_13_11'>A copy of the completed form will be sent to this email address.<\/div><\/div><div id=\"field_13_88\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >This health history is correct, so far as I know, and the person herein has permission to engage in all prescribed program activities. I give permission to the Sons of Norway District Six Language\/Heritage Camp to order X-Rays, routine tests and treatment for the health of my child, and in the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Sons of Norway District Six Language\/Heritage Camp to hospitalize, secure proper treatment for and to order injection and\/or anesthesia and\/or surgery for my child named above.<\/div><div id=\"field_13_19\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_19'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_19' id='input_13_19_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_13_19_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><canvas id='input_13_19' width='600' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/sofn6.org\/arv\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_13_19_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_13_19_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_13_19_data' name='input_13_19_data' value=''><\/div><div class='gfield_description' id='gfield_description_13_19'>Sign here using mouse or digital pen.<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_15' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_13_15' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_13_3_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_3' class='gform_page' data-js='page-field-id-15' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_13_16\" class=\"gfield gfield--type-list gfield--input-type-list gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Emergency Contacts<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Name<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Phone<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Relationship<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_16_cell1 gform-grid-col' data-label='Name'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_13_16\" aria-label='Name, Row 1' data-aria-label-template='Name, Row {0}' type='text' name='input_16[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_16_cell2 gform-grid-col' data-label='Phone'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_13_16\" aria-label='Phone, Row 1' data-aria-label-template='Phone, Row {0}' type='text' name='input_16[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_16_cell3 gform-grid-col' data-label='Relationship'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_13_16\" aria-label='Relationship, Row 1' data-aria-label-template='Relationship, Row {0}' type='text' name='input_16[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 5)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 5)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_13_16'>Please provide one or more emergency contacts other than Parent\/Guardian. Click on the \"+\" to add additional contact rows.<\/div><\/fieldset><fieldset id=\"field_13_18\" class=\"gfield gfield--type-list gfield--input-type-list gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Child Release Authorizaiton<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Name<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Phone<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Relationship<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_18_cell1 gform-grid-col' data-label='Name'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_13_18\" aria-label='Name, Row 1' data-aria-label-template='Name, Row {0}' type='text' name='input_18[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_18_cell2 gform-grid-col' data-label='Phone'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_13_18\" aria-label='Phone, Row 1' data-aria-label-template='Phone, Row {0}' type='text' name='input_18[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_18_cell3 gform-grid-col' data-label='Relationship'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_13_18\" aria-label='Relationship, Row 1' data-aria-label-template='Relationship, Row {0}' type='text' name='input_18[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 10)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 10)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_13_18'>All the above listed individuates are authorized to pick up my child from Camp Trollfjell or Trollfjell Folkeh\u00f8gskule. (Please include parent(s) and\/or guardian(s).<\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_17' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_13_17' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_13_4_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_4' class='gform_page' data-js='page-field-id-17' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_22\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third 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_13_22'>Health Insurance Company<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_13_22' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_23\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third 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_13_23'>Policy Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_13_23' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_93\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_93'>Insurance Co. Toll Free Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_93' id='input_13_93' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_24\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Child&#039;s Physician<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_13_24'>\n                            <span id='input_13_24_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' >\n                                                    <select name='input_24.2' id='input_13_24_2'    aria-required='false'   >\n                          <option value=''><\/option><option value='Dr.' selected='selected'>Dr.<\/option><option value='Mr.' >Mr.<\/option><option value='Mrs.' >Mrs.<\/option><option value='Miss' >Miss<\/option><option value='Ms.' >Ms.<\/option><option value='Prof.' >Prof.<\/option><option value='Rev.' >Rev.<\/option>\n                      <\/select>\n                                                    <label for='input_13_24_2' class='gform-field-label gform-field-label--type-sub '>Prefix<\/label>\n                                                  <\/span>\n                            <span id='input_13_24_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.3' id='input_13_24_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_13_24_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_13_24_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.6' id='input_13_24_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_13_24_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_13_25\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half 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_13_25'>Physician&#039;s Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_25' id='input_13_25' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_26\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Child&#039;s Dentist<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_13_26'>\n                            <span id='input_13_26_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' >\n                                                    <select name='input_26.2' id='input_13_26_2'    aria-required='false'   >\n                          <option value=''><\/option><option value='Dr.' selected='selected'>Dr.