{"id":1895,"date":"2025-11-18T14:53:44","date_gmt":"2025-11-18T20:53:44","guid":{"rendered":"https:\/\/staging5.nsd.tech\/?page_id=1895"},"modified":"2025-11-18T15:13:49","modified_gmt":"2025-11-18T21:13:49","slug":"lbv-agency-referral","status":"publish","type":"page","link":"https:\/\/staging5.nsd.tech\/uk\/lbv\/lbv-agency-referral\/","title":{"rendered":"LBV Agency Referral"},"content":{"rendered":"<div id=\"cs-content\" class=\"cs-content\"><div class=\"x-section e1895-e1 m1gn-0\"><div class=\"x-row x-container max width e1895-e2 m1gn-1 m1gn-2\"><div class=\"x-row-inner\"><div class=\"x-col e1895-e3 m1gn-3 NsdSpacerSmallAll\"><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar 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#112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><h2>Agency Referral form<\/h2><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_425' id='gform_425'  action='\/uk\/wp-json\/wp\/v2\/pages\/1895' data-formid='425' novalidate>\n        <div id='gf_progressbar_wrapper_425' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> \u0437 <span class='gf_step_page_count'>2<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_50' style='width:50%;'><span>50%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_425_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_425' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_425_276\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_425_276'>Comments<\/label><div class='ginput_container'><input name='input_276' id='input_425_276' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_425_276'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_425_196\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Referral Information<\/h3><\/div><fieldset id=\"field_425_230\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Please identify yourself by answering the following questions:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_425_230'>\n\t\t\t<div class='gchoice gchoice_425_230_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_230' type='radio' value='Third Choice'  id='choice_425_230_0' onchange='gformToggleRadioOther( this )'  tabindex='1'  \/>\n\t\t\t\t\t<label for='choice_425_230_0' id='label_425_230_0' class='gform-field-label gform-field-label--type-inline'>I am referring myself<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_425_230_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_230' type='radio' value='First Choice'  id='choice_425_230_1' onchange='gformToggleRadioOther( this )'  tabindex='2'  \/>\n\t\t\t\t\t<label for='choice_425_230_1' id='label_425_230_1' class='gform-field-label gform-field-label--type-inline'>I am referring a friend, family member, or community member<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_425_230_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_230' type='radio' value='Second Choice'  id='choice_425_230_2' onchange='gformToggleRadioOther( this )'  tabindex='3'  \/>\n\t\t\t\t\t<label for='choice_425_230_2' id='label_425_230_2' class='gform-field-label gform-field-label--type-inline'>I am a service provider, referring one of my clients<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_425_231\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full CONSENTS gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >All individuals\/families should be aware of and consent to the referral being made on their behalf for this services.  Have you spoken to the individual or family about this referral and received their consent?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_425_231'>\n\t\t\t<div class='gchoice gchoice_425_231_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_231' type='radio' value='0421'  id='choice_425_231_0' onchange='gformToggleRadioOther( this )'  tabindex='4'  \/>\n\t\t\t\t\t<label for='choice_425_231_0' id='label_425_231_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_425_231_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_231' type='radio' value='N'  id='choice_425_231_1' onchange='gformToggleRadioOther( this )'  tabindex='5'  \/>\n\t\t\t\t\t<label for='choice_425_231_1' id='label_425_231_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_425_233\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Please ensure you speak with all individuals and families first and obtain their consent before proceeding with this referral.<\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_425_232' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='6' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_425_2' class='gform_page' data-js='page-field-id-232' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_425_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_425_260\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Referral Information<\/h3><\/div><div id=\"field_425_261\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half REFERCONT_NAME gf_hide_charleft 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_425_261'>Referring Individual Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_261' id='input_425_261' type='text' value='' class='large' maxlength='50'  tabindex='7' placeholder='(in case more information is needed)' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_262\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half REFERCONT_RELATION 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_425_262'>Relation to Referred Person<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_262' id='input_425_262' class='large gfield_select' tabindex='8'   aria-required=\"true\" aria-invalid=\"false\" autocomplete=\"new-password\"><option value='' ><\/option><option value='59' >Community Member<\/option><option value='19' >Friend<\/option><option value='54' >Family<\/option><\/select><\/div><\/div><div id=\"field_425_263\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half REFERCONT_TELE1 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_425_263'>Referring Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_263' id='input_425_263' type='text' value='' class='large'   tabindex='9' placeholder='___-___-____' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_264\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half REFERCONT_EMAIL gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gpev-field\"  data-field-class=\"gpev-field\" ><label class='gfield_label gform-field-label' for='input_425_264'>Referring Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_264' id='input_425_264' type='email' value='' class='large' tabindex='10'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_425_242\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Agency Information<\/h3><\/div><div id=\"field_425_198\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half REFERCONT_ORG gf_hide_charleft field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_425_198'>Name of Referring Agency<\/label><div class='ginput_container ginput_container_text'><input name='input_198' id='input_425_198' type='text' value='' class='large' maxlength='100'  tabindex='11'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_204\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half REFERCONT_NAME gf_hide_charleft 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_425_204'>Worker&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_204' id='input_425_204' type='text' value='' class='large' maxlength='50'  tabindex='12'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_203\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third REFERCONT_TELE1 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_425_203'>Referring Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_203' id='input_425_203' type='text' value='' class='large'   tabindex='13' placeholder='___-___-____' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_205\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third REFERCONT_EMAIL gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gpev-field\"  data-field-class=\"gpev-field\" ><label class='gfield_label gform-field-label' for='input_425_205'>Referring Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_205' id='input_425_205' type='email' value='' class='large' tabindex='14'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_425_67\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Client Information<\/h3><\/div><div id=\"field_425_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter FIRST_NAME gf_hide_charleft 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_425_27'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_425_27' type='text' value='' class='large' maxlength='50'  tabindex='15'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_30\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter LAST_NAME gf_hide_charleft 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_425_30'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_425_30' type='text' value='' class='large' maxlength='50'  tabindex='16'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_265\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter NICK_NAME gf_hide_charleft field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_425_265'>Preferred Name<\/label><div class='ginput_container ginput_container_text'><input name='input_265' id='input_425_265' type='text' value='' class='large' maxlength='50'  tabindex='17'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_15\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter DATE_BIRTH gcldf-field gcldf-field-date gcldf-date-format-dmy_dash gfield_trigger_change 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_425_15'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_15' id='input_425_15' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon' tabindex='18'  placeholder='\u0434\u0434-\u043c\u043c-\u0440\u0440\u0440\u0440' aria-describedby=\"input_425_15_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_425_15_date_format' class='screen-reader-text'>\u0414\u0414 \u0442\u0438\u0440\u0435 \u041c\u041c \u0442\u0438\u0440\u0435 \u0420\u0420\u0420\u0420<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_425_15' class='gform_hidden' value='https:\/\/staging5.nsd.tech\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_425_234\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Parent \/ Legal Guardian Information<\/h3><div class='gsection_description' id='gfield_description_425_234'>For referrals of children and youth age 17 and younger, we require the names and contact information for ALL legal guardians, as they all must consent to the child or youth receiving services.