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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>Enhanced Horizons (EH) - Transitional Living</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false"><i class="fa fa-header"></i><label>Admission Application</label><hr></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">Instructions: This admission Application is to be used by all potential residents of the Enhanced Horizons (EH) campus in Ingram, TX. If you have not done so, please reach out to one od our caring individuals to coordinate an initial consultation. Brian Ellsworth 830-367-4330 ext. 222 ehdir@enhancedhorizons.org. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">If areas of the application are not relevant to you, please skip them.</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">Applicant Information</div></li></ul><ul class="er_fld_row"><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">Full Name: Last, First and M.I.</label><input name="CST_1" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Other Names: (maiden, married, etc)</label><input name="CST_2" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 100%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Address:</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Street Address: </label><input name="CST_3" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Apartment/Unit#:</label><input name="CST_4" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">City;</label><input name="CST_5" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">State: </label><input name="CST_6" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Zip Code:</label><input name="CST_7" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Cell Phone: </label><input name="CST_8" type="text"></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Safe to leave message:</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_10" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_10" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_10" value="Other:">Other:<input class="cst_Other" name="CST_10_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Work Phone: </label><input name="CST_9" type="text"></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Safe tp leave message:</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_11" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_11" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_11" value="Other:">Other:<input class="cst_Other" name="CST_11_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Emergency Contact:</label><input name="CST_12" type="text"></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Safe to leave message:</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="No">No</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_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Date of Birth: </label><input name="CST_14" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Social Security Number;</label><input name="CST_15" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Driver's License Number:</label><input name="CST_16" type="text"></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Driver's License Suspended?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_18" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_18" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_18" value="Other:">Other:<input class="cst_Other" name="CST_18_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Email:</label><input name="CST_17" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col3" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Race (check all that Apply)</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="White">White</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="African American">African American</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Hispanic">Hispanic</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Asian/Pacific Islander ">Asian/Pacific Islander </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Other">Other</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_19" value="Other:">Other:<input class="cst_Other" name="CST_19_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">US Citizen?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_20" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_20" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_20" value="Other:">Other:<input class="cst_Other" name="CST_20_Other" type="text"></label></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Authorized to work in U.S.?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_21" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_21" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_21" value="Other:">Other:<input class="cst_Other" name="CST_21_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Have you ever been convicted of a felony?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_22" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_22" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_22" value="Other:">Other:<input class="cst_Other" name="CST_22_Other" type="text"></label></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Have you ever been convicted of a misdemeanor?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_24" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_24" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_24" value="Other:">Other:<input class="cst_Other" name="CST_24_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">If yes, explain.: </label><textarea name="CST_25" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Are you in any legaltrouble (tickets, debt, etc?)</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_26" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_26" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_26" value="Other:">Other:<input class="cst_Other" name="CST_26_Other" type="text"></label></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Are you on Probation?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_27" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_27" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_27" value="Other:">Other:<input class="cst_Other" name="CST_27_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">Other countries you have lived in:</label><textarea name="CST_28" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Have you been diagnosed with a mental illiness?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_29" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_29" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_29" value="Other:">Other:<input class="cst_Other" name="CST_29_Other" type="text"></label></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">HAve you had a psychological evaluation?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_30" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_30" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_30" value="Other:">Other:<input class="cst_Other" name="CST_30_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">If yes, when & what was the diagnosis/result?</label><textarea name="CST_31" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Have you ever attempted suicide?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_32" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_32" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_32" value="Other:">Other:<input class="cst_Other" name="CST_32_Other" type="text"></label></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">If yes, did you receive treatment?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_33" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_33" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_33" value="Other:">Other:<input class="cst_Other" name="CST_33_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">What were the circumstances?</label><textarea name="CST_34" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Have you received counseling?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_35" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_35" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_35" value="Other:">Other:<input class="cst_Other" name="CST_35_Other" type="text"></label></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Do you have a history of physcal or sexual abuse?