<\/option><option value='Mr.' >Mr.<\/option><option value='Mrs.' >Mrs.<\/option><option value='Miss' >Miss<\/option><option value='Ms.' >Ms.<\/option><option value='Prof.' >Prof.<\/option><option value='Rev.' >Rev.<\/option>\n                      <\/select>\n                                                    <label for='input_13_26_2' class='gform-field-label gform-field-label--type-sub '>Prefix<\/label>\n                                                  <\/span>\n                            <span id='input_13_26_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_26.3' id='input_13_26_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_13_26_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_13_26_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_26.6' id='input_13_26_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_13_26_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_13_26_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_26.8' id='input_13_26_8' value='DDS'   aria-required='false'     \/>\n                                                    <label for='input_13_26_8' class='gform-field-label gform-field-label--type-sub '>Suffix<\/label>\n                                                <\/span>\n                        <\/div><\/fieldset><div id=\"field_13_28\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half 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_13_28'>Dentist&#039;s Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_28' id='input_13_28' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_27' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_13_27' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_13_5_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_5' class='gform_page' data-js='page-field-id-27' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_34\" class=\"gfield gfield--type-html gfield--input-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\"  >Enter the date for the most recent immunizations (Enter January 1, 1915 (1\/1\/1915) to indicate no immunization) :<\/div><div id=\"field_13_35\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-quarter gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_35'>DTaP<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_35' id='input_13_35' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_13_35_date_format gfield_description_13_35\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_13_35_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_13_35' class='gform_hidden' value='https:\/\/sofn6.org\/arv\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_13_35'>diphtheria - pertussis  - tetanus <\/div><\/div><div id=\"field_13_37\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-quarter 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_13_37'>Hepatitis A<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_37' id='input_13_37' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_13_37_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_13_37_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_13_37' class='gform_hidden' value='https:\/\/sofn6.org\/arv\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_13_94\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-quarter 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_13_94'>Hepatitis B<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_94' id='input_13_94' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_13_94_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_13_94_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_13_94' class='gform_hidden' value='https:\/\/sofn6.org\/arv\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_13_38\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-quarter gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_38'>MMR<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_38' id='input_13_38' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_13_38_date_format gfield_description_13_38\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_13_38_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_13_38' class='gform_hidden' value='https:\/\/sofn6.org\/arv\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_13_38'>measles - mumps - rubella<\/div><\/div><div id=\"field_13_41\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third 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_13_41'>Polio<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_41' id='input_13_41' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_13_41_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_13_41_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_13_41' class='gform_hidden' value='https:\/\/sofn6.org\/arv\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_13_42\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third 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_13_42'>Chicken Pox<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_42' id='input_13_42' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_13_42_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_13_42_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_13_42' class='gform_hidden' value='https:\/\/sofn6.org\/arv\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_13_96\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_96'>COVID-19<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_96' id='input_13_96' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_13_96_date_format gfield_description_13_96\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_13_96_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_13_96' class='gform_hidden' value='https:\/\/sofn6.org\/arv\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_13_96'>If you camper\/student has not received a COVID vaccination, enter January 1, 1915 (1\/1\/1915). We will understand this date to mean no vaccination.<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_29' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_13_29' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_13_6_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_6' class='gform_page' data-js='page-field-id-29' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_44\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Check all that currently or may apply at the time of Camp. Please describe or explain any checked items.<\/div><fieldset id=\"field_13_43\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >General Health History<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_13_43'><div class='gchoice gchoice_13_43_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.1' type='checkbox'  value='Asthma'  id='choice_13_43_1'   aria-describedby=\"gfield_description_13_43\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_1' id='label_13_43_1' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.2' type='checkbox'  value='ADD\/ADHD'  id='choice_13_43_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_2' id='label_13_43_2' class='gform-field-label gform-field-label--type-inline'>ADD\/ADHD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.3' type='checkbox'  value='Autism\/asperger'  id='choice_13_43_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_3' id='label_13_43_3' class='gform-field-label gform-field-label--type-inline'>Autism\/asperger<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.4' type='checkbox'  value='Back pain\/problems'  id='choice_13_43_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_4' id='label_13_43_4' class='gform-field-label gform-field-label--type-inline'>Back