<\/div><\/div><div id=\"field_425_236\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third EMER_NAME gf_hide_charleft 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_425_236'>Full Name (Parent\/Legal Guardian 1)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_236' id='input_425_236' type='text' value='' class='large' maxlength='50'  tabindex='19'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_238\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third EMER_EMAIL gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gpev-field\"  data-field-class=\"gpev-field\" ><label class='gfield_label gform-field-label' for='input_425_238'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_238' id='input_425_238' type='email' value='' class='large' tabindex='20'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_425_239\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third EMER_TELE1 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_425_239'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_239' id='input_425_239' type='text' value='' class='large'   tabindex='21' placeholder='___-___-____' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_255\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-five-twelfths EMER_RELATION 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_425_255'>Relation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_255' id='input_425_255' class='large gfield_select' tabindex='22'   aria-required=\"true\" aria-invalid=\"false\" autocomplete=\"new-password\"><option value='' ><\/option><option value='15' >Father<\/option><option value='27' >Mother<\/option><option value='24' >Grandparent<\/option><option value='25' >Legal Guardian<\/option><option value='32' >No Relation<\/option><\/select><\/div><\/div><div id=\"field_425_241\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-seven-twelfths EMER_ADDRESS gf_hide_charleft 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_425_241'>Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_241' id='input_425_241' type='text' value='' class='large' maxlength='200'  tabindex='23'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_243\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third EMER2_NAME gf_hide_charleft field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_425_243'>Full Name (Parent\/Legal Guardian 2)<\/label><div class='ginput_container ginput_container_text'><input name='input_243' id='input_425_243' type='text' value='' class='large' maxlength='50'  tabindex='24'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_244\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third EMER2_EMAIL field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gpev-field\"  data-field-class=\"gpev-field\" ><label class='gfield_label gform-field-label' for='input_425_244'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_244' id='input_425_244' type='email' value='' class='large' tabindex='25'    aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_425_245\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third EMER2_TELE field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_425_245'>Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_245' id='input_425_245' type='text' value='' class='large'   tabindex='26' placeholder='___-___-____'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_240\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-five-twelfths EMER2_RELATION field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_425_240'>Relation<\/label><div class='ginput_container ginput_container_select'><select name='input_240' id='input_425_240' class='large gfield_select' tabindex='27'    aria-invalid=\"false\" autocomplete=\"new-password\"><option value='' ><\/option><option value='15' >Father<\/option><option value='27' >Mother<\/option><option value='24' >Grandparent<\/option><option value='25' >Legal Guardian<\/option><option value='32' >No Relation<\/option><\/select><\/div><\/div><div id=\"field_425_247\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-seven-twelfths EMER2_ADDRESS gf_hide_charleft field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_425_247'>Address<\/label><div class='ginput_container ginput_container_text'><input name='input_247' id='input_425_247' type='text' value='' class='large' maxlength='200'  tabindex='28'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_250\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full GENREMARKS 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_425_250'>If parents\/legal guardians do not live together, are separated, or divorced, please describe the custody arrangement:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_250' id='input_425_250' class='large gfield_select' tabindex='29'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Joint court ordered custody' >Joint court ordered custody<\/option><option value='Joint custody by mutual agreement' >Joint custody by mutual agreement<\/option><option value='Sole custody' >Sole custody<\/option><option value='Current legal custody proceedings' >Current legal custody proceedings<\/option><option value='Current legal custody proceedings' >Current legal custody proceedings<\/option><option value='Custody not yet established' >Custody not yet established<\/option><option value='Not relevant \u2013 Parents live together' >Not relevant \u2013 Parents live together<\/option><\/select><\/div><\/div><div id=\"field_425_235\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Client information continued<\/h3><\/div><div id=\"field_425_249\" class=\"gfield gfield--type-section gfield--input-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=\"\u0426\u0435 \u043f\u043e\u043b\u0435 \u043f\u0440\u0438\u0445\u043e\u0432\u0430\u043d\u0435 \u043f\u0456\u0434 \u0447\u0430\u0441 \u043f\u0435\u0440\u0435\u0433\u043b\u044f\u0434\u0443 \u0444\u043e\u0440\u043c\u0438\"><\/i><span>\u0426\u0435 \u043f\u043e\u043b\u0435 \u043f\u0440\u0438\u0445\u043e\u0432\u0430\u043d\u0435 \u043f\u0456\u0434 \u0447\u0430\u0441 \u043f\u0435\u0440\u0435\u0433\u043b\u044f\u0434\u0443 \u0444\u043e\u0440\u043c\u0438<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_425_180\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half EMAIL gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gpev-field\"  data-field-class=\"gpev-field\" ><label class='gfield_label gform-field-label' for='input_425_180'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_180' id='input_425_180' type='email' value='' class='large' tabindex='30'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_425_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half TELE1 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_425_56'>Primary Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_425_56' type='text' value='' class='large'   tabindex='31' placeholder='___-___-____' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_65\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third POSTALCODE 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_425_65'>Postal Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_425_65' type='text' value='' class='large'   tabindex='32'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_6\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third GENDER 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_425_6'>Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_425_6' class='large gfield_select' tabindex='33'   aria-required=\"true\" aria-invalid=\"false\" ><option value=''  class='gf_placeholder'>\u2000<\/option><option value='F' >Female<\/option><option value='M' >Male<\/option><option value='X' >Other<\/option><option value='U' >Prefer not to disclose<\/option><\/select><\/div><\/div><div id=\"field_425_217\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third PRONOUNS field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_425_217'>Pronouns<\/label><div class='ginput_container ginput_container_select'><select name='input_217' id='input_425_217' class='large gfield_select' tabindex='34'    aria-invalid=\"false\" ><option value='' ><\/option><option value='0079' >She\/Her<\/option><option value='0078' >He\/Him<\/option><option value='0080' >They\/Them<\/option><option value='0118' >Other<\/option><\/select><\/div><\/div><div id=\"field_425_66\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third PROVINCE 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_425_66'>Province<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_66' id='input_425_66' class='large gfield_select' tabindex='35'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>\u2003<\/option><option