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_36" value="Other:">Other:<input class="cst_Other" name="CST_36_Other" type="text"></label></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"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Do you use orhave a historyf using drugs or alcohol?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_37" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_37" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_37" value="Other:">Other:<input class="cst_Other" name="CST_37_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">If so, What substance(s)?</label><textarea name="CST_40" style="width:100%;"></textarea></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"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Do you use tobacco, vape or e-cgarettes?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_39" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_39" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_39" value="Other:">Other:<input class="cst_Other" name="CST_39_Other" type="text"></label></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"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Are you currently under a physician's care?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_41" value="Yes ">Yes </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_41" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_41" value="Other:">Other:<input class="cst_Other" name="CST_41_Other" type="text"></label></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"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Are you currently on medications?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_42" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_42" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_42" value="Other:">Other:<input class="cst_Other" name="CST_42_Other" type="text"></label></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"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Are you currently pregnant?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_43" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_43" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_43" value="Other:">Other:<input class="cst_Other" name="CST_43_Other" type="text"></label></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"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Do you have a crib, car seat, etc., which meet the current safety standards?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_44" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_44" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_44" value="Other:">Other:<input class="cst_Other" name="CST_44_Other" type="text"></label></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"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Have you ever been a past resident in any of Hill Country Youth Ranch programs?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_45" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_45" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_45" value="Other:">Other:<input class="cst_Other" name="CST_45_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">If yes, name & address of facility:</label><textarea name="CST_46" style="width:100%;"></textarea></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">Who will be responsible for transporting you to the hospital, apointments, etc., if needed?</label><textarea name="CST_47" style="width:100%;"></textarea></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">Who will be responsible for the care of your children if you are unable to care for them?</label><textarea name="CST_49" style="width:100%;"></textarea></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">What is the reason you are seeking placement in the EH program?</label><textarea name="CST_50" style="width:100%;"></textarea></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">How do your children feel about living in the EH program?</label><textarea name="CST_51" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Do you attend church? If so, where?</label><textarea name="CST_52" style="width:100%;"></textarea></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">Name of person or agency referring you to EH?</label><textarea name="CST_53" style="width:100%;"></textarea></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">Describe your relationship with your family of origin (i.e. parents, grandparents, siblings, etc.):</label><textarea name="CST_54" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false"><i class="fa fa-header"></i><label>Marital Status</label><hr></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"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Are you currently in a relationship?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_55" value="Other:">Other:<input class="cst_Other" name="CST_55_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col3" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Marital Status:</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_56" value="Married">Married</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_56" value="Widowed">Widowed</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_56" value="Divorced/Separated">Divorced/Separated</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_56" value="Nver married">Nver married</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_56" value="other">other</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_56" value="Other:">Other:<input class="cst_Other" name="CST_56_Other" type="text"></label></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">List of Previous Marriage(s):</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name:</label><input name="CST_57" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Date of Marriage:</label><input name="CST_58" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Date of Divorce:</label><input name="CST_59" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name:</label><input name="CST_60" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Date of Marriage:</label><input name="CST_61" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Date of Divorce:</label><input name="CST_62" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name: </label><input name="CST_63" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Date of Marriage:</label><input name="CST_65" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Date of Dvorce:</label><input name="CST_64" type="text"></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">Please list three reference (use only one family member and one friend; other can include coworkers, landlords, pastor, etc.)</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Full Name:</label><input name="CST_66" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Relationship:</label><input name="CST_67" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Company:</label><input name="CST_69" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone: </label><input name="CST_68" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Full Name:</label><input name="CST_71" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Relationship:</label><input name="CST_70" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Company:</label><input name="CST_73" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone: </label><input name="CST_72" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Full Name:</label><input name="CST_75" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Relationship:</label><input name="CST_74" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Company:</label><input name="CST_77" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone: </label><input name="CST_76" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Full Name:</label><input name="CST_79" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Relationship:</label><input name="CST_78" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Company:</label><input name="CST_81" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone: </label><input name="CST_80" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Full Name:</label><input name="CST_83" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Relationship:</label><input name="CST_82" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Company:</label><input name="CST_84" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone: </label><input name="CST_85" type="text"></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">Transportation</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Do you own/have car?