{"id":215383,"date":"2022-03-29T16:41:56","date_gmt":"2022-03-29T20:41:56","guid":{"rendered":"https:\/\/www.samaritanspurse.org\/?p=215383"},"modified":"2025-02-25T16:28:26","modified_gmt":"2025-02-25T21:28:26","slug":"serve-with-world-medical-mission-2","status":"publish","type":"post","link":"https:\/\/samaritanspurse.org\/es\/medical\/serve-with-world-medical-mission-2\/","title":{"rendered":"Serve with World Medical Mission (private)"},"content":{"rendered":"    <main>\r\n        <header class=\"no-img\">\r\n            <hgroup class=\"space-small\">\r\n                <h1>Serve with World Medical&nbsp;Mission<\/h1>\r\n            <\/hgroup>\r\n        <\/header>   \r\n        \r\n        <section>\r\n            <div class=\"space\">\r\n                <p>World Medical Mission places Christian physicians, dentists, and other medical professionals in short-term service as volunteers at mission hospitals and clinics in Africa, Asia, Oceania, Latin America, and the Middle East. <strong>We&nbsp;coordinate all the details of the assignment, including:<\/strong><\/p>\r\n                \r\n                <ul>\r\n                    <li>Matching interests, abilities, and time frame with a hospital<\/li>\r\n                    <li>Providing orientation and spiritual resources before and during the assignment<\/li>\r\n                    <li>Arranging international travel schedules and airline ticketing<\/li>\r\n                    <li>Assisting with necessary visas, permits, and other field requirements<\/li>\r\n                    <li>Coordinating field housing and transportation<\/li>\r\n                <\/ul>   \r\n            <\/div>\r\n        <\/section>\r\n        \r\n        <section class=\"space\">\r\n            <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar 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d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_70' style='display:none'><div id='gf_70' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_70'  action='\/es\/wp-json\/wp\/v2\/posts\/215383#gf_70' data-formid='70' novalidate> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n        <div id='gf_progressbar_wrapper_70' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Paso <span class='gf_step_current_page'>1<\/span> de <span class='gf_step_page_count'>7<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_14' style='width:14%;'><span>14%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_70_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_70' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_70_207\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>World Medical Mission serves evangelical Christian mission hospitals and clinics around the world. The completion of the form below will enable World Medical Mission to consider you for short-term ministry. All information will be confidential and will only be shared with appropriate personnel.<\/p>\n\n<p>Applicants will be asked for a character reference from their church pastor, associate pastor, small group leader, or other church leadership. <strong>You may download the character reference form  <a target=\"_blank\"  href=\"https:\/\/s3.amazonaws.com\/static.samaritanspurse.org\/wmm\/Character%20Reference.pdf\">here<\/a>.  In addition, all medical applicants will be asked to submit two professional references (preferably signed and on letterhead).<\/strong>  All medical and non-medical applicants age 18 and older will also be required to authorize a personal background check prior to being placed at one of the partner mission hospitals.<\/p>\n \n<p>Volunteers will be expected to agree to and sign our statement of faith, statement of conduct, and statement of practice.\n<\/p>\n\n<p>At any point during the application process you may click \"Save and Continue Later\" to receive an email link that will allow you to come back at a later time and not have to re-enter the fields you have already filled.<\/p><\/li><li id=\"field_70_409\" class=\"gfield gfield--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\"  ><p>World Medical Mission serves evangelical Christian mission hospitals and clinics around the world. The completion of the form below will enable World Medical Mission to consider you for short-term ministry. All information will be confidential and will only be shared with appropriate personnel.<\/p>\n\n<p>Applicants will be asked for a character reference from their church pastor, associate pastor, small group leader, or other church leadership. <strong>You may download the character reference form  <a target=\"_blank\"  href=\"https:\/\/sp-comm-arkfiles.s3.theark.cloud\/website\/pdfs\/WMM\/CharacterReference.pdf\">here<\/a>.  <\/strong>  All medical and non-medical applicants age 18 and older will also be required to authorize a personal background check prior to being placed at one of the partner mission hospitals.<\/p>\n \n<p>Volunteers will be expected to agree to and sign our statement of faith, statement of conduct, and statement of practice.\n<\/p>\n\n<p>At any point during the application process you may click \"Save and Continue Later\" to receive an email link that will allow you to come back at a later time and not have to re-enter the fields you have already filled.<\/p><\/li><li id=\"field_70_218\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_218'>What is your country of residence?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_218' id='input_70_218' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='United States of America' selected='selected'>United States of America<\/option><option value='Australia' >Australia<\/option><option value='Canada' >Canada<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='Algeria (El Djazair)' >Algeria (El Djazair)<\/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='Angullia' >Angullia<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua' >Antigua<\/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='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='Bosnia' >Bosnia<\/option><option value='Bosnia-Herzegovina' >Bosnia-Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='Bristish Indian Ocean Territory' >Bristish Indian Ocean Territory<\/option><option value='British Honduras' >British Honduras<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Fasco' >Burkina Fasco<\/option><option value='Burma' >Burma<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canal Zone' >Canal Zone<\/option><option value='Canary Islands' >Canary Islands<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Ceylon' >Ceylon<\/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='Colombia' >Colombia<\/option><option value='Comoro Islands' >Comoro Islands<\/option><option value='Congo, Republic of' >Congo, Republic of<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Cote D&#039;&#039;lvoire (Ivory Coast)' >Cote D&#039;&#039;lvoire (Ivory Coast)<\/option><option value='Cote d&#039;Ivoire' >Cote d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Croatia (Hrvatska)' >Croatia (Hrvatska)<\/option><option value='Cuba' >Cuba<\/option><option value='Curaco, Netherlands Antilles' >Curaco, Netherlands Antilles<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Dem Rep of the Congo - Kinshasa' >Dem Rep of the Congo - Kinshasa<\/option><option value='Dem. People&#039;s Rep. of Korea' >Dem. People&#039;s Rep. of Korea<\/option><option value='Democratic Republic of the Congo' >Democratic Republic of the Congo<\/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='East Timor' >East Timor<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='England' >England<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Faeroe Islands' >Faeroe Islands<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Federated States of Micronesia' >Federated States of Micronesia<\/option><option value='Fiji' >Fiji<\/option><option value='Fiji Islands' >Fiji Islands<\/option><option value='Finland' >Finland<\/option><option value='For anonymous donor records' >For anonymous donor records<\/option><option value='Formosa' >Formosa<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/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='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Grenada, West Indies' >Grenada, West Indies<\/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='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='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kazakstan' >Kazakstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea' >Korea<\/option><option value='Korle-Gommo, West Africa' >Korle-Gommo, West Africa<\/option><option value='Kosovo' >Kosovo<\/option><option value='Kurdistan' >Kurdistan<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Laos' >Laos<\/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='Macau - China' >Macau - China<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Mail' >Mail<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Malta' >Malta<\/option><option value='Marinique' >Marinique<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mauritius, Indian Ocean' >Mauritius, Indian Ocean<\/option><option value='Maurt' >Maurt<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/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='Netherlands Antilles' >Netherlands Antilles<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='New Zealand (Aotearoa)' >New Zealand (Aotearoa)<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Niger Republic' >Niger Republic<\/option><option value='Niger, West Africa' >Niger, West Africa<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='North Korea' >North Korea<\/option><option value='North Sudan' >North Sudan<\/option><option value='Northern Ireland' >Northern Ireland<\/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' >Palestine<\/option><option value='Panama' >Panama<\/option><option value='Papua' >Papua<\/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='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Principat D&#039;andorra' >Principat D&#039;andorra<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Rep Du Burundi' >Rep Du Burundi<\/option><option value='Rep Du Gabon' >Rep Du Gabon<\/option><option value='Rep Du Mali' >Rep Du Mali<\/option><option value='Rep Du Senegal' >Rep Du Senegal<\/option><option value='Rep of Congo - Brazzaville' >Rep of Congo - Brazzaville<\/option><option value='Rep of Guinea-Bissau' >Rep of Guinea-Bissau<\/option><option value='Republic of Benin' >Republic of Benin<\/option><option value='Republic of Burkina Faso' >Republic of Burkina Faso<\/option><option value='Republic of China' >Republic of China<\/option><option value='Republic of Korea' >Republic of Korea<\/option><option value='Republic of Singapore' >Republic of Singapore<\/option><option value='Republic of South Africa' >Republic of South Africa<\/option><option value='Republic of Upper Volta' >Republic of Upper Volta<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/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='Scotland' >Scotland<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Serbia and Montenegro' >Serbia and Montenegro<\/option><option value='Seychelles' >Seychelles<\/option><option value='Seychelles, Indian Ocean' >Seychelles, Indian Ocean<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/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='Somaliland' >Somaliland<\/option><option value='Somolia' >Somolia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia\/South Sandwich Islands' >South Georgia\/South Sandwich Islands<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='South Vietnam' >South Vietnam<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='St Kitts, Leeward Islands' >St Kitts, Leeward Islands<\/option><option value='St Maarten, Leeward Islands' >St Maarten, Leeward Islands<\/option><option value='St. Lucia' >St. Lucia<\/option><option value='St. Vincent' >St. Vincent<\/option><option value='Sudan' >Sudan<\/option><option value='Sultan of Oman' >Sultan of Oman<\/option><option value='Suriname' >Suriname<\/option><option value='Suriname, South America' >Suriname, South America<\/option><option value='Swaziland' >Swaziland<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Taiwan, Republic Of China' >Taiwan, Republic Of China<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='The Netherlands' >The Netherlands<\/option><option value='Tibet' >Tibet<\/option><option value='Togo' >Togo<\/option><option value='Tonga' >Tonga<\/option><option value='Tonga Islands, South Pacific' >Tonga Islands, South Pacific<\/option><option value='Transkei, Africa' >Transkei, Africa<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Turks in Caicos Island' >Turks in Caicos Island<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United States Minor Outlying Islands' >United States Minor Outlying Islands<\/option><option value='Unknown Country' >Unknown Country<\/option><option value='Unknown Name\/Address' >Unknown Name\/Address<\/option><option value='Uruguay' >Uruguay<\/option><option value='USSR' >USSR<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Vatican City' >Vatican City<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wales' >Wales<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='West Germany' >West Germany<\/option><option value='West Indies' >West Indies<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Western Samoa' >Western Samoa<\/option><option value='Yemen' >Yemen<\/option><option value='Yemen Arab Republic' >Yemen Arab Republic<\/option><option value='Yugoslavia' >Yugoslavia<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select><\/div><\/li><li id=\"field_70_273\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Canada privacy statement<\/h2>\nBy submitting this application you are agreeing to Samaritan\u2019s Purse Canada Legal and our Privacy Policies. Samaritan's Purse \u2013 Canada (SPC) retains your personal information as confidential. The information you provide will be used to inform you of our programs and projects, to help encourage you spiritually, and to provide you opportunities to support our work. Please contact SPC at 1 800 663 6500 or email info@samaritan.ca if you do not want your information used for the purposes described. <br><br>Please be aware that Samaritan\u2019s Purse Canada carries out the World Medical Mission program in collaboration with Samaritan\u2019s Purse\u2019s International Head Office in Boone, North Carolina, USA. Therefore, to effectively deliver this program your personal information will also be provided to Samaritan\u2019s Purse in the United States of America where your personal information may be collected, used, processed, stored or disclosed in accordance with the <a href=\"https:\/\/www.samaritanspurse.org\/our-ministry\/privacy-policy\/\" alt=\"US Privacy Policy\">Privacy Policy<\/a> of Samaritan\u2019s Purse in the United States and US legislation regarding personal information privacy. <\/li><li id=\"field_70_212\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_70_212'>To effectively deliver this program, Samaritan\u2019s Purse may collect, use, process, stored or disclose your personal data in accordance with our <a href=\"https:\/\/www.samaritanspurse.org\/our-ministry\/privacy-policy\/\" alt=\"US Privacy Policy\">Privacy Policy<\/a> and US legislation regarding personal information privacy.<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_70_212'><li class='gchoice gchoice_70_212_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_212.1' type='checkbox'  value='Yes, I consent, please process my application'  id='choice_70_212_1'   aria-describedby=\"gfield_description_70_212\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_70_212_1' id='label_70_212_1' class='gform-field-label gform-field-label--type-inline'>Yes, I consent, please process my application<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_70_64\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you a medical professional<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_70_64'>\n\t\t\t<li class='gchoice gchoice_70_64_0'>\n\t\t\t\t<input name='input_64' type='radio' value='Yes'  id='choice_70_64_0'    \/>\n\t\t\t\t<label for='choice_70_64_0' id='label_70_64_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_70_64_1'>\n\t\t\t\t<input name='input_64' type='radio' value='No'  id='choice_70_64_1'    \/>\n\t\t\t\t<label for='choice_70_64_1' id='label_70_64_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_70_64_2'>\n\t\t\t\t<input name='input_64' type='radio' value='No, but I am traveling with one'  id='choice_70_64_2'    \/>\n\t\t\t\t<label for='choice_70_64_2' id='label_70_64_2' class='gform-field-label gform-field-label--type-inline'>No, but I am traveling with one<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_70_407\" class=\"gfield gfield--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\"  ><p>\nWorld Medical Mission is currently covering the cost of the medical volunteer's economy airfare and the volunteer is responsible for all other mission trip expenses.\n<\/p><\/li><li id=\"field_70_408\" class=\"gfield gfield--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\"  ><p>\nPlease note that non-medical volunteers are responsible for all of their mission trip expenses.\n<\/p><\/li><li id=\"field_70_330\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_330'>Medical Profession Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_330' id='input_70_330' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Physician or Resident' >Physician or Resident<\/option><option value='Dentist' >Dentist<\/option><option value='Other Medical Professional' >Other Medical Professional<\/option><\/select><\/div><\/li><li id=\"field_70_65\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>\nThank you for your interest in volunteering with World Medical Mission. Unfortunately, we can only place volunteers that are medical professionals or are traveling as part of a team that includes medical professionals.\n<\/p><\/li><li id=\"field_70_66\" class=\"gfield gfield--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_70_66'>Please enter the name of the medical professional with whom you are traveling<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_70_66' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_208\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Statements of Faith\/Conduct\/Practice<\/h2><\/li><li id=\"field_70_1\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background:#f2f2f2; padding:20px;\">\n\t<h3>STATEMENT OF FAITH<\/strong> <\/h3>\n\t<p>\n\t\t<strong>What a person believes is the foundation for both life and ministry. Please prayerfully read the Samaritan's Purse Statement of Faith.<\/strong>\n\t<\/p>\n\t<div>\n\t\t<p>1.&nbsp;We believe the Bible to be the inspired, the only infallible, authoritative Word of God revealing the love of God to the world.&nbsp;<br><strong>1 Thessalonians 2:13; 2 Timothy 3:15-17; John 3:16.<\/strong><\/p>\n\t\t<p>2.&nbsp;We believe that there is one God, eternally existent in three persons: Father, Son, and Holy Spirit.&nbsp;<br><strong>Matthew 28:19; John 10:30; Ephesians 4:4-6.<\/strong><\/p>\n\t\t<p>3.&nbsp;We believe in the deity of the Lord Jesus Christ, in His virgin birth, in His sinless life, in His miracles, in His vicarious and atoning death through His shed blood on the cross, in His bodily resurrection, in His ascension to the right hand of the Father, and in His personal return in power and glory.&nbsp;<br><strong>Matthew 1:23; John 1:1-4 and 1:29; Acts 1:11 and 2:22-24; Romans 8:34; 1 Corinthians 15:3-4; 2 Corinthians 5:21; Philippians 2:5-11; Hebrews 1:1-4 and 4:15.<\/strong><\/p>\n\t\t<p>4.&nbsp;We believe that all men everywhere are lost and face the judgment of God, that Jesus Christ is the only way of salvation, and that for the salvation of lost and sinful man, repentance of sin and faith in Jesus Christ results in regeneration by the Holy Spirit. Furthermore, we believe that God will reward the righteous with eternal life in heaven, and that He will banish the unrighteous to everlasting punishment in hell.&nbsp;<br><strong>Luke 24:46-47; John 14:6; Acts 4:12; Romans 3:23; 2 Corinthians 5:10-11; Ephesians 1:7 and 2:8-9; Titus 3:4-7.<\/strong><\/p>\n\t\t<p>5. We believe in the present ministry of the Holy Spirit, whose indwelling enables the Christian to live a godly life.&nbsp;<br><strong>John 3:5-8; Acts 1:8 and 4:31; Romans 8:9; 1 Corinthians 2:14; Galatians 5:16-18; Ephesians 6:12; Colossians 2:6-10.<\/strong><\/p>\n\t\t<p>6. We believe in the resurrection of both the saved and the lost; the saved unto the resurrection of eternal life and the lost unto the resurrection of damnation and eternal punishment.&nbsp;<br><strong>1 Corinthians 15:51-57; Revelation 20:11-15.<\/strong><\/p>\n\t\t<p>7. We believe in the spiritual unity of believers in the Lord Jesus Christ and that all true believers are members of His body, the Church.&nbsp;<br><strong>1 Corinthians 12:12, 27; Ephesians 1:22-23.<\/strong><\/p>\n\t\t<p>8. We believe that the ministry of evangelism (sharing and proclaiming the message of salvation only possible by grace through faith in Jesus Christ) and discipleship (helping followers of Christ grow up into maturity in Christ) is a responsibility of all followers of Jesus Christ.<br><strong>Matthew 28:18-20; Acts 1:8; Romans 10:9-15; 1 Peter 3:15.<\/strong><\/p>\n\t\t<p>9. We believe God\u2019s plan for human sexuality is to be expressed only within the context of marriage, that God created man and woman as unique biological persons made to complete each other. God instituted monogamous marriage between male and female as the foundation of the family and the basic structure of human society. For this reason, we believe that marriage is exclusively the union of one genetic male and one genetic female. <br><strong>Genesis 2:24; Matthew 19:5-6; Mark 10:6-9; Romans 1:26-27; 1 Corinthians 6:9.<\/strong><\/p>\n\t\t<p>10. We believe that we must dedicate ourselves to prayer, to the service of our Lord, to His authority over our lives, and to the ministry of evangelism. <br><strong>Matthew 9:35-38; 22:37-39, and 28:18-20; Acts 1:8; Romans 10:9-15 and 12:20-21; Galatians 6:10; Colossians 2:6-10; 1 Peter 3:15.<\/strong><\/p>\n\t\t<p>11. We believe that human life is sacred from conception to its natural end; and that we must have concern for the physical and spiritual needs of our fellowmen.<br><strong>&nbsp;Psalm 139:13; Isaiah 49:1; Jeremiah 1:5; Matthew 22:37-39; Romans 12:20-21; Galatians 6:10.<\/strong><\/p>\n\t<\/div>\n<\/div><\/li><li id=\"field_70_356\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Do you agree with this Statement of Faith?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_70_356'>\n\t\t\t<li class='gchoice gchoice_70_356_0'>\n\t\t\t\t<input name='input_356' type='radio' value='I agree'  id='choice_70_356_0'    \/>\n\t\t\t\t<label for='choice_70_356_0' id='label_70_356_0' class='gform-field-label gform-field-label--type-inline'>I agree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_70_356_1'>\n\t\t\t\t<input name='input_356' type='radio' value='I do not agree'  id='choice_70_356_1'    \/>\n\t\t\t\t<label for='choice_70_356_1' id='label_70_356_1' class='gform-field-label gform-field-label--type-inline'>I do not agree<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_70_2\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background:#f2f2f2; padding:20px;\">\n<h3>STATEMENT OF CHRISTIAN CONDUCT<\/h3>\n<p>Samaritan\u2019s Purse\/World Medical Mission are Christian organizations wholly devoted to spreading the message of the Gospel of the Lord Jesus Christ throughout the world.  It is important that all our volunteers consistently demonstrate Christian conduct, whether while working at the mission hospital or during travel time, which was arranged by your Logistics Coordinator at World Medical Mission.<\/p>\n<p>Some examples of Christian Conduct:<\/p>\n<ol start=\"1\">\n    <li>Exhibit conduct consistent with the highest degree of moral, ethical, legal and biblical integrity.<\/li>\n    <li>Maintain high standards of individual behavior at all times and avoid the appearance of improper or questionable conduct. Male and female volunteers should honor each other by incorporating respect and purity which is stated and established by God in His Word. It is our policy that we not allow unmarried members of the opposite sex to travel alone as a couple or be perceived as an unmarried couple at Mission Hospitals. This is unacceptable by the Mission Hospitals and by Samaritan\u2019s Purse\/World Medical Mission.<\/li>\n    <li>The use of illegal drugs and alcohol is prohibited.  Samaritan\u2019s Purse\/World Medical Mission are responsible for the reputation of the organization and must be conscious of public perception. We ask that you refrain from any use of illegal drugs and\/or alcohol from the time you leave the U.S. until returning to the U.S.<\/li>\n    <li>Be aware of cultural differences and abide by cultural standards when in their country.<\/li>\n    <li>Go to the assigned area with a humble heart.  Always ask \u201cwhat can I do to help you\u201d rather than \u201cwhat do you have planned for me\u201d.