value='04002' >British Columbia<\/option><\/select><\/div><\/div><div id=\"field_425_172\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third CITY 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_425_172'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_172' id='input_425_172' class='large gfield_select' tabindex='36'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>\u2002<\/option><option value='' ><\/option><option value='0400201253' >Vancouver<\/option><option value='0400201165' >North Vancouver<\/option><option value='0400201260' >West Vancouver<\/option><option value='0400201202' >Richmond<\/option><option value='0400201035' >Burnaby<\/option><option value='0400201162' >New Westminster<\/option><option value='0400201186' >Port Moody<\/option><option value='0400201053' >Coquitlam<\/option><option value='0400201181' >Port Coquitlam<\/option><\/select><\/div><\/div><div id=\"field_425_159\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third ADDRESS1 gf_hide_charleft 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_425_159'>Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_159' id='input_425_159' type='text' value='' class='large' maxlength='200'  tabindex='37'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_93\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third DATE_ARRIVAL 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_425_93'>Date of Arrival In Canada<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_93' id='input_425_93' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon' tabindex='38'  placeholder='\u0434\u0434-\u043c\u043c-\u0440\u0440\u0440\u0440' aria-describedby=\"input_425_93_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_425_93_date_format' class='screen-reader-text'>\u0414\u0414 \u0442\u0438\u0440\u0435 \u041c\u041c \u0442\u0438\u0440\u0435 \u0420\u0420\u0420\u0420<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_425_93' class='gform_hidden' value='https:\/\/staging5.nsd.tech\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_425_229\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third CAN_STATUS 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_425_229'>Status in Canada<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_229' id='input_425_229' class='large gfield_select' tabindex='39'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='0002' >Government Assisted Refugees (GAR)<\/option><option value='0003' >Permanent Resident<\/option><option value='0022' >Private Sponsored Refugees (PSR)<\/option><option value='0025' >Protected Person (IRPA 95)<\/option><option value='0401' >Family Sponsorship<\/option><option value='0402' >Federal Skilled Worker<\/option><\/select><\/div><\/div><div id=\"field_425_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third FOSSIDNO 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_425_52'>UCI \/ PR Number (Optional)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_425_52' type='text' value='' class='large'   tabindex='40'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_50\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third CNT_CITIZENSHIP 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_425_50'>Country of Origin<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_50' id='input_425_50' class='large gfield_select' tabindex='41'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>\u2000<\/option><option value='002' >Afghanistan<\/option><option value='003' >Albania<\/option><option value='004' >Alderney<\/option><option value='005' >Algeria<\/option><option value='006' >American Samoa<\/option><option value='007' >Andorra<\/option><option value='008' >Angola<\/option><option value='009' >Anguilla<\/option><option value='010' >Antigua and Barbuda<\/option><option value='011' >Argentina<\/option><option value='012' >Armenia<\/option><option value='014' >Australia<\/option><option value='015' >Austria<\/option><option value='016' >Azerbaijan<\/option><option value='017' >Bahamas<\/option><option value='018' >Bahrain<\/option><option value='019' >Bangladesh<\/option><option value='020' >Barbados<\/option><option value='021' >Belarus<\/option><option value='022' >Belgium<\/option><option value='023' >Belize<\/option><option value='024' >Benin<\/option><option value='025' >Bermuda<\/option><option value='026' >Bhutan<\/option><option value='027' >Bolivia<\/option><option value='028' >Bophuthatswana<\/option><option value='029' >Bosnia and Herzegovina<\/option><option value='030' >Botswana<\/option><option value='031' >Brazil<\/option><option value='033' >British Virgin Islands<\/option><option value='034' >Brunei<\/option><option value='035' >Bulgaria<\/option><option value='036' >Burkina Faso<\/option><option value='037' >Myanmar (formerly Burma)<\/option><option value='038' >Burundi<\/option><option value='039' >Cameroon<\/option><option value='040' >Canada<\/option><option value='041' >Canary Islands<\/option><option value='042' >Cabo Verde<\/option><option value='043' >Cayman Islands<\/option><option value='044' >Central African Republic<\/option><option value='045' >Chad<\/option><option value='047' >Chile<\/option><option value='048' >China (PRC)<\/option><option value='049' >Colombia<\/option><option value='050' >Comoros<\/option><option value='051' >Congo Democratic Republic of<\/option><option value='052' >Congo (Congo Republic)<\/option><option value='054' >Costa Rica<\/option><option value='055' >Croatia<\/option><option value='056' >Cuba<\/option><option value='057' >Cyprus<\/option><option value='058' >Czechia (Czech Republic)<\/option><option value='059' >Denmark<\/option><option value='060' >Djibouti<\/option><option value='061' >Dominican Republic<\/option><option value='062' >Ecuador<\/option><option value='063' >Egypt<\/option><option value='064' >El Salvador<\/option><option value='065' >England<\/option><option value='066' >Equatorial Guinea<\/option><option value='067' >Eritrea<\/option><option value='068' >Estonia<\/option><option value='069' >Ethiopia<\/option><option value='071' >Germany<\/option><option value='072' >Fiji<\/option><option value='073' >Finland<\/option><option value='075' >Fr. Polynesia<\/option><option value='076' >France<\/option><option value='077' >French Guiana<\/option><option value='078' >Gabon<\/option><option value='079' >Gambia<\/option><option value='080' >Georgia<\/option><option value='081' >Ghana<\/option><option value='083' >Greece<\/option><option value='084' >Greenland<\/option><option value='085' >Grenada<\/option><option value='086' >Guadaloupe<\/option><option value='087' >Guam<\/option><option value='088' >Guatemala<\/option><option value='089' >Guinea<\/option><option value='090' >Guinea-bissau<\/option><option value='091' >Guyana<\/option><option value='092' >Haiti<\/option><option value='093' >Honduras<\/option><option value='094' >Hong Kong<\/option><option value='095' >Hungary<\/option><option value='096' >Iceland<\/option><option value='097' >India<\/option><option value='098' >Indonesia<\/option><option value='099' >Iran<\/option><option value='100' >Iraq<\/option><option value='101' >Ireland<\/option><option value='102' >Israel<\/option><option value='103' >Italy<\/option><option value='104' >Cote d Ivoire (Ivory Coast)<\/option><option value='105' >Jamaica<\/option><option value='106' >Japan<\/option><option value='107' >Jordan<\/option><option value='108' >Kampuchea Democratic<\/option><option value='109' >Kazakhstan<\/option><option value='110' >Kenya<\/option><option value='111' >Kerguelen Islands<\/option><option value='112' >Kyrgyzstan<\/option><option value='113' >Kiribati<\/option><option value='114' >Korea, North<\/option><option value='115' >Korea, South<\/option><option value='116' >Kosovo<\/option><option value='117' >Kuwait<\/option><option value='118' >Laos<\/option><option value='119' >Latvia<\/option><option value='120' >Lebanon<\/option><option value='121' >Lesotho<\/option><option value='122' >Liberia<\/option><option value='123' >Libya<\/option><option value='124' >Liechtenstein<\/option><option value='125' >Lithuania<\/option><option value='126' >Luxembourg<\/option><option value='128' >North Macedonia<\/option><option value='129' >Madagascar<\/option><option value='130' >Malawi<\/option><option value='131' >Malaysia<\/option><option value='132' >Maldives<\/option><option value='133' >Mali<\/option><option value='134' >Malta<\/option><option value='135' >Marshall Islands<\/option><option value='137' >Mauritania<\/option><option value='138' >Mauritius<\/option><option value='140' >Mexico<\/option><option value='141' >Moldova<\/option><option value='142' >Monaco<\/option><option value='143' >Mongolia<\/option><option value='144' >Montserrat<\/option><option value='145' >Morocco<\/option><option value='146' >Mozambique<\/option><option value='147' >Namibia<\/option><option value='148' >Nauru<\/option><option value='149' >Nepal<\/option><option value='150' >Netherlands<\/option><option value='153' >New Caledonia<\/option><option value='154' >New Zealand<\/option><option value='155' >Nicaragua<\/option><option value='156' >Niger<\/option><option value='157' >Nigeria<\/option><option value='158' >Northern Ireland<\/option><option value='159' >Norway<\/option><option value='160' >Pakistan<\/option><option value='161' >Palestine<\/option><option value='162' >Panama<\/option><option value='164' >Papua New Guinea<\/option><option value='165' >Paraguay<\/option><option value='166' >Peru<\/option><option value='167' >Philippines<\/option><option value='168' >Pitcairn Islands<\/option><option value='169' >Poland<\/option><option