{"id":25365,"date":"2024-01-30T02:12:29","date_gmt":"2024-01-30T08:12:29","guid":{"rendered":"https:\/\/swopehealth.org\/?page_id=25365"},"modified":"2025-03-20T16:19:23","modified_gmt":"2025-03-20T21:19:23","slug":"swope-health-community-support-request","status":"publish","type":"page","link":"https:\/\/swopehealth.org\/swope-health-community-support-request\/","title":{"rendered":"Swope Health Community Support Request"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"25365\" class=\"elementor elementor-25365\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-1554413 elementor-section-height-min-height animated-slow header_on_page elementor-section-items-stretch elementor-section-full_width elementor-section-height-default\" data-id=\"1554413\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;none&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-cc3f033\" data-id=\"cc3f033\" data-element_type=\"column\" data-settings=\"{&quot;animation&quot;:&quot;none&quot;,&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-e2165e7 elementor-section-content-middle elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"e2165e7\" data-element_type=\"section\" data-settings=\"{&quot;animation&quot;:&quot;none&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-a688911\" data-id=\"a688911\" data-element_type=\"column\" data-settings=\"{&quot;animation&quot;:&quot;none&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-3d3ed4f elementor-widget__width-initial elementor-widget elementor-widget-heading\" data-id=\"3d3ed4f\" data-element_type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;none&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Community Support Request<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-bb2a9f8 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"bb2a9f8\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;none&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-b90fe46\" data-id=\"b90fe46\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-c8c29ea elementor-section-content-middle elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"c8c29ea\" data-element_type=\"section\" data-settings=\"{&quot;animation&quot;:&quot;none&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-c7c2dba\" data-id=\"c7c2dba\" data-element_type=\"column\" data-settings=\"{&quot;animation&quot;:&quot;none&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-2cddb94 elementor-widget elementor-widget-heading\" data-id=\"2cddb94\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Swope Health Community Support Request<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-a302352 elementor-widget elementor-widget-text-editor\" data-id=\"a302352\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>We make every attempt to support community needs, but we need two months notice to secure medical personnel scheduling and supplies. For COVID-19 vaccination events, three weeks notice is required.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-a26b8e0 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"a26b8e0\" data-element_type=\"section\" id=\"meeting_room_form\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-95df597\" data-id=\"95df597\" data-element_type=\"column\" data-settings=\"{&quot;animation&quot;:&quot;none&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-1b5f7f9 elementor-widget elementor-widget-shortcode\" data-id=\"1b5f7f9\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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enctype='multipart\/form-data'  id='gform_14'  action='\/wp-json\/wp\/v2\/pages\/25365' data-formid='14' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_14' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_14_10\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_14_10\" ><label class='gfield_label gform-field-label' for='input_14_10'>Date of request<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_10' id='input_14_10' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_14_10_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_14_10_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_14_10' class='gform_hidden' value='https:\/\/swopehealth.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_14_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_14_3\" ><label class='gfield_label gform-field-label' for='input_14_3'>First Name (Primary contact)<\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_14_3' type='text' value='' class='large'    placeholder='Type your first name'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_30\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_14_30\" ><label class='gfield_label gform-field-label' for='input_14_30'>Last (Primary contact)<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_14_30' type='text' value='' class='large'    placeholder='Type your last name'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_29\" 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\"  data-js-reload=\"field_14_29\" ><label class='gfield_label gform-field-label' for='input_14_29'>Name of Organization<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_14_29' type='text' value='' class='large'    placeholder='Type Your Organization Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_4\" 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\"  data-js-reload=\"field_14_4\" ><label class='gfield_label gform-field-label' for='input_14_4'>Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_14_4' type='text' value='' class='large'    placeholder='Type Address' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_31\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_14_31\" ><label class='gfield_label gform-field-label' for='input_14_31'>City<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_14_31' type='text' value='' class='large'    placeholder='Type your city name'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_14_32\" ><label class='gfield_label gform-field-label' for='input_14_32'>State<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_14_32' type='text' value='' class='large'    placeholder='Type state name'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_14_33\" ><label class='gfield_label gform-field-label' for='input_14_33'>Zip \/ Postal code<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_14_33' type='text' value='' class='large'    placeholder='Type zip\/postal code'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_14_9\" ><label class='gfield_label gform-field-label' for='input_14_9'>Phone( Daytime)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_14_9' type='text' value='' class='large'    placeholder='Phone Number' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_14_7\" ><label class='gfield_label gform-field-label' for='input_14_7'>Alternative Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_14_7' type='text' value='' class='large'    placeholder='Phone Number'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_8\" 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\"  data-js-reload=\"field_14_8\" ><label class='gfield_label gform-field-label' for='input_14_8'>Email Address of Requestor<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_14_8' type='text' value='Type Your Email Address' class='large'    placeholder='Type your email address' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_12\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_14_12\" ><label class='gfield_label gform-field-label' for='input_14_12'>Description and location of Event<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_14_12' class='textarea medium'  aria-describedby=\"gfield_description_14_12\"  placeholder='Description' aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_14_12'>*At its sole discretion, Swope Health reserves the right to restrict the use of our space for any event not in keeping with our mission or terminate Organization\u2019s use of our space immediately .<\/div><\/div><div id=\"field_14_19\" 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\"  data-js-reload=\"field_14_19\" ><label class='gfield_label gform-field-label' for='input_14_19'>Date of Event<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_19' id='input_14_19' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_14_19_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_14_19_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_14_19' class='gform_hidden' value='https:\/\/swopehealth.