<\/li>\n<\/ol>\n<\/div>\n<\/li><li id=\"field_70_357\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Do you agree with this Statement of Christian Conduct<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_70_357'>\n\t\t\t<li class='gchoice gchoice_70_357_0'>\n\t\t\t\t<input name='input_357' type='radio' value='I agree'  id='choice_70_357_0'    \/>\n\t\t\t\t<label for='choice_70_357_0' id='label_70_357_0' class='gform-field-label gform-field-label--type-inline'>I agree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_70_357_1'>\n\t\t\t\t<input name='input_357' type='radio' value='I do not agree'  id='choice_70_357_1'    \/>\n\t\t\t\t<label for='choice_70_357_1' id='label_70_357_1' class='gform-field-label gform-field-label--type-inline'>I do not agree<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_70_3\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background:#f2f2f2; padding:20px;\">\n<h3>STATEMENT OF PRACTICE<\/h3>\n<p>The commitment of World Medical Mission is <em>to serve and not to be served<\/em>. Serving on assignment means your agreement to the following:<\/p>\n<ol start=\"1\">\n    <li>I am willing to set aside personal preferences, habits and schedule in the interest of others to fulfill the ministry of the mission hospital to which I am assigned and to seek to win patients to Jesus Christ.<\/li>\n    <li>I understand there are variations in practice and understanding of Scripture in some areas of doctrine, Christian living, and witness. In serving with World Medical Mission, I will abide by the standards of the hospital to which assigned in all areas including dress, entertainment, activities, etc. This includes a willing agreement to abstain from the use of alcohol, drugs, and tobacco, and being sensitive to cultural, regional, church, and hospital expectations and standards.<\/li>\n    <li>I understand that hospitals served by World Medical Mission are Protestant evangelical mission hospitals in basic harmony with the World Medical Mission Statement of Faith. However, due to varied viewpoints on some Christian doctrines (examples: eschatology, spiritual gifts, security of the believer, etc.),  while serving, I agree to refrain from promoting, discussing or practicing in public any doctrine, teaching or gift that is contrary to the beliefs, standards, and practices of the mission hospital in which I may serve.<\/li>\n\t<li>I understand that use of profanity is detrimental to my witness and should not be a part of my speech during my time as a volunteer serving at the affiliate locations.<\/li>\n    <li>In cooperation with the hospital, I will seek to provide excellence in medical care and to present Jesus Christ as Lord and Savior.<\/li>\n<\/ol>\n<\/div><\/li><li id=\"field_70_358\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Do you agree with this Statement of Practice<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_70_358'>\n\t\t\t<li class='gchoice gchoice_70_358_0'>\n\t\t\t\t<input name='input_358' type='radio' value='I agree'  id='choice_70_358_0'    \/>\n\t\t\t\t<label for='choice_70_358_0' id='label_70_358_0' class='gform-field-label gform-field-label--type-inline'>I agree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_70_358_1'>\n\t\t\t\t<input name='input_358' type='radio' value='I do not agree'  id='choice_70_358_1'    \/>\n\t\t\t\t<label for='choice_70_358_1' id='label_70_358_1' class='gform-field-label gform-field-label--type-inline'>I do not agree<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_70_426\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent 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 gfield_label_before_complex' >Background Check<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_426.1' id='input_70_426_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_70_426\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_70_426_1' >I agree to the background check policy.<\/label><input type='hidden' name='input_426.2' value='I agree to the background check policy.' class='gform_hidden' \/><input type='hidden' name='input_426.3' value='14' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_70_426' tabindex='0'>A current background check is required in order to volunteer or travel with World Medical Mission, a project of Samaritan\u2019s Purse. I direct Samaritan\u2019s Purse and World Medical Mission to request that Accurate Background conduct a criminal background check on me. Upon completion, I authorize Accurate Background to furnish their findings to Samaritan\u2019s Purse and World Medical Mission, including, but not limited to any criminal record information discovered during the course of the background check. I understand that Samaritan\u2019s Purse and World Medical Mission will consider the results of the background check when reviewing my application to volunteer or travel with Samaritan\u2019s Purse and World Medical Mission. Samaritan\u2019s Purse and World Medical Mission may rely on this authorization to conduct additional background checks in the event I decide to volunteer with them again in the future. I certify that the information I provide to Samaritan\u2019s Purse and\/or Accurate Background to perform the background check is accurate. I release Samaritan\u2019s Purse\/World Medical Mission and any other entities, involved in performing or providing background check information and their respective officers, director, employees, and representatives, from any liability arising from Samaritan\u2019s Purse and World Medical Mission\u2019s request that Accurate Background conduct a criminal background check on me.<\/div><\/li><li id=\"field_70_211\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Please click \"Next\" to continue<\/strong><\/li><li id=\"field_70_359\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Thank you for your interest in serving with World Medical Mission. Agreement with these statements is required prior to service. We encourage you to seek opportunities with other organizations. <\/p><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_70_7' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_70_2_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_70_2' class='gform_page' data-js='page-field-id-7' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_70_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_70_399\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Please note:<\/h2>\n<p>\nPlease use the \u201cPrevious\u201d and \u201cNext\u201d buttons at the bottom of the form rather than clicking your browser\u2019s back button, or clicking \"Backspace\" (on some browsers).\n<br \/><br \/>\nIf you accidentally click your browser\u2019s back button, simply click the forward button and then refresh the page.  If you are asked, click to confirm that you wish to resubmit the form.\n<\/p><\/li><li id=\"field_70_16\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Personal Information<\/h2><\/li><li id=\"field_70_11\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_11'>Title<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_11' id='input_70_11' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Mr.' >Mr.<\/option><option value='Mrs.' >Mrs.<\/option><option value='Ms.' >Ms.<\/option><option value='Miss' >Miss<\/option><option value='Dr.' >Dr.<\/option><option value='Rev.' >Rev.<\/option><option value='Pastor' >Pastor<\/option><option value='Chaplain' >Chaplain<\/option><option value='Minister' >Minister<\/option><option value='Bishop' >Bishop<\/option><option value='Father' >Father<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_70_9\" class=\"gfield gfield--type-text gf_left_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_70_9'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_70_9' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_12\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_12'>Middle Initial<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_70_12' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_10\" class=\"gfield gfield--type-text gf_right_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_70_10'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_70_10' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_424\" class=\"gfield gfield--type-address gfield--width-full temp_hide field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Mailing Address (temp_hide)<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_70_424' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_70_424_1_container' >\n                                        <input type='text' name='input_424.1' id='input_70_424_1' value=''    aria-required='false'    \/>\n                                        <label for='input_70_424_1' id='input_70_424_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_70_424_2_container' >\n                                        <input type='text' name='input_424.2' id='input_70_424_2' value=''     aria-required='false'   \/>\n                                        <label for='input_70_424_2' id='input_70_424_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_70_424_3_container' >\n                                    <input type='text' name='input_424.3' id='input_70_424_3' value=''    aria-required='false'    \/>\n                                    <label for='input_70_424_3' id='input_70_424_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_70_424_4_container' >\n                                        <select name='input_424.4' id='input_70_424_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='AL' >Alabama<\/option><option value='AK' >Alaska<\/option><option value='AZ' >Arizona<\/option><option value='AR' >Arkansas<\/option><option value='CA' >California<\/option><option value='CO' >Colorado<\/option><option value='CT' >Connecticut<\/option><option value='DE' >Delaware<\/option><option value='DC' >District of Columbia<\/option><option value='FL' >Florida<\/option><option value='GA' >Georgia<\/option><option value='GU' >Guam<\/option><option value='HI' >Hawaii<\/option><option value='ID' >Idaho<\/option><option value='IL' >Illinois<\/option><option value='IN' >Indiana<\/option><option value='IA' >Iowa<\/option><option value='KS' >Kansas<\/option><option value='KY' >Kentucky<\/option><option value='LA' >Louisiana<\/option><option value='ME' >Maine<\/option><option value='MD' >Maryland<\/option><option value='MA' >Massachusetts<\/option><option value='MI' >Michigan<\/option><option value='MN' >Minnesota<\/option><option value='MS' >Mississippi<\/option><option value='MO' >Missouri<\/option><option value='MT' >Montana<\/option><option value='NE' >Nebraska<\/option><option value='NV' >Nevada<\/option><option value='NH' >New Hampshire<\/option><option value='NJ' >New Jersey<\/option><option value='NM' >New Mexico<\/option><option value='NY' >New York<\/option><option value='NC' >North Carolina<\/option><option value='ND' >North Dakota<\/option><option value='OH' >Ohio<\/option><option value='OK' >Oklahoma<\/option><option value='OR' >Oregon<\/option><option value='PA' >Pennsylvania<\/option><option value='PR' >Puerto Rico<\/option><option value='RI' >Rhode Island<\/option><option value='SC' >South Carolina<\/option><option value='SD' >South Dakota<\/option><option value='TN' >Tennessee<\/option><option value='TX' >Texas<\/option><option value='UT' >Utah<\/option><option value='VT' >Vermont<\/option><option value='VA' >Virginia<\/option><option value='WA' >Washington<\/option><option value='WV' >West Virginia<\/option><option value='WI' >Wisconsin<\/option><option value='WY' >Wyoming<\/option><\/select>\n                                        <label for='input_70_424_4' id='input_70_424_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_70_424_5_container' >\n                                    <input type='text' name='input_424.5' id='input_70_424_5' value=''    aria-required='false'    \/>\n                                    <label for='input_70_424_5' id='input_70_424_5_label' class='gform-field-label gform-field-label--type-sub '>Zip Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_424.6' id='input_70_424_6' value='USAB' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_70_275\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Mailing Address<\/h2><\/li><li id=\"field_70_282\" class=\"gfield gfield--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_70_282'>Mailing Address 1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_282' id='input_70_282' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_283\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_283'>Mailing Address 2<\/label><div class='ginput_container ginput_container_text'><input name='input_283' id='input_70_283' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_285\" class=\"gfield gfield--type-text gf_left_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_70_285'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_285' id='input_70_285' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_284\" class=\"gfield gfield--type-select gf_right_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_70_284'>State \/ Province<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_284' id='input_70_284' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Alberta' >Alberta<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><option value='Australian Capital Territory' >Australian Capital Territory<\/option><option value='British Columbia' >British Columbia<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Federated States of Micronesia' >Federated States of Micronesia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Manitoba' >Manitoba<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New South Wales' >New South Wales<\/option><option value='New York' >New York<\/option><option value='Newfoundland' >Newfoundland<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Northern Territory' >Northern Territory<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Ontario' >Ontario<\/option><option value='Oregon' >Oregon<\/option><option value='Palau' >Palau<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Quebec' >Quebec<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Queensland' >Queensland<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='South Australia' >South Australia<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tasmania' >Tasmania<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Victoria' >Victoria<\/option><option value='Virgin Islands' >Virgin Islands<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Western Australia' >Western Australia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Yukon Territory' >Yukon Territory<\/option><\/select><\/div><\/li><li id=\"field_70_298\" class=\"gfield gfield--type-text gf_right_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_70_298'>State \/ Province \/ Region<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_298' id='input_70_298' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_286\" class=\"gfield gfield--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_70_286'>ZIP \/ Postal Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_286' id='input_70_286' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_276\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Street Address same as Mailing Address?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_70_276'>\n\t\t\t<li class='gchoice gchoice_70_276_0'>\n\t\t\t\t<input name='input_276' type='radio' value='Yes' checked='checked' id='choice_70_276_0'    \/>\n\t\t\t\t<label for='choice_70_276_0' id='label_70_276_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_70_276_1'>\n\t\t\t\t<input name='input_276' type='radio' value='No'  id='choice_70_276_1'    \/>\n\t\t\t\t<label for='choice_70_276_1' id='label_70_276_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_70_274\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Street Address<\/h2><\/li><li id=\"field_70_425\" class=\"gfield gfield--type-address gfield--width-full temp_hide field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Street Address (temp_hide)<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_70_425' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_70_425_1_container' >\n                                        <input type='text' name='input_425.1' id='input_70_425_1' value=''    aria-required='false'    \/>\n                                        <label for='input_70_425_1' id='input_70_425_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_70_425_2_container' >\n                                        <input type='text' name='input_425.2' id='input_70_425_2' value=''     aria-required='false'   \/>\n                                        <label for='input_70_425_2' id='input_70_425_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_70_425_3_container' >\n                                    <input type='text' name='input_425.3' id='input_70_425_3' value=''    aria-required='false'    \/>\n                                    <label for='input_70_425_3' id='input_70_425_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_70_425_4_container' >\n                                        <select name='input_425.4' id='input_70_425_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='AL' >Alabama<\/option><option value='AK' >Alaska<\/option><option value='AZ' >Arizona<\/option><option value='AR' >Arkansas<\/option><option value='CA' >California<\/option><option value='CO' >Colorado<\/option><option value='CT' >Connecticut<\/option><option value='DE' >Delaware<\/option><option value='DC' >District of Columbia<\/option><option value='FL' >Florida<\/option><option value='GA' >Georgia<\/option><option value='GU' >Guam<\/option><option value='HI' >Hawaii<\/option><option value='ID' >Idaho<\/option><option value='IL' >Illinois<\/option><option value='IN' >Indiana<\/option><option value='IA' >Iowa<\/option><option value='KS' >Kansas<\/option><option value='KY' >Kentucky<\/option><option value='LA' >Louisiana<\/option><option value='ME' >Maine<\/option><option value='MD' >Maryland<\/option><option value='MA' >Massachusetts<\/option><option value='MI' >Michigan<\/option><option value='MN' >Minnesota<\/option><option value='MS' >Mississippi<\/option><option value='MO' >Missouri<\/option><option value='MT' >Montana<\/option><option value='NE' >Nebraska<\/option><option value='NV' >Nevada<\/option><option value='NH' >New Hampshire<\/option><option value='NJ' >New Jersey<\/option><option value='NM' >New Mexico<\/option><option value='NY' >New York<\/option><option value='NC' >North Carolina<\/option><option value='ND' >North Dakota<\/option><option value='OH' >Ohio<\/option><option value='OK' >Oklahoma<\/option><option value='OR' >Oregon<\/option><option value='PA' >Pennsylvania<\/option><option value='PR' >Puerto Rico<\/option><option value='RI' >Rhode Island<\/option><option value='SC' >South Carolina<\/option><option value='SD' >South Dakota<\/option><option value='TN' >Tennessee<\/option><option value='TX' >Texas<\/option><option value='UT' >Utah<\/option><option value='VT' >Vermont<\/option><option value='VA' >Virginia<\/option><option value='WA' >Washington<\/option><option value='WV' >West Virginia<\/option><option value='WI' >Wisconsin<\/option><option value='WY' >Wyoming<\/option><\/select>\n                                        <label for='input_70_425_4' id='input_70_425_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_70_425_5_container' >\n                                    <input type='text' name='input_425.5' id='input_70_425_5' value=''    aria-required='false'    \/>\n                                    <label for='input_70_425_5' id='input_70_425_5_label' class='gform-field-label gform-field-label--type-sub '>Zip Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_425.6' id='input_70_425_6' value='USAB' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_70_219\" class=\"gfield gfield--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_70_219'>Street Address 1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_219' id='input_70_219' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_220\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_220'>Street Address 2<\/label><div class='ginput_container ginput_container_text'><input name='input_220' id='input_70_220' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_221\" class=\"gfield gfield--type-text gf_left_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_70_221'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_221' id='input_70_221' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_224\" class=\"gfield gfield--type-select gf_right_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_70_224'>State \/ Province<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_224' id='input_70_224' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Alberta' >Alberta<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><option value='Australian Capital Territory' >Australian Capital Territory<\/option><option value='British Columbia' >British Columbia<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Federated States of Micronesia' >Federated States of Micronesia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Manitoba' >Manitoba<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New South Wales' >New South Wales<\/option><option value='New York' >New York<\/option><option value='Newfoundland' >Newfoundland<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Northern Territory' >Northern Territory<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Ontario' >Ontario<\/option><option value='Oregon' >Oregon<\/option><option value='Palau' >Palau<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Quebec' >Quebec<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Queensland' >Queensland<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='South Australia' >South Australia<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tasmania' >Tasmania<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Victoria' >Victoria<\/option><option value='Virgin Islands' >Virgin Islands<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Western Australia' >Western Australia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Yukon Territory' >Yukon Territory<\/option><\/select><\/div><\/li><li id=\"field_70_226\" class=\"gfield gfield--type-text gf_right_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_70_226'>State \/ Province \/ Region<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_226' id='input_70_226' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_222\" class=\"gfield gfield--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_70_222'>ZIP \/ Postal Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_222' id='input_70_222' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_277\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Contact Details<\/h2><\/li><li id=\"field_70_8\" class=\"gfield gfield--type-email emailBlock 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' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_70_8_container'>\n                                <span id='input_70_8_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_8' id='input_70_8' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_70_8' class='gform-field-label gform-field-label--type-sub '>Introduce un email<\/label>\n                                <\/span>\n                                <span id='input_70_8_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_8_2' id='input_70_8_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_70_8_2' class='gform-field-label gform-field-label--type-sub '>Confirmar email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_70_17\" class=\"gfield gfield--type-phone gf_left_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_70_17'>Primary 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_17' id='input_70_17' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_402\" class=\"gfield gfield--type-phone gf_left_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_70_402'>Primary 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_402' id='input_70_402' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_400\" class=\"gfield gfield--type-select gf_right_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_70_400'>Phone Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_400' id='input_70_400' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Mobile' selected='selected'>Mobile<\/option><\/select><\/div><\/li><li id=\"field_70_293\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_293'>Secondary Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_293' id='input_70_293' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_332\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_332'>Secondary Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_332' id='input_70_332' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_217\" class=\"gfield gfield--type-select gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_217'>Phone Type<\/label><div class='ginput_container ginput_container_select'><select name='input_217' id='input_70_217' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='Mobile' >Mobile<\/option><option value='Home' >Home<\/option><option value='Business' >Business<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_70_21\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_21'>Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_21' id='input_70_21' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='Male' >Male<\/option><option value='Female' >Female<\/option><\/select><\/div><\/li><li id=\"field_70_410\" class=\"gfield gfield--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\"  ><label class='gfield_label gform-field-label' for='input_70_410'>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_410' id='input_70_410' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_70_410_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_70_410_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_70_410' class='gform_hidden' value='https:\/\/samaritanspurse.