pain\/problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.5' type='checkbox'  value='Bed Wetting'  id='choice_13_43_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_5' id='label_13_43_5' class='gform-field-label gform-field-label--type-inline'>Bed Wetting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.6' type='checkbox'  value='Chest pain during exercise'  id='choice_13_43_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_6' id='label_13_43_6' class='gform-field-label gform-field-label--type-inline'>Chest pain during exercise<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.7' type='checkbox'  value='Chicken Pox'  id='choice_13_43_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_7' id='label_13_43_7' class='gform-field-label gform-field-label--type-inline'>Chicken Pox<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.8' type='checkbox'  value='Constipation'  id='choice_13_43_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_8' id='label_13_43_8' class='gform-field-label gform-field-label--type-inline'>Constipation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.9' type='checkbox'  value='Contacts'  id='choice_13_43_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_9' id='label_13_43_9' class='gform-field-label gform-field-label--type-inline'>Contacts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.11' type='checkbox'  value='Diabetes'  id='choice_13_43_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_11' id='label_13_43_11' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.12' type='checkbox'  value='Diarrhea'  id='choice_13_43_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_12' id='label_13_43_12' class='gform-field-label gform-field-label--type-inline'>Diarrhea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.13' type='checkbox'  value='Dizziness'  id='choice_13_43_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_13' id='label_13_43_13' class='gform-field-label gform-field-label--type-inline'>Dizziness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.14' type='checkbox'  value='Ear Infections'  id='choice_13_43_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_14' id='label_13_43_14' class='gform-field-label gform-field-label--type-inline'>Ear Infections<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.15' type='checkbox'  value='Eating problems\/disorder'  id='choice_13_43_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_15' id='label_13_43_15' class='gform-field-label gform-field-label--type-inline'>Eating problems\/disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.16' type='checkbox'  value='Fainting'  id='choice_13_43_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_16' id='label_13_43_16' class='gform-field-label gform-field-label--type-inline'>Fainting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.17' type='checkbox'  value='Glasses'  id='choice_13_43_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_17' id='label_13_43_17' class='gform-field-label gform-field-label--type-inline'>Glasses<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.18' type='checkbox'  value='Headaches'  id='choice_13_43_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_18' id='label_13_43_18' class='gform-field-label gform-field-label--type-inline'>Headaches<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.19' type='checkbox'  value='Head injury'  id='choice_13_43_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_19' id='label_13_43_19' class='gform-field-label gform-field-label--type-inline'>Head injury<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.21' type='checkbox'  value='Head lice'  id='choice_13_43_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_21' id='label_13_43_21' class='gform-field-label gform-field-label--type-inline'>Head lice<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.22' type='checkbox'  value='Hearing aids'  id='choice_13_43_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_22' id='label_13_43_22' class='gform-field-label gform-field-label--type-inline'>Hearing aids<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.23' type='checkbox'  value='Heart defect\/disease'  id='choice_13_43_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_23' id='label_13_43_23' class='gform-field-label gform-field-label--type-inline'>Heart defect\/disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.24' type='checkbox'  value='Heart murmur'  id='choice_13_43_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_24' id='label_13_43_24' class='gform-field-label gform-field-label--type-inline'>Heart murmur<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.25' type='checkbox'  value='High blood pressure'  id='choice_13_43_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_25' id='label_13_43_25' class='gform-field-label gform-field-label--type-inline'>High blood pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.26' type='checkbox'  value='Joint pain'  id='choice_13_43_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_26' id='label_13_43_26' class='gform-field-label gform-field-label--type-inline'>Joint pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.27' type='checkbox'  value='Measles'  id='choice_13_43_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_27' id='label_13_43_27' class='gform-field-label gform-field-label--type-inline'>Measles<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.28' type='checkbox'  value='Menstruation'  id='choice_13_43_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_28' id='label_13_43_28' class='gform-field-label gform-field-label--type-inline'>Menstruation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.29' type='checkbox'  value='Mononucleosis'  id='choice_13_43_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_29' id='label_13_43_29' class='gform-field-label gform-field-label--type-inline'>Mononucleosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.31' type='checkbox'  value='Night terrors'  id='choice_13_43_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_31' id='label_13_43_31' class='gform-field-label gform-field-label--type-inline'>Night terrors<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.32' type='checkbox'  value='Orthodontia'  id='choice_13_43_32'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_32' id='label_13_43_32' class='gform-field-label gform-field-label--type-inline'>Orthodontia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.33' type='checkbox'  value='Seizures'  id='choice_13_43_33'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_33' id='label_13_43_33' class='gform-field-label gform-field-label--type-inline'>Seizures<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.34' type='checkbox'  value='Skin problems'  id='choice_13_43_34'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_34' id='label_13_43_34' class='gform-field-label gform-field-label--type-inline'>Skin problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_35'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.35' type='checkbox'  value='Sleepwalking'  id='choice_13_43_35'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_35' id='label_13_43_35' class='gform-field-label gform-field-label--type-inline'>Sleepwalking<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_36'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.36' type='checkbox'  value='Tuberculosis'  id='choice_13_43_36'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_36' id='label_13_43_36' class='gform-field-label gform-field-label--type-inline'>Tuberculosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_37'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.37' type='checkbox'  value='None of the above'  id='choice_13_43_37'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_37' id='label_13_43_37' class='gform-field-label gform-field-label--type-inline'>None of the above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_13_43'>Check all that apply.