value='170' >Portugal<\/option><option value='171' >Puerto Rico<\/option><option value='172' >Qatar<\/option><option value='173' >Reunion<\/option><option value='174' >Romania<\/option><option value='175' >Russia<\/option><option value='176' >Rwanda<\/option><option value='177' >Samoa<\/option><option value='178' >San Marino<\/option><option value='179' >Sao Tome and Principe<\/option><option value='180' >Saudi Arabia<\/option><option value='181' >Scotland<\/option><option value='182' >Senegal<\/option><option value='183' >Serbia<\/option><option value='184' >Seychelles<\/option><option value='185' >Sierra Leone<\/option><option value='186' >Singapore<\/option><option value='187' >Solomon Islands<\/option><option value='188' >Somalia<\/option><option value='189' >South Africa<\/option><option value='190' >Spain<\/option><option value='191' >Sri Lanka<\/option><option value='192' >St. Helena<\/option><option value='193' >St. Kitts and Nevis<\/option><option value='194' >St. Lucia<\/option><option value='195' >St. Pierre Et Miquelon<\/option><option value='196' >St. Vincent And The Grenadines<\/option><option value='197' >Stateless<\/option><option value='198' >Sudan<\/option><option value='199' >Suriname<\/option><option value='200' >Eswatini (formerly Swaziland)<\/option><option value='201' >Sweden<\/option><option value='202' >Switzerland<\/option><option value='203' >Syria<\/option><option value='204' >Tajikistan<\/option><option value='205' >Tanzania<\/option><option value='206' >Thailand<\/option><option value='207' >Tibet<\/option><option value='208' >Togo<\/option><option value='209' >Tonga<\/option><option value='210' >Trinidad &amp; Tobago<\/option><option value='211' >Tunisia<\/option><option value='212' >Turkey<\/option><option value='213' >Turkmenistan<\/option><option value='214' >Turks &amp; Caicos<\/option><option value='215' >Tuvalu<\/option><option value='216' >U.S. Virgin Islands<\/option><option value='217' >United States of America<\/option><option value='219' >Uganda<\/option><option value='220' >Ukraine<\/option><option value='221' >United Arab Emirates<\/option><option value='223' >Uruguay<\/option><option value='224' >Uzbekistan<\/option><option value='225' >Vanuatu<\/option><option value='226' >Holy See (Vatican City)<\/option><option value='227' >Venezuela<\/option><option value='228' >Vietnam<\/option><option value='231' >Wales<\/option><option value='233' >Western Sahara<\/option><option value='234' >Yemen<\/option><option value='235' >Yugoslavia<\/option><option value='236' >Zaire (now Congo DRC)<\/option><option value='237' >Zambia<\/option><option value='238' >Zimbabwe<\/option><option value='239' >Oman<\/option><option value='240' >Sudan, South<\/option><option value='241' >United Kingdom<\/option><option value='242' >Slovenia<\/option><option value='243' >Slovakia (Slovak Republic)<\/option><option value='244' >Taiwan (ROC)<\/option><option value='245' >Cambodia<\/option><option value='246' >Dominica<\/option><option value='247' >East Timor (Timor-Leste)<\/option><option value='248' >Micronesia<\/option><option value='249' >Montenegro<\/option><option value='250' >Palau<\/option><\/select><\/div><\/div><div id=\"field_425_53\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third PRIMARYLANG 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_425_53'>Native Language<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_53' id='input_425_53' class='large gfield_select' tabindex='42'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>\u200e\u2000<\/option><option value='058' >English<\/option><option value='069' >French<\/option><option value='001' >Acholi<\/option><option value='002' >Ada<\/option><option value='003' >Affar<\/option><option value='004' >Afghan<\/option><option value='005' >Afrikaans<\/option><option value='006' >Aka<\/option><option value='007' >Akan<\/option><option value='212' >Aklanon<\/option><option value='008' >Akra<\/option><option value='009' >Albanian<\/option><option value='213' >American Sign Language (ASL)<\/option><option value='010' >Amharic<\/option><option value='011' >Anuak (Anywa)<\/option><option value='013' >Arabic<\/option><option value='214' >Aran<\/option><option value='014' >Armenian<\/option><option value='015' >Ashanti<\/option><option value='215' >Assamese<\/option><option value='016' >Assyrian<\/option><option value='017' >Azeri<\/option><option value='018' >Bahasa Indonesian<\/option><option value='216' >Balochi<\/option><option value='019' >Bambara<\/option><option value='020' >Bantu<\/option><option value='217' >Baule<\/option><option value='218' >Belarusian<\/option><option value='021' >Belen<\/option><option value='022' >Bemba<\/option><option value='023' >Bembe<\/option><option value='024' >Bengali<\/option><option value='025' >Beni<\/option><option value='219' >Benin<\/option><option value='026' >Berber<\/option><option value='027' >Bhari<\/option><option value='220' >Bicol\/Bikol\/Bicolano<\/option><option value='221' >Bijaiya<\/option><option value='222' >Bilen<\/option><option value='028' >Bini<\/option><option value='029' >Bisaya<\/option><option value='030' >Bissa<\/option><option value='223' >Bontok<\/option><option value='224' >Braille (translation only)<\/option><option value='031' >Breton<\/option><option value='032' >Bulgarian<\/option><option value='033' >Burmese<\/option><option value='034' >Busan<\/option><option value='035' >Busango<\/option><option value='036' >Cantonese<\/option><option value='037' >Catalan<\/option><option value='038' >Cebuano<\/option><option value='039' >Chakma<\/option><option value='040' >Chaldean<\/option><option value='041' >Chaocho<\/option><option value='225' >Chavacano<\/option><option value='042' >Chichewa<\/option><option value='043' >Chin<\/option><option value='044' >Chinese<\/option><option value='226' >Chinese - Simplified (TRANSLATION ONLY)<\/option><option value='227' >Chinese - Traditional (TRANSLATION ONLY)<\/option><option value='228' >Chiuchow<\/option><option value='045' >Chiyao<\/option><option value='046' >Chowchau<\/option><option value='229' >Concani<\/option><option value='047' >Creole<\/option><option value='048' >Croatian<\/option><option value='049' >Czech<\/option><option value='050' >Danish<\/option><option value='051' >Dari<\/option><option value='052' >Deaf-mute<\/option><option value='053' >Dinka<\/option><option value='054' >Dioula<\/option><option value='055' >Dutch<\/option><option value='230' >Dzongkha<\/option><option value='056' >Edo<\/option><option value='057' >Efik<\/option><option value='059' >Estonian<\/option><option value='060' >Ewe<\/option><option value='062' >Fang<\/option><option value='063' >Fanti<\/option><option value='064' >Farsi (Persian)<\/option><option value='316' >Filipino<\/option><option value='065' >Finnish<\/option><option value='066' >Flemish<\/option><option value='231' >Foochow<\/option><option value='067' >Fouki<\/option><option value='068' >Foullah<\/option><option value='070' >Fukinese<\/option><option value='071' >Fulani<\/option><option value='072' >Ga<\/option><option value='073' >Gaelic<\/option><option value='232' >Georgian<\/option><option value='074' >German<\/option><option value='075' >Greek<\/option><option value='076' >Guerze<\/option><option value='077' >Gujarati<\/option><option value='233' >Hainam<\/option><option value='234' >Hakha Chin<\/option><option value='078' >Hakka<\/option><option value='235' >Harara<\/option><option value='236' >Harary<\/option><option value='079' >Hargar<\/option><option value='080' >Hassanya<\/option><option value='081' >Hausa<\/option><option value='082' >Hebrew<\/option><option value='237' >Hiligaynon<\/option><option value='083' >Hindi<\/option><option value='084' >Hindko<\/option><option value='085' >Hokkin<\/option><option value='086' >Hungarian<\/option><option value='238' >Ibibio<\/option><option value='087' >Ibo<\/option><option value='239' >Icelandic<\/option><option value='240' >Igbo<\/option><option value='241' >Igorot<\/option><option value='242' >Ijaw<\/option><option value='243' >Ika<\/option><option value='244' >Ilican<\/option><option value='245' >Ilocano<\/option><option value='088' >Ilongo<\/option><option value='246' >Indonesian<\/option><option value='089' >Ishan<\/option><option value='090' >Italian<\/option><option value='247' >Itsekiri<\/option><option value='248' >Ivbiosakon<\/option><option value='091' >Izi<\/option><option value='092' >Japanese<\/option><option value='249' >Jarai<\/option><option value='093' >Javanese<\/option><option value='094' >Jolay<\/option><option value='012' >Juba Arabic<\/option><option value='095' >Kacchi<\/option><option value='250' >Kakwa<\/option><option value='096' >Kanarese<\/option><option value='097' >Kandahari<\/option><option value='098' >Kankani<\/option><option value='251' >Kannada<\/option><option value='252' >Kapampangan<\/option><option value='099' >Karen<\/option><option value='253' >Kashmiri<\/option><option value='254' >Kazakh<\/option><option value='100' >Khmer<\/option><option value='101' >Kifuliru<\/option><option value='102' >Kihavu<\/option><option value='103' >Kikongo<\/option><option value='255' >Kinyamulenge<\/option><option value='104' >Kinyarwanda<\/option><option value='105' >Kirega<\/option><option value='106' >Kirundi<\/option><option value='107' >Kiswahili<\/option><option value='256' >Kituba<\/option><option value='257' >Konkani<\/option><option value='108' >Korean<\/option><option value='109' >Krio<\/option><option value='110' >Kurdish<\/option><option value='313' >Kurmanji<\/option><option value='258' >Kyrgyz<\/option><option value='259' >La langue des signes