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_70_28\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Are you physically fit to perform the volunteer services for which you are applying?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_70_28'>\n\t\t\t<li class='gchoice gchoice_70_28_0'>\n\t\t\t\t<input name='input_28' type='radio' value='Yes'  id='choice_70_28_0'    \/>\n\t\t\t\t<label for='choice_70_28_0' id='label_70_28_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_70_28_1'>\n\t\t\t\t<input name='input_28' type='radio' value='No'  id='choice_70_28_1'    \/>\n\t\t\t\t<label for='choice_70_28_1' id='label_70_28_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_70_29\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_29'>Please enter any chronic health conditions or comments:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_29' id='input_70_29' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_70_162\" class=\"gfield gfield--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_70_162'>Your Profession\/Occupation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_162' id='input_70_162' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_70_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_70_30' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_70_3_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_70_3' class='gform_page' data-js='page-field-id-30' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_70_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_70_31\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Education<\/h2><\/li><li id=\"field_70_155\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_155'>What is the highest level of education you have completed?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_155' id='input_70_155' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='Middle School' >Middle School<\/option><option value='High School' >High School<\/option><option value='Vocational\/Technical Training' >Vocational\/Technical Training<\/option><option value='College\/University' >College\/University<\/option><option value='Postgraduate' >Postgraduate<\/option><\/select><\/div><\/li><li id=\"field_70_160\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_160'>Select grade level completed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_160' id='input_70_160' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='6th' >6th<\/option><option value='7th' >7th<\/option><option value='8th' >8th<\/option><option value='9th' >9th<\/option><option value='10th' >10th<\/option><option value='11th' >11th<\/option><option value='12th' >12th<\/option><\/select><\/div><\/li><li id=\"field_70_376\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Community\/Technical College?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_70_376'>\n\t\t\t<li class='gchoice gchoice_70_376_0'>\n\t\t\t\t<input name='input_376' type='radio' value='Yes'  id='choice_70_376_0'    \/>\n\t\t\t\t<label for='choice_70_376_0' id='label_70_376_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_70_376_1'>\n\t\t\t\t<input name='input_376' type='radio' value='No'  id='choice_70_376_1'    \/>\n\t\t\t\t<label for='choice_70_376_1' id='label_70_376_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_70_156\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Community\/Technical College<\/h2><\/li><li id=\"field_70_349\" class=\"gfield gfield--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_70_349'>School Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_349' id='input_70_349' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_350\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_350'>School Country<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_350' id='input_70_350' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='Australia' >Australia<\/option><option value='Canada' >Canada<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States of America' >United States of America<\/option><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='Algeria (El Djazair)' >Algeria (El Djazair)<\/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='Angullia' >Angullia<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua' >Antigua<\/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='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='Bosnia' >Bosnia<\/option><option value='Bosnia-Herzegovina' >Bosnia-Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='Bristish Indian Ocean Territory' >Bristish Indian Ocean Territory<\/option><option value='British Honduras' >British Honduras<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Fasco' >Burkina Fasco<\/option><option value='Burma' >Burma<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canal Zone' >Canal Zone<\/option><option value='Canary Islands' >Canary Islands<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Ceylon' >Ceylon<\/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='Colombia' >Colombia<\/option><option value='Comoro Islands' >Comoro Islands<\/option><option value='Congo, Republic of' >Congo, Republic of<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Cote D&#039;&#039;lvoire (Ivory Coast)' >Cote D&#039;&#039;lvoire (Ivory Coast)<\/option><option value='Cote d&#039;Ivoire' >Cote d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Croatia (Hrvatska)' >Croatia (Hrvatska)<\/option><option value='Cuba' >Cuba<\/option><option value='Curaco, Netherlands Antilles' >Curaco, Netherlands Antilles<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Dem Rep of the Congo - Kinshasa' >Dem Rep of the Congo - Kinshasa<\/option><option value='Dem. People&#039;s Rep. of Korea' >Dem. People&#039;s Rep. of Korea<\/option><option value='Democratic Republic of the Congo' >Democratic Republic of the Congo<\/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='East Timor' >East Timor<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='England' >England<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Faeroe Islands' >Faeroe Islands<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Federated States of Micronesia' >Federated States of Micronesia<\/option><option value='Fiji' >Fiji<\/option><option value='Fiji Islands' >Fiji Islands<\/option><option value='Finland' >Finland<\/option><option value='For anonymous donor records' >For anonymous donor records<\/option><option value='Formosa' >Formosa<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/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='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Grenada, West Indies' >Grenada, West Indies<\/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='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='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kazakstan' >Kazakstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea' >Korea<\/option><option value='Korle-Gommo, West Africa' >Korle-Gommo, West Africa<\/option><option value='Kosovo' >Kosovo<\/option><option value='Kurdistan' >Kurdistan<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Laos' >Laos<\/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='Macau - China' >Macau - China<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Mail' >Mail<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Malta' >Malta<\/option><option value='Marinique' >Marinique<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mauritius, Indian Ocean' >Mauritius, Indian Ocean<\/option><option value='Maurt' >Maurt<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/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='Netherlands Antilles' >Netherlands Antilles<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='New Zealand (Aotearoa)' >New Zealand (Aotearoa)<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Niger Republic' >Niger Republic<\/option><option value='Niger, West Africa' >Niger, West Africa<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='North Korea' >North Korea<\/option><option value='North Sudan' >North Sudan<\/option><option value='Northern Ireland' >Northern Ireland<\/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' >Palestine<\/option><option value='Panama' >Panama<\/option><option value='Papua' >Papua<\/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='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Principat D&#039;andorra' >Principat D&#039;andorra<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Rep Du Burundi' >Rep Du Burundi<\/option><option value='Rep Du Gabon' >Rep Du Gabon<\/option><option value='Rep Du Mali' >Rep Du Mali<\/option><option value='Rep Du Senegal' >Rep Du Senegal<\/option><option value='Rep of Congo - Brazzaville' >Rep of Congo - Brazzaville<\/option><option value='Rep of Guinea-Bissau' >Rep of Guinea-Bissau<\/option><option value='Republic of Benin' >Republic of Benin<\/option><option value='Republic of Burkina Faso' >Republic of Burkina Faso<\/option><option value='Republic of China' >Republic of China<\/option><option value='Republic of Korea' >Republic of Korea<\/option><option value='Republic of Singapore' >Republic of Singapore<\/option><option value='Republic of South Africa' >Republic of South Africa<\/option><option value='Republic of Upper Volta' >Republic of Upper Volta<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/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='Scotland' >Scotland<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Serbia and Montenegro' >Serbia and Montenegro<\/option><option value='Seychelles' >Seychelles<\/option><option value='Seychelles, Indian Ocean' >Seychelles, Indian Ocean<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/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='Somaliland' >Somaliland<\/option><option value='Somolia' >Somolia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia\/South Sandwich Islands' >South Georgia\/South Sandwich Islands<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='South Vietnam' >South Vietnam<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='St Kitts, Leeward Islands' >St Kitts, Leeward Islands<\/option><option value='St Maarten, Leeward Islands' >St Maarten, Leeward Islands<\/option><option value='St. Lucia' >St. Lucia<\/option><option value='St. Vincent' >St. Vincent<\/option><option value='Sudan' >Sudan<\/option><option value='Sultan of Oman' >Sultan of Oman<\/option><option value='Suriname' >Suriname<\/option><option value='Suriname, South America' >Suriname, South America<\/option><option value='Swaziland' >Swaziland<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Taiwan, Republic Of China' >Taiwan, Republic Of China<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='The Netherlands' >The Netherlands<\/option><option value='Tibet' >Tibet<\/option><option value='Togo' >Togo<\/option><option value='Tonga' >Tonga<\/option><option value='Tonga Islands, South Pacific' >Tonga Islands, South Pacific<\/option><option value='Transkei, Africa' >Transkei, Africa<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Turks in Caicos Island' >Turks in Caicos Island<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United States Minor Outlying Islands' >United States Minor Outlying Islands<\/option><option value='Unknown Country' >Unknown Country<\/option><option value='Unknown Name\/Address' >Unknown Name\/Address<\/option><option value='Uruguay' >Uruguay<\/option><option value='USSR' >USSR<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Vatican City' >Vatican City<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wales' >Wales<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='West Germany' >West Germany<\/option><option value='West Indies' >West Indies<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Western Samoa' >Western Samoa<\/option><option value='Yemen' >Yemen<\/option><option value='Yemen Arab Republic' >Yemen Arab Republic<\/option><option value='Yugoslavia' >Yugoslavia<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select><\/div><\/li><li id=\"field_70_354\" class=\"gfield gfield--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_70_354'>Field of Study<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_354' id='input_70_354' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_385\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_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_70_385'>End Date<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_385' id='input_70_385' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='MM\/DD\/YYYY' aria-describedby=\"input_70_385_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_70_385_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_70_385' class='gform_hidden' value='https:\/\/samaritanspurse.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_70_355\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Graduated?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_70_355'>\n\t\t\t<li class='gchoice gchoice_70_355_0'>\n\t\t\t\t<input name='input_355' type='radio' value='Yes'  id='choice_70_355_0'    \/>\n\t\t\t\t<label for='choice_70_355_0' id='label_70_355_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_70_355_1'>\n\t\t\t\t<input name='input_355' type='radio' value='No'  id='choice_70_355_1'    \/>\n\t\t\t\t<label for='choice_70_355_1' id='label_70_355_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_70_378\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_70_377\" class=\"gfield gfield--type-radio gfield--type-choice 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' >College\/University?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_70_377'>\n\t\t\t<li class='gchoice gchoice_70_377_0'>\n\t\t\t\t<input name='input_377' type='radio' value='Yes'  id='choice_70_377_0'    \/>\n\t\t\t\t<label for='choice_70_377_0' id='label_70_377_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_70_377_1'>\n\t\t\t\t<input name='input_377' type='radio' value='No'  id='choice_70_377_1'    \/>\n\t\t\t\t<label for='choice_70_377_1' id='label_70_377_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_70_348\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">College \/ University<\/h2><\/li><li id=\"field_70_36\" class=\"gfield gfield--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_70_36'>School Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_70_36' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_228\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_228'>School Country<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_228' id='input_70_228' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='Australia' >Australia<\/option><option value='Canada' >Canada<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States of America' >United States of America<\/option><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='Algeria (El Djazair)' >Algeria (El Djazair)<\/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='Angullia' >Angullia<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua' >Antigua<\/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='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='Bosnia' >Bosnia<\/option><option value='Bosnia-Herzegovina' >Bosnia-Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='Bristish Indian Ocean Territory' >Bristish Indian Ocean Territory<\/option><option value='British Honduras' >British Honduras<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Fasco' >Burkina Fasco<\/option><option value='Burma' >Burma<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canal Zone' >Canal Zone<\/option><option value='Canary Islands' >Canary Islands<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Ceylon' >Ceylon<\/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='Colombia' >Colombia<\/option><option value='Comoro Islands' >Comoro Islands<\/option><option value='Congo, Republic of' >Congo, Republic of<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Cote D&#039;&#039;lvoire (Ivory Coast)' >Cote D&#039;&#039;lvoire (Ivory Coast)<\/option><option value='Cote d&#039;Ivoire' >Cote d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Croatia (Hrvatska)' >Croatia (Hrvatska)<\/option><option value='Cuba' >Cuba<\/option><option value='Curaco, Netherlands Antilles' >Curaco, Netherlands Antilles<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Dem Rep of the Congo - Kinshasa' >Dem Rep of the Congo - Kinshasa<\/option><option value='Dem. People&#039;s Rep. of Korea' >Dem. People&#039;s Rep. of Korea<\/option><option value='Democratic Republic of the Congo' >Democratic Republic of the Congo<\/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='East Timor' >East Timor<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='England' >England<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Faeroe Islands' >Faeroe Islands<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Federated States of Micronesia' >Federated States of Micronesia<\/option><option value='Fiji' >Fiji<\/option><option value='Fiji Islands' >Fiji Islands<\/option><option value='Finland' >Finland<\/option><option value='For anonymous donor records' >For anonymous donor records<\/option><option value='Formosa' >Formosa<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/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='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Grenada, West Indies' >Grenada, West Indies<\/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='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='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kazakstan' >Kazakstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea' >Korea<\/option><option value='Korle-Gommo, West Africa' >Korle-Gommo, West Africa<\/option><option value='Kosovo' >Kosovo<\/option><option value='Kurdistan' >Kurdistan<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Laos' >Laos<\/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='Macau - China' >Macau - China<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Mail' >Mail<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Malta' >Malta<\/option><option value='Marinique' >Marinique<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mauritius, Indian Ocean' >Mauritius, Indian Ocean<\/option><option value='Maurt' >Maurt<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/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='Netherlands Antilles' >Netherlands Antilles<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='New Zealand (Aotearoa)' >New Zealand (Aotearoa)<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Niger Republic' >Niger Republic<\/option><option value='Niger, West Africa' >Niger, West Africa<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='North Korea' >North Korea<\/option><option value='North Sudan' >North Sudan<\/option><option value='Northern Ireland' >Northern Ireland<\/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' >Palestine<\/option><option value='Panama' >Panama<\/option><option value='Papua' >Papua<\/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='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Principat D&#039;andorra' >Principat D&#039;andorra<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Rep Du Burundi' >Rep Du Burundi<\/option><option value='Rep Du Gabon' >Rep Du Gabon<\/option><option value='Rep Du Mali' >Rep Du Mali<\/option><option value='Rep Du Senegal' >Rep Du Senegal<\/option><option value='Rep of Congo - Brazzaville' >Rep of Congo - Brazzaville<\/option><option value='Rep of Guinea-Bissau' >Rep of Guinea-Bissau<\/option><option value='Republic of Benin' >Republic of Benin<\/option><option value='Republic of Burkina Faso' >Republic of Burkina Faso<\/option><option value='Republic of China' >Republic of China<\/option><option value='Republic of Korea' >Republic of Korea<\/option><option value='Republic of Singapore' >Republic of Singapore<\/option><option value='Republic of South Africa' >Republic of South Africa<\/option><option value='Republic of Upper Volta' >Republic of Upper Volta<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/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='Scotland' >Scotland<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Serbia and Montenegro' >Serbia and Montenegro<\/option><option value='Seychelles' >Seychelles<\/option><option value='Seychelles, Indian Ocean' >Seychelles, Indian Ocean<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/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='Somaliland' >Somaliland<\/option><option value='Somolia' >Somolia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia\/South Sandwich Islands' >South Georgia\/South Sandwich Islands<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='South Vietnam' >South Vietnam<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='St Kitts, Leeward Islands' >St Kitts, Leeward Islands<\/option><option value='St Maarten, Leeward Islands' >St Maarten, Leeward Islands<\/option><option value='St. Lucia' >St. Lucia<\/option><option value='St. Vincent' >St. Vincent<\/option><option value='Sudan' >Sudan<\/option><option value='Sultan of Oman' >Sultan of Oman<\/option><option value='Suriname' >Suriname<\/option><option value='Suriname, South America' >Suriname, South America<\/option><option value='Swaziland' >Swaziland<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Taiwan, Republic Of China' >Taiwan, Republic Of China<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='The Netherlands' >The Netherlands<\/option><option value='Tibet' >Tibet<\/option><option value='Togo' >Togo<\/option><option value='Tonga' >Tonga<\/option><option value='Tonga Islands, South Pacific' >Tonga Islands, South Pacific<\/option><option value='Transkei, Africa' >Transkei, Africa<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Turks in Caicos Island' >Turks in Caicos Island<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United States Minor Outlying Islands' >United States Minor Outlying Islands<\/option><option value='Unknown Country' >Unknown Country<\/option><option value='Unknown Name\/Address' >Unknown Name\/Address<\/option><option value='Uruguay' >Uruguay<\/option><option value='USSR' >USSR<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Vatican City' >Vatican City<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wales' >Wales<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='West Germany' >West Germany<\/option><option value='West Indies' >West Indies<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Western Samoa' >Western Samoa<\/option><option value='Yemen' >Yemen<\/option><option value='Yemen Arab Republic' >Yemen Arab Republic<\/option><option value='Yugoslavia' >Yugoslavia<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select><\/div><\/li><li id=\"field_70_37\" class=\"gfield gfield--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_70_37'>Field of Study<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_70_37' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_38\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_38'>Degree\/Specialty<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_38' id='input_70_38' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='AA' >AA<\/option><option value='BA' >BA<\/option><option value='BS' >BS<\/option><option value='MA' >MA<\/option><option value='MS' >MS<\/option><option value='BDIV' >BDIV<\/option><option value='PHD' >PHD<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_70_384\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_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_70_384'>End Date<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_384' id='input_70_384' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='MM\/DD\/YYYY' aria-describedby=\"input_70_384_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_70_384_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_70_384' class='gform_hidden' value='https:\/\/samaritanspurse.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_70_157\" class=\"gfield gfield--type-section gsection hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_70_419\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><h2 class=\"gsection_title\">Other Other<\/h2><\/li><li id=\"field_70_418\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Other School?