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_14_11\" class=\"gfield gfield--type-time gfield--input-type-time gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_14_11\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Time of Event<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_14_11'>\n                            <input type='number' maxlength='2' name='input_11[]' id='input_14_11_1' value=''  min='0' max='24' step='1'  placeholder='HH' aria-required='true'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_14_11_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' maxlength='2' name='input_11[]' id='input_14_11_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_14_11_2'>Minutes<\/label>\n                        <\/div>\n                        \n                    <\/div><\/fieldset><div id=\"field_14_13\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_14_13\" ><label class='gfield_label gform-field-label' for='input_14_13'>Description of Target Audience<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_13' id='input_14_13' class='textarea medium'    placeholder='Description'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_14_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_14_14\" ><label class='gfield_label gform-field-label' for='input_14_14'>Expected Attendance<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_14_14' type='text' value='' class='large'  aria-describedby=\"gfield_description_14_14\"  placeholder='Expected Attendance'  aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_14_14'>*All spaces have occupancy guidelines which must be strictly adhered to.<\/div><\/div><fieldset id=\"field_14_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_14_16\" ><legend class='gfield_label gform-field-label' >Is this a first time event?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_16'>\n\t\t\t<div class='gchoice gchoice_14_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Yes'  id='choice_14_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_16_0' id='label_14_16_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='No'  id='choice_14_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_16_1' id='label_14_16_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_25\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_14_25\" ><label class='gfield_label gform-field-label' for='input_14_25'>if no, how many years has the event been held?<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_14_25' type='text' value='' class='large'    placeholder='EG: 3'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_15\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_14_15\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What specifically are you requesting?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_15'><div class='gchoice gchoice_14_15_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.1' type='checkbox'  value='COVID-19 vaccine'  id='choice_14_15_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_15_1' id='label_14_15_1' class='gform-field-label gform-field-label--type-inline'>COVID-19 vaccine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_15_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.2' type='checkbox'  value='General information on Swope Health services'  id='choice_14_15_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_15_2' id='label_14_15_2' class='gform-field-label gform-field-label--type-inline'>General information on Swope Health services<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_15_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.3' type='checkbox'  value='Information on insurance marketplace options\/Affordable Care Act'  id='choice_14_15_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_15_3' id='label_14_15_3' class='gform-field-label gform-field-label--type-inline'>Information on insurance marketplace options\/Affordable Care Act<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_15_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.4' type='checkbox'  value='Wellness programming'  id='choice_14_15_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_15_4' id='label_14_15_4' class='gform-field-label gform-field-label--type-inline'>Wellness programming<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_15_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.5' type='checkbox'  value='Education on a specific medical condition such as diabetes, high blood pressure, depression, or kidney disease'  id='choice_14_15_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_15_5' id='label_14_15_5' class='gform-field-label gform-field-label--type-inline'>Education on a specific medical condition such as diabetes, high blood pressure, depression, or kidney disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_15_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.6' type='checkbox'  value='Other (please be as specific as possible):'  id='choice_14_15_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_15_6' id='label_14_15_6' class='gform-field-label gform-field-label--type-inline'>Other (please be as specific as possible):<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_34\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_14_34\" ><label class='gfield_label gform-field-label' for='input_14_34'>What other healthcare organizations are participating or have been invited to participate?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_14_34' class='textarea medium'    placeholder='Description'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_14_26\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_14_26\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How has the event been advertised?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_26'><div class='gchoice gchoice_14_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='Radio'  id='choice_14_26_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_26_1' id='label_14_26_1' class='gform-field-label gform-field-label--type-inline'>Radio<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='Television'  id='choice_14_26_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_26_2' id='label_14_26_2' class='gform-field-label gform-field-label--type-inline'>Television<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_26_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.3' type='checkbox'  value='Newspaper'  id='choice_14_26_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_26_3' id='label_14_26_3' class='gform-field-label gform-field-label--type-inline'>Newspaper<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_26_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.4' type='checkbox'  value='Fliers'  id='choice_14_26_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_26_4' id='label_14_26_4' class='gform-field-label gform-field-label--type-inline'>Fliers<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_26_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.5' type='checkbox'  value='Social Media'  id='choice_14_26_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_26_5' id='label_14_26_5' class='gform-field-label gform-field-label--type-inline'>Social Media<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_26_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.6' type='checkbox'  value='Other'  id='choice_14_26_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_26_6' id='label_14_26_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_14_27\" ><label class='gfield_label gform-field-label' for='input_14_27'>If applicable, please list any sponsors you have for this event<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_14_27' type='text' value='' class='large'    placeholder='if applicable, please list any sponsors you have for this event'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_14_35\" ><legend class='gfield_label gform-field-label' >Are you providing the booth, furniture and supporting materials?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_35'>\n\t\t\t<div class='gchoice gchoice_14_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Yes'  id='choice_14_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_35_0' id='label_14_35_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_14_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_35_1' id='label_14_35_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_36\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_14_36\" ><label class='gfield_label gform-field-label' for='input_14_36'>Organizer shall defend, indemnify and hold Swope Health, its officers, employees and agents harmless from and against any and all liability, loss, expense, attorneys&#039; fees, or claims for injury or damages arising out of or in connection with the willful misconduct or the negligent acts or omission of Organizer.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_36' id='input_14_36' class='textarea medium'    placeholder='Write here'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <div class=\"gf-turnstile-container\"> <div 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