qu\u00e9b\u00e9coise (LSQ)<\/option><option value='111' >Laotian<\/option><option value='112' >Latvian<\/option><option value='113' >Lebanese<\/option><option value='260' >Lengie<\/option><option value='114' >Lingala<\/option><option value='115' >Lithuanian<\/option><option value='116' >Lowma<\/option><option value='261' >Luganda<\/option><option value='262' >Lugishu<\/option><option value='263' >Lutoro<\/option><option value='117' >Maban<\/option><option value='118' >Macedonian<\/option><option value='264' >Macena<\/option><option value='119' >Macua<\/option><option value='120' >Mahou<\/option><option value='265' >Makonde<\/option><option value='121' >Malagasy<\/option><option value='122' >Malay<\/option><option value='123' >Malayalam<\/option><option value='124' >Maligo<\/option><option value='125' >Malinke<\/option><option value='126' >Maltese<\/option><option value='127' >Mandarin<\/option><option value='128' >Mandingo<\/option><option value='129' >Marathi<\/option><option value='311' >Masalit<\/option><option value='130' >Mashi<\/option><option value='131' >Mende<\/option><option value='132' >Mina<\/option><option value='266' >Mizo<\/option><option value='267' >Moldovan<\/option><option value='268' >Mongolian<\/option><option value='269' >Moore<\/option><option value='270' >Naandi\/Cemual<\/option><option value='271' >Ndebele<\/option><option value='133' >Nepali<\/option><option value='134' >Norwegian<\/option><option value='272' >Nubian<\/option><option value='135' >Nuer<\/option><option value='136' >Nzima<\/option><option value='273' >Oko<\/option><option value='137' >Okpe<\/option><option value='138' >Oriya<\/option><option value='139' >Oromo<\/option><option value='274' >Osal<\/option><option value='140' >Other African Languages<\/option><option value='141' >Other Chinese Dialects<\/option><option value='142' >Other European Languages<\/option><option value='143' >Other Languages<\/option><option value='144' >Other Middle Eastern Languages<\/option><option value='275' >Other Signed Languages<\/option><option value='145' >Other South Asian Languages<\/option><option value='146' >Other South East Asian Lang.<\/option><option value='276' >Otuho<\/option><option value='277' >Pahari<\/option><option value='278' >Pampango<\/option><option value='279' >Pangasinan<\/option><option value='154' >Pashto<\/option><option value='148' >Peul<\/option><option value='280' >Phuockien<\/option><option value='149' >Pidgin<\/option><option value='281' >Plautdietsch<\/option><option value='150' >Polish<\/option><option value='151' >Portuguese<\/option><option value='152' >Poular<\/option><option value='153' >Punjabi<\/option><option value='282' >Rohingya<\/option><option value='283' >Romani<\/option><option value='155' >Romanian<\/option><option value='284' >Rukiga<\/option><option value='285' >Runyankole<\/option><option value='156' >Russian<\/option><option value='286' >Rutooro<\/option><option value='157' >Samoan<\/option><option value='287' >Sango<\/option><option value='288' >Sanskrit<\/option><option value='289' >Sara<\/option><option value='158' >Scoula<\/option><option value='159' >Sechuan<\/option><option value='290' >Senufo<\/option><option value='160' >Serbian<\/option><option value='161' >Serbo-Croatian<\/option><option value='291' >Sesotho<\/option><option value='162' >Seswi<\/option><option value='163' >Seychelles<\/option><option value='292' >Shan<\/option><option value='164' >Shanghai<\/option><option value='165' >Shansai<\/option><option value='166' >Shilluk<\/option><option value='293' >Shona<\/option><option value='167' >Sign Language<\/option><option value='168' >Sindhi<\/option><option value='170' >Sinhalese<\/option><option value='171' >Slovak<\/option><option value='172' >Slovene<\/option><option value='173' >Somali<\/option><option value='312' >Songhai<\/option><option value='174' >Soninke<\/option><option value='314' >Sorani<\/option><option value='294' >Sotho<\/option><option value='175' >Soussou<\/option><option value='295' >Southern Burun<\/option><option value='176' >Spanish<\/option><option value='177' >Suesue<\/option><option value='296' >Sukuma<\/option><option value='178' >Swahili<\/option><option value='179' >Swazai<\/option><option value='180' >Swedish<\/option><option value='317' >Swiss German<\/option><option value='181' >Tagalog<\/option><option value='297' >Taichew<\/option><option value='315' >Tamasheq<\/option><option value='182' >Tamil<\/option><option value='183' >Tari<\/option><option value='298' >Tatar<\/option><option value='184' >Tatshanese<\/option><option value='185' >Telugu<\/option><option value='299' >Temne<\/option><option value='300' >Teochew<\/option><option value='186' >Thai<\/option><option value='187' >Tibetan<\/option><option value='188' >Tichiew<\/option><option value='301' >Tigre<\/option><option value='189' >Tigrigna<\/option><option value='190' >Timini<\/option><option value='191' >Tiv<\/option><option value='302' >Toishan<\/option><option value='192' >Tshiluba<\/option><option value='193' >Tsibula<\/option><option value='194' >Turkish<\/option><option value='195' >Twi<\/option><option value='318' >Uduk<\/option><option value='200' >Uhrobo<\/option><option value='196' >Uigrigma<\/option><option value='197' >Ukrainian<\/option><option value='303' >Umbundu<\/option><option value='304' >Unama<\/option><option value='198' >Unknown<\/option><option value='199' >Urdu<\/option><option value='319' >Uyghur<\/option><option value='201' >Uzbek<\/option><option value='202' >Vietnamese<\/option><option value='305' >Visayan<\/option><option value='306' >Waray<\/option><option value='203' >Welsh<\/option><option value='204' >Western Hemisphere Indian Lang<\/option><option value='205' >Wolof<\/option><option value='206' >Xhosa<\/option><option value='307' >Yako\/Loko\/Lokaa<\/option><option value='308' >Yekhee\/Afenmai\/Afemai<\/option><option value='207' >Yiboe<\/option><option value='208' >Yiddish<\/option><option value='209' >Yoruba<\/option><option value='210' >Zande<\/option><option value='309' >Zshiluba<\/option><option value='310' >Zuganda<\/option><option value='211' >Zulu<\/option><\/select><\/div><\/div><div id=\"field_425_193\" class=\"gfield gfield--type-multiselect gfield--input-type-multiselect gfield--width-third LANGS field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_425_193'>Other Languages (type to search)<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_193[]' id='input_425_193' class='large gfield_select' tabindex='43'  aria-invalid=\"false\"  ><option value='001' >Acholi<\/option><option value='002' >Ada<\/option><option value='003' >Affar<\/option><option value='004' >Afghan<\/option><option value='005' >Afrikaans<\/option><option value='006' >Aka<\/option><option value='007' >Akan<\/option><option value='212' >Aklanon<\/option><option value='008' >Akra<\/option><option value='009' >Albanian<\/option><option value='213' >American Sign Language (ASL)<\/option><option value='010' >Amharic<\/option><option value='011' >Anuak (Anywa)<\/option><option value='013' >Arabic<\/option><option value='214' >Aran<\/option><option value='014' >Armenian<\/option><option value='015' >Ashanti<\/option><option value='215' >Assamese<\/option><option value='016' >Assyrian<\/option><option value='017' >Azeri<\/option><option value='018' >Bahasa Indonesian<\/option><option value='216' >Balochi<\/option><option value='019' >Bambara<\/option><option value='020' >Bantu<\/option><option value='217' >Baule<\/option><option value='218' >Belarusian<\/option><option value='021' >Belen<\/option><option value='022' >Bemba<\/option><option value='023' >Bembe<\/option><option value='024' >Bengali<\/option><option value='025' >Beni<\/option><option value='219' >Benin<\/option><option value='026' >Berber<\/option><option value='027' >Bhari<\/option><option value='220' >Bicol\/Bikol\/Bicolano<\/option><option value='221' >Bijaiya<\/option><option value='222' >Bilen<\/option><option value='028' >Bini<\/option><option value='029' >Bisaya<\/option><option value='030' >Bissa<\/option><option value='223' >Bontok<\/option><option value='224' >Braille (translation only)<\/option><option value='031' >Breton<\/option><option value='032' >Bulgarian<\/option><option value='033' >Burmese<\/option><option value='034' >Busan<\/option><option value='035' >Busango<\/option><option value='036' >Cantonese<\/option><option value='037' >Catalan<\/option><option value='038' >Cebuano<\/option><option value='039' >Chakma<\/option><option value='040' >Chaldean<\/option><option value='041' >Chaocho<\/option><option value='225' >Chavacano<\/option><option value='042' >Chichewa<\/option><option value='043' >Chin<\/option><option value='044' >Chinese<\/option><option value='226' >Chinese - Simplified (TRANSLATION ONLY)<\/option><option value='227' >Chinese - Traditional (TRANSLATION ONLY)<\/option><option value='228' >Chiuchow<\/option><option value='045' >Chiyao<\/option><option value='046' >Chowchau<\/option><option value='229' >Concani<\/option><option value='047' >Creole<\/option><option value='048' >Croatian<\/option><option value='049' >Czech<\/option><option value='050' >Danish<\/option><option value='051' >Dari<\/option><option value='052' >Deaf-mute<\/option><option value='053' >Dinka<\/option><option value='054' >Dioula<\/option><option value='055' >Dutch<\/option><option value='230' >Dzongkha<\/option><option value='056' >Edo<\/option><option value='057' >Efik<\/option><option value='058' >English<\/option><option value='059' >Estonian<\/option><option value='060' >Ewe<\/option><option value='062' >Fang<\/option><option value='063' >Fanti<\/option><option value='064' >Farsi (Persian)<\/option><option value='316' >Filipino<\/option><option value='065' >Finnish<\/option><option value='066' >Flemish<\/option><option value='231' >Foochow<\/option><option value='067' >Fouki<\/option><option value='068' >Foullah<\/option><option value='069' >French<\/option><option value='070' >Fukinese<\/option><option value='071' >Fulani<\/option><option value='072' >Ga<\/option><option value='073' >Gaelic<\/option><option value='232' >Georgian<\/option><option value='074' >German<\/option><option value='075' >Greek<\/option><option value='076' >Guerze<\/option><option value='077' >Gujarati<\/option><option value='233' >Hainam<\/option><option value='234' >Hakha Chin<\/option><option value='078' >Hakka<\/option><option value='235' >Harara<\/option><option value='236' >Harary<\/option><option value='079' >Hargar<\/option><option value='080' >Hassanya<\/option><option value='081' >Hausa<\/option><option value='082' >Hebrew<\/option><option value='237' >Hiligaynon<\/option><option value='083' >Hindi<\/option><option value='084' >Hindko<\/option><option value='085' >Hokkin<\/option><option value='086' >Hungarian<\/option><option value='238' >Ibibio<\/option><option value='087' >Ibo<\/option><option value='239' >Icelandic<\/option><option value='240' >Igbo<\/option><option value='241' >Igorot<\/option><option value='242' >Ijaw<\/option><option value='243' >Ika<\/option><option value='244' >Ilican<\/option><option value='245' >Ilocano<\/option><option value='088' >Ilongo<\/option><option value='246' >Indonesian<\/option><option value='089' >Ishan<\/option><option value='090' >Italian<\/option><option value='247' >Itsekiri<\/option><option value='248' >Ivbiosakon<\/option><option value='091' >Izi<\/option><option value='092' >Japanese<\/option><option value='249' >Jarai<\/option><option value='093' >Javanese<\/option><option value='094' >Jolay<\/option><option value='012' >Juba Arabic<\/option><option value='095' >Kacchi<\/option><option value='250' >Kakwa<\/option><option value='096' >Kanarese<\/option><option value='097' >Kandahari<\/option><option value='098' >Kankani<\/option><option value='251' >Kannada<\/option><option value='252' >Kapampangan<\/option><option value='099' >Karen<\/option><option value='253' >Kashmiri<\/option><option value='254' >Kazakh<\/option><option value='100' >Khmer<\/option><option value='101' >Kifuliru<\/option><option value='102' >Kihavu<\/option><option value='103' >Kikongo<\/option><option value='255' >Kinyamulenge<\/option><option value='104' >Kinyarwanda<\/option><option value='105' >Kirega<\/option><option value='106' >Kirundi<\/option><option value='107' >Kiswahili<\/option><option value='256' >Kituba<\/option><option value='257' >Konkani<\/option><option value='108' >Korean<\/option><option value='109' >Krio<\/option><option value='110' >Kurdish<\/option><option value='313' >Kurmanji<\/option><option value='258' >Kyrgyz<\/option><option value='259' >La langue des signes qu\u00e9b\u00e9coise (LSQ)<\/option><option value='111' >Laotian<\/option><option value='112' >Latvian<\/option><option value='113' >Lebanese<\/option><option value='260' >Lengie<\/option><option value='114' >Lingala<\/option><option value='115' >Lithuanian<\/option><option value='116' >Lowma<\/option><option value='261' >Luganda<\/option><option value='262' >Lugishu<\/option><option value='263' >Lutoro<\/option><option value='117' >Maban<\/option><option value='118' >Macedonian<\/option><option value='264' >Macena<\/option><option value='119' >Macua<\/option><option value='120' >Mahou<\/option><option value='265' >Makonde<\/option><option value='121' >Malagasy<\/option><option value='122' >Malay<\/option><option value='123' >Malayalam<\/option><option value='124' >Maligo<\/option><option value='125' >Malinke<\/option><option value='126' >Maltese<\/option><option value='127' >Mandarin<\/option><option value='128' >Mandingo<\/option><option value='129' >Marathi<\/option><option value='311' >Masalit<\/option><option value='130' >Mashi<\/option><option value='131' >Mende<\/option><option value='132' >Mina<\/option><option value='266' >Mizo<\/option><option value='267' >Moldovan<\/option><option value='268' >Mongolian<\/option><option value='269' >Moore<\/option><option value='270' >Naandi\/Cemual<\/option><option value='271' >Ndebele<\/option><option value='133' >Nepali<\/option><option value='134' >Norwegian<\/option><option value='272' >Nubian<\/option><option value='135' >Nuer<\/option><option value='136' >Nzima<\/option><option value='273' >Oko<\/option><option value='137' >Okpe<\/option><option value='138' >Oriya<\/option><option value='139' >Oromo<\/option><option value='274' >Osal<\/option><option value='140' >Other African Languages<\/option><option value='141' >Other Chinese Dialects<\/option><option value='142' >Other European Languages<\/option><option value='143' >Other Languages<\/option><option value='144' >Other Middle Eastern Languages<\/option><option value='275' >Other Signed Languages<\/option><option value='145' >Other South Asian Languages<\/option><option value='146' >Other South East Asian Lang.<\/option><option value='276' >Otuho<\/option><option value='277' >Pahari<\/option><option value='278' >Pampango<\/option><option value='279' >Pangasinan<\/option><option value='154' >Pashto<\/option><option value='148' >Peul<\/option><option value='280' >Phuockien<\/option><option value='149' >Pidgin<\/option><option value='281' >Plautdietsch<\/option><option value='150' >Polish<\/option><option value='151' >Portuguese<\/option><option value='152' >Poular<\/option><option value='153' >Punjabi<\/option><option value='282' >Rohingya<\/option><option value='283' >Romani<\/option><option value='155' >Romanian<\/option><option value='284' >Rukiga<\/option><option value='285' >Runyankole<\/option><option value='156' >Russian<\/option><option value='286' >Rutooro<\/option><option value='157' >Samoan<\/option><option value='287' >Sango<\/option><option value='288' >Sanskrit<\/option><option value='289' >Sara<\/option><option value='158' >Scoula<\/option><option value='159' >Sechuan<\/option><option value='290' >Senufo<\/option><option value='160' >Serbian<\/option><option value='161' >Serbo-Croatian<\/option><option value='291' >Sesotho<\/option><option value='162' >Seswi<\/option><option value='163' >Seychelles<\/option><option value='292' >Shan<\/option><option value='164' >Shanghai<\/option><option value='165' >Shansai<\/option><option value='166' >Shilluk<\/option><option value='293' >Shona<\/option><option value='167' >Sign Language<\/option><option value='168' >Sindhi<\/option><option value='170' >Sinhalese<\/option><option value='171' >Slovak<\/option><option value='172' >Slovene<\/option><option value='173' >Somali<\/option><option value='312' >Songhai<\/option><option value='174' >Soninke<\/option><option value='314' >Sorani<\/option><option value='294' >Sotho<\/option><option value='175' >Soussou<\/option><option value='295' >Southern Burun<\/option><option value='176' >Spanish<\/option><option value='177' >Suesue<\/option><option value='296' >Sukuma<\/option><option value='178' >Swahili<\/option><option value='179' >Swazai<\/option><option value='180' >Swedish<\/option><option value='317' >Swiss German<\/option><option value='181' >Tagalog<\/option><option value='297' >Taichew<\/option><option value='315' >Tamasheq<\/option><option value='182' >Tamil<\/option><option value='183' >Tari<\/option><option value='298' >Tatar<\/option><option value='184' >Tatshanese<\/option><option value='185' >Telugu<\/option><option value='299' >Temne<\/option><option value='300' >Teochew<\/option><option value='186' >Thai<\/option><option value='187' >Tibetan<\/option><option value='188' >Tichiew<\/option><option value='301' >Tigre<\/option><option value='189' >Tigrigna<\/option><option value='190' >Timini<\/option><option value='191' >Tiv<\/option><option value='302' >Toishan<\/option><option value='192' >Tshiluba<\/option><option value='193' >Tsibula<\/option><option value='194' >Turkish<\/option><option value='195' >Twi<\/option><option value='318' >Uduk<\/option><option value='200' >Uhrobo<\/option><option value='196' >Uigrigma<\/option><option value='197' >Ukrainian<\/option><option value='303' >Umbundu<\/option><option value='304' >Unama<\/option><option value='198' >Unknown<\/option><option value='199' >Urdu<\/option><option value='319' >Uyghur<\/option><option value='201' >Uzbek<\/option><option value='202' >Vietnamese<\/option><option value='305' >Visayan<\/option><option value='306' >Waray<\/option><option value='203' >Welsh<\/option><option value='204' >Western Hemisphere Indian Lang<\/option><option value='205' >Wolof<\/option><option value='206' >Xhosa<\/option><option value='307' >Yako\/Loko\/Lokaa<\/option><option value='308' >Yekhee\/Afenmai\/Afemai<\/option><option value='207' >Yiboe<\/option><option value='208' >Yiddish<\/option><option value='209' >Yoruba<\/option><option value='210' >Zande<\/option><option value='309' >Zshiluba<\/option><option value='310' >Zuganda<\/option><option value='211' >Zulu<\/option><\/select><\/div><\/div><fieldset id=\"field_425_267\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full EMP_BARRIERS gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Identified Needs or Barriers<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_425_267'><div class='gchoice gchoice_425_267_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_267.1' type='checkbox'  value='0292'  id='choice_425_267_1' tabindex='44'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_425_267_1' id='label_425_267_1' class='gform-field-label