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_70_418'>\n\t\t\t<li class='gchoice gchoice_70_418_0'>\n\t\t\t\t<input name='input_418' type='radio' value='Yes'  id='choice_70_418_0'    \/>\n\t\t\t\t<label for='choice_70_418_0' id='label_70_418_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_70_418_1'>\n\t\t\t\t<input name='input_418' type='radio' value='No'  id='choice_70_418_1'    \/>\n\t\t\t\t<label for='choice_70_418_1' id='label_70_418_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_70_417\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><h2 class=\"gsection_title\">Professional School Section (hidden)<\/h2><\/li><li id=\"field_70_346\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"font-weight: 700;font-size: 1.25em;margin-top:30px;\">Medical School<\/h3>\n<hr style=\"margin-top:0;\"><\/li><li id=\"field_70_412\" class=\"gfield gfield--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\"  ><h3 style=\"font-weight: 700;font-size: 1.25em;margin-top:30px;\">Dental School<\/h3>\n<hr style=\"margin-top:0;\"><\/li><li id=\"field_70_347\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"font-weight: 700;font-size: 1.25em;margin-top:30px;\">Other School<\/h3>\n<hr style=\"margin-top:0;\"><\/li><li id=\"field_70_41\" class=\"gfield gfield--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_70_41'>School Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_70_41' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_234\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_234'>School Country<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_234' id='input_70_234' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='Australia' >Australia<\/option><option value='Canada' >Canada<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States of America' >United States of America<\/option><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='Algeria (El Djazair)' >Algeria (El Djazair)<\/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='Angullia' >Angullia<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua' >Antigua<\/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='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='Bosnia' >Bosnia<\/option><option value='Bosnia-Herzegovina' >Bosnia-Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='Bristish Indian Ocean Territory' >Bristish Indian Ocean Territory<\/option><option value='British Honduras' >British Honduras<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Fasco' >Burkina Fasco<\/option><option value='Burma' >Burma<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canal Zone' >Canal Zone<\/option><option value='Canary Islands' >Canary Islands<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Ceylon' >Ceylon<\/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='Colombia' >Colombia<\/option><option value='Comoro Islands' >Comoro Islands<\/option><option value='Congo, Republic of' >Congo, Republic of<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Cote D&#039;&#039;lvoire (Ivory Coast)' >Cote D&#039;&#039;lvoire (Ivory Coast)<\/option><option value='Cote d&#039;Ivoire' >Cote d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Croatia (Hrvatska)' >Croatia (Hrvatska)<\/option><option value='Cuba' >Cuba<\/option><option value='Curaco, Netherlands Antilles' >Curaco, Netherlands Antilles<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Dem Rep of the Congo - Kinshasa' >Dem Rep of the Congo - Kinshasa<\/option><option value='Dem. People&#039;s Rep. of Korea' >Dem. People&#039;s Rep. of Korea<\/option><option value='Democratic Republic of the Congo' >Democratic Republic of the Congo<\/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='East Timor' >East Timor<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='England' >England<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Faeroe Islands' >Faeroe Islands<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Federated States of Micronesia' >Federated States of Micronesia<\/option><option value='Fiji' >Fiji<\/option><option value='Fiji Islands' >Fiji Islands<\/option><option value='Finland' >Finland<\/option><option value='For anonymous donor records' >For anonymous donor records<\/option><option value='Formosa' >Formosa<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/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='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Grenada, West Indies' >Grenada, West Indies<\/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='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='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kazakstan' >Kazakstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea' >Korea<\/option><option value='Korle-Gommo, West Africa' >Korle-Gommo, West Africa<\/option><option value='Kosovo' >Kosovo<\/option><option value='Kurdistan' >Kurdistan<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Laos' >Laos<\/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='Macau - China' >Macau - China<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Mail' >Mail<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Malta' >Malta<\/option><option value='Marinique' >Marinique<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mauritius, Indian Ocean' >Mauritius, Indian Ocean<\/option><option value='Maurt' >Maurt<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/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='Netherlands Antilles' >Netherlands Antilles<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='New Zealand (Aotearoa)' >New Zealand (Aotearoa)<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Niger Republic' >Niger Republic<\/option><option value='Niger, West Africa' >Niger, West Africa<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='North Korea' >North Korea<\/option><option value='North Sudan' >North Sudan<\/option><option value='Northern Ireland' >Northern Ireland<\/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' >Palestine<\/option><option value='Panama' >Panama<\/option><option value='Papua' >Papua<\/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='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Principat D&#039;andorra' >Principat D&#039;andorra<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Rep Du Burundi' >Rep Du Burundi<\/option><option value='Rep Du Gabon' >Rep Du Gabon<\/option><option value='Rep Du Mali' >Rep Du Mali<\/option><option value='Rep Du Senegal' >Rep Du Senegal<\/option><option value='Rep of Congo - Brazzaville' >Rep of Congo - Brazzaville<\/option><option value='Rep of Guinea-Bissau' >Rep of Guinea-Bissau<\/option><option value='Republic of Benin' >Republic of Benin<\/option><option value='Republic of Burkina Faso' >Republic of Burkina Faso<\/option><option value='Republic of China' >Republic of China<\/option><option value='Republic of Korea' >Republic of Korea<\/option><option value='Republic of Singapore' >Republic of Singapore<\/option><option value='Republic of South Africa' >Republic of South Africa<\/option><option value='Republic of Upper Volta' >Republic of Upper Volta<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/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='Scotland' >Scotland<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Serbia and Montenegro' >Serbia and Montenegro<\/option><option value='Seychelles' >Seychelles<\/option><option value='Seychelles, Indian Ocean' >Seychelles, Indian Ocean<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/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='Somaliland' >Somaliland<\/option><option value='Somolia' >Somolia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia\/South Sandwich Islands' >South Georgia\/South Sandwich Islands<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='South Vietnam' >South Vietnam<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='St Kitts, Leeward Islands' >St Kitts, Leeward Islands<\/option><option value='St Maarten, Leeward Islands' >St Maarten, Leeward Islands<\/option><option value='St. Lucia' >St. Lucia<\/option><option value='St. Vincent' >St. Vincent<\/option><option value='Sudan' >Sudan<\/option><option value='Sultan of Oman' >Sultan of Oman<\/option><option value='Suriname' >Suriname<\/option><option value='Suriname, South America' >Suriname, South America<\/option><option value='Swaziland' >Swaziland<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Taiwan, Republic Of China' >Taiwan, Republic Of China<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='The Netherlands' >The Netherlands<\/option><option value='Tibet' >Tibet<\/option><option value='Togo' >Togo<\/option><option value='Tonga' >Tonga<\/option><option value='Tonga Islands, South Pacific' >Tonga Islands, South Pacific<\/option><option value='Transkei, Africa' >Transkei, Africa<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Turks in Caicos Island' >Turks in Caicos Island<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United States Minor Outlying Islands' >United States Minor Outlying Islands<\/option><option value='Unknown Country' >Unknown Country<\/option><option value='Unknown Name\/Address' >Unknown Name\/Address<\/option><option value='Uruguay' >Uruguay<\/option><option value='USSR' >USSR<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Vatican City' >Vatican City<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wales' >Wales<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='West Germany' >West Germany<\/option><option value='West Indies' >West Indies<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Western Samoa' >Western Samoa<\/option><option value='Yemen' >Yemen<\/option><option value='Yemen Arab Republic' >Yemen Arab Republic<\/option><option value='Yugoslavia' >Yugoslavia<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select><\/div><\/li><li id=\"field_70_43\" class=\"gfield gfield--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_70_43'>Degree\/Specialty<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_70_43' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_145\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_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_70_145'>End Date<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_145' id='input_70_145' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='MM\/DD\/YYYY' aria-describedby=\"input_70_145_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_70_145_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_70_145' class='gform_hidden' value='https:\/\/samaritanspurse.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_70_158\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Residency<\/h2><\/li><li id=\"field_70_46\" class=\"gfield gfield--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_70_46'>Residency Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_70_46' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_280\" class=\"gfield gfield--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_70_280'>Residency Specialty<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_280' id='input_70_280' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_70\" class=\"gfield gfield--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_70_70'>Length of program<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_70_70' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_240\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_240'>Residency Country<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_240' id='input_70_240' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='Australia' >Australia<\/option><option value='Canada' >Canada<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States of America' >United States of America<\/option><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='Algeria (El Djazair)' >Algeria (El Djazair)<\/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='Angullia' >Angullia<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua' >Antigua<\/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='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='Bosnia' >Bosnia<\/option><option value='Bosnia-Herzegovina' >Bosnia-Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='Bristish Indian Ocean Territory' >Bristish Indian Ocean Territory<\/option><option value='British Honduras' >British Honduras<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Fasco' >Burkina Fasco<\/option><option value='Burma' >Burma<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canal Zone' >Canal Zone<\/option><option value='Canary Islands' >Canary Islands<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Ceylon' >Ceylon<\/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='Colombia' >Colombia<\/option><option value='Comoro Islands' >Comoro Islands<\/option><option value='Congo, Republic of' >Congo, Republic of<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Cote D&#039;&#039;lvoire (Ivory Coast)' >Cote D&#039;&#039;lvoire (Ivory Coast)<\/option><option value='Cote d&#039;Ivoire' >Cote d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Croatia (Hrvatska)' >Croatia (Hrvatska)<\/option><option value='Cuba' >Cuba<\/option><option value='Curaco, Netherlands Antilles' >Curaco, Netherlands Antilles<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Dem Rep of the Congo - Kinshasa' >Dem Rep of the Congo - Kinshasa<\/option><option value='Dem. People&#039;s Rep. of Korea' >Dem. People&#039;s Rep. of Korea<\/option><option value='Democratic Republic of the Congo' >Democratic Republic of the Congo<\/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='East Timor' >East Timor<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='England' >England<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Faeroe Islands' >Faeroe Islands<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Federated States of Micronesia' >Federated States of Micronesia<\/option><option value='Fiji' >Fiji<\/option><option value='Fiji Islands' >Fiji Islands<\/option><option value='Finland' >Finland<\/option><option value='For anonymous donor records' >For anonymous donor records<\/option><option value='Formosa' >Formosa<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/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='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Grenada, West Indies' >Grenada, West Indies<\/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='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='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kazakstan' >Kazakstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea' >Korea<\/option><option value='Korle-Gommo, West Africa' >Korle-Gommo, West Africa<\/option><option value='Kosovo' >Kosovo<\/option><option value='Kurdistan' >Kurdistan<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Laos' >Laos<\/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='Macau - China' >Macau - China<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Mail' >Mail<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Malta' >Malta<\/option><option value='Marinique' >Marinique<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mauritius, Indian Ocean' >Mauritius, Indian Ocean<\/option><option value='Maurt' >Maurt<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/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='Netherlands Antilles' >Netherlands Antilles<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='New Zealand (Aotearoa)' >New Zealand (Aotearoa)<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Niger Republic' >Niger Republic<\/option><option value='Niger, West Africa' >Niger, West Africa<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='North Korea' >North Korea<\/option><option value='North Sudan' >North Sudan<\/option><option value='Northern Ireland' >Northern Ireland<\/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' >Palestine<\/option><option value='Panama' >Panama<\/option><option value='Papua' >Papua<\/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='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Principat D&#039;andorra' >Principat D&#039;andorra<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Rep Du Burundi' >Rep Du Burundi<\/option><option value='Rep Du Gabon' >Rep Du Gabon<\/option><option value='Rep Du Mali' >Rep Du Mali<\/option><option value='Rep Du Senegal' >Rep Du Senegal<\/option><option value='Rep of Congo - Brazzaville' >Rep of Congo - Brazzaville<\/option><option value='Rep of Guinea-Bissau' >Rep of Guinea-Bissau<\/option><option value='Republic of Benin' >Republic of Benin<\/option><option value='Republic of Burkina Faso' >Republic of Burkina Faso<\/option><option value='Republic of China' >Republic of China<\/option><option value='Republic of Korea' >Republic of Korea<\/option><option value='Republic of Singapore' >Republic of Singapore<\/option><option value='Republic of South Africa' >Republic of South Africa<\/option><option value='Republic of Upper Volta' >Republic of Upper Volta<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/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='Scotland' >Scotland<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Serbia and Montenegro' >Serbia and Montenegro<\/option><option value='Seychelles' >Seychelles<\/option><option value='Seychelles, Indian Ocean' >Seychelles, Indian Ocean<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/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='Somaliland' >Somaliland<\/option><option value='Somolia' >Somolia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia\/South Sandwich Islands' >South Georgia\/South Sandwich Islands<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='South Vietnam' >South Vietnam<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='St Kitts, Leeward Islands' >St Kitts, Leeward Islands<\/option><option value='St Maarten, Leeward Islands' >St Maarten, Leeward Islands<\/option><option value='St. Lucia' >St. Lucia<\/option><option value='St. Vincent' >St. Vincent<\/option><option value='Sudan' >Sudan<\/option><option value='Sultan of Oman' >Sultan of Oman<\/option><option value='Suriname' >Suriname<\/option><option value='Suriname, South America' >Suriname, South America<\/option><option value='Swaziland' >Swaziland<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Taiwan, Republic Of China' >Taiwan, Republic Of China<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='The Netherlands' >The Netherlands<\/option><option value='Tibet' >Tibet<\/option><option value='Togo' >Togo<\/option><option value='Tonga' >Tonga<\/option><option value='Tonga Islands, South Pacific' >Tonga Islands, South Pacific<\/option><option value='Transkei, Africa' >Transkei, Africa<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Turks in Caicos Island' >Turks in Caicos Island<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United States Minor Outlying Islands' >United States Minor Outlying Islands<\/option><option value='Unknown Country' >Unknown Country<\/option><option value='Unknown Name\/Address' >Unknown Name\/Address<\/option><option value='Uruguay' >Uruguay<\/option><option value='USSR' >USSR<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Vatican City' >Vatican City<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wales' >Wales<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='West Germany' >West Germany<\/option><option value='West Indies' >West Indies<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Western Samoa' >Western Samoa<\/option><option value='Yemen' >Yemen<\/option><option value='Yemen Arab Republic' >Yemen Arab Republic<\/option><option value='Yugoslavia' >Yugoslavia<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select><\/div><\/li><li id=\"field_70_242\" class=\"gfield gfield--type-text gf_left_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_70_242'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_242' id='input_70_242' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_243\" class=\"gfield gfield--type-select gf_right_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_70_243'>State \/ Province<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_243' id='input_70_243' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Alberta' >Alberta<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><option value='Australian Capital Territory' >Australian Capital Territory<\/option><option value='British Columbia' >British Columbia<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Federated States of Micronesia' >Federated States of Micronesia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Manitoba' >Manitoba<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New South Wales' >New South Wales<\/option><option value='New York' >New York<\/option><option value='Newfoundland' >Newfoundland<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Northern Territory' >Northern Territory<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Ontario' >Ontario<\/option><option value='Oregon' >Oregon<\/option><option value='Palau' >Palau<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Quebec' >Quebec<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Queensland' >Queensland<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='South Australia' >South Australia<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tasmania' >Tasmania<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Victoria' >Victoria<\/option><option value='Virgin Islands' >Virgin Islands<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Western Australia' >Western Australia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Yukon Territory' >Yukon Territory<\/option><\/select><\/div><\/li><li id=\"field_70_244\" class=\"gfield gfield--type-text gf_right_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_70_244'>State \/ Province \/ Region<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_244' id='input_70_244' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_146\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_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_70_146'>Start Date<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_146' id='input_70_146' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='MM\/DD\/YYYY' aria-describedby=\"input_70_146_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_70_146_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_70_146' class='gform_hidden' value='https:\/\/samaritanspurse.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_70_147\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_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_70_147'>End Date<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_147' id='input_70_147' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='MM\/DD\/YYYY' aria-describedby=\"input_70_147_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_70_147_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_70_147' class='gform_hidden' value='https:\/\/samaritanspurse.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_70_48\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Completed Residency?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_70_48'>\n\t\t\t<li class='gchoice gchoice_70_48_0'>\n\t\t\t\t<input name='input_48' type='radio' value='Yes'  id='choice_70_48_0'    \/>\n\t\t\t\t<label for='choice_70_48_0' id='label_70_48_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_70_48_1'>\n\t\t\t\t<input name='input_48' type='radio' value='No'  id='choice_70_48_1'    \/>\n\t\t\t\t<label for='choice_70_48_1' id='label_70_48_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_70_302\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Fellowship?