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_86" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_86" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_86" value="Other:">Other:<input class="cst_Other" name="CST_86_Other" type="text"></label></li><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Is the registration current?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_87" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_87" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_87" value="Other:">Other:<input class="cst_Other" name="CST_87_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">License Plate:</label><input name="CST_88" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Year:</label><input name="CST_89" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Make:</label><input name="CST_90" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Model:</label><input name="CST_91" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Running Condtion:</label><input name="CST_93" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name on Title:</label><input name="CST_92" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Do youave insurance</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_94" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_94" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_94" value="Other:">Other:<input class="cst_Other" name="CST_94_Other" type="text"></label></li><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Is there a note/debt o the vehicle?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_95" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_95" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_95" value="Other:">Other:<input class="cst_Other" name="CST_95_Other" type="text"></label></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">Education</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">High School:</label><input name="CST_97" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">City:</label><input name="CST_98" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">State:</label><input name="CST_96" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">From:</label><input name="CST_99" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">To:</label><input name="CST_100" type="text"></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 20%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Did you graduate?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_101" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_101" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_101" value="Other:">Other:<input class="cst_Other" name="CST_101_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Diploma:</label><input name="CST_102" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">College:</label><input name="CST_104" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">City:</label><input name="CST_105" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">State:</label><input name="CST_103" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">From:</label><input name="CST_107" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">To:</label><input name="CST_106" type="text"></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 20%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Did you graduate?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_108" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_108" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_108" value="Other:">Other:<input class="cst_Other" name="CST_108_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Diploma:</label><input name="CST_109" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Other:</label><input name="CST_112" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">City:</label><input name="CST_113" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">State:</label><input name="CST_111" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">From:</label><input name="CST_114" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">To:</label><input name="CST_110" type="text"></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 20%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Did you graduate?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_115" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_115" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_115" value="Other:">Other:<input class="cst_Other" name="CST_115_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Diploma</label><input name="CST_116" type="text"></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">Work History</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Company:</label><input name="CST_117" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone:</label><input name="CST_118" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address:</label><input name="CST_120" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Supervisor:</label><input name="CST_119" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Job Title:</label><input name="CST_122" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Monthly Salary:</label><input name="CST_121" type="text"></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">Responsibilities: </label><textarea name="CST_124" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">From:</label><input name="CST_125" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">To:</label><input name="CST_123" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Reason for Leaving:</label><input name="CST_126" type="text"></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"><i class="fa fa-check-square-o"></i><label class="er_fld_label">May we contact your previous supervisor for a reference?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_128" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_128" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_128" value="Other:">Other:<input class="cst_Other" name="CST_128_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Company:</label><input name="CST_129" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone:</label><input name="CST_127" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address:</label><input name="CST_130" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Supervisor:</label><input name="CST_131" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Job Title:</label><input name="CST_133" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Monthly Salary:</label><input name="CST_132" type="text"></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">Responsibilities:</label><textarea name="CST_134" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">From:</label><input name="CST_136" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">To:</label><input name="CST_137" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Reasonfor leaving:</label><input name="CST_135" type="text"></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"><i class="fa fa-check-square-o"></i><label class="er_fld_label">May we contact your previous supervsor for a reference?