gform-field-label--type-inline'>Lack of Canadian work experience<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_425_267_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_267.2' type='checkbox'  value='0473'  id='choice_425_267_2' tabindex='45'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_425_267_2' id='label_425_267_2' class='gform-field-label gform-field-label--type-inline'>Language barriers (English or French)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_425_267_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_267.3' type='checkbox'  value='0474'  id='choice_425_267_3' tabindex='46'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_425_267_3' id='label_425_267_3' class='gform-field-label gform-field-label--type-inline'>Non-recognition of foreign credentials or education<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_425_267_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_267.4' type='checkbox'  value='0475'  id='choice_425_267_4' tabindex='47'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_425_267_4' id='label_425_267_4' class='gform-field-label gform-field-label--type-inline'>Limited professional network in Canada<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_425_267_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_267.5' type='checkbox'  value='0476'  id='choice_425_267_5' tabindex='48'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_425_267_5' id='label_425_267_5' class='gform-field-label gform-field-label--type-inline'>Lack of soft skills or Canadian workplace culture understanding<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_425_267_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_267.6' type='checkbox'  value='0477'  id='choice_425_267_6' tabindex='49'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_425_267_6' id='label_425_267_6' class='gform-field-label gform-field-label--type-inline'>Lack of affordable childcare<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_425_267_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_267.7' type='checkbox'  value='0478'  id='choice_425_267_7' tabindex='50'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_425_267_7' id='label_425_267_7' class='gform-field-label gform-field-label--type-inline'>Lack of job search skills (e.g., resume\/interview techniques)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_425_267_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_267.8' type='checkbox'  value='0479'  id='choice_425_267_8' tabindex='51'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_425_267_8' id='label_425_267_8' class='gform-field-label gform-field-label--type-inline'>Discrimination (e.g., based on race, gender, age, or disability)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_425_267_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_267.9' type='checkbox'  value='0480'  id='choice_425_267_9' tabindex='52'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_425_267_9' id='label_425_267_9' class='gform-field-label gform-field-label--type-inline'>Lack of confidence or self-esteem<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_425_267_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_267.11' type='checkbox'  value='0481'  id='choice_425_267_11' tabindex='53'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_425_267_11' id='label_425_267_11' class='gform-field-label gform-field-label--type-inline'>Physical health or chronic illness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_425_267_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_267.12' type='checkbox'  value='0482'  id='choice_425_267_12' tabindex='54'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_425_267_12' id='label_425_267_12' class='gform-field-label gform-field-label--type-inline'>Inadequate or unstable housing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_425_267_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_267.13' type='checkbox'  value='0483'  id='choice_425_267_13' tabindex='55'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_425_267_13' id='label_425_267_13' class='gform-field-label gform-field-label--type-inline'>Limited access to technology or internet<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_425_267_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_267.14' type='checkbox'  value='0484'  id='choice_425_267_14' tabindex='56'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_425_267_14' id='label_425_267_14' class='gform-field-label gform-field-label--type-inline'>Lack of formal education or essential skills<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_425_267_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_267.15' type='checkbox'  value='0485'  id='choice_425_267_15' tabindex='57'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_425_267_15' id='label_425_267_15' class='gform-field-label gform-field-label--type-inline'>Need for legal services<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_425_267_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_267.16' type='checkbox'  value='0486'  id='choice_425_267_16' tabindex='58'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_425_267_16' id='label_425_267_16' class='gform-field-label gform-field-label--type-inline'>Family or domestic violence<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_425_267_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_267.17' type='checkbox'  value='0487'  id='choice_425_267_17' tabindex='59'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_425_267_17' id='label_425_267_17' class='gform-field-label gform-field-label--type-inline'>Cultural barriers or culture shock<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_425_267_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_267.18' type='checkbox'  value='0488'  id='choice_425_267_18' tabindex='60'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_425_267_18' id='label_425_267_18' class='gform-field-label gform-field-label--type-inline'>Mental health, wellness, or trauma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_425_267_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_267.19' type='checkbox'  value='0489'  id='choice_425_267_19' tabindex='61'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_425_267_19' id='label_425_267_19' class='gform-field-label gform-field-label--type-inline'>Lack of clothing, furniture, or food<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_425_267_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_267.21' type='checkbox'  value='0490'  id='choice_425_267_21' tabindex='62'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_425_267_21' id='label_425_267_21' class='gform-field-label gform-field-label--type-inline'>Immediate or long-term financial difficulties<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_425_268\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full DOCUMENT_FIELD11 nsd-gravity-upload nsd-fileupload-single gf_inline exclude show_description field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_425_268'>Submit Documents (maximum 5 documents; maximum 10mb per document)<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_425_268' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_425_268&quot;,&quot;container&quot;:&quot;gform_multifile_upload_425_268&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_425_268&quot;,&quot;filelist&quot;:&quot;gform_preview_425_268&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/staging5.nsd.tech\\\/?gf_page=f8eaeb02f5fcc9f&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/staging5.nsd.tech\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/staging5.nsd.tech\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;\\u0414\\u043e\\u0437\\u0432\\u043e\\u043b\\u0435\\u043d\\u0456 \\u0444\\u0430\\u0439\\u043b\\u0438&quot;,&quot;extensions&quot;:&quot;pdf,docx,doc,jpg,gif,tiff&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:425,&quot;field_id&quot;:268,&quot;_gform_file_upload_nonce_425_268&quot;:&quot;77011e0818&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;5&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_425_268&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_425_268' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_425_268' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_425_268 gfield_description_425_268\" tabindex='63' >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_425_268'>\u0422\u0438\u043f\u0438 \u0444\u0430\u0439\u043b\u0456\u0432, \u0449\u043e \u043f\u0440\u0438\u0439\u043c\u0430\u044e\u0442\u044c\u0441\u044f: pdf, docx, doc, jpg, gif, tiff, \u041c\u0430\u043a\u0441. \u0440\u043e\u0437\u043c\u0456\u0440 \u0444\u0430\u0439\u043b\u0443: 10 MB, \u041c\u0430\u043a\u0441. \u0444\u0430\u0439\u043b\u0456\u0432: 5.