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_70_302'>\n\t\t\t<li class='gchoice gchoice_70_302_0'>\n\t\t\t\t<input name='input_302' type='radio' value='Yes'  id='choice_70_302_0'    \/>\n\t\t\t\t<label for='choice_70_302_0' id='label_70_302_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_70_302_1'>\n\t\t\t\t<input name='input_302' type='radio' value='No'  id='choice_70_302_1'    \/>\n\t\t\t\t<label for='choice_70_302_1' id='label_70_302_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_70_159\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Fellowship<\/h2><\/li><li id=\"field_70_50\" class=\"gfield gfield--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_70_50'>Location Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_70_50' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_245\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_245'>Country<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_245' id='input_70_245' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='Australia' >Australia<\/option><option value='Canada' >Canada<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States of America' >United States of America<\/option><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='Algeria (El Djazair)' >Algeria (El Djazair)<\/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='Angullia' >Angullia<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua' >Antigua<\/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='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='Bosnia' >Bosnia<\/option><option value='Bosnia-Herzegovina' >Bosnia-Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='Bristish Indian Ocean Territory' >Bristish Indian Ocean Territory<\/option><option value='British Honduras' >British Honduras<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Fasco' >Burkina Fasco<\/option><option value='Burma' >Burma<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canal Zone' >Canal Zone<\/option><option value='Canary Islands' >Canary Islands<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Ceylon' >Ceylon<\/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='Colombia' >Colombia<\/option><option value='Comoro Islands' >Comoro Islands<\/option><option value='Congo, Republic of' >Congo, Republic of<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Cote D&#039;&#039;lvoire (Ivory Coast)' >Cote D&#039;&#039;lvoire (Ivory Coast)<\/option><option value='Cote d&#039;Ivoire' >Cote d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Croatia (Hrvatska)' >Croatia (Hrvatska)<\/option><option value='Cuba' >Cuba<\/option><option value='Curaco, Netherlands Antilles' >Curaco, Netherlands Antilles<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Dem Rep of the Congo - Kinshasa' >Dem Rep of the Congo - Kinshasa<\/option><option value='Dem. People&#039;s Rep. of Korea' >Dem. People&#039;s Rep. of Korea<\/option><option value='Democratic Republic of the Congo' >Democratic Republic of the Congo<\/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='East Timor' >East Timor<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='England' >England<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Faeroe Islands' >Faeroe Islands<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Federated States of Micronesia' >Federated States of Micronesia<\/option><option value='Fiji' >Fiji<\/option><option value='Fiji Islands' >Fiji Islands<\/option><option value='Finland' >Finland<\/option><option value='For anonymous donor records' >For anonymous donor records<\/option><option value='Formosa' >Formosa<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/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='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Grenada, West Indies' >Grenada, West Indies<\/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='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='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kazakstan' >Kazakstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea' >Korea<\/option><option value='Korle-Gommo, West Africa' >Korle-Gommo, West Africa<\/option><option value='Kosovo' >Kosovo<\/option><option value='Kurdistan' >Kurdistan<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Laos' >Laos<\/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='Macau - China' >Macau - China<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Mail' >Mail<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Malta' >Malta<\/option><option value='Marinique' >Marinique<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mauritius, Indian Ocean' >Mauritius, Indian Ocean<\/option><option value='Maurt' >Maurt<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/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='Netherlands Antilles' >Netherlands Antilles<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='New Zealand (Aotearoa)' >New Zealand (Aotearoa)<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Niger Republic' >Niger Republic<\/option><option value='Niger, West Africa' >Niger, West Africa<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='North Korea' >North Korea<\/option><option value='North Sudan' >North Sudan<\/option><option value='Northern Ireland' >Northern Ireland<\/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' >Palestine<\/option><option value='Panama' >Panama<\/option><option value='Papua' >Papua<\/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='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Principat D&#039;andorra' >Principat D&#039;andorra<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Rep Du Burundi' >Rep Du Burundi<\/option><option value='Rep Du Gabon' >Rep Du Gabon<\/option><option value='Rep Du Mali' >Rep Du Mali<\/option><option value='Rep Du Senegal' >Rep Du Senegal<\/option><option value='Rep of Congo - Brazzaville' >Rep of Congo - Brazzaville<\/option><option value='Rep of Guinea-Bissau' >Rep of Guinea-Bissau<\/option><option value='Republic of Benin' >Republic of Benin<\/option><option value='Republic of Burkina Faso' >Republic of Burkina Faso<\/option><option value='Republic of China' >Republic of China<\/option><option value='Republic of Korea' >Republic of Korea<\/option><option value='Republic of Singapore' >Republic of Singapore<\/option><option value='Republic of South Africa' >Republic of South Africa<\/option><option value='Republic of Upper Volta' >Republic of Upper Volta<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/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='Scotland' >Scotland<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Serbia and Montenegro' >Serbia and Montenegro<\/option><option value='Seychelles' >Seychelles<\/option><option value='Seychelles, Indian Ocean' >Seychelles, Indian Ocean<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/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='Somaliland' >Somaliland<\/option><option value='Somolia' >Somolia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia\/South Sandwich Islands' >South Georgia\/South Sandwich Islands<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='South Vietnam' >South Vietnam<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='St Kitts, Leeward Islands' >St Kitts, Leeward Islands<\/option><option value='St Maarten, Leeward Islands' >St Maarten, Leeward Islands<\/option><option value='St. Lucia' >St. Lucia<\/option><option value='St. Vincent' >St. Vincent<\/option><option value='Sudan' >Sudan<\/option><option value='Sultan of Oman' >Sultan of Oman<\/option><option value='Suriname' >Suriname<\/option><option value='Suriname, South America' >Suriname, South America<\/option><option value='Swaziland' >Swaziland<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Taiwan, Republic Of China' >Taiwan, Republic Of China<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='The Netherlands' >The Netherlands<\/option><option value='Tibet' >Tibet<\/option><option value='Togo' >Togo<\/option><option value='Tonga' >Tonga<\/option><option value='Tonga Islands, South Pacific' >Tonga Islands, South Pacific<\/option><option value='Transkei, Africa' >Transkei, Africa<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Turks in Caicos Island' >Turks in Caicos Island<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United States Minor Outlying Islands' >United States Minor Outlying Islands<\/option><option value='Unknown Country' >Unknown Country<\/option><option value='Unknown Name\/Address' >Unknown Name\/Address<\/option><option value='Uruguay' >Uruguay<\/option><option value='USSR' >USSR<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Vatican City' >Vatican City<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wales' >Wales<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='West Germany' >West Germany<\/option><option value='West Indies' >West Indies<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Western Samoa' >Western Samoa<\/option><option value='Yemen' >Yemen<\/option><option value='Yemen Arab Republic' >Yemen Arab Republic<\/option><option value='Yugoslavia' >Yugoslavia<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select><\/div><\/li><li id=\"field_70_247\" class=\"gfield gfield--type-text gf_left_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_70_247'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_247' id='input_70_247' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_248\" class=\"gfield gfield--type-select gf_right_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_70_248'>State \/ Province<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_248' id='input_70_248' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Alberta' >Alberta<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><option value='Australian Capital Territory' >Australian Capital Territory<\/option><option value='British Columbia' >British Columbia<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Federated States of Micronesia' >Federated States of Micronesia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Manitoba' >Manitoba<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New South Wales' >New South Wales<\/option><option value='New York' >New York<\/option><option value='Newfoundland' >Newfoundland<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Northern Territory' >Northern Territory<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Ontario' >Ontario<\/option><option value='Oregon' >Oregon<\/option><option value='Palau' >Palau<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Quebec' >Quebec<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Queensland' >Queensland<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='South Australia' >South Australia<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tasmania' >Tasmania<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Victoria' >Victoria<\/option><option value='Virgin Islands' >Virgin Islands<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Western Australia' >Western Australia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Yukon Territory' >Yukon Territory<\/option><\/select><\/div><\/li><li id=\"field_70_249\" class=\"gfield gfield--type-text gf_right_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_70_249'>State \/ Province \/ Region<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_249' id='input_70_249' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_52\" class=\"gfield gfield--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_70_52'>Degree\/Specialty<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_70_52' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_148\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_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_70_148'>Start Date<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_148' id='input_70_148' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='MM\/DD\/YYYY' aria-describedby=\"input_70_148_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_70_148_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_70_148' class='gform_hidden' value='https:\/\/samaritanspurse.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_70_149\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_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_70_149'>End Date<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_149' id='input_70_149' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='MM\/DD\/YYYY' aria-describedby=\"input_70_149_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_70_149_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_70_149' class='gform_hidden' value='https:\/\/samaritanspurse.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_70_214\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Other Education\/Training<\/h2><\/li><li id=\"field_70_54\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_54'>Other Education or Training<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_54' id='input_70_54' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_70_331\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Military Experience<\/h2><\/li><li id=\"field_70_281\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Military Experience?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_70_281'>\n\t\t\t<li class='gchoice gchoice_70_281_0'>\n\t\t\t\t<input name='input_281' type='radio' value='Yes'  id='choice_70_281_0'    \/>\n\t\t\t\t<label for='choice_70_281_0' id='label_70_281_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_70_281_1'>\n\t\t\t\t<input name='input_281' type='radio' value='No'  id='choice_70_281_1'    \/>\n\t\t\t\t<label for='choice_70_281_1' id='label_70_281_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_70_55\" class=\"gfield gfield--type-textarea 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_70_55'>Please List Military Experience<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_55' id='input_70_55' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_70_56' 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_70_56' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_70_4_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_70_4' class='gform_page' data-js='page-field-id-56' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_70_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_70_345\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Physician Type<\/h2><\/li><li id=\"field_70_338\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_338'>Physician Category<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_338' id='input_70_338' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Medical Doctor' >Medical Doctor<\/option><option value='Doctor of Osteopathy' >Doctor of Osteopathy<\/option><option value='Resident \u2013 Medical Doctor - 1st Year' >Resident \u2013 Medical Doctor - 1st Year<\/option><option value='Resident \u2013 Medical Doctor \u2013 2nd Year' >Resident \u2013 Medical Doctor \u2013 2nd Year<\/option><option value='Resident \u2013 Medical Doctor \u2013 3rd Year' >Resident \u2013 Medical Doctor \u2013 3rd Year<\/option><option value='Resident \u2013 Medical Doctor \u2013 4th Year' >Resident \u2013 Medical Doctor \u2013 4th Year<\/option><option value='Resident \u2013 Medical Doctor \u2013 5th Year' >Resident \u2013 Medical Doctor \u2013 5th Year<\/option><option value='Resident \u2013 Medical Doctor \u2013 6th Year' >Resident \u2013 Medical Doctor \u2013 6th Year<\/option><option value='Resident \u2013 Medical Doctor \u2013 7th Year' >Resident \u2013 Medical Doctor \u2013 7th Year<\/option><option value='Resident \u2013 Doctor of Osteopathic Medicine \u2013 1st Year' >Resident \u2013 Doctor of Osteopathic Medicine \u2013 1st Year<\/option><option value='Resident \u2013 Doctor of Osteopathic Medicine \u2013 2nd Year' >Resident \u2013 Doctor of Osteopathic Medicine \u2013 2nd Year<\/option><option value='Resident \u2013 Doctor of Osteopathic Medicine \u2013 3rd Year' >Resident \u2013 Doctor of Osteopathic Medicine \u2013 3rd Year<\/option><option value='Resident \u2013 Doctor of Osteopathic Medicine \u2013 4th Year' >Resident \u2013 Doctor of Osteopathic Medicine \u2013 4th Year<\/option><option value='Resident \u2013 Doctor of Osteopathic Medicine \u2013 5th Year' >Resident \u2013 Doctor of Osteopathic Medicine \u2013 5th Year<\/option><option value='Resident \u2013 Doctor of Osteopathic Medicine \u2013 6th Year' >Resident \u2013 Doctor of Osteopathic Medicine \u2013 6th Year<\/option><option value='Resident \u2013 Doctor of Osteopathic Medicine \u2013 7th Year' >Resident \u2013 Doctor of Osteopathic Medicine \u2013 7th Year<\/option><option value='Resident (not licensed yet) \u2013 1st Year' >Resident (not licensed yet) \u2013 1st Year<\/option><option value='Resident (not licensed yet) \u2013 2nd Year' >Resident (not licensed yet) \u2013 2nd Year<\/option><option value='Resident (not licensed yet) \u2013 3rd Year' >Resident (not licensed yet) \u2013 3rd Year<\/option><option value='Resident (not licensed yet) \u2013 4th Year' >Resident (not licensed yet) \u2013 4th Year<\/option><option value='Resident (not licensed yet) \u2013 5th Year' >Resident (not licensed yet) \u2013 5th Year<\/option><option value='Resident (not licensed yet) \u2013 6th Year' >Resident (not licensed yet) \u2013 6th Year<\/option><option value='Resident (not licensed yet) \u2013 7th Year' >Resident (not licensed yet) \u2013 7th Year<\/option><\/select><\/div><\/li><li id=\"field_70_58\" class=\"gfield gfield--type-select gf_left_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_70_58'>Primary Specialty - Physician<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_58' id='input_70_58' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Allergy\/Immunology' >Allergy\/Immunology<\/option><option value='Anesthesiology' >Anesthesiology<\/option><option value='Cardiology' >Cardiology<\/option><option value='Critical Care\/Intensivists' >Critical Care\/Intensivists<\/option><option value='Dermatology' >Dermatology<\/option><option value='Emergency Medicine' >Emergency Medicine<\/option><option value='Endocrinology' >Endocrinology<\/option><option value='Family Practice\/Family Medicine' >Family Practice\/Family Medicine<\/option><option value='Gastroenterology' >Gastroenterology<\/option><option value='General Practitioner' >General Practitioner<\/option><option value='Geriatric Medicine' >Geriatric Medicine<\/option><option value='Hematology' >Hematology<\/option><option value='Hematology\/Oncology' >Hematology\/Oncology<\/option><option value='Infectious Disease' >Infectious Disease<\/option><option value='Internal Medicine' >Internal Medicine<\/option><option value='Internal Medicine Pediatrician' >Internal Medicine Pediatrician<\/option><option value='Neonatology' >Neonatology<\/option><option value='Nephrology' >Nephrology<\/option><option value='Neurology' >Neurology<\/option><option value='Obstetrician\/Gynecology - Both' >Obstetrician\/Gynecology - Both<\/option><option value='Obstetrician\/Gynecology - Obstetrics' >Obstetrician\/Gynecology - Obstetrics<\/option><option value='Obstetrician\/Gynecology - Gynecology' >Obstetrician\/Gynecology - Gynecology<\/option><option value='Oncology' >Oncology<\/option><option value='Ophthalmology' >Ophthalmology<\/option><option value='Pathology' >Pathology<\/option><option value='Pathology - Anatomical' >Pathology - Anatomical<\/option><option value='Pathology - Anatomical\/Clinical' >Pathology - Anatomical\/Clinical<\/option><option value='Pathology - Clinical' >Pathology - Clinical<\/option><option value='Pediatrician' >Pediatrician<\/option><option value='Physical Medicine &amp; Rehabilitation' >Physical Medicine &amp; Rehabilitation<\/option><option value='Preventive Medicine Physician' >Preventive Medicine Physician<\/option><option value='Psychology' >Psychology<\/option><option value='Pulmonology' >Pulmonology<\/option><option value='Pulmonology - Critical Care' >Pulmonology - Critical Care<\/option><option value='Radiology' >Radiology<\/option><option value='Radiology - General' >Radiology - General<\/option><option value='Radiology - Neuroradiology' >Radiology - Neuroradiology<\/option><option value='Rheumatology' >Rheumatology<\/option><option value='Sports Medicine Physician' >Sports Medicine Physician<\/option><option value='Surgery - Cardiovascular' >Surgery - Cardiovascular<\/option><option value='Surgery - Colo-Rectal' >Surgery - Colo-Rectal<\/option><option value='Surgery - General' >Surgery - General<\/option><option value='Surgery - Gynecology' >Surgery - Gynecology<\/option><option value='Surgery - Neurosurgery' >Surgery - Neurosurgery<\/option><option value='Surgery - Obstetrics' >Surgery - Obstetrics<\/option><option value='Surgery - Obstetrics\/Gynecology' >Surgery - Obstetrics\/Gynecology<\/option><option value='Surgery - Oncology' >Surgery - Oncology<\/option><option value='Surgery - Oral Maxillofacial' >Surgery - Oral Maxillofacial<\/option><option value='Surgery - Orthopedics' >Surgery - Orthopedics<\/option><option value='Surgery - Otolaryngology' >Surgery - Otolaryngology<\/option><option value='Surgery - Pediatrics' >Surgery - Pediatrics<\/option><option value='Surgery - Peripheral Vascular' >Surgery - Peripheral Vascular<\/option><option value='Surgery - Plastic Surgery' >Surgery - Plastic Surgery<\/option><option value='Surgery - Thoracic' >Surgery - Thoracic<\/option><option value='Surgery - Trauma' >Surgery - Trauma<\/option><option value='Urology' >Urology<\/option><\/select><\/div><\/li><li id=\"field_70_339\" class=\"gfield gfield--type-select gf_right_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_70_339'>Primary Specialty - Physician - Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_339' id='input_70_339' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Adults' >Adults<\/option><option value='Pediatrics' >Pediatrics<\/option><option value='Adults &amp; Pediatrics' >Adults &amp; Pediatrics<\/option><option value='Not Applicable' >Not Applicable<\/option><\/select><\/div><\/li><li id=\"field_70_340\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_340'>Primary Specialty - Physician - Subspecialty<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_340' id='input_70_340' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Inpatient' >Inpatient<\/option><option value='Outpatient' >Outpatient<\/option><option value='Inpatient\/Outpatient' >Inpatient\/Outpatient<\/option><option value='Obstetrics' >Obstetrics<\/option><option value='Emergency' >Emergency<\/option><option value='Other' >Other<\/option><option value='Not Applicable' >Not Applicable<\/option><\/select><\/div><\/li><li id=\"field_70_341\" class=\"gfield gfield--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_70_341'>Primary Specialty - Physician - Subspecialty (Other)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_341' id='input_70_341' type='text' value='' class='medium'  aria-describedby=\"gfield_description_70_341\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_70_341'>Please describe your subspecialty<\/div><\/li><li id=\"field_70_343\" class=\"gfield gfield--type-select gf_right_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_70_343'>Primary Specialty - Pediatric Subspecialty<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_343' id='input_70_343' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Inpatient' >Inpatient<\/option><option value='Outpatient' >Outpatient<\/option><option value='Inpatient\/Outpatient' >Inpatient\/Outpatient<\/option><option value='Intensive Care Unit' >Intensive Care Unit<\/option><option value='Neonatal Intensive Care Unit' >Neonatal Intensive Care Unit<\/option><option value='Critical Care' >Critical Care<\/option><option value='Emergency' >Emergency<\/option><option value='Other' >Other<\/option><option value='Not Applicable' >Not Applicable<\/option><\/select><\/div><\/li><li id=\"field_70_342\" class=\"gfield gfield--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_70_342'>Primary Specialty - Pediatric Subspecialty (Other)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_342' id='input_70_342' type='text' value='' class='medium'  aria-describedby=\"gfield_description_70_342\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_70_342'>Please describe your subspecialty<\/div><\/li><li id=\"field_70_59\" class=\"gfield gfield--type-select gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_59'>Secondary Specialty - Physician<\/label><div class='ginput_container ginput_container_select'><select name='input_59' id='input_70_59' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Allergy\/Immunology' >Allergy\/Immunology<\/option><option value='Anesthesiology' >Anesthesiology<\/option><option value='Cardiology' >Cardiology<\/option><option value='Critical Care\/Intensivists' >Critical Care\/Intensivists<\/option><option value='Dermatology' >Dermatology<\/option><option value='Emergency Medicine' >Emergency Medicine<\/option><option value='Endocrinology' >Endocrinology<\/option><option value='Family Practice\/Family Medicine' >Family Practice\/Family Medicine<\/option><option value='Gastroenterology' >Gastroenterology<\/option><option value='General Practitioner' >General Practitioner<\/option><option value='Geriatric Medicine' >Geriatric Medicine<\/option><option value='Hematology' >Hematology<\/option><option value='Hematology\/Oncology' >Hematology\/Oncology<\/option><option value='Infectious Disease' >Infectious Disease<\/option><option value='Internal Medicine' >Internal Medicine<\/option><option value='Neonatology' >Neonatology<\/option><option value='Nephrology' >Nephrology<\/option><option value='Neurology' >Neurology<\/option><option value='Obstetrician\/Gynecology - Both' >Obstetrician\/Gynecology - Both<\/option><option value='Obstetrician\/Gynecology - Obstetrics' >Obstetrician\/Gynecology - Obstetrics<\/option><option value='Obstetrician\/Gynecology - Gynecology' >Obstetrician\/Gynecology - Gynecology<\/option><option value='Oncology' >Oncology<\/option><option value='Ophthalmology' >Ophthalmology<\/option><option value='Pathology' >Pathology<\/option><option value='Pathology - Anatomical' >Pathology - Anatomical<\/option><option value='Pathology - Anatomical\/Clinical' >Pathology - Anatomical\/Clinical<\/option><option value='Pathology - Clinical' >Pathology - Clinical<\/option><option value='Pediatrician' >Pediatrician<\/option><option value='Physical Medicine &amp; Rehabilitation' >Physical Medicine &amp; Rehabilitation<\/option><option value='Preventive Medicine Physician' >Preventive Medicine Physician<\/option><option value='Psychology' >Psychology<\/option><option value='Pulmonology' >Pulmonology<\/option><option value='Pulmonology - Critical Care' >Pulmonology - Critical Care<\/option><option value='Radiology' >Radiology<\/option><option value='Radiology - General' >Radiology - General<\/option><option value='Radiology - Neuroradiology' >Radiology - Neuroradiology<\/option><option value='Rheumatology' >Rheumatology<\/option><option value='Sports Medicine Physician' >Sports Medicine Physician<\/option><option value='Surgery - Cardiovascular' >Surgery - Cardiovascular<\/option><option value='Surgery - Colo-Rectal' >Surgery - Colo-Rectal<\/option><option value='Surgery - General' >Surgery - General<\/option><option value='Surgery - Gynecology' >Surgery - Gynecology<\/option><option value='Surgery - Neurosurgery' >Surgery - Neurosurgery<\/option><option value='Surgery - Obstetrics' >Surgery - Obstetrics<\/option><option value='Surgery - Obstetrics\/Gynecology' >Surgery - Obstetrics\/Gynecology<\/option><option value='Surgery - Oncology' >Surgery - Oncology<\/option><option value='Surgery - Oral Maxillofacial' >Surgery - Oral Maxillofacial<\/option><option value='Surgery - Orthopedics' >Surgery - Orthopedics<\/option><option value='Surgery - Otolaryngology' >Surgery - Otolaryngology<\/option><option value='Surgery - Pediatrics' >Surgery - Pediatrics<\/option><option value='Surgery - Peripheral Vascular' >Surgery - Peripheral Vascular<\/option><option value='Surgery - Plastic Surgery' >Surgery - Plastic