<\/div><\/fieldset><div id=\"field_13_31\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_31'>Explain Asthma<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_13_31' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_45\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_45'>Explain ADD\/ADHD<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_13_45' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_33\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_33'>Explain Autism\/asperger<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_13_33' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_46\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_46'>Explain Back pain\/problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_13_46' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_47\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_47'>Explain Bed Wetting<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_13_47' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_48\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_48'>Explain Chest pain during exercise<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_13_48' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_49\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_49'>Explain Chicken Pox<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_13_49' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_50\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_50'>Explain Constipation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_13_50' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_51\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_51'>Explain Contacts<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_13_51' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_52\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_52'>Explain Diabetes<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_13_52' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_53\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_53'>Explain Diarrhea<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_13_53' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_54\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_54'>Explain Dizziness<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_13_54' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_55\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_55'>Explain Ear Infections<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_13_55' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_56\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_56'>Explain Eating problems\/disorder<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_13_56' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_57\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_57'>Explain Fainting<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_13_57' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_58\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_58'>Explain Glasses<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_13_58' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_59\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_59'>Explain Headaches<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_13_59' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_60\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_60'>Explain Head injury<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_13_60' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_61\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_61'>Explain Head lice<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_13_61' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_62\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_62'>Explain Hearing aids<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_13_62' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_63\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_63'>Explain Heart defect\/disease<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_13_63' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_64\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_64'>Explain Heart murmur<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_13_64' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_65\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_65'>Explain High blood pressure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_13_65' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_66\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_66'>Explain Joint pain<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_13_66' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_67\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_67'>Explain Measles<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_13_67' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_69\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_69'>Explain Mononucleosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_13_69' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_98\" class=\"gfield gfield--type-text gfield--input-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_13_98'>Explain night terrors<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_13_98' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_70\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_70'>Explain Orthodontia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_13_70' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_71\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_71'>Explain Seizures<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_13_71' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_72\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_72'>Explain Skin problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_13_72' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_73\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_73'>Explain Sleepwalking<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_13_73' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_74\" class=\"gfield gfield--type-text gfield--input-type-text 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_13_74'>Explain Tuberculosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_13_74' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_75\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_75'>Has your child had any recent injury, illness or infectious disease?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_13_75' type='text' value='' class='large'  aria-describedby=\"gfield_description_13_75\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_13_75'>Enter \"None\" or a description.<\/div><\/div><div id=\"field_13_76\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_76'>Has your child had a chronic or recurring illness\/condition?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_13_76' type='text' value='' class='large'  aria-describedby=\"gfield_description_13_76\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_13_76'>Enter \"None\" or a description.<\/div><\/div><div id=\"field_13_77\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_77'>Has your child ever been hospitalized or had surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_13_77' type='text' value='' class='large'  aria-describedby=\"gfield_description_13_77\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_13_77'>Enter \"None\" or a description.