{"id":2461,"date":"2024-01-26T20:48:59","date_gmt":"2024-01-27T02:48:59","guid":{"rendered":"https:\/\/westernndhf.org\/?page_id=2461"},"modified":"2025-01-19T22:36:38","modified_gmt":"2025-01-20T04:36:38","slug":"pre-flight-veteran-medical-form","status":"publish","type":"page","link":"https:\/\/westernndhf.org\/?page_id=2461","title":{"rendered":"Pre-Flight &#8211; Veteran Medical Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2461\" class=\"elementor elementor-2461\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-f4db5ec elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"f4db5ec\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-fbc5efd\" data-id=\"fbc5efd\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-3ff5183 elementor-widget elementor-widget-wpforms\" data-id=\"3ff5183\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-2435\"><form id=\"wpforms-form-2435\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"2435\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F2461\" data-token=\"a2a5204058fd53cea372648b1d2c973b\" data-token-time=\"1777639648\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-page-indicator connector\" data-indicator=\"connector\" data-indicator-color=\"#066aab\" data-scroll=\"1\" role=\"progressbar\" aria-valuenow=\"1\" aria-valuemin=\"1\" aria-valuemax=\"3\" tabindex=\"-1\"><div class=\"wpforms-page-indicator-page active wpforms-page-indicator-page-1\" style=\"min-width:33.333333333333%;\" data-page=\"1\"><span class=\"wpforms-page-indicator-page-number\" style=\"background-color:#066aab\" data-page=\"1\">1<span class=\"wpforms-page-indicator-page-triangle\" style=\"border-top-color:#066aab\"><\/span><\/span><span class=\"wpforms-page-indicator-page-title\">Page 1<\/span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-2\" style=\"min-width:33.333333333333%;\" data-page=\"2\"><span class=\"wpforms-page-indicator-page-number\"  data-page=\"2\">2<span class=\"wpforms-page-indicator-page-triangle\" ><\/span><\/span><span class=\"wpforms-page-indicator-page-title\">Page 2<\/span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-3\" style=\"min-width:33.333333333333%;\" data-page=\"3\"><span class=\"wpforms-page-indicator-page-number\"  data-page=\"3\">3<span class=\"wpforms-page-indicator-page-triangle\" ><\/span><\/span><span class=\"wpforms-page-indicator-page-title\">Page 3<\/span><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-2435-field_21-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"21\"><\/div><div id=\"wpforms-2435-field_66-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"66\"><div id=\"wpforms-2435-field_66\" class=\"wpforms-field-large wpforms-field-row\" aria-errormessage=\"wpforms-2435-field_66-error\"><h1>Pre-Fligh Medical Form - Veteran<\/h1>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-2435-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"1\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-2435-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" aria-errormessage=\"wpforms-2435-field_1-error\" required><label for=\"wpforms-2435-field_1\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-fifth\"><input type=\"text\" id=\"wpforms-2435-field_1-middle\" class=\"wpforms-field-name-middle\" name=\"wpforms[fields][1][middle]\" aria-errormessage=\"wpforms-2435-field_1-middle-error\" ><label for=\"wpforms-2435-field_1-middle\" class=\"wpforms-field-sublabel after\">Middle<\/label><\/div><div class=\"wpforms-field-row-block wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-2435-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" aria-errormessage=\"wpforms-2435-field_1-last-error\" required><label for=\"wpforms-2435-field_1-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-2435-field_64-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"64\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_64\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-2435-field_64\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][64]\" spellcheck=\"false\" aria-errormessage=\"wpforms-2435-field_64-error\" aria-describedby=\"wpforms-2435-field_64-description\" required><div id=\"wpforms-2435-field_64-description\" class=\"wpforms-field-description\">Entering a valid email will allow the Western ND Honor Flight to send you an email confirmation after this form has been submitted.  <\/div><\/div><div id=\"wpforms-2435-field_2-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"2\"><div id=\"wpforms-2435-field_2\" class=\"wpforms-field-large wpforms-field-row\" aria-errormessage=\"wpforms-2435-field_2-error\"><p>This information is necessary so that we may provide you with appropriate medical support during your trip. This information is for the Honor Flight medical team only and will remain confidential. Your responses to these questions will not affect your eligibility. Please fill out this page completely. If something does not apply to you, please write N\/A or NONE. <strong>Do not leave any questions blank<\/strong>.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-2435-field_3-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_3\">List any drug allergies and what type of reaction for each individual drug? