Online Inquiry
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<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">Want to learn more about 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 we will be in touch!</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: 33.3333%;"> <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" draggable="false" style="width: 33.3333%;" map_to="FH_EMail"> <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: 25%;" 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: 25%;" 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><li class="er_fld_type_date" draggable="false" style="width: 25%;" map_to="FH_DOB_A"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Birth</label><input class="cst_datepicker er_fld_required" name="CST_22" type="text"></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 required">Address 1</label><input name="CST_10" type="text" class="er_fld_required"></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 required">City</label><input name="CST_11" 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_Address_Zip"> <i class="fa fa-font"></i><label class="er_fld_label required">Zip</label><input name="CST_12" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Address_County"> <i class="fa fa-font"></i><label class="er_fld_label required">County</label><input name="CST_25" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" 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_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Marital Status</label><select name="CST_18" class="er_fld_required er_fld_width50"><option value="- Choose One -" selected="">- Choose One -</option><option value="Single">Single</option><option value="Married">Married</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" map_to="FH_Name_First_B" er_fld_condfld="CST_18" er_fld_condvals="er_fld_showif_values=Married"> <i class="fa fa-font"></i><label class="er_fld_label required">Spouse First Name</label><input name="CST_19" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" map_to="FH_Name_Last_B" er_fld_condfld="CST_18" er_fld_condvals="er_fld_showif_values=Married"> <i class="fa fa-font"></i><label class="er_fld_label required">Spouse Last Name</label><input name="CST_20" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 50%;" map_to="FH_DOB_B" er_fld_condfld="CST_18" er_fld_condvals="er_fld_showif_values=Married"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Spouse Date of Birth</label><input class="cst_datepicker er_fld_required" name="CST_21" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_18" er_fld_condvals="er_fld_showif_values=Married" map_to="FH_Phone_Mobile_B"> <i class="fa fa-font"></i><label class="er_fld_label required">Spouse Mobile Phone #</label><input name="CST_24" 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 required">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"><input class="type_checkbox" type="checkbox" name="CST_13" value="Transfer Agencies">Transfer Agencies</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_13" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_13_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_selected er_fld_showif" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_13" er_fld_condvals="er_fld_showif_values=Foster+Care&er_fld_showif_values=Foster+Care+to+Adopt&er_fld_showif_values=Transfer+Agencies"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">I want to attend the following Foster Parent Pre-Service </label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_27" value="March 15-16; 22-23: New Philadelphia, OH">March 15-16; 22-23: New Philadelphia, OH</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_27" value="May 3-4; 17-18: Medina, OH">May 3-4; 17-18: Medina, OH</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_27" value="June 21-22; 28-29: Coshocton, OH">June 21-22; 28-29: Coshocton, OH</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_27" value="July 19-20; 26-27: Dalton, OH">July 19-20; 26-27: Dalton, OH</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_27" value="Oct. 4-5; 11-12: Millersburg, OH">Oct. 4-5; 11-12: Millersburg, OH</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_27" value="Not sure yet/not applicable">Not sure yet/not applicable</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_27" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_27_Other" type="text"></label></li><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_13" er_fld_condvals="er_fld_showif_values=Foster+Care&er_fld_showif_values=Foster+Care+to+Adopt&er_fld_showif_values=Transfer+Agencies"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">For more information about our Foster Parent Pre-Service go to encouragefostercare.org/training.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 100%;" map_to="FH_Inquiry_Why_Parents"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">What led you to consider being a foster parent?</label><textarea name="CST_17" style="width:100%;" class="er_fld_required er_fld_blank"></textarea></li></ul>
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