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_425_268'><\/ul> <div id='gform_preview_425_268' class='ginput_preview_list'><\/div><\/div><div class='gfield_description' id='gfield_description_425_268'><p data-start=\"136\" data-end=\"296\">Please upload documents  that verify the  current legal status in Canada for the clients. (if applicable). Upload both sides where applicable. Acceptable documents include (as applicable):<\/p>\n<ul data-start=\"297\" data-end=\"632\">\n<li data-start=\"297\" data-end=\"346\">\n<p data-start=\"299\" data-end=\"346\">Permanent Resident (PR) Card &ndash; front and back<\/p>\n<\/li>\n<li data-start=\"347\" data-end=\"393\">\n<p data-start=\"349\" data-end=\"393\">Confirmation of Permanent Residence (COPR)<\/p>\n<\/li>\n<li data-start=\"394\" data-end=\"428\">\n<p data-start=\"396\" data-end=\"428\">Single Journey Travel Document<\/p>\n<\/li>\n<li data-start=\"429\" data-end=\"451\">\n<p data-start=\"431\" data-end=\"451\">Notice of Decision<\/p>\n<\/li>\n<li data-start=\"452\" data-end=\"507\">\n<p data-start=\"454\" data-end=\"507\">Refugee Protection Claimant Document (RPCD) or RPID<\/p>\n<\/li>\n<li data-start=\"508\" data-end=\"532\">\n<p data-start=\"510\" data-end=\"532\">Study or Work Permit<\/p>\n<\/li>\n<li data-start=\"533\" data-end=\"574\">\n<p data-start=\"535\" data-end=\"574\">Interim Federal Health (IFH) document<\/p>\n<\/li>\n<li data-start=\"575\" data-end=\"632\">\n<p data-start=\"577\" data-end=\"632\">Passport or Birth Certificate (for Canadian citizens)<\/p>\n<\/li>\n<\/ul><\/div><\/div><div id=\"field_425_199\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full GENREMARKS gf_hide_charleft show_description 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_425_199'>Reason for referral<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_199' id='input_425_199' class='textarea small' tabindex='64'  maxlength='1000'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_425_270\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Consent<\/h3><\/div><fieldset id=\"field_425_272\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full CONSENTS gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_425_272'><div class='gchoice gchoice_425_272_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_272.1' type='checkbox'  value='0418'  id='choice_425_272_1' tabindex='65'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_425_272_1' id='label_425_272_1' class='gform-field-label gform-field-label--type-inline'>I, authorize the sharing of my information with the francophone community centre la Boussole for the purpose of receiving settlement services.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_425_273\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half SIGN1_PATH gf_hide_charleft field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_425_273'>Please either enter you initials here  OR Sign in next box<\/label><div class='ginput_container ginput_container_text'><input name='input_273' id='input_425_273' type='text' value='' class='small' maxlength='5'  tabindex='66'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_274\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-half SIGN1_PATH 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_425_274'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u041e\u0431\u043e\u0432&#039;\u044f\u0437\u043a\u043e\u0432\u043e)<\/span><\/span><\/label><input type='hidden' value='' name='input_274' id='input_425_274_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_425_274_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_425_274' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/staging5.nsd.tech\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_425_274_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_425_274_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_425_274_data' name='input_425_274_data' value=''><\/div><\/div><div id=\"field_425_275\" class=\"gfield gfield--type-section gfield--input-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=\"\u0426\u0435 \u043f\u043e\u043b\u0435 \u043f\u0440\u0438\u0445\u043e\u0432\u0430\u043d\u0435 \u043f\u0456\u0434 \u0447\u0430\u0441 \u043f\u0435\u0440\u0435\u0433\u043b\u044f\u0434\u0443 \u0444\u043e\u0440\u043c\u0438\"><\/i><span>\u0426\u0435 \u043f\u043e\u043b\u0435 \u043f\u0440\u0438\u0445\u043e\u0432\u0430\u043d\u0435 \u043f\u0456\u0434 \u0447\u0430\u0441 \u043f\u0435\u0440\u0435\u0433\u043b\u044f\u0434\u0443 \u0444\u043e\u0440\u043c\u0438<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_425_259\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_425_259'>CAPTCHA<\/label><div id='input_425_259' class='ginput_container ginput_recaptcha' data-sitekey='6LdQ_KQqAAAAAOZ5dT_twxSmxS7Hk-VjwJnkXATw'  data-theme='light' data-tabindex='67'  data-badge=''><\/div><\/div><div id=\"field_425_227\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter REASON exclude 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=\"\u0426\u0435 \u043f\u043e\u043b\u0435 \u043f\u0440\u0438\u0445\u043e\u0432\u0430\u043d\u0435 \u043f\u0456\u0434 \u0447\u0430\u0441 \u043f\u0435\u0440\u0435\u0433\u043b\u044f\u0434\u0443 \u0444\u043e\u0440\u043c\u0438\"><\/i><span>\u0426\u0435 \u043f\u043e\u043b\u0435 \u043f\u0440\u0438\u0445\u043e\u0432\u0430\u043d\u0435 \u043f\u0456\u0434 \u0447\u0430\u0441 \u043f\u0435\u0440\u0435\u0433\u043b\u044f\u0434\u0443 \u0444\u043e\u0440\u043c\u0438<\/span><\/div><label class='gfield_label gform-field-label' for='input_425_227'>Program (Admin Only)<\/label><div class='ginput_container ginput_container_text'><input name='input_227' id='input_425_227' type='text' value='0001' class='large'   tabindex='68'   aria-invalid=\"false\"  autocomplete=\"new-password\" \/><\/div><\/div><div id=\"field_425_45\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter DATE_VISITED exclude 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=\"\u0426\u0435 \u043f\u043e\u043b\u0435 \u043f\u0440\u0438\u0445\u043e\u0432\u0430\u043d\u0435 \u043f\u0456\u0434 \u0447\u0430\u0441 \u043f\u0435\u0440\u0435\u0433\u043b\u044f\u0434\u0443 \u0444\u043e\u0440\u043c\u0438\"><\/i><span>\u0426\u0435 \u043f\u043e\u043b\u0435 \u043f\u0440\u0438\u0445\u043e\u0432\u0430\u043d\u0435 \u043f\u0456\u0434 \u0447\u0430\u0441 \u043f\u0435\u0440\u0435\u0433\u043b\u044f\u0434\u0443 \u0444\u043e\u0440\u043c\u0438<\/span><\/div><label class='gfield_label gform-field-label' for='input_425_45'>Date Visited (Admin Only)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_45' id='input_425_45' type='text' value='26\/04\/2026' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon' tabindex='69'  placeholder='\u0434\u0434\/\u043c\u043c\/\u0440\u0440\u0440\u0440' aria-describedby=\"input_425_45_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_425_45_date_format' class='screen-reader-text'>\u0414\u0414 \u0441\u043a\u0456\u0441\u043d\u0430 \u0440\u0438\u0441\u043a\u0430 \u041c\u041c \u0441\u043a\u0456\u0441\u043d\u0430 \u0440\u0438\u0441\u043a\u0430 \u0420\u0420\u0420\u0420<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_425_45' class='gform_hidden' value='https:\/\/staging5.nsd.tech\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_425_228\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter CurrentJobStatus exclude 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=\"\u0426\u0435 \u043f\u043e\u043b\u0435 \u043f\u0440\u0438\u0445\u043e\u0432\u0430\u043d\u0435 \u043f\u0456\u0434 \u0447\u0430\u0441 \u043f\u0435\u0440\u0435\u0433\u043b\u044f\u0434\u0443 \u0444\u043e\u0440\u043c\u0438\"><\/i><span>\u0426\u0435 \u043f\u043e\u043b\u0435 \u043f\u0440\u0438\u0445\u043e\u0432\u0430\u043d\u0435 \u043f\u0456\u0434 \u0447\u0430\u0441 \u043f\u0435\u0440\u0435\u0433\u043b\u044f\u0434\u0443 \u0444\u043e\u0440\u043c\u0438<\/span><\/div><label class='gfield_label gform-field-label' for='input_425_228'>Employment Status (Admin Only)<\/label><div class='ginput_container ginput_container_text'><input name='input_228' id='input_425_228' type='text' value='0005' class='large'   tabindex='70'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_257\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter OF_LANG exclude 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=\"\u0426\u0435 \u043f\u043e\u043b\u0435 \u043f\u0440\u0438\u0445\u043e\u0432\u0430\u043d\u0435 \u043f\u0456\u0434 \u0447\u0430\u0441 \u043f\u0435\u0440\u0435\u0433\u043b\u044f\u0434\u0443 \u0444\u043e\u0440\u043c\u0438\"><\/i><span>\u0426\u0435 \u043f\u043e\u043b\u0435 \u043f\u0440\u0438\u0445\u043e\u0432\u0430\u043d\u0435 \u043f\u0456\u0434 \u0447\u0430\u0441 \u043f\u0435\u0440\u0435\u0433\u043b\u044f\u0434\u0443 \u0444\u043e\u0440\u043c\u0438<\/span><\/div><label class='gfield_label gform-field-label' for='input_425_257'>Official Language (Admin Only)<\/label><div class='ginput_container ginput_container_text'><input name='input_257' id='input_425_257' type='text' value='2' class='large'   tabindex='71'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_425_269\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full DOCUMENT_TYPE11 exclude 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=\"\u0426\u0435 \u043f\u043e\u043b\u0435 \u043f\u0440\u0438\u0445\u043e\u0432\u0430\u043d\u0435 \u043f\u0456\u0434 \u0447\u0430\u0441 \u043f\u0435\u0440\u0435\u0433\u043b\u044f\u0434\u0443 \u0444\u043e\u0440\u043c\u0438\"><\/i><span>\u0426\u0435 \u043f\u043e\u043b\u0435 \u043f\u0440\u0438\u0445\u043e\u0432\u0430\u043d\u0435 \u043f\u0456\u0434 \u0447\u0430\u0441 \u043f\u0435\u0440\u0435\u0433\u043b\u044f\u0434\u0443 \u0444\u043e\u0440\u043c\u0438<\/span><\/div><label class='gfield_label gform-field-label' for='input_425_269'>doc type<\/label><div class='ginput_container ginput_container_text'><input name='input_269' id='input_425_269' type='text' value='0007' class='small'   tabindex='72'   aria-invalid=\"false\"   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value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_425' id='gform_style_settings_425' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_425' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='425' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='CAD' value='bMeiuRQb1mv+mjNquUHs4JcnX0SH\/pEoAlfju9HiAp7Qbg\/Y64ovB8LuA9OAk4Ed03nvBqrxaysxWo6mrbaJv7qtcG22ymfLFpMFPO2aWbVMPKw=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_425' value='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' 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