Online Inquiry
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<ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>General Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="FH_Name_First_A" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">First Name</label><input name="CST_1" type="text" class="er_fld_required er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;" map_to="FH_Name_Last_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name</label><input name="CST_2" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2 er_fld_selected" style="white-space: normal; width: 50%;" draggable="false" map_to="FH_Interest"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Areas of Interest</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_5" value="Foster Care">Foster Care</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_5" value="DCS Adoption">DCS Adoption</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_5" value="Infant Adoption">Infant Adoption</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_5" value="Kinship">Kinship</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_5" value="Therapeutic Foster Care">Therapeutic Foster Care</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_5" value="Disabled">Disabled</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_5" value="STRONG Families for Children">STRONG Families for Children</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_5" value="Mentoring">Mentoring</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_5" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_5_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Comments or Questions</label><textarea name="CST_15" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;" map_to="FH_ReferralSource"><i class="fa fa-caret-down"></i><label class="er_fld_label required">How did you hear about Christian Family Care?</label><select name="CST_22" class="er_fld_required er_fld_width100"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Internet Search">Internet Search</option><option value="Friend">Friend</option><option value="Social Media">Social Media</option><option value="DCS">DCS</option><option value="CFC Employee">CFC Employee</option><option value="Other Organization">Other Organization</option><option value="Event">Event</option><option value="TV/Radio">TV/Radio</option><option value="CFC Thrift Store">CFC Thrift Store</option><option value="Other">Other</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;" map_to="FH_Inquiry_How_Referred"> <i class="fa fa-font"></i><label class="er_fld_label">Whom may we thank for referring you?</label><input name="CST_23" type="text" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Contact Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="FH_EMail" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Email Address</label><input name="CST_3" type="text" class="er_fld_required er_fld_width100" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;" map_to="FH_Phone_Home"> <i class="fa fa-font"></i><label class="er_fld_label required">Primary Phone</label><input name="CST_24" type="text" class="er_fld_required er_fld_width100" value="(xxx) xxx-xxxx"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Address_Street_1"> <i class="fa fa-font"></i><label class="er_fld_label">Street Address</label><input name="CST_4" type="text" class="er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Address_Street_2"> <i class="fa fa-font"></i><label class="er_fld_label">Address Line 2</label><input name="CST_10" type="text" class="er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Address_City"> <i class="fa fa-font"></i><label class="er_fld_label required">City</label><input name="CST_8" type="text" class="er_fld_required er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;" map_to="FH_Address_State"><i class="fa fa-caret-down"></i><label class="er_fld_label">State</label><select name="CST_13" class="er_fld_width100"><option value="Alabama">Alabama</option><option value="Alaska">Alaska</option><option value="Arizona" selected="">Arizona</option><option value="Arkansas">Arkansas</option><option value="California">California</option><option value="Colorado">Colorado</option><option value="Connecticut">Connecticut</option><option value="Delaware">Delaware</option><option value="Florida">Florida</option><option value="Georgia">Georgia</option><option value="Hawaii">Hawaii</option><option value="Idaho">Idaho</option><option value="Illinois">Illinois</option><option value="Indiana">Indiana</option><option value="Iowa">Iowa</option><option value="Kansas">Kansas</option><option value="Kentucky">Kentucky</option><option value="Louisiana">Louisiana</option><option value="Maine">Maine</option><option value="Maryland">Maryland</option><option value="Massachusetts">Massachusetts</option><option value="Michigan">Michigan</option><option value="Minnesota">Minnesota</option><option value="Mississippi">Mississippi</option><option value="Missouri">Missouri</option><option value="Montana">Montana</option><option value="Nebraska">Nebraska</option><option value="Nevada">Nevada</option><option value="New Hampshire">New Hampshire</option><option value="New Jersey">New Jersey</option><option value="New Mexico">New Mexico</option><option value="New York">New York</option><option value="North Carolina">North Carolina</option><option value="North Dakota">North Dakota</option><option value="Ohio">Ohio</option><option value="Oklahoma">Oklahoma</option><option value="Oregon">Oregon</option><option value="Pennsylvania">Pennsylvania</option><option value="Rhode Island">Rhode Island</option><option value="South Carolina">South Carolina</option><option value="South Dakota">South Dakota</option><option value="Tennessee">Tennessee</option><option value="Texas">Texas</option><option value="Utah">Utah</option><option value="Vermont">Vermont</option><option value="Virginia">Virginia</option><option value="Washington">Washington</option><option value="West Virginia">West Virginia</option><option value="Wisconsin">Wisconsin</option><option value="Wyoming">Wyoming</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_number" draggable="false" style="width: 100%;" map_to="FH_Address_Zip"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Zip</label><input name="CST_14" type="text" class="er_fld_required er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Best Time to Contact</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_time" draggable="false" style="width: 50%;"><i class="fa fa-clock-o"></i><label class="er_fld_label">From</label><input class="cst_timepicker er_fld_width100" name="CST_16" type="text" value="10:00am"></li></ul><ul class="er_fld_row" id="er_row_last"><li class="er_fld_type_time" draggable="false" style="width: 100%;"><i class="fa fa-clock-o"></i><label class="er_fld_label">Till</label><input class="cst_timepicker er_fld_width100" name="CST_17" type="text" value="05:00pm"></li></ul>
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