<\/div><\/div><div id=\"field_13_78\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_78'>Has your child ever been knocked unconscious?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_13_78' type='text' value='' class='large'  aria-describedby=\"gfield_description_13_78\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_13_78'>Enter \"No\" or a description.<\/div><\/div><div id=\"field_13_79\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_79'>Has your child ever passed out during or after exercise?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_13_79' type='text' value='' class='large'  aria-describedby=\"gfield_description_13_79\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_13_79'>Enter \"No\" or a description.<\/div><\/div><div id=\"field_13_80\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_80'>At the time of Camp, will your child have been out of the country in the last 30 days?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_13_80' type='text' value='' class='large'  aria-describedby=\"gfield_description_13_80\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_13_80'>Enter \"No\" or list countries.<\/div><\/div><div id=\"field_13_81\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_81'>If you child has been in Mexico within the last 30 days, please state where:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_13_81' type='text' value='' class='large'  aria-describedby=\"gfield_description_13_81\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_13_81'>Enter \"No\" or list cities.<\/div><\/div><fieldset id=\"field_13_102\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Swimming<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_102'>\n\t\t\t<div class='gchoice gchoice_13_102_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_102' type='radio' value='This camper has experience swimming'  id='choice_13_102_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_102_0' id='label_13_102_0' class='gform-field-label gform-field-label--type-inline'>This camper has experience swimming<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_102_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_102' type='radio' value='This camper can not swim' checked='checked' id='choice_13_102_1' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_13_102\"   \/>\n\t\t\t\t\t<label for='choice_13_102_1' id='label_13_102_1' class='gform-field-label gform-field-label--type-inline'>This camper can not swim<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_13_102'>Swim skill level will be determined by the lifeguard at Camp before they are allowed to swim.<\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_30' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_13_30' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_13_7_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_7' class='gform_page' data-js='page-field-id-30' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_84\" class=\"gfield gfield--type-html gfield--input-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\"  >Please list ALL medications (including over-the-counter or nonprescription drugs) taken routinely. Bring enough medication to last the entire time at camp. <strong>Keep it in the original packaging\/bottle<\/strong> that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration. <\/div><fieldset id=\"field_13_85\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Regular Medications<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_85'>\n\t\t\t<div class='gchoice gchoice_13_85_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='This camper\/student takes NO medications on a routine basis.'  id='choice_13_85_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_85_0' id='label_13_85_0' class='gform-field-label gform-field-label--type-inline'>This camper\/student takes NO medications on a routine basis.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_85_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='This camper\/student takes the following medications.'  id='choice_13_85_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_85_1' id='label_13_85_1' class='gform-field-label gform-field-label--type-inline'>This camper\/student takes the following medications.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_86\" class=\"gfield gfield--type-list gfield--input-type-list gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Prescription Medications<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Name of medication<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Dosage<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Frequency<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Specific times taken each day<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Reason for taking<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_86_cell1 gform-grid-col' data-label='Name of medication'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_13_86\" aria-label='Name of medication, Row 1' data-aria-label-template='Name of medication, Row {0}' type='text' name='input_86[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_86_cell2 gform-grid-col' data-label='Dosage'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_13_86\" aria-label='Dosage, Row 1' data-aria-label-template='Dosage, Row {0}' type='text' name='input_86[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_86_cell3 gform-grid-col' data-label='Frequency'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_13_86\" aria-label='Frequency, Row 1' data-aria-label-template='Frequency, Row {0}' type='text' name='input_86[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_86_cell4 gform-grid-col' data-label='Specific times taken each day'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_13_86\" aria-label='Specific times taken each day, Row 1' data-aria-label-template='Specific times taken each day, Row {0}' type='text' name='input_86[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_86_cell5 gform-grid-col' data-label='Reason for taking'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_13_86\" aria-label='Reason for taking, Row 1' data-aria-label-template='Reason for taking, Row {0}' type='text' name='input_86[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_13_86'>List all prescription medications (click on \"+\" to add additional medications).<\/div><\/fieldset><fieldset id=\"field_13_87\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Identify any medications taken during the school year that participant does\/may not take during the summer:<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Name of Medication<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Allow \/ Disallow<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_87_cell1 gform-grid-col' data-label='Name of Medication'><input aria-invalid='false'  aria-describedby=\"gfield_description_13_87\" aria-label='Name of Medication, Row 1' data-aria-label-template='Name of Medication, Row {0}' type='text' name='input_87[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_87_cell2 gform-grid-col' data-label='Allow \/ Disallow'><input aria-invalid='false'  aria-describedby=\"gfield_description_13_87\" aria-label='Allow \/ Disallow, Row 1' data-aria-label-template='Allow \/ Disallow, Row {0}' type='text' name='input_87[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_13_87'>Click on the \"+\" to add additional rows.<\/div><\/fieldset><div id=\"field_13_100\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Please check all over-the-counter medications you would allow the nurse to give your child <strong>as needed<\/strong> while at camp.