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_138" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_138" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_138" value="Other:">Other:<input class="cst_Other" name="CST_138_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Company:</label><input name="CST_140" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone:</label><input name="CST_139" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address:</label><input name="CST_142" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Supervisor:</label><input name="CST_141" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Job Title:</label><input name="CST_144" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Monthly Salary:</label><input name="CST_143" type="text"></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">Responsibilities:</label><textarea name="CST_145" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">From:</label><input name="CST_147" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">To:</label><input name="CST_148" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Reson for leaving:</label><input name="CST_146" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space:normal;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">May we contact you previous supervisor?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_149" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_149" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_149" value="Other:">Other:<input class="cst_Other" name="CST_149_Other" type="text"></label></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">Child(ren) Information</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Full Name:</label><input name="CST_150" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">D.O.B.</label><input name="CST_151" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Age/Grade:</label><input name="CST_152" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Father's/Mother's Name:</label><input name="CST_153" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Child Support:</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_155" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_155" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_155" value="Other:">Other:<input class="cst_Other" name="CST_155_Other" type="text"></label></li><li class="er_fld_type_checkbox er_fld_type_radio_col3" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Custody of Child:</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_154" value="Joint">Joint</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_154" value="Sole (Mother)">Sole (Mother)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_154" value="Sole (Father)">Sole (Father)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_154" value="Other">Other</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_154" value="Foster Care">Foster Care</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_154" value="Other:">Other:<input class="cst_Other" name="CST_154_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">Visit Arrangements:</label><textarea name="CST_163" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Day Care/School:</label><input name="CST_157" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone:</label><input name="CST_158" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Has child ever been physically or sexually abouse?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_159" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_159" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_159" value="Other:">Other:<input class="cst_Other" name="CST_159_Other" type="text"></label></li><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Has the child had a psychological evaulation?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_160" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_160" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_160" value="Other:">Other:<input class="cst_Other" name="CST_160_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Has he/she ever received counseling?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_162" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_162" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_162" value="Other:">Other:<input class="cst_Other" name="CST_162_Other" type="text"></label></li><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 33.3333%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">If yes, please explain:</label><textarea name="CST_164" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Has the child been in legal trouble?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_165" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_165" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_165" value="Other:">Other:<input class="cst_Other" name="CST_165_Other" type="text"></label></li><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 33.3333%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">If yes, please explain:</label><textarea name="CST_167" style="width:100%;"></textarea></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">Medication & Dosages:</label><textarea name="CST_168" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Full Name:</label><input name="CST_170" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">D.O.B.:</label><input name="CST_169" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Age/Grade:</label><input name="CST_171" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Father's/Mother's Name:</label><input name="CST_175" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Child Support:</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_173" value="Yes ">Yes </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_173" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_173" value="Other:">Other:<input class="cst_Other" name="CST_173_Other" type="text"></label></li><li class="er_fld_type_checkbox er_fld_type_radio_col3" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Custody of care:</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_172" value="Joint">Joint</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_172" value="Sole(mother)">Sole(mother)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_172" value="Sole(father)">Sole(father)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_172" value="Other ">Other </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_172" value="Foster Care">Foster Care</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_172" value="Other:">Other:<input class="cst_Other" name="CST_172_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">Visit Arrangements:</label><textarea name="CST_174" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Day Care/School</label><input name="CST_176" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone:</label><input name="CST_187" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Has the child ever beenphysically or sexually abuse?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_178" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_178" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_178" value="Other:">Other:<input class="cst_Other" name="CST_178_Other" type="text"></label></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Has the child had a psychological evaluation?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_177" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_177" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_177" value="Other:">Other:<input class="cst_Other" name="CST_177_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Has he/she ever received counseling?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_179" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_179" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_179" value="Other:">Other:<input class="cst_Other" name="CST_179_Other" type="text"></label></li><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 33.3333%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">If yes, please explain:</label><textarea name="CST_180" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Has the child been in legal trouble?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_181" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_181" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_181" value="Other:">Other:<input class="cst_Other" name="CST_181_Other" type="text"></label></li><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 33.3333%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">If yes, please explain:</label><textarea name="CST_182" style="width:100%;"></textarea></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">Medication & Dosages:</label><textarea name="CST_183" style="width:100%;"></textarea></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"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Do you have any additional children that would not be living on campus?