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-2435-field_3\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-2435-field_3-error\" aria-describedby=\"wpforms-2435-field_3-description\" required><\/textarea><div id=\"wpforms-2435-field_3-description\" class=\"wpforms-field-description\">Type NONE if none.<\/div><\/div><div id=\"wpforms-2435-field_4-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_4\">List any food allergies and what type of reaction for each individual food item? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-2435-field_4\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-2435-field_4-error\" aria-describedby=\"wpforms-2435-field_4-description\" required><\/textarea><div id=\"wpforms-2435-field_4-description\" class=\"wpforms-field-description\">Type NONE if none.<\/div><\/div><div id=\"wpforms-2435-field_5-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-type=\"radio\" data-field-id=\"5\"><fieldset><legend class=\"wpforms-field-label\">Do you use OXYGEN? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2435-field_5\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_5_1\" name=\"wpforms[fields][5]\" value=\"Yes\" aria-errormessage=\"wpforms-2435-field_5_1-error\" aria-describedby=\"wpforms-2435-field_5-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_5_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_5_2\" name=\"wpforms[fields][5]\" value=\"No\" aria-errormessage=\"wpforms-2435-field_5_2-error\" aria-describedby=\"wpforms-2435-field_5-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_5_2\">No<\/label><\/li><\/ul><div id=\"wpforms-2435-field_5-description\" class=\"wpforms-field-description\">*If you use oxygen, a medical team member will be in contact with you.<\/div><\/fieldset><\/div><div id=\"wpforms-2435-field_6-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"text\" data-field-id=\"6\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_6\">How many liters?\t <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2435-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-2435-field_6-error\" required><\/div><div id=\"wpforms-2435-field_8-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"radio\" data-field-id=\"8\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">How often? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2435-field_8\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_8_1\" name=\"wpforms[fields][8]\" value=\"Continuous\" aria-errormessage=\"wpforms-2435-field_8_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_8_1\">Continuous<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_8_2\" name=\"wpforms[fields][8]\" value=\"With activity only\" aria-errormessage=\"wpforms-2435-field_8_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_8_2\">With activity only<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_8_3\" name=\"wpforms[fields][8]\" value=\"At night only\" aria-errormessage=\"wpforms-2435-field_8_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_8_3\">At night only<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_8_4\" name=\"wpforms[fields][8]\" value=\"With CPAP\" aria-errormessage=\"wpforms-2435-field_8_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_8_4\">With CPAP<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2435-field_9-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"9\"><fieldset><legend class=\"wpforms-field-label\">Do you use a CPAP Machine? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2435-field_9\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_9_1\" name=\"wpforms[fields][9]\" value=\"Yes\" aria-errormessage=\"wpforms-2435-field_9_1-error\" aria-describedby=\"wpforms-2435-field_9-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_9_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_9_2\" name=\"wpforms[fields][9]\" value=\"No\" aria-errormessage=\"wpforms-2435-field_9_2-error\" aria-describedby=\"wpforms-2435-field_9-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_9_2\">No<\/label><\/li><\/ul><div id=\"wpforms-2435-field_9-description\" class=\"wpforms-field-description\">(you may bring this with you)<\/div><\/fieldset><\/div><div id=\"wpforms-2435-field_67-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"67\"><fieldset><legend class=\"wpforms-field-label\">Do you use a NEBULIZER for breathing problems?<\/legend><ul id=\"wpforms-2435-field_67\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_67_1\" name=\"wpforms[fields][67]\" value=\"Yes\" aria-errormessage=\"wpforms-2435-field_67_1-error\" aria-describedby=\"wpforms-2435-field_67-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_67_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_67_2\" name=\"wpforms[fields][67]\" value=\"No\" aria-errormessage=\"wpforms-2435-field_67_2-error\" aria-describedby=\"wpforms-2435-field_67-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_67_2\">No<\/label><\/li><\/ul><div id=\"wpforms-2435-field_67-description\" class=\"wpforms-field-description\">(you may bring this with you)<\/div><\/fieldset><\/div><div id=\"wpforms-2435-field_10-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"10\"><fieldset><legend class=\"wpforms-field-label\">Do you have CONGESTIVE HEART FAILURE? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2435-field_10\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_10_1\" name=\"wpforms[fields][10]\" value=\"Yes\" aria-errormessage=\"wpforms-2435-field_10_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_10_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_10_2\" name=\"wpforms[fields][10]\" value=\"No\" aria-errormessage=\"wpforms-2435-field_10_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_10_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2435-field_11-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"11\"><fieldset><legend class=\"wpforms-field-label\">Do you have PACEMAKER\/DEFIBRILLATOR? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2435-field_11\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_11_1\" name=\"wpforms[fields][11]\" value=\"Yes\" aria-errormessage=\"wpforms-2435-field_11_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_11_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_11_2\" name=\"wpforms[fields][11]\" value=\"No\" aria-errormessage=\"wpforms-2435-field_11_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_11_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2435-field_12-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-type=\"radio\" data-field-id=\"12\"><fieldset><legend class=\"wpforms-field-label\">Do you have DIABETES? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2435-field_12\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_12_1\" name=\"wpforms[fields][12]\" value=\"Yes\" aria-errormessage=\"wpforms-2435-field_12_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_12_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_12_2\" name=\"wpforms[fields][12]\" value=\"No\" aria-errormessage=\"wpforms-2435-field_12_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_12_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2435-field_14-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"checkbox\" data-field-id=\"14\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Do you use <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2435-field_14\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2435-field_14_1\" name=\"wpforms[fields][14][]\" value=\"PILLS\" aria-errormessage=\"wpforms-2435-field_14_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_14_1\">PILLS<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2435-field_14_2\" name=\"wpforms[fields][14][]\" value=\"INSULIN\" aria-errormessage=\"wpforms-2435-field_14_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_14_2\">INSULIN<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-2435-field_14_3\" name=\"wpforms[fields][14][]\" value=\"NOTHING\" aria-errormessage=\"wpforms-2435-field_14_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_14_3\">NOTHING<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2435-field_15-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"15\"><fieldset><legend class=\"wpforms-field-label\">Do you have SEIZURES? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2435-field_15\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_15_1\" name=\"wpforms[fields][15]\" value=\"Yes\" aria-errormessage=\"wpforms-2435-field_15_1-error\" aria-describedby=\"wpforms-2435-field_15-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_15_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_15_2\" name=\"wpforms[fields][15]\" value=\"No\" aria-errormessage=\"wpforms-2435-field_15_2-error\" aria-describedby=\"wpforms-2435-field_15-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_15_2\">No<\/label><\/li><\/ul><div id=\"wpforms-2435-field_15-description\" class=\"wpforms-field-description\">If yes, a member of our medical team will contact you.<\/div><\/fieldset><\/div><div id=\"wpforms-2435-field_16-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"16\"><fieldset><legend class=\"wpforms-field-label\">Do you have DEMENTIA\/MEMORY PROBLEMS\/BEHAVIORAL ISSUES? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2435-field_16\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_16_1\" name=\"wpforms[fields][16]\" value=\"Yes\" aria-errormessage=\"wpforms-2435-field_16_1-error\" aria-describedby=\"wpforms-2435-field_16-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_16_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_16_2\" name=\"wpforms[fields][16]\" value=\"No\" aria-errormessage=\"wpforms-2435-field_16_2-error\" aria-describedby=\"wpforms-2435-field_16-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_16_2\">No<\/label><\/li><\/ul><div id=\"wpforms-2435-field_16-description\" class=\"wpforms-field-description\">If the veteran has dementia\/memory issues, additional accommodations need to be discussed  <\/div><\/fieldset><\/div><div id=\"wpforms-2435-field_19-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_19\">If yes to any of the above questions, please describe:<\/label><textarea id=\"wpforms-2435-field_19\" class=\"wpforms-field-small\" name=\"wpforms[fields][19]\" aria-errormessage=\"wpforms-2435-field_19-error\" ><\/textarea><\/div><div id=\"wpforms-2435-field_23-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_23\">Please list other medical conditions:  <\/label><textarea id=\"wpforms-2435-field_23\" class=\"wpforms-field-medium\" name=\"wpforms[fields][23]\" aria-errormessage=\"wpforms-2435-field_23-error\" aria-describedby=\"wpforms-2435-field_23-description\" ><\/textarea><div id=\"wpforms-2435-field_23-description\" class=\"wpforms-field-description\">*If yes to any of the above questions, a medical team member may contact you.  <\/div><\/div><div id=\"wpforms-2435-field_68-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"68\"><fieldset><legend class=\"wpforms-field-label\">Do you use a wheelchair full-time? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2435-field_68\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_68_1\" name=\"wpforms[fields][68]\" value=\"Yes\" aria-errormessage=\"wpforms-2435-field_68_1-error\" aria-describedby=\"wpforms-2435-field_68-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_68_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_68_2\" name=\"wpforms[fields][68]\" value=\"No\" aria-errormessage=\"wpforms-2435-field_68_2-error\" aria-describedby=\"wpforms-2435-field_68-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_68_2\">No<\/label><\/li><\/ul><div id=\"wpforms-2435-field_68-description\" class=\"wpforms-field-description\">*Walkers or motorized scooters are not allowed.  Canes ARE allowed.  We will gladly provide you with a wheelchair for any amount of time you need it.<\/div><\/fieldset><\/div><div id=\"wpforms-2435-field_25-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"25\"><fieldset><legend class=\"wpforms-field-label\">Do you think you may need a wheelchair for this trip for any amount of time? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2435-field_25\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_25_1\" name=\"wpforms[fields][25]\" value=\"Yes\" aria-errormessage=\"wpforms-2435-field_25_1-error\" aria-describedby=\"wpforms-2435-field_25-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_25_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_25_2\" name=\"wpforms[fields][25]\" value=\"No\" aria-errormessage=\"wpforms-2435-field_25_2-error\" aria-describedby=\"wpforms-2435-field_25-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_25_2\">No<\/label><\/li><\/ul><div id=\"wpforms-2435-field_25-description\" class=\"wpforms-field-description\">*Walkers or motorized scooters are not allowed.  Canes ARE allowed.  We will gladly provide you with a wheelchair for any amount of time you need it.<\/div><\/fieldset><\/div><div id=\"wpforms-2435-field_69-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"69\"><fieldset><legend class=\"wpforms-field-label\">Do you need an ADA hotel room? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2435-field_69\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_69_1\" name=\"wpforms[fields][69]\" value=\"Yes\" aria-errormessage=\"wpforms-2435-field_69_1-error\" aria-describedby=\"wpforms-2435-field_69-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_69_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2435-field_69_2\" name=\"wpforms[fields][69]\" value=\"No\" aria-errormessage=\"wpforms-2435-field_69_2-error\" aria-describedby=\"wpforms-2435-field_69-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2435-field_69_2\">No<\/label><\/li><\/ul><div id=\"wpforms-2435-field_69-description\" class=\"wpforms-field-description\">*Walkers or motorized scooters are not allowed.  Canes ARE allowed.  We will gladly provide you with a wheelchair for any amount of time you need it.<\/div><\/fieldset><\/div><div id=\"wpforms-2435-field_20-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"20\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"1\" data-formid=\"2435\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-2435-field_35-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"35\"><div id=\"wpforms-2435-field_35\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-2435-field_35-error\"><h4>EMERGENCY CONTACT<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-2435-field_28-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"28\"><fieldset><legend class=\"wpforms-field-label\">Emergency Contact Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-2435-field_28\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][28][first]\" aria-errormessage=\"wpforms-2435-field_28-error\" required><label for=\"wpforms-2435-field_28\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-2435-field_28-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][28][last]\" aria-errormessage=\"wpforms-2435-field_28-last-error\" required><label for=\"wpforms-2435-field_28-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-2435-field_29-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_29\">Relationship <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2435-field_29\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][29]\" aria-errormessage=\"wpforms-2435-field_29-error\" required><\/div><div id=\"wpforms-2435-field_30-container\" class=\"wpforms-field wpforms-field-address\" data-field-type=\"address\" data-field-id=\"30\"><fieldset><legend