Surgery<\/option><option value='Surgery - Thoracic' >Surgery - Thoracic<\/option><option value='Surgery - Trauma' >Surgery - Trauma<\/option><option value='Urology' >Urology<\/option><\/select><\/div><\/li><li id=\"field_70_361\" class=\"gfield gfield--type-select gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_361'>Secondary Specialty - Physician - Type<\/label><div class='ginput_container ginput_container_select'><select name='input_361' id='input_70_361' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Adults' >Adults<\/option><option value='Pediatrics' >Pediatrics<\/option><option value='Adults &amp; Pediatrics' >Adults &amp; Pediatrics<\/option><option value='Not Applicable' >Not Applicable<\/option><\/select><\/div><\/li><li id=\"field_70_362\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_362'>Secondary Specialty - Physician - Subspecialty<\/label><div class='ginput_container ginput_container_select'><select name='input_362' id='input_70_362' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Inpatient' >Inpatient<\/option><option value='Outpatient' >Outpatient<\/option><option value='Inpatient\/Outpatient' >Inpatient\/Outpatient<\/option><option value='Obstetrics' >Obstetrics<\/option><option value='Emergency' >Emergency<\/option><option value='Other' >Other<\/option><option value='Not Applicable' >Not Applicable<\/option><\/select><\/div><\/li><li id=\"field_70_363\" class=\"gfield gfield--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_70_363'>Secondary Specialty - Physician - Subspecialty (Other)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_363' id='input_70_363' type='text' value='' class='medium'  aria-describedby=\"gfield_description_70_363\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_70_363'>Please describe your subspecialty<\/div><\/li><li id=\"field_70_364\" class=\"gfield gfield--type-select gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_364'>Secondary Specialty - Pediatric Subspecialty<\/label><div class='ginput_container ginput_container_select'><select name='input_364' id='input_70_364' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Inpatient' >Inpatient<\/option><option value='Outpatient' >Outpatient<\/option><option value='Inpatient\/Outpatient' >Inpatient\/Outpatient<\/option><option value='Intensive Care Unit' >Intensive Care Unit<\/option><option value='Neonatal Intensive Care Unit' >Neonatal Intensive Care Unit<\/option><option value='Critical Care' >Critical Care<\/option><option value='Emergency' >Emergency<\/option><option value='Other' >Other<\/option><option value='Not Applicable' >Not Applicable<\/option><\/select><\/div><\/li><li id=\"field_70_365\" class=\"gfield gfield--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_70_365'>Secondary Specialty - Pediatric Subspecialty (Other)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_365' id='input_70_365' type='text' value='' class='medium'  aria-describedby=\"gfield_description_70_365\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_70_365'>Please describe your subspecialty<\/div><\/li><li id=\"field_70_333\" class=\"gfield gfield--type-select gf_left_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_70_333'>Primary Specialty - Dentist<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_333' id='input_70_333' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Endodontics' >Endodontics<\/option><option value='General Dentistry' >General Dentistry<\/option><option value='Oral Surgery' >Oral Surgery<\/option><option value='Orthodontics' >Orthodontics<\/option><option value='Pedodontics' >Pedodontics<\/option><option value='Periodontology' >Periodontology<\/option><option value='Doctor of Dental Surgery' >Doctor of Dental Surgery<\/option><\/select><\/div><\/li><li id=\"field_70_336\" class=\"gfield gfield--type-select gf_right_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_70_336'>Primary Sub-Specialty - Dentist<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_336' id='input_70_336' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Adults' >Adults<\/option><option value='Pediatrics' >Pediatrics<\/option><option value='Adults &amp; Pediatrics' >Adults &amp; Pediatrics<\/option><option value='Not Applicable' >Not Applicable<\/option><\/select><\/div><\/li><li id=\"field_70_335\" class=\"gfield gfield--type-select gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_335'>Secondary Specialty - Dentist<\/label><div class='ginput_container ginput_container_select'><select name='input_335' id='input_70_335' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Endodontics' >Endodontics<\/option><option value='General Dentistry' >General Dentistry<\/option><option value='Oral Surgery' >Oral Surgery<\/option><option value='Orthodontics' >Orthodontics<\/option><option value='Pedodontics' >Pedodontics<\/option><option value='Periodontology' >Periodontology<\/option><option value='Doctor of Dental Surgery' >Doctor of Dental Surgery<\/option><\/select><\/div><\/li><li id=\"field_70_337\" class=\"gfield gfield--type-select gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_337'>Secondary Sub-Specialty - Dentist<\/label><div class='ginput_container ginput_container_select'><select name='input_337' id='input_70_337' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Adults' >Adults<\/option><option value='Pediatrics' >Pediatrics<\/option><option value='Adults &amp; Pediatrics' >Adults &amp; Pediatrics<\/option><option value='Not Applicable' >Not Applicable<\/option><\/select><\/div><\/li><li id=\"field_70_60\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_70_60'>Any other specialties?<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_70_60' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_366\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Medical Professional Specialty<\/h2><\/li><li id=\"field_70_370\" class=\"gfield gfield--type-select gf_left_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_70_370'>Specialty<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_370' id='input_70_370' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Anesthesiologist Assistant' >Anesthesiologist Assistant<\/option><option value='Audiologist' >Audiologist<\/option><option value='Bio-Medical Technician' >Bio-Medical Technician<\/option><option value='Certified Professional Midwife' >Certified Professional Midwife<\/option><option value='Certificed Surgical Techinician' >Certificed Surgical Techinician<\/option><option value='Child Life Specialist' >Child Life Specialist<\/option><option value='Clinical Nutrition Specialist' >Clinical Nutrition Specialist<\/option><option value='Dental Assistant' >Dental Assistant<\/option><option value='Dental Hygienist' >Dental Hygienist<\/option><option value='Dental Public Health' >Dental Public Health<\/option><option value='Dietitian' >Dietitian<\/option><option value='Echo Cardio Graphic Tech' >Echo Cardio Graphic Tech<\/option><option value='Eeg Technologist' >Eeg Technologist<\/option><option value='Emergency Medical Technician' >Emergency Medical Technician<\/option><option value='Hospital Administrator' >Hospital Administrator<\/option><option value='Laboratory Technician' >Laboratory Technician<\/option><option value='Marriage And Family Counselor' >Marriage And Family Counselor<\/option><option value='Master\u2019S Public Health' >Master\u2019S Public Health<\/option><option value='Medical Assistant' >Medical Assistant<\/option><option value='Medical Sonographer' >Medical Sonographer<\/option><option value='Medical Student' >Medical Student<\/option><option value='Medical Technologist' >Medical Technologist<\/option><option value='Medical Transcriptionist' >Medical Transcriptionist<\/option><option value='Micro-Biology' >Micro-Biology<\/option><option value='Nurse \u2013 Advanced Registered Nurse Practitioner' >Nurse \u2013 Advanced Registered Nurse Practitioner<\/option><option value='Nurse - Certified Nursing Assistant' >Nurse - Certified Nursing Assistant<\/option><option value='Nurse - Licensed Practical Nurse' >Nurse - Licensed Practical Nurse<\/option><option value='Nurse - Licensed Vocational Nurse' >Nurse - Licensed Vocational Nurse<\/option><option value='Nurse - Registered Nurse' >Nurse - Registered Nurse<\/option><option value='Nurse - BSN' >Nurse - BSN<\/option><option value='Nurse - MSN' >Nurse - MSN<\/option><option value='Nurse - Nurse Practitioner' >Nurse - Nurse Practitioner<\/option><option value='Nurse - DNP' >Nurse - DNP<\/option><option value='Occupational Medicine' >Occupational Medicine<\/option><option value='Occupational Therapist' >Occupational Therapist<\/option><option value='Operating Room Technician' >Operating Room Technician<\/option><option value='Optician' >Optician<\/option><option value='Optometrist' >Optometrist<\/option><option value='Orthopedic Technician' >Orthopedic Technician<\/option><option value='Paramedic' >Paramedic<\/option><option value='Pathology Assistant' >Pathology Assistant<\/option><option value='Perfusionist' >Perfusionist<\/option><option value='Pharmacist' >Pharmacist<\/option><option value='Physical Therapist' >Physical Therapist<\/option><option value='Physical Therapy Assistant' >Physical Therapy Assistant<\/option><option value='Physician Assistant' >Physician Assistant<\/option><option value='Physician Associate' >Physician Associate<\/option><option value='Podiatrist' >Podiatrist<\/option><option value='Premed Student' >Premed Student<\/option><option value='Prosthetist\/Orthotist' >Prosthetist\/Orthotist<\/option><option value='Psychiatry' >Psychiatry<\/option><option value='Psychology' >Psychology<\/option><option value='Radiology Technician' >Radiology Technician<\/option><option value='Respiratory Therapist' >Respiratory Therapist<\/option><option value='Social Worker' >Social Worker<\/option><option value='Speech Therapist' >Speech Therapist<\/option><option value='Sterilization Technician' >Sterilization Technician<\/option><option value='Student Nurse' >Student Nurse<\/option><option value='Student Dental' >Student Dental<\/option><option value='Student Pharmacy' >Student Pharmacy<\/option><option value='Student Physician Assistant' >Student Physician Assistant<\/option><option value='Technical Consultant' >Technical Consultant<\/option><option value='Other Medical Professional Not Listed:' >Other Medical Professional Not Listed:<\/option><\/select><\/div><\/li><li id=\"field_70_371\" class=\"gfield gfield--type-text gf_right_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_70_371'>Other<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_371' id='input_70_371' type='text' value='' class='medium'  aria-describedby=\"gfield_description_70_371\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_70_371'>Please enter your medical profession.<\/div><\/li><li id=\"field_70_372\" class=\"gfield gfield--type-select gf_left_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_70_372'>Nursing Specialty<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_372' id='input_70_372' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Burn Care Nurse' >Burn Care Nurse<\/option><option value='Cardiac Care Nurse' >Cardiac Care Nurse<\/option><option value='Cardiac Cath Lab Nurse' >Cardiac Cath Lab Nurse<\/option><option value='Certified Nurse Midwife' >Certified Nurse Midwife<\/option><option value='Certified Registered Nurse Anesthetist' >Certified Registered Nurse Anesthetist<\/option><option value='Correctional Facility Nurse' >Correctional Facility Nurse<\/option><option value='Critical Care Nurse' >Critical Care Nurse<\/option><option value='Dermatology Nurse' >Dermatology Nurse<\/option><option value='Diabetes Nurse' >Diabetes Nurse<\/option><option value='Emergency Nurse' >Emergency Nurse<\/option><option value='Family Nurse Practitioner' >Family Nurse Practitioner<\/option><option value='Flight\/Transport Nurse' >Flight\/Transport Nurse<\/option><option value='Gastroenterology Nurse' >Gastroenterology Nurse<\/option><option value='Geriatric Nurse' >Geriatric Nurse<\/option><option value='Gerontological Nurse Practitioner' >Gerontological Nurse Practitioner<\/option><option value='Hematology Nurse' >Hematology Nurse<\/option><option value='HIV\/AIDS Nurse' >HIV\/AIDS Nurse<\/option><option value='Home Health Care Nurse' >Home Health Care Nurse<\/option><option value='Hospice Nurse' >Hospice Nurse<\/option><option value='Infection Control Nurse' >Infection Control Nurse<\/option><option value='Infusion Nurse' >Infusion Nurse<\/option><option value='Intensive Care Nurse' >Intensive Care Nurse<\/option><option value='Labor and Delivery Nurse' >Labor and Delivery Nurse<\/option><option value='Lactation Consultant' >Lactation Consultant<\/option><option value='Long-Term Care Nurse' >Long-Term Care Nurse<\/option><option value='Medical-Surgical Nurse' >Medical-Surgical Nurse<\/option><option value='Neonatal Intensive Care Nurse' >Neonatal Intensive Care Nurse<\/option><option value='Nephrology Nurse' >Nephrology Nurse<\/option><option value='Obstetrics Nurse\/Gynecology Nurse' >Obstetrics Nurse\/Gynecology Nurse<\/option><option value='Oncology Nurse' >Oncology Nurse<\/option><option value='Ophthalmic Nurse' >Ophthalmic Nurse<\/option><option value='Orthopedic Nurse' >Orthopedic Nurse<\/option><option value='Otorhinolaryngology Nurse' >Otorhinolaryngology Nurse<\/option><option value='Pain Management Nurse' >Pain Management Nurse<\/option><option value='Pediatric Endocrinology Nurse' >Pediatric Endocrinology Nurse<\/option><option value='Pediatric Nurse' >Pediatric Nurse<\/option><option value='Pediatric Nurse Practitioner' >Pediatric Nurse Practitioner<\/option><option value='Perioperative (Surgical) Nurse' >Perioperative (Surgical) Nurse<\/option><option value='Plastic Surgery Nurse' >Plastic Surgery Nurse<\/option><option value='Psychiatric Nurse' >Psychiatric Nurse<\/option><option value='Psychiatric Nurse Practitioner' >Psychiatric Nurse Practitioner<\/option><option value='Public Health Nurse' >Public Health Nurse<\/option><option value='Pulmonary Care Nurse' >Pulmonary Care Nurse<\/option><option value='Rehabilitation Nurse' >Rehabilitation Nurse<\/option><option value='Rheumatology Nurse' >Rheumatology Nurse<\/option><option value='School Nurse' >School Nurse<\/option><option value='Substance Abuse Nurse' >Substance Abuse Nurse<\/option><option value='Telemetry Nurse' >Telemetry Nurse<\/option><option value='Transplant Nurse' >Transplant Nurse<\/option><option value='Trauma Nurse' >Trauma Nurse<\/option><option value='Travel Nurse' >Travel Nurse<\/option><option value='Urologic Nurse' >Urologic Nurse<\/option><option value='Wound, Ostomy and Continence Nurse' >Wound, Ostomy and Continence Nurse<\/option><option value='Other:' >Other:<\/option><\/select><\/div><\/li><li id=\"field_70_374\" class=\"gfield gfield--type-text gf_left_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_70_374'>Please enter your nursing specialty<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_374' id='input_70_374' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_373\" class=\"gfield gfield--type-select gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_373'>Nursing Subspecialty<\/label><div class='ginput_container ginput_container_select'><select name='input_373' id='input_70_373' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Adults' >Adults<\/option><option value='Pediatrics' >Pediatrics<\/option><option value='Adults &amp; Pediatrics' >Adults &amp; Pediatrics<\/option><option value='Not Applicable' >Not Applicable<\/option><\/select><\/div><\/li><li id=\"field_70_375\" class=\"gfield gfield--type-select gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_375'>Subspecialty<\/label><div class='ginput_container ginput_container_select'><select name='input_375' id='input_70_375' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Adults' >Adults<\/option><option value='Pediatrics' >Pediatrics<\/option><option value='Adults &amp; Pediatrics' >Adults &amp; Pediatrics<\/option><option value='Not Applicable' >Not Applicable<\/option><\/select><\/div><\/li><li id=\"field_70_57\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Employment<\/h2><\/li><li id=\"field_70_61\" class=\"gfield gfield--type-text gf_left_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_70_61'>Employer<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_70_61' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_62\" class=\"gfield gfield--type-select gf_right_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_70_62'>Practicing<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_62' id='input_70_62' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Full-time' >Full-time<\/option><option value='Part-time' >Part-time<\/option><option value='Retired' >Retired<\/option><option value='Fellow' >Fellow<\/option><option value='Resident' >Resident<\/option><option value='Student' >Student<\/option><\/select><\/div><\/li><li id=\"field_70_71\" class=\"gfield gfield--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_70_71'>Year of retirement<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_70_71' type='text' value='' class='medium'    placeholder='YYYY' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_395\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Presently involved in malpractice litigation?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_70_395'>\n\t\t\t<li class='gchoice gchoice_70_395_0'>\n\t\t\t\t<input name='input_395' type='radio' value='Yes'  id='choice_70_395_0'    \/>\n\t\t\t\t<label for='choice_70_395_0' id='label_70_395_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_70_395_1'>\n\t\t\t\t<input name='input_395' type='radio' value='No'  id='choice_70_395_1'    \/>\n\t\t\t\t<label for='choice_70_395_1' id='label_70_395_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_70_396\" class=\"gfield gfield--type-textarea 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_70_396'>Please explain<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_396' id='input_70_396' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_70_386\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Board Certified?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_70_386'>\n\t\t\t<li class='gchoice gchoice_70_386_0'>\n\t\t\t\t<input name='input_386' type='radio' value='Yes'  id='choice_70_386_0'    \/>\n\t\t\t\t<label for='choice_70_386_0' id='label_70_386_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_70_386_1'>\n\t\t\t\t<input name='input_386' type='radio' value='No'  id='choice_70_386_1'    \/>\n\t\t\t\t<label for='choice_70_386_1' id='label_70_386_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_70_387\" class=\"gfield gfield--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_70_387'>Certifying Agency<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_387' id='input_70_387' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_72\" class=\"gfield gfield--type-textarea 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_70_72'>Board Certification<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_72' id='input_70_72' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_70_73\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_73'>Current Staff\/Faculty Appointments (Title, Institution, and Location)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_73' id='input_70_73' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_70_74\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_74'>Professional Organizations<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_74' id='input_70_74' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_70_75\" class=\"gfield gfield--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_70_75'>Current Medical\/Dental License or Certificate No.<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_70_75' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_76\" class=\"gfield gfield--type-text gf_left_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_70_76'>State\/Province\/Region Issued<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_70_76' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_265\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_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_70_265'>Expiration<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_265' id='input_70_265' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_70_265_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_70_265_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_70_265' class='gform_hidden' value='https:\/\/samaritanspurse.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_70_420\" class=\"gfield gfield--type-sp_attachment_upload gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_420'>Resume\/CV Upload<\/label><div class='gfield_description' id='gfield_description_70_420'><p style='font-size:14px !important;padding-left:0 !important;'><i><label class=\"gfield_label\">Please attach a scanned copy of your resume or CV.<\/label>\n<p style=\"font-size:14px !important;padding-left:0 !important;\"><strong><i>Files should be no larger than 5MB, and may be in one of the following formats: JPG, JPEG, GIF, or PDF.<\/i><\/strong><\/p><\/i><\/p><\/div><div class='ginput_container ginput_container_text large'>\t\t\t<div class='spau-content-wrapper'>\n\t\t\t\t<span id='input_70_420_btn-photo' data-photobutton class='btn btn-success fileinput-button'>\n\t\t\t\t<i class='glyphicon glyphicon-plus'><\/i>\n\t\t\t\t<span>Add file...<\/span>\n\t\t\t\t<!-- The file input field used as target for the file upload widget -->\n\t\t\t\t\t\t\t\t<input id='input_70_420_fileupload' data-file-upload type='file' name='input_70_420_files[]'>\n\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t<span id='input_70_420_fileUploadedBool' data-uploadbutton>Your file has not been uploaded.<\/span>\n\t\t\t\t<br>\n\t\t\t\t<br>\n\t\t\t\t<!-- The global progress bar -->\n\t\t\t\t<div id='input_70_420_progress' data-progress-bar class='progress'>\n\t\t\t\t\t<div class='progress-bar progress-bar-success'><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<!-- The container for the uploaded files -->\n\t\t\t\t<div id='input_70_420_files' data-file-wrapper class='input_70_420_files'><\/div>\n\t\t\t\t<br>\n\t\t\t\t\t\t\t\t\t\t<input type=hidden name='input_420' id='input_70_420_field' value='' \/>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_70_78' 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_70_78' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_70_5_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_70_5' class='gform_page' data-js='page-field-id-78' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_70_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_70_104\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Christian Testimony and Character Reference<\/h2><div class='gsection_description' id='gfield_description_70_104'>Please have your Senior Pastor, Associate Pastor, or small group leader <strong>fill out and sign <a target=\"_blank\" href=\"https:\/\/s3.theark.cloud\/sp-comm-arkfiles\/website\/pdfs\/WMM\/Character%20Reference.pdf\">this form<\/a>.<\/strong>  Scan it and attach it to your application using the interface below.  <br><br>Provide the complete mailing address, phone number, and email address of character references, as we may contact them for additional information. <\/div><\/li><li id=\"field_70_421\" class=\"gfield gfield--type-sp_attachment_upload gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_421'>Attach character reference<\/label><div class='gfield_description' id='gfield_description_70_421'><p style='font-size:14px !important;padding-left:0 !important;'><i><label class=\"gfield_label\">Please attach a scanned copy of your character reference from your pastor or other church leader.<\/label>\n<p style=\"font-size:14px !important;padding-left:0 !important;\"><strong><i>Files should be no larger than 5MB, and may be in one of the following formats: JPG, JPEG, GIF, or PDF.<\/i><\/strong><\/p><\/i><\/p><\/div><div class='ginput_container ginput_container_text large'>\t\t\t<div class='spau-content-wrapper'>\n\t\t\t\t<span id='input_70_421_btn-photo' data-photobutton class='btn btn-success fileinput-button'>\n\t\t\t\t<i class='glyphicon glyphicon-plus'><\/i>\n\t\t\t\t<span>Add file...<\/span>\n\t\t\t\t<!-- The file input field used as target for the file upload widget -->\n\t\t\t\t\t\t\t\t<input id='input_70_421_fileupload' data-file-upload type='file' name='input_70_421_files[]'>\n\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t<span id='input_70_421_fileUploadedBool' data-uploadbutton>Your file has not been uploaded.<\/span>\n\t\t\t\t<br>\n\t\t\t\t<br>\n\t\t\t\t<!-- The global progress bar -->\n\t\t\t\t<div id='input_70_421_progress' data-progress-bar class='progress'>\n\t\t\t\t\t<div class='progress-bar progress-bar-success'><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<!