<\/div><fieldset id=\"field_13_14\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Non-Prescription Medications<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_13_14'><div class='gchoice gchoice_13_14_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.1' type='checkbox'  value='Tylenol'  id='choice_13_14_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_14_1' id='label_13_14_1' class='gform-field-label gform-field-label--type-inline'>Tylenol<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_14_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.2' type='checkbox'  value='Ibuprofen'  id='choice_13_14_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_14_2' id='label_13_14_2' class='gform-field-label gform-field-label--type-inline'>Ibuprofen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_14_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.3' type='checkbox'  value='Benadryl'  id='choice_13_14_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_14_3' id='label_13_14_3' class='gform-field-label gform-field-label--type-inline'>Benadryl<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_14_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.4' type='checkbox'  value='Pepto Bismol'  id='choice_13_14_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_14_4' id='label_13_14_4' class='gform-field-label gform-field-label--type-inline'>Pepto Bismol<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_14_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.5' type='checkbox'  value='Chloraseptic'  id='choice_13_14_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_14_5' id='label_13_14_5' class='gform-field-label gform-field-label--type-inline'>Chloraseptic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_14_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.6' type='checkbox'  value='Cough Drops'  id='choice_13_14_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_14_6' id='label_13_14_6' class='gform-field-label gform-field-label--type-inline'>Cough Drops<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_14_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.7' type='checkbox'  value='Calamine Lotion'  id='choice_13_14_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_14_7' id='label_13_14_7' class='gform-field-label gform-field-label--type-inline'>Calamine Lotion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_14_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.8' type='checkbox'  value='Hydocortisone Cream'  id='choice_13_14_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_14_8' id='label_13_14_8' class='gform-field-label gform-field-label--type-inline'>Hydocortisone Cream<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_14_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.9' type='checkbox'  value='Clortrimazole Cream'  id='choice_13_14_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_14_9' id='label_13_14_9' class='gform-field-label gform-field-label--type-inline'>Clortrimazole Cream<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_14_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.11' type='checkbox'  value='None of the above'  id='choice_13_14_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_14_11' id='label_13_14_11' class='gform-field-label gform-field-label--type-inline'>None of the above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_32' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_13_32' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_13_8_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_8' class='gform_page' data-js='page-field-id-32' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_89\" class=\"gfield gfield--type-html gfield--input-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\"  >List all known allergies:<\/div><fieldset id=\"field_13_90\" class=\"gfield gfield--type-list gfield--input-type-list gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Medication allergies<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Name of Medication:<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Describe reaction and management of the reaction.<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_90_cell1 gform-grid-col' data-label='Name of Medication:'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_13_90\" aria-label='Name of Medication:, Row 1' data-aria-label-template='Name of Medication:, Row {0}' type='text' name='input_90[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_90_cell2 gform-grid-col' data-label='Describe reaction and management of the reaction.'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_13_90\" aria-label='Describe reaction and management of the reaction., Row 1' data-aria-label-template='Describe reaction and management of the reaction., Row {0}' type='text' name='input_90[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_13_90'>Enter \"None\" if camper\/student has no know medical allergies. Click on the \"+\" to add additional medications. <\/div><\/fieldset><fieldset id=\"field_13_91\" class=\"gfield gfield--type-list gfield--input-type-list gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Food allergies and dietary restrictions<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Food name:<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Describe reaction and management of the reaction or notes on restrictions:<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_91_cell1 gform-grid-col' data-label='Food name:'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_13_91\" aria-label='Food name:, Row 1' data-aria-label-template='Food name:, Row {0}' type='text' name='input_91[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_91_cell2 gform-grid-col' data-label='Describe reaction and management of the reaction or notes on restrictions:'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_13_91\" aria-label='Describe reaction and management of the reaction or notes on restrictions:, Row 1' data-aria-label-template='Describe reaction and management of the reaction or notes on restrictions:, Row {0}' type='text' name='input_91[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_13_91'>Enter \"None\" if camper\/student has no know food allergies or restrictions. Click on the \"+\" to add additional foods. <\/div><\/fieldset><fieldset id=\"field_13_92\" class=\"gfield gfield--type-list gfield--input-type-list gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Other allergies<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Type of allergy:<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Describe reaction and management of the reaction.<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_92_cell1 gform-grid-col' data-label='Type of allergy:'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_13_92\" aria-label='Type of allergy:, Row 1' data-aria-label-template='Type of allergy:, Row {0}' type='text' name='input_92[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_92_cell2 gform-grid-col' data-label='Describe reaction and management of the reaction.'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_13_92\" aria-label='Describe reaction and management of the reaction., Row 1' data-aria-label-template='Describe reaction and management of the reaction., Row {0}' type='text' name='input_92[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_13_92'>Include insect stings, hay fever, asthma, animal dander, poison oak\/ivy etc. Enter \"None\" if camper\/student has no know allergies. 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