class=\"wpforms-field-label\">Emergency Contact Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-2435-field_30\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][30][address1]\" aria-errormessage=\"wpforms-2435-field_30-error\" required><label for=\"wpforms-2435-field_30\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-2435-field_30-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][30][address2]\" aria-errormessage=\"wpforms-2435-field_30-address2-error\" ><label for=\"wpforms-2435-field_30-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-2435-field_30-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][30][city]\" aria-errormessage=\"wpforms-2435-field_30-city-error\" required><label for=\"wpforms-2435-field_30-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-2435-field_30-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][30][state]\" aria-errormessage=\"wpforms-2435-field_30-state-error\" required><label for=\"wpforms-2435-field_30-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-2435-field_30-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][30][postal]\" aria-errormessage=\"wpforms-2435-field_30-postal-error\" required><label for=\"wpforms-2435-field_30-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-2435-field_30-country\" class=\"wpforms-field-address-country wpforms-field-required\" name=\"wpforms[fields][30][country]\" value=\"US\" aria-errormessage=\"wpforms-2435-field_30-country-error\" required><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\"  selected='selected'>United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-2435-field_30-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-2435-field_32-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"32\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-33-33-33\"><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-2435-field_31-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_31\">Contact Day Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-2435-field_31\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][31]\" aria-label=\"Contact Day Phone\" aria-errormessage=\"wpforms-2435-field_31-error\" required><\/div><div id=\"wpforms-2435-field_44-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_44\">Emergency Contact Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-2435-field_44\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][44]\" spellcheck=\"false\" aria-errormessage=\"wpforms-2435-field_44-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-2435-field_33-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_33\">Contact Evening Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-2435-field_33\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][33]\" aria-label=\"Contact Evening Phone\" aria-errormessage=\"wpforms-2435-field_33-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-2435-field_34-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_34\">Contact Cell Phone<\/label><input type=\"tel\" id=\"wpforms-2435-field_34\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][34]\" aria-label=\"Contact Cell Phone\" aria-errormessage=\"wpforms-2435-field_34-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-2435-field_46-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"46\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"2\" data-formid=\"2435\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3 last \" data-page=\"3\" style=\"display:none;\"><div id=\"wpforms-2435-field_47-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"47\"><div id=\"wpforms-2435-field_47\" class=\"wpforms-field-large wpforms-field-row\" aria-errormessage=\"wpforms-2435-field_47-error\"><h4>MEDICATIONS<\/h4>\n<p>List each of your medications separately in the below boxes<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-2435-field_48-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"48\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-33-33-33\"><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-2435-field_49-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_49\">Medication 1<\/label><input type=\"text\" id=\"wpforms-2435-field_49\" class=\"wpforms-field-medium\" name=\"wpforms[fields][49]\" aria-errormessage=\"wpforms-2435-field_49-error\" ><\/div><div id=\"wpforms-2435-field_56-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_56\">Medication 3<\/label><input type=\"text\" id=\"wpforms-2435-field_56\" class=\"wpforms-field-medium\" name=\"wpforms[fields][56]\" aria-errormessage=\"wpforms-2435-field_56-error\" ><\/div><div id=\"wpforms-2435-field_55-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_55\">Medication 5<\/label><input type=\"text\" id=\"wpforms-2435-field_55\" class=\"wpforms-field-medium\" name=\"wpforms[fields][55]\" aria-errormessage=\"wpforms-2435-field_55-error\" ><\/div><div id=\"wpforms-2435-field_54-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"54\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_54\">Medication 7<\/label><input type=\"text\" id=\"wpforms-2435-field_54\" class=\"wpforms-field-medium\" name=\"wpforms[fields][54]\" aria-errormessage=\"wpforms-2435-field_54-error\" ><\/div><div