-- The container for the uploaded files -->\n\t\t\t\t<div id='input_70_421_files' data-file-wrapper class='input_70_421_files'><\/div>\n\t\t\t\t<br>\n\t\t\t\t\t\t\t\t\t\t<input type=hidden name='input_421' id='input_70_421_field' value='' \/>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div><\/li><li id=\"field_70_105\" class=\"gfield gfield--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_70_105'>Church Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_70_105' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_113\" class=\"gfield gfield--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_70_113'>Character Reference Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_113' id='input_70_113' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_296\" class=\"gfield gfield--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_70_296'>Character Reference Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_296' id='input_70_296' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_116\" class=\"gfield gfield--type-email emailBlock 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' >Character Reference Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_70_116_container'>\n                                <span id='input_70_116_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_116' id='input_70_116' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_70_116' class='gform-field-label gform-field-label--type-sub '>Introduce un email<\/label>\n                                <\/span>\n                                <span id='input_70_116_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_116_2' id='input_70_116_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_70_116_2' class='gform-field-label gform-field-label--type-sub '>Confirmar email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_70_108\" class=\"gfield gfield--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_70_108'>Denomination<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_108' id='input_70_108' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_117\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_117'>Offices and Activities in Church<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_117' id='input_70_117' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_70_118\" class=\"gfield gfield--type-textarea 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_70_118'>Please provide us with a statement of your personal Christian testimony. Please address each of the following within your testimony: How and when you became a Christian; What Jesus Christ means to you in your daily life; your understanding of the basis of your salvation; and your devotional habits.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_118' id='input_70_118' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_70_121\" class=\"gfield gfield--type-textarea 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_70_121'>Why are you seeking to serve in a Christian mission hospital or setting?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_121' id='input_70_121' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_70_103' 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_70_103' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_70_6_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_70_6' class='gform_page' data-js='page-field-id-103' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_70_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_70_79\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Professional References<\/h2><div class='gsection_description' id='gfield_description_70_79'>In order to properly process your application, please provide the complete mailing address, phone number, and email address of references who will be contacted for professional recommendations. \n\nA physician\u2019s reference is preferred. For residents or fellows, one of these should be your department chairperson or advisor. \n\nThe professional reference should be submitted on letterhead and sent as an attachment.<\/div><\/li><li id=\"field_70_422\" class=\"gfield gfield--type-sp_attachment_upload gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_422'>Attach professional reference 1<\/label><div class='gfield_description' id='gfield_description_70_422'><p style='font-size:14px !important;padding-left:0 !important;'><i><label class=\"gfield_label\">Please attach a scanned copy of your first professional reference.<\/label>\n<p style=\"font-size:14px !important;padding-left:0 !important;\"><strong><i>Images should be no larger than 5MB, and may be in one of the following formats: JPG, JPEG, GIF, or PDF.<\/i><\/strong><\/p><\/i><\/p><\/div><div class='ginput_container ginput_container_text large'>\t\t\t<div class='spau-content-wrapper'>\n\t\t\t\t<span id='input_70_422_btn-photo' data-photobutton class='btn btn-success fileinput-button'>\n\t\t\t\t<i class='glyphicon glyphicon-plus'><\/i>\n\t\t\t\t<span>Add file...<\/span>\n\t\t\t\t<!-- The file input field used as target for the file upload widget -->\n\t\t\t\t\t\t\t\t<input id='input_70_422_fileupload' data-file-upload type='file' name='input_70_422_files[]'>\n\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t<span id='input_70_422_fileUploadedBool' data-uploadbutton>Your file has not been uploaded.<\/span>\n\t\t\t\t<br>\n\t\t\t\t<br>\n\t\t\t\t<!-- The global progress bar -->\n\t\t\t\t<div id='input_70_422_progress' data-progress-bar class='progress'>\n\t\t\t\t\t<div class='progress-bar progress-bar-success'><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<!-- The container for the uploaded files -->\n\t\t\t\t<div id='input_70_422_files' data-file-wrapper class='input_70_422_files'><\/div>\n\t\t\t\t<br>\n\t\t\t\t\t\t\t\t\t\t<input type=hidden name='input_422' id='input_70_422_field' value='' \/>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div><\/li><li id=\"field_70_423\" class=\"gfield gfield--type-sp_attachment_upload gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_423'>Attach professional reference 2<\/label><div class='gfield_description' id='gfield_description_70_423'><p style='font-size:14px !important;padding-left:0 !important;'><i><label class=\"gfield_label\">Please attach a scanned copy of your second professional reference.<\/label>\n<p style=\"font-size:14px !important;padding-left:0 !important;\"><strong><i>Images should be no larger than 5MB, and may be in one of the following formats: JPG, JPEG, GIF, or PDF.<\/i><\/strong><\/p><\/i><\/p><\/div><div class='ginput_container ginput_container_text large'>\t\t\t<div class='spau-content-wrapper'>\n\t\t\t\t<span id='input_70_423_btn-photo' data-photobutton class='btn btn-success fileinput-button'>\n\t\t\t\t<i class='glyphicon glyphicon-plus'><\/i>\n\t\t\t\t<span>Add file...<\/span>\n\t\t\t\t<!-- The file input field used as target for the file upload widget -->\n\t\t\t\t\t\t\t\t<input id='input_70_423_fileupload' data-file-upload type='file' name='input_70_423_files[]'>\n\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t<span id='input_70_423_fileUploadedBool' data-uploadbutton>Your file has not been uploaded.<\/span>\n\t\t\t\t<br>\n\t\t\t\t<br>\n\t\t\t\t<!-- The global progress bar -->\n\t\t\t\t<div id='input_70_423_progress' data-progress-bar class='progress'>\n\t\t\t\t\t<div class='progress-bar progress-bar-success'><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<!-- The container for the uploaded files -->\n\t\t\t\t<div id='input_70_423_files' data-file-wrapper class='input_70_423_files'><\/div>\n\t\t\t\t<br>\n\t\t\t\t\t\t\t\t\t\t<input type=hidden name='input_423' id='input_70_423_field' value='' \/>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div><\/li><li id=\"field_70_80\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Professional Reference 1<\/h2><\/li><li id=\"field_70_397\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_397'>Title<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_397' id='input_70_397' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Mr.' >Mr.<\/option><option value='Mrs.' >Mrs.<\/option><option value='Ms.' >Ms.<\/option><option value='Dr.' >Dr.<\/option><option value='Rev.' >Rev.<\/option><option value='Pastor' >Pastor<\/option><option value='Chaplain' >Chaplain<\/option><option value='Minister' >Minister<\/option><option value='Bishop' >Bishop<\/option><option value='Father' >Father<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_70_81\" class=\"gfield gfield--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_70_81'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_70_81' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_82\" class=\"gfield gfield--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_70_82'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_70_82' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_250\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_250'>Professional Reference 1 - Country of Residence<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_250' id='input_70_250' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='Australia' >Australia<\/option><option value='Canada' >Canada<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States of America' >United States of America<\/option><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='Algeria (El Djazair)' >Algeria (El Djazair)<\/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='Angullia' >Angullia<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua' >Antigua<\/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='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='Bosnia' >Bosnia<\/option><option value='Bosnia-Herzegovina' >Bosnia-Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='Bristish Indian Ocean Territory' >Bristish Indian Ocean Territory<\/option><option value='British Honduras' >British Honduras<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Fasco' >Burkina Fasco<\/option><option value='Burma' >Burma<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canal Zone' >Canal Zone<\/option><option value='Canary Islands' >Canary Islands<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Ceylon' >Ceylon<\/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='Colombia' >Colombia<\/option><option value='Comoro Islands' >Comoro Islands<\/option><option value='Congo, Republic of' >Congo, Republic of<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Cote D&#039;&#039;lvoire (Ivory Coast)' >Cote D&#039;&#039;lvoire (Ivory Coast)<\/option><option value='Cote d&#039;Ivoire' >Cote d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Croatia (Hrvatska)' >Croatia (Hrvatska)<\/option><option value='Cuba' >Cuba<\/option><option value='Curaco, Netherlands Antilles' >Curaco, Netherlands Antilles<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Dem Rep of the Congo - Kinshasa' >Dem Rep of the Congo - Kinshasa<\/option><option value='Dem. People&#039;s Rep. of Korea' >Dem. People&#039;s Rep. of Korea<\/option><option value='Democratic Republic of the Congo' >Democratic Republic of the Congo<\/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='East Timor' >East Timor<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='England' >England<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Faeroe Islands' >Faeroe Islands<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Federated States of Micronesia' >Federated States of Micronesia<\/option><option value='Fiji' >Fiji<\/option><option value='Fiji Islands' >Fiji Islands<\/option><option value='Finland' >Finland<\/option><option value='For anonymous donor records' >For anonymous donor records<\/option><option value='Formosa' >Formosa<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/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='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Grenada, West Indies' >Grenada, West Indies<\/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='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='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kazakstan' >Kazakstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea' >Korea<\/option><option value='Korle-Gommo, West Africa' >Korle-Gommo, West Africa<\/option><option value='Kosovo' >Kosovo<\/option><option value='Kurdistan' >Kurdistan<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Laos' >Laos<\/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='Macau - China' >Macau - China<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Mail' >Mail<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Malta' >Malta<\/option><option value='Marinique' >Marinique<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mauritius, Indian Ocean' >Mauritius, Indian Ocean<\/option><option value='Maurt' >Maurt<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/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='Netherlands Antilles' >Netherlands Antilles<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='New Zealand (Aotearoa)' >New Zealand (Aotearoa)<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Niger Republic' >Niger Republic<\/option><option value='Niger, West Africa' >Niger, West Africa<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='North Korea' >North Korea<\/option><option value='North Sudan' >North Sudan<\/option><option value='Northern Ireland' >Northern Ireland<\/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' >Palestine<\/option><option value='Panama' >Panama<\/option><option value='Papua' >Papua<\/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='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Principat D&#039;andorra' >Principat D&#039;andorra<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Rep Du Burundi' >Rep Du Burundi<\/option><option value='Rep Du Gabon' >Rep Du Gabon<\/option><option value='Rep Du Mali' >Rep Du Mali<\/option><option value='Rep Du Senegal' >Rep Du Senegal<\/option><option value='Rep of Congo - Brazzaville' >Rep of Congo - Brazzaville<\/option><option value='Rep of Guinea-Bissau' >Rep of Guinea-Bissau<\/option><option value='Republic of Benin' >Republic of Benin<\/option><option value='Republic of Burkina Faso' >Republic of Burkina Faso<\/option><option value='Republic of China' >Republic of China<\/option><option value='Republic of Korea' >Republic of Korea<\/option><option value='Republic of Singapore' >Republic of Singapore<\/option><option value='Republic of South Africa' >Republic of South Africa<\/option><option value='Republic of Upper Volta' >Republic of Upper Volta<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/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='Scotland' >Scotland<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Serbia and Montenegro' >Serbia and Montenegro<\/option><option value='Seychelles' >Seychelles<\/option><option value='Seychelles, Indian Ocean' >Seychelles, Indian Ocean<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/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='Somaliland' >Somaliland<\/option><option value='Somolia' >Somolia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia\/South Sandwich Islands' >South Georgia\/South Sandwich Islands<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='South Vietnam' >South Vietnam<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='St Kitts, Leeward Islands' >St Kitts, Leeward Islands<\/option><option value='St Maarten, Leeward Islands' >St Maarten, Leeward Islands<\/option><option value='St. Lucia' >St. Lucia<\/option><option value='St. Vincent' >St. Vincent<\/option><option value='Sudan' >Sudan<\/option><option value='Sultan of Oman' >Sultan of Oman<\/option><option value='Suriname' >Suriname<\/option><option value='Suriname, South America' >Suriname, South America<\/option><option value='Swaziland' >Swaziland<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Taiwan, Republic Of China' >Taiwan, Republic Of China<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='The Netherlands' >The Netherlands<\/option><option value='Tibet' >Tibet<\/option><option value='Togo' >Togo<\/option><option value='Tonga' >Tonga<\/option><option value='Tonga Islands, South Pacific' >Tonga Islands, South Pacific<\/option><option value='Transkei, Africa' >Transkei, Africa<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Turks in Caicos Island' >Turks in Caicos Island<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United States Minor Outlying Islands' >United States Minor Outlying Islands<\/option><option value='Unknown Country' >Unknown Country<\/option><option value='Unknown Name\/Address' >Unknown Name\/Address<\/option><option value='Uruguay' >Uruguay<\/option><option value='USSR' >USSR<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Vatican City' >Vatican City<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wales' >Wales<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='West Germany' >West Germany<\/option><option value='West Indies' >West Indies<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Western Samoa' >Western Samoa<\/option><option value='Yemen' >Yemen<\/option><option value='Yemen Arab Republic' >Yemen Arab Republic<\/option><option value='Yugoslavia' >Yugoslavia<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select><\/div><\/li><li id=\"field_70_294\" class=\"gfield gfield--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_70_294'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_294' id='input_70_294' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_88\" class=\"gfield gfield--type-email emailBlock 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' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_70_88_container'>\n                                <span id='input_70_88_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_88' id='input_70_88' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_70_88' class='gform-field-label gform-field-label--type-sub '>Introduce un email<\/label>\n                                <\/span>\n                                <span id='input_70_88_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_88_2' id='input_70_88_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_70_88_2' class='gform-field-label gform-field-label--type-sub '>Confirmar email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_70_89\" class=\"gfield gfield--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_70_89'>Reference 1 Occupation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_89' id='input_70_89' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_90\" class=\"gfield gfield--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_70_90'>Reference 1 Relationship<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_90' id='input_70_90' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_92\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Professional Reference 2<\/h2><\/li><li id=\"field_70_398\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_398'>Title<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_398' id='input_70_398' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Mr.' >Mr.<\/option><option value='Mrs.' >Mrs.<\/option><option value='Ms.' >Ms.<\/option><option value='Dr.' >Dr.<\/option><option value='Rev.' >Rev.<\/option><option value='Pastor' >Pastor<\/option><option value='Chaplain' >Chaplain<\/option><option value='Minister' >Minister<\/option><option value='Bishop' >Bishop<\/option><option value='Father' >Father<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_70_93\" class=\"gfield gfield--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_70_93'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_70_93' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_94\" class=\"gfield gfield--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_70_94'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_70_94' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_253\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_253'>Professional Reference 2 - Country of Residence<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_253' id='input_70_253' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='Australia' >Australia<\/option><option value='Canada' >Canada<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States of America' >United States of America<\/option><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='Algeria (El Djazair)' >Algeria (El Djazair)<\/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='Angullia' >Angullia<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua' >Antigua<\/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='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='Bosnia' >Bosnia<\/option><option value='Bosnia-Herzegovina' >Bosnia-Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='Bristish Indian Ocean Territory' >Bristish Indian Ocean Territory<\/option><option value='British Honduras' >British Honduras<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Fasco' >Burkina Fasco<\/option><option value='Burma' >Burma<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canal Zone' >Canal Zone<\/option><option value='Canary Islands' >Canary Islands<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Ceylon' >Ceylon<\/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='Colombia' >Colombia<\/option><option value='Comoro Islands' >Comoro Islands<\/option><option value='Congo, Republic of' >Congo, Republic of<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Cote D&#039;&#039;lvoire (Ivory Coast)' >Cote D&#039;&#039;lvoire (Ivory Coast)<\/option><option value='Cote d&#039;Ivoire' >Cote d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Croatia (Hrvatska)' >Croatia (Hrvatska)<\/option><option value='Cuba' >Cuba<\/option><option value='Curaco, Netherlands Antilles' >Curaco, Netherlands Antilles<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Dem Rep of the Congo - Kinshasa' >Dem Rep of the Congo - Kinshasa<\/option><option value='Dem. People&#039;s Rep. of Korea' >Dem. People&#039;s Rep. of Korea<\/option><option value='Democratic Republic of the Congo' >Democratic Republic of the Congo<\/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='East Timor' >East Timor<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='England' >England<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Faeroe Islands' >Faeroe Islands<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Federated States of Micronesia' >Federated States of Micronesia<\/option><option value='Fiji' >Fiji<\/option><option value='Fiji Islands' >Fiji Islands<\/option><option value='Finland' >Finland<\/option><option value='For anonymous donor records' >For anonymous donor records<\/option><option value='Formosa' >Formosa<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/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='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Grenada, West Indies' >Grenada, West Indies<\/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='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='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kazakstan' >Kazakstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea' >Korea<\/option><option value='Korle-Gommo, West Africa' >Korle-Gommo, West Africa<\/option><option value='Kosovo' >Kosovo<\/option><option value='Kurdistan' >Kurdistan<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Laos' >Laos<\/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='Macau - China' >Macau - China<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Mail' >Mail<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Malta' >Malta<\/option><option value='Marinique' >Marinique<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mauritius, Indian Ocean' >Mauritius, Indian Ocean<\/option><option value='Maurt' >Maurt<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/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='Netherlands Antilles' >Netherlands Antilles<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='New Zealand (Aotearoa)' >New Zealand (Aotearoa)<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Niger Republic' >Niger Republic<\/option><option value='Niger, West Africa' >Niger, West Africa<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='North Korea' >North Korea<\/option><option value='North Sudan' >North Sudan<\/option><option value='Northern Ireland' >Northern Ireland<\/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' >Palestine<\/option><option value='Panama' >Panama<\/option><option value='Papua' >Papua<\/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='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Principat D&#039;andorra' >Principat D&#039;andorra<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Rep Du Burundi' >Rep Du Burundi<\/option><option value='Rep Du Gabon' >Rep Du Gabon<\/option><option value='Rep Du Mali' >Rep Du Mali<\/option><option value='Rep Du Senegal' >Rep Du Senegal<\/option><option value='Rep of Congo - Brazzaville' >Rep of Congo - Brazzaville<\/option><option value='Rep of Guinea-Bissau' >Rep of Guinea-Bissau<\/option><option value='Republic of Benin' >Republic of Benin<\/option><option value='Republic of Burkina Faso' >Republic of Burkina Faso<\/option><option value='Republic of China' >Republic of China<\/option><option value='Republic of Korea' >Republic of Korea<\/option><option value='Republic of Singapore' >Republic of Singapore<\/option><option value='Republic of South Africa' >Republic of South Africa<\/option><option value='Republic of Upper Volta' >Republic of Upper Volta<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/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='Scotland' >Scotland<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Serbia and Montenegro' >Serbia and Montenegro<\/option><option value='Seychelles' >Seychelles<\/option><option value='Seychelles, Indian Ocean' >Seychelles, Indian Ocean<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/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='Somaliland' >Somaliland<\/option><option