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_161" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_161" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_161" value="Other:">Other:<input class="cst_Other" name="CST_161_Other" type="text"></label></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">Financial Resources, Assets and Assistance</div></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"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Do you own real estate?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_188" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_188" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_188" value="Other:">Other:<input class="cst_Other" name="CST_188_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Value:</label><input name="CST_190" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Loan Balance:</label><input name="CST_191" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Account Status:</label><input name="CST_189" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Do you have medical insurance?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_192" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_192" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_192" value="Other:">Other:<input class="cst_Other" name="CST_192_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Company:</label><input name="CST_193" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Do you receive Medicaid benefits?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_194" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_194" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_194" value="Other:">Other:<input class="cst_Other" name="CST_194_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">For Whom?</label><input name="CST_195" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Do you recieve TANF benefits?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_196" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_196" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_196" value="Other:">Other:<input class="cst_Other" name="CST_196_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Amount per month?</label><input name="CST_197" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Do you recieve WIC benefits?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_198" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_198" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_198" value="Other:">Other:<input class="cst_Other" name="CST_198_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Amount per month?</label><input name="CST_199" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Do you recieve SS benefits?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_200" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_200" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_200" value="Other:">Other:<input class="cst_Other" name="CST_200_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Amount peronth?</label><input name="CST_201" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Do yourchildren recieve SS benefits?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_202" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_202" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_202" value="Other:">Other:<input class="cst_Other" name="CST_202_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Amount per month?</label><input name="CST_203" type="text"></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">Explain your family's circumstances and whatyou want toaccomplish by moving to the EH campus:</label><textarea name="CST_204" style="width:100%;"></textarea></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">I certify my answers are true and complete to the best of m knowledge. If this application leads to placements in program, I understand that false or misleading information in my application or interview may result in my release.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature" draggable="false" style="width: 33.3333%;"> <i class="fa fa-pencil"></i><label class="er_fld_label">Signature</label><div class="cst_signaturepad"></div><input name="CST_205" type="text"><button class="type_button" disabled="">Clear Signature</button></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Date:</label><input name="CST_206" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Personal Data</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Last Name:</label><input name="CST_208" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">First Name:</label><input name="CST_209" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Middle Name:</label><input name="CST_207" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Date of Birth:</label><input name="CST_211" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Other Name Used:</label><input name="CST_212" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Year(s) used.</label><input name="CST_210" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Social Security Number:</label><input name="CST_213" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">DL#:</label><input name="CST_215" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">State:</label><input name="CST_214" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Email address:</label><input name="CST_216" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Current Address:</label><input name="CST_218" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">City:</label><input name="CST_219" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">State:</label><input name="CST_217" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">From:</label><input name="CST_221" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">To:</label><input name="CST_220" type="text"></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">Past Living Address (last 7 Years)</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Street:</label><input name="CST_223" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">City:</label><input name="CST_224" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">State:</label><input name="CST_222" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">From:</label><input name="CST_226" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">To:</label><input name="CST_225" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Street:</label><input name="CST_228" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">City:</label><input name="CST_229" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">State:</label><input name="CST_227" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">From:</label><input name="CST_231" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">To:</label><input name="CST_230" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Street:</label><input name="CST_233" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">City:</label><input name="CST_234" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">State:</label><input name="CST_232" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">From:</label><input name="CST_236" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">To:</label><input name="CST_235" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Street:</label><input name="CST_238" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">City:</label><input name="CST_239" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">State:</label><input name="CST_237" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">From:</label><input name="CST_241" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">To:</label><input name="CST_240" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Street:</label><input name="CST_243" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">City:</label><input name="CST_244" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">State:</label><input name="CST_242" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">From:</label><input name="CST_246" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">To:</label><input name="CST_245" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Street:</label><input name="CST_248" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">City:</label><input name="CST_249" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">State:</label><input name="CST_247" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">From:</label><input name="CST_251" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">To:</label><input name="CST_250" type="text"></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">I have the right to make a request to IntelliCorp Records, Inc., upon identification, to request the nature and substance of all information in it's files on me at the time of my request, including sources of information, and the recipients of any reports on me which IntelliCorp Records, Inc., has previously furnished within the past two-year period preceding my request. I certify that all the elements of the personal data I have provided are true, accurate and complete. I understand and agree that any omission, false statement, misleading statement, or answer made by me on my application or any supplements to it and in any interviews may be sufficient grounds for rejection to the program.