id=\"wpforms-2435-field_53-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_53\">Medication 9<\/label><input type=\"text\" id=\"wpforms-2435-field_53\" class=\"wpforms-field-medium\" name=\"wpforms[fields][53]\" aria-errormessage=\"wpforms-2435-field_53-error\" ><\/div><div id=\"wpforms-2435-field_52-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"52\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_52\">Medication 11<\/label><input type=\"text\" id=\"wpforms-2435-field_52\" class=\"wpforms-field-medium\" name=\"wpforms[fields][52]\" aria-errormessage=\"wpforms-2435-field_52-error\" ><\/div><div id=\"wpforms-2435-field_51-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_51\">Medication 13<\/label><input type=\"text\" id=\"wpforms-2435-field_51\" class=\"wpforms-field-medium\" name=\"wpforms[fields][51]\" aria-errormessage=\"wpforms-2435-field_51-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-2435-field_57-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_57\">Medication 2<\/label><input type=\"text\" id=\"wpforms-2435-field_57\" class=\"wpforms-field-medium\" name=\"wpforms[fields][57]\" aria-errormessage=\"wpforms-2435-field_57-error\" ><\/div><div id=\"wpforms-2435-field_58-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"58\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_58\">Medication 4<\/label><input type=\"text\" id=\"wpforms-2435-field_58\" class=\"wpforms-field-medium\" name=\"wpforms[fields][58]\" aria-errormessage=\"wpforms-2435-field_58-error\" ><\/div><div id=\"wpforms-2435-field_59-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"59\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_59\">Medication 6<\/label><input type=\"text\" id=\"wpforms-2435-field_59\" class=\"wpforms-field-medium\" name=\"wpforms[fields][59]\" aria-errormessage=\"wpforms-2435-field_59-error\" ><\/div><div id=\"wpforms-2435-field_60-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"60\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_60\">Medication 8<\/label><input type=\"text\" id=\"wpforms-2435-field_60\" class=\"wpforms-field-medium\" name=\"wpforms[fields][60]\" aria-errormessage=\"wpforms-2435-field_60-error\" ><\/div><div id=\"wpforms-2435-field_61-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"61\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_61\">Medication 10<\/label><input type=\"text\" id=\"wpforms-2435-field_61\" class=\"wpforms-field-medium\" name=\"wpforms[fields][61]\" aria-errormessage=\"wpforms-2435-field_61-error\" ><\/div><div id=\"wpforms-2435-field_62-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"62\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_62\">Medication 12<\/label><input type=\"text\" id=\"wpforms-2435-field_62\" class=\"wpforms-field-medium\" name=\"wpforms[fields][62]\" aria-errormessage=\"wpforms-2435-field_62-error\" ><\/div><div id=\"wpforms-2435-field_63-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"63\"><label class=\"wpforms-field-label\" for=\"wpforms-2435-field_63\">Medication 14<\/label><input type=\"text\" id=\"wpforms-2435-field_63\" class=\"wpforms-field-medium\" name=\"wpforms[fields][63]\" aria-errormessage=\"wpforms-2435-field_63-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><\/div><\/div><\/div><div id=\"wpforms-2435-field_22-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"22\"><\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"2435\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/westernndhf.org\/index.php?rest_route=\/wp\/v2\/pages\/2461\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-2435\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/westernndhf.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. &#8211; Step 1 of 3 Name * FirstMiddleLast This information is necessary so that we may provide you with appropriate medical support during your trip. This information is for the Honor Flight medical team only and<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":2485,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-fullwidth.php","meta":{"_coblocks_attr":"","_coblocks_dimensions":"","_coblocks_responsive_height":"","_coblocks_accordion_ie_support":"","_mc_calendar":[],"footnotes":""},"class_list":["post-2461","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/westernndhf.org\/index.php?rest_route=\/wp\/v2\/pages\/2461","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/westernndhf.org\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/westernndhf.org\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/westernndhf.org\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/westernndhf.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2461"}],"version-history":[{"count":5,"href":"https:\/\/westernndhf.org\/index.php?rest_route=\/wp\/v2\/pages\/2461\/revisions"}],"predecessor-version":[{"id":3156,"href":"https:\/\/westernndhf.org\/index.php?rest_route=\/wp\/v2\/pages\/2461\/revisions\/3156"}],"up":[{"embeddable":true,"href":"https:\/\/westernndhf.org\/index.php?rest_route=\/wp\/v2\/pages\/2485"}],"wp:attachment":[{"href":"https:\/\/westernndhf.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2461"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}