value='Somolia' >Somolia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia\/South Sandwich Islands' >South Georgia\/South Sandwich Islands<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='South Vietnam' >South Vietnam<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='St Kitts, Leeward Islands' >St Kitts, Leeward Islands<\/option><option value='St Maarten, Leeward Islands' >St Maarten, Leeward Islands<\/option><option value='St. Lucia' >St. Lucia<\/option><option value='St. Vincent' >St. Vincent<\/option><option value='Sudan' >Sudan<\/option><option value='Sultan of Oman' >Sultan of Oman<\/option><option value='Suriname' >Suriname<\/option><option value='Suriname, South America' >Suriname, South America<\/option><option value='Swaziland' >Swaziland<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Taiwan, Republic Of China' >Taiwan, Republic Of China<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='The Netherlands' >The Netherlands<\/option><option value='Tibet' >Tibet<\/option><option value='Togo' >Togo<\/option><option value='Tonga' >Tonga<\/option><option value='Tonga Islands, South Pacific' >Tonga Islands, South Pacific<\/option><option value='Transkei, Africa' >Transkei, Africa<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Turks in Caicos Island' >Turks in Caicos Island<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United States Minor Outlying Islands' >United States Minor Outlying Islands<\/option><option value='Unknown Country' >Unknown Country<\/option><option value='Unknown Name\/Address' >Unknown Name\/Address<\/option><option value='Uruguay' >Uruguay<\/option><option value='USSR' >USSR<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Vatican City' >Vatican City<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wales' >Wales<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='West Germany' >West Germany<\/option><option value='West Indies' >West Indies<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Western Samoa' >Western Samoa<\/option><option value='Yemen' >Yemen<\/option><option value='Yemen Arab Republic' >Yemen Arab Republic<\/option><option value='Yugoslavia' >Yugoslavia<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select><\/div><\/li><li id=\"field_70_295\" class=\"gfield gfield--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_70_295'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_295' id='input_70_295' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_100\" class=\"gfield gfield--type-email emailBlock 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' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_70_100_container'>\n                                <span id='input_70_100_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_100' id='input_70_100' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_70_100' class='gform-field-label gform-field-label--type-sub '>Introduce un email<\/label>\n                                <\/span>\n                                <span id='input_70_100_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_100_2' id='input_70_100_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_70_100_2' class='gform-field-label gform-field-label--type-sub '>Confirmar email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_70_101\" class=\"gfield gfield--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_70_101'>Reference 2 Occupation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_70_101' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_102\" class=\"gfield gfield--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_70_102'>Reference 2 Relationship<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_102' id='input_70_102' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_70_122' 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_70_122' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_70_7_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_70_7' class='gform_page' data-js='page-field-id-122' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_70_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_70_123\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Missions Interest, Skills, and Experience<\/h2><\/li><li id=\"field_70_124\" class=\"gfield gfield--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_70_124'>How many weeks are you available to serve?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_70_124' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_168\" class=\"gfield gfield--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_70_168'>How much time (e.g. hours\/day) are you available to volunteer while you are serving with your spouse\/family?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_168' id='input_70_168' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_125\" class=\"gfield gfield--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_70_125'>Dates Available<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_70_125' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_126\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_126'>Hospitals of Interest?<\/label><div class='ginput_container ginput_container_text'><input name='input_126' id='input_70_126' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_127\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_127'>Countries of Interest?<\/label><div class='ginput_container ginput_container_text'><input name='input_127' id='input_70_127' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_128\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_128'>Previous Mission or International Experience. Please include with whom, places, and dates.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_128' id='input_70_128' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_70_129\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Travel and Passport Information<\/h2><\/li><li id=\"field_70_130\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_130'>Who will you be traveling with?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_130' id='input_70_130' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Alone' >Alone<\/option><option value='With Spouse' >With Spouse<\/option><option value='With Child(ren)' >With Child(ren)<\/option><option value='With Spouse and Child(ren)' >With Spouse and Child(ren)<\/option><option value='With Parent(s)' >With Parent(s)<\/option><option value='With Other' >With Other<\/option><\/select><\/div><\/li><li id=\"field_70_150\" class=\"gfield gfield--type-textarea 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_70_150'>List the name(s), relationship(s) and age of person(s) traveling with you<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_150' id='input_70_150' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_70_403\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Do you have a valid passport?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_70_403'>\n\t\t\t<li class='gchoice gchoice_70_403_0'>\n\t\t\t\t<input name='input_403' type='radio' value='Yes'  id='choice_70_403_0'    \/>\n\t\t\t\t<label for='choice_70_403_0' id='label_70_403_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_70_403_1'>\n\t\t\t\t<input name='input_403' type='radio' value='No'  id='choice_70_403_1'    \/>\n\t\t\t\t<label for='choice_70_403_1' id='label_70_403_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_70_135\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_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_70_135'>Expiration date<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_135' id='input_70_135' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='MM\/DD\/YYYY' aria-describedby=\"input_70_135_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_70_135_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_70_135' class='gform_hidden' value='https:\/\/samaritanspurse.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_70_140\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Language(s) Skills<\/h2>\n\nPlease enter languages (other than English) that you speak, and your competency in each of them.<\/li><li id=\"field_70_329\" class=\"gfield gfield--type-list field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Languages<\/label><style type=\"text\/css\">\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons {\n\t\t\t\t\t\t\tvertical-align: middle !important;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons img {\n\t\t\t\t\t\t\tbackground-color: transparent !important;\n\t\t\t\t\t\t\tbackground-position: 0 0;\n\t\t\t\t\t\t\tbackground-size: 16px 16px !important;\n\t\t\t\t\t\t\tbackground-repeat: no-repeat;\n\t\t\t\t\t\t\tborder: none !important;\n\t\t\t\t\t\t\twidth: 16px !important;\n\t\t\t\t\t\t\theight: 16px !important;\n\t\t\t\t\t\t\topacity: 0.5;\n\t\t\t\t\t\t\ttransition: opacity .5s ease-out;\n\t\t\t\t\t\t    -moz-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -webkit-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -o-transition: opacity .5s ease-out;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons a:hover img {\n\t\t\t\t\t\t\topacity: 1.0;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\t<\/style><div class='ginput_container ginput_container_list ginput_list'><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_329_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_329_col_2' class='gfield_list_col_even' \/><col id='gfield_list_329_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_329_col_4' class='gfield_list_col_even' \/><col id='gfield_list_329_col_5' class='gfield_list_col_odd' \/><col id='gfield_list_329_col_6' class='gfield_list_col_even' \/><col id='gfield_list_329_col_7' class='gfield_list_col_odd' \/><col id='gfield_list_329_col_8' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th scope=\"col\">Language<\/th><th scope=\"col\">This is my native language<\/th><th scope=\"col\">Comprehension<\/th><th scope=\"col\">Overall<\/th><th scope=\"col\">Reading<\/th><th scope=\"col\">Speaking<\/th><th scope=\"col\">Writing<\/th><td>&nbsp;<\/td><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_329_cell1' data-label='Language'><select name='input_329[]'   aria-invalid='false'   aria-label='Language, Fila 1' data-aria-label-template='Language, Fila {0}'><option value='' ><\/option><option value='Albanian' >Albanian<\/option><option value='Afrikaans' >Afrikaans<\/option><option value='Amharic' >Amharic<\/option><option value='Arabic' >Arabic<\/option><option value='Armenian' >Armenian<\/option><option value='Azerbaijani' >Azerbaijani<\/option><option value='Basque' >Basque<\/option><option value='Belarusian' >Belarusian<\/option><option value='Bengali' >Bengali<\/option><option value='Bosnian' >Bosnian<\/option><option value='Bulgarian' >Bulgarian<\/option><option value='Burmese' >Burmese<\/option><option value='Catalan' >Catalan<\/option><option value='Chinese' >Chinese<\/option><option value='Croatian' >Croatian<\/option><option value='Czech' >Czech<\/option><option value='Danish' >Danish<\/option><option value='Dutch' >Dutch<\/option><option value='English' >English<\/option><option value='Estonian' >Estonian<\/option><option value='Finnish' >Finnish<\/option><option value='French' >French<\/option><option value='Georgian' >Georgian<\/option><option value='German' >German<\/option><option value='Greek' >Greek<\/option><option value='Gujarati' >Gujarati<\/option><option value='Haitian' >Haitian<\/option><option value='Hausa' >Hausa<\/option><option value='Hebrew' >Hebrew<\/option><option value='Hindi' >Hindi<\/option><option value='Hungarian' >Hungarian<\/option><option value='Icelandic' >Icelandic<\/option><option value='Indonesian' >Indonesian<\/option><option value='Irish' >Irish<\/option><option value='Italian' >Italian<\/option><option value='Japanese' >Japanese<\/option><option value='Kannada' >Kannada<\/option><option value='Kazakh' >Kazakh<\/option><option value='Khmer' >Khmer<\/option><option value='Korean' >Korean<\/option><option value='Kyrgyz' >Kyrgyz<\/option><option value='Lao' >Lao<\/option><option value='Latin' >Latin<\/option><option value='Latvian' >Latvian<\/option><option value='Lithuanian' >Lithuanian<\/option><option value='Macedonian' >Macedonian<\/option><option value='Malay' >Malay<\/option><option value='Malayalam' >Malayalam<\/option><option value='Mandarin' >Mandarin<\/option><option value='Marathi' >Marathi<\/option><option value='Mongolian' >Mongolian<\/option><option value='Nepali' >Nepali<\/option><option value='Norwegian' >Norwegian<\/option><option value='Other' >Other<\/option><option value='Pashto' >Pashto<\/option><option value='Persian' >Persian<\/option><option value='Polish' >Polish<\/option><option value='Portuguese' >Portuguese<\/option><option value='Punjabi' >Punjabi<\/option><option value='Quechua' >Quechua<\/option><option value='Romanian' >Romanian<\/option><option value='Russian' >Russian<\/option><option value='Serbian' >Serbian<\/option><option value='Sindhi' >Sindhi<\/option><option value='Sinhala' >Sinhala<\/option><option value='Slovak' >Slovak<\/option><option value='Slovene' >Slovene<\/option><option value='Somali' >Somali<\/option><option value='Spanish' >Spanish<\/option><option value='Swahili' >Swahili<\/option><option value='Swedish' >Swedish<\/option><option value='Tagalog' >Tagalog<\/option><option value='Tajik' >Tajik<\/option><option value='Tamil' >Tamil<\/option><option value='Telugu' >Telugu<\/option><option value='Thai' >Thai<\/option><option value='Tibetan' >Tibetan<\/option><option value='Turkish' >Turkish<\/option><option value='Turkmen' >Turkmen<\/option><option value='Uighur' >Uighur<\/option><option value='Ukrainian' >Ukrainian<\/option><option value='Urdu' >Urdu<\/option><option value='Uzbek' >Uzbek<\/option><option value='Vietnamese' >Vietnamese<\/option><option value='Yoruba' >Yoruba<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_329_cell2' data-label='This is my native language'><select name='input_329[]'   aria-invalid='false'   aria-label='This is my native language, Fila 1' data-aria-label-template='This is my native language, Fila {0}'><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_329_cell3' data-label='Comprehension'><select name='input_329[]'   aria-invalid='false'   aria-label='Comprehension, Fila 1' data-aria-label-template='Comprehension, Fila {0}'><option value='' ><\/option><option value='1 - Beginner' >1 - Beginner<\/option><option value='2 - Classroom Study' >2 - Classroom Study<\/option><option value='3 - Intermediate' >3 - Intermediate<\/option><option value='4 - Advanced' >4 - Advanced<\/option><option value='5 - Fluent' >5 - Fluent<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_329_cell4' data-label='Overall'><select name='input_329[]'   aria-invalid='false'   aria-label='Overall, Fila 1' data-aria-label-template='Overall, Fila {0}'><option value='' ><\/option><option value='1 - Beginner' >1 - Beginner<\/option><option value='2 - Classroom Study' >2 - Classroom Study<\/option><option value='3 - Intermediate' >3 - Intermediate<\/option><option value='4 - Advanced' >4 - Advanced<\/option><option value='5 - Fluent' >5 - Fluent<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_329_cell5' data-label='Reading'><select name='input_329[]'   aria-invalid='false'   aria-label='Reading, Fila 1' data-aria-label-template='Reading, Fila {0}'><option value='' ><\/option><option value='1 - Beginner' >1 - Beginner<\/option><option value='2 - Classroom Study' >2 - Classroom Study<\/option><option value='3 - Intermediate' >3 - Intermediate<\/option><option value='4 - Advanced' >4 - Advanced<\/option><option value='5 - Fluent' >5 - Fluent<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_329_cell6' data-label='Speaking'><select name='input_329[]'   aria-invalid='false'   aria-label='Speaking, Fila 1' data-aria-label-template='Speaking, Fila {0}'><option value='' ><\/option><option value='1 - Beginner' >1 - Beginner<\/option><option value='2 - Classroom Study' >2 - Classroom Study<\/option><option value='3 - Intermediate' >3 - Intermediate<\/option><option value='4 - Advanced' >4 - Advanced<\/option><option value='5 - Fluent' >5 - Fluent<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_329_cell7' data-label='Writing'><select name='input_329[]'   aria-invalid='false'   aria-label='Writing, Fila 1' data-aria-label-template='Writing, Fila {0}'><option value='' ><\/option><option value='1 - Beginner' >1 - Beginner<\/option><option value='2 - Classroom Study' >2 - Classroom Study<\/option><option value='3 - Intermediate' >3 - Intermediate<\/option><option value='4 - Advanced' >4 - Advanced<\/option><option value='5 - Fluent' >5 - Fluent<\/option><\/select><\/td><td class='gfield_list_icons'>   <a href='javascript:void(0);' class='add_list_item ' aria-label='A\u00f1adir otra fila' onclick='gformAddListItem(this, 10)' onkeypress='gformAddListItem(this, 10)'><img src='https:\/\/samaritanspurse.org\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' alt='' title='A\u00f1ade una nueva fila' \/><\/a>   <a href='javascript:void(0);' class='delete_list_item' aria-label='Eliminar esta fila' onclick='gformDeleteListItem(this, 10)' onkeypress='gformDeleteListItem(this, 10)' style=\"visibility:hidden;\"><img src='https:\/\/samaritanspurse.org\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' alt='' title='Eliminar esta fila' \/><\/a><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id=\"field_70_141\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_141'>Please tell us how you heard about this opportunity<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_141' id='input_70_141' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='Web' >Web<\/option><option value='Conference' >Conference<\/option><option value='Printed Material' >Printed Material<\/option><option value='Personal Referral' >Personal Referral<\/option><option value='Other' >Other<\/option><option value='Parent (for traveling children)' >Parent (for traveling children)<\/option><\/select><\/div><\/li><li id=\"field_70_268\" class=\"gfield gfield--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_70_268'>How you heard - Other<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_268' id='input_70_268' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_151\" class=\"gfield gfield--type-multiselect 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_70_151'>Which conference? (hold CTRL to select multiple)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_151[]' id='input_70_151' class='medium gfield_select'   aria-invalid=\"false\" aria-required=\"true\" ><option value='PFR' >Prescription for Renewal (PFR)<\/option><option value='CMDA' >CMDA National Convention<\/option><option value='GMHC' >Global Missions Health Conference (GMHC)<\/option><option value='M3' >Mobilizing Medical Missions (M3)<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_70_152\" class=\"gfield gfield--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_70_152'>Conference - Other<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_152' id='input_70_152' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_153\" class=\"gfield gfield--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_70_153'>Name of the personal reference<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_153' id='input_70_153' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_154\" class=\"gfield gfield--type-multiselect 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_70_154'>Printed material(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_154[]' id='input_70_154' class='medium gfield_select'   aria-invalid=\"false\" aria-required=\"true\" ><option value='On Call Magazine' >On Call Magazine<\/option><option value='PrayerPoint Magazine' >PrayerPoint Magazine<\/option><option value='Franklin Graham monthly newsletter' >Franklin Graham monthly newsletter<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_70_267\" class=\"gfield gfield--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_70_267'>Other - printed material(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_267' id='input_70_267' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_70_381\" class=\"gfield gfield--type-radio gfield--type-choice hidden field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' >Are you interested in serving on a DART?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_70_381'>\n\t\t\t<li class='gchoice gchoice_70_381_0'>\n\t\t\t\t<input name='input_381' type='radio' value='Yes'  id='choice_70_381_0'    \/>\n\t\t\t\t<label for='choice_70_381_0' id='label_70_381_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_70_381_1'>\n\t\t\t\t<input name='input_381' type='radio' value='No'  id='choice_70_381_1'    \/>\n\t\t\t\t<label for='choice_70_381_1' id='label_70_381_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_70_381'>The Samaritan\u2019s Purse International Disaster Assistance Response Team (DART) provides water, food, shelter, and medical care to victims of war, poverty, famine, disease, and natural disaster while sharing the Good News of Jesus Christ.<\/div><\/li><li id=\"field_70_406\" class=\"gfield gfield--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\"  ><br><br>\n<strong>Post-Residency Program<\/strong>\n<br>Is the Lord calling you to medical missions? Are you wondering how to make the transition from residency or fellowship to the mission field? If so, the World Medical Mission Post-Residency Program has been created for you.\n\nTo learn more, visit our Post-Residency Program page <a title=\"Post-Residency Program\" href=\"\/world-medical-mission\/post-residency-program\/\">here<\/a>.<\/li><li id=\"field_70_405\" class=\"gfield gfield--type-checkbox gfield--type-choice 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 gfield_label_before_complex' >Disaster Assistance Response Team<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_70_405'><li class='gchoice gchoice_70_405_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_405.1' type='checkbox'  value='I am also interested in DART'  id='choice_70_405_1'   aria-describedby=\"gfield_description_70_405\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_70_405_1' id='label_70_405_1' class='gform-field-label gform-field-label--type-inline'>I am also interested in DART<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_70_405'>If you are interested in hearing more about Disaster Assistance Response Team (DART) please check here and we will email you additional information. Please be aware that DART members are considered employees of Samaritan's Purse so you will need to complete a separate application and there is a required in-person security training prior to deployment.<\/div><\/li><li id=\"field_70_170\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Gifts Assesment<\/h2><div class='gsection_description' id='gfield_description_70_170'>God has given everyone both physical and spiritual gifts that can be used to expand the Kingdom. Everyone can contribute. Please indicate the area(s) of service where you would like to lend support and your level of proficiency at each.<\/div><\/li><li id=\"field_70_172\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Office & Administration<\/h2><\/li><li id=\"field_70_262\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_262'>For example: computer hardware repair\/support, office software support, general office support, or related.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_262' id='input_70_262' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_70_178\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Maintenance\/Construction\/Physical plant operation<\/h2><\/li><li id=\"field_70_263\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_263'>For example: Concrete\/masonry work, carpentry, plumbing, electrical, welding, water systems, diesel\/auto\/machinery repair, gardening, painting, etc.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_263' id='input_70_263' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_70_194\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Hospital\/Compound\/Surrounding Area<\/h2><\/li><li id=\"field_70_264\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_264'>For example: praying with patients\/families\/children, leading VBS, child care, arts &amp; crafts, hosting meals, teaching, pastoral care, public health, nutrition, etc.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_264' id='input_70_264' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_70_304\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Other Gifts\/Skills<\/h2><\/li><li id=\"field_70_303\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_70_303'><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_303' id='input_70_303' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_70_413\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Submit Application<\/h2><\/li><li id=\"field_70_404\" class=\"gfield gfield--type-captcha field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_404'>CAPTCHA<\/label><div id='input_70_404' class='ginput_container ginput_recaptcha' data-sitekey='6Lf0AB8TAAAAAP7xMAjKpqybInRR1NE24y4zL4cM'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/li><\/ul><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_70' 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='submit' id='gform_submit_button_70' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_70_footer_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and 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