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Printed Name</label><input name="CST_252" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Date</label><input name="CST_254" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature" draggable="false" style="width: 50%;"> <i class="fa fa-pencil"></i><label class="er_fld_label">Signature</label><div class="cst_signaturepad"></div><input name="CST_253" type="text"><button class="type_button" disabled="">Clear Signature</button></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 100%;"><i class="fa fa-header"></i><label>Authorzation to seek and obtain confidential information</label><hr></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">To Whom It May Concern: I, </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name</label><input name="CST_255" type="text"></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">do hereby authorize Hill Country Youth Ranch (Enhanced Horizons) to obtain any financial, medical, psychological social, or school information from any employer person, agency school or hospital, having such information in it's possession, which pertains to me and/or my childhood. </div></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">Children's Names: </label><textarea name="CST_257" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature" draggable="false" style="width: 33.3333%;"> <i class="fa fa-pencil"></i><label class="er_fld_label">Signed: </label><div class="cst_signaturepad"></div><input name="CST_258" type="text"><button class="type_button" disabled="">Clear Signature</button></li><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date</label><input class="cst_datepicker" name="CST_259" type="text"></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>Disclosure and Authorization form to obtain reports for Program Admission Purposes</label><hr></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">Please Read Carefully Before Signing the Authorization</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">Disclosure</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">In Considering you for our program, Hill Country Youth Ranch / Enhanced Horizons may request and rely upon one or more reports or investigative consumer reports about you that we obtain from a consumer reporting agency, such as IntelliCorp Records, Inc. For explanation purposes: A consumer report is written, oral or other communication of any information by a consumer reporting agency bearing on your creditworthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in making a client-related decision about you. Such information may include for example, credit information, criminal history reports, or driving records; and Before the company can obtain a consumer report or investigative consumer report about you for a client assessment purpose, we must have your written authorization. Before we take adverse action on the basis, in whole or in part, or the information in that report, you will be provided with a copy of that report, and the name address, and telephone number of the reporting agency. Authorization I have read and understand the fore going disclosure and authorize Hill Country Youth Ranch / Enhanced Horizons to obtain and rely upon consumer reports or investigative consumer reports in considering me for their program. By my signature below, I authorize Hill Country Youth Ranch / Enhanced Horizons to obtain any such reports and to share the information received with any person involved in the decision about me. I also agree that this disclosure and authorization in original, faxed, photocopied, or electronic (including electronically signed) form will be valid for any consumer reports or investigative consumer reports that may be requested about me by or on behalf of the Hill Country Youth Ranch / Enhanced Horizons. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature" draggable="false" style="width: 33.3333%;"> <i class="fa fa-pencil"></i><label class="er_fld_label">Signature</label><div class="cst_signaturepad"></div><input name="CST_260" type="text"><button class="type_button" disabled="">Clear Signature</button></li><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date</label><input class="cst_datepicker" name="CST_261" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 100%;"><i class="fa fa-header"></i><label>ENHANCED HORIZONS -TRANSITIONAL LIVING</label><hr></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">Required Admission Documents </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox sortable-chosen" style="white-space:normal;" draggable="true"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Resident must provide the following documentation prior to admission:</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Copy of each child's immunization records">Copy of each child's immunization records</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Copy of Social Security cards for adult residents">Copy of Social Security cards for adult residents</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Copy of Birth Certificates for parents and each child">Copy of Birth Certificates for parents and each child</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Copy of Proof of Child Custody (if divorced)">Copy of Proof of Child Custody (if divorced)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Copy of Medicaid papers of medical insurance">Copy of Medicaid papers of medical insurance</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Coy of parent's High School Diploma or GED Certificate of Equivalence">Coy of parent's High School Diploma or GED Certificate of Equivalence</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Copy of parent's College Transcript, if applicable">Copy of parent's College Transcript, if applicable</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Copy of Proof of Care Insurance">Copy of Proof of Care Insurance</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Copy of Vehicle Registration">Copy of Vehicle Registration</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Copy of Proof of Employment ">Copy of Proof of Employment </label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_262" value="Other:">Other:<input class="cst_Other" name="CST_262_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Applicable Reference Documents</div></li></ul><ul id="er_row_last" class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space:normal;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label"></label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_263" value="Welcome Packet and Residence Rules">Welcome Packet and Residence Rules</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_263" value="Financial Budget">Financial Budget</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_263" value="Transitional Living Plan">Transitional Living Plan</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_263" value="Other:">Other:<input class="cst_Other" name="CST_263_Other" type="text"></label></li></ul>
Submit