Online Inquiry
Please attach a hard copy of this form below, or reenable the web form.
<ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Ready to take the next steps in becoming a foster parent? </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Great! Simply fill out the form below and an Encourage employee will be in touch to get the process started!</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Fields marked with an * are required</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 50%;"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Inquiry</label><input class="cst_datepicker er_fld_required er_fld_width50" name="CST_5" type="text"></li><li class="er_fld_type_text er_fld_selected" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Email Address</label><input name="CST_15" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Name_First_A"> <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"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" 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_text" draggable="false" style="width: 25%;" map_to="FH_Address_Street_1"> <i class="fa fa-font"></i><label class="er_fld_label">Address 1</label><input name="CST_10" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Address_Street_2"> <i class="fa fa-font"></i><label class="er_fld_label">Apt. #</label><input name="CST_9" type="text"></li><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">City</label><input name="CST_11" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Address_Zip"> <i class="fa fa-font"></i><label class="er_fld_label">Zip</label><input name="CST_12" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Address_County"> <i class="fa fa-font"></i><label class="er_fld_label required">County </label><input name="CST_7" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Phone_Mobile"> <i class="fa fa-font"></i><label class="er_fld_label required">Mobile Phone #</label><input name="CST_3" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false" map_to="FH_ReferralSource"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Referral Source</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Billboard">Billboard</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Church / Pastor">Church / Pastor</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Community Information Section">Community Information Section</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Display Table at Event">Display Table at Event</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Employee">Employee</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Facebook Ads">Facebook Ads</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Foster Parent">Foster Parent</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Google Ads">Google Ads</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Other Agency">Other Agency</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Protective Services">Protective Services</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Radio / TV Ad">Radio / TV Ad</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Website">Website</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Yellow Pages / Phone Book">Yellow Pages / Phone Book</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_8" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_8_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" 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">Interested In</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Foster Care">Foster Care</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Foster Care to Adopt">Foster Care to Adopt</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Mentor">Mentor</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_13" value="Other:">Other:<input class="cst_Other" name="CST_13_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</label><textarea name="CST_14" style="width:100%;"></textarea></li></ul>
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