{"id":3139,"date":"2025-09-11T15:34:41","date_gmt":"2025-09-11T22:34:41","guid":{"rendered":"https:\/\/ofsn.org\/?page_id=3139"},"modified":"2025-09-11T15:34:41","modified_gmt":"2025-09-11T22:34:41","slug":"about-your-child-form","status":"publish","type":"page","link":"https:\/\/ofsn.org\/es\/about-your-child-form\/","title":{"rendered":"About Your Child Form"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full wpforms-block\" id=\"wpforms-2846\"><form id=\"wpforms-form-2846\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"2846\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/es\/wp-json\/wp\/v2\/pages\/3139\" data-token=\"5406ad91d7e392457d363792a792244d\" data-token-time=\"1778060535\"><noscript class=\"wpforms-error-noscript\">Por favor, activa JavaScript en tu navegador para completar este formulario.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-2846-field_21-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_21\">Date<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-2846-field_21\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][21][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-2846-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\">Child&#039;s Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-2846-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" required><label for=\"wpforms-2846-field_0\" class=\"wpforms-field-sublabel after\">Nombre<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-2846-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" required><label for=\"wpforms-2846-field_0-last\" class=\"wpforms-field-sublabel after\">Apellidos<\/label><\/div><\/div><\/div><div id=\"wpforms-2846-field_59-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"59\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2846-field_62-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"62\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_62\">Child&#039;s Nickname<\/label><input type=\"text\" id=\"wpforms-2846-field_62\" class=\"wpforms-field-medium\" name=\"wpforms[fields][62]\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2846-field_63-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"63\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_63\">Ethnicity<\/label><input type=\"text\" id=\"wpforms-2846-field_63\" class=\"wpforms-field-medium\" name=\"wpforms[fields][63]\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2846-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_16\">Date of Birth <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2846-field_16\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][16]\" placeholder=\"MM\/DD\/YYYY\" required><\/div><div id=\"wpforms-2846-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_23\">Gender<\/label><input type=\"text\" id=\"wpforms-2846-field_23\" class=\"wpforms-field-small\" name=\"wpforms[fields][23]\" ><\/div><div id=\"wpforms-2846-field_56-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"56\"><label class=\"wpforms-field-label\">Who is your health insurance provider <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-2846-field_56\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2846-field_56_1\" name=\"wpforms[fields][56]\" value=\"Oregon Health Plan\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2846-field_56_1\">Oregon Health Plan<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2846-field_56_2\" name=\"wpforms[fields][56]\" value=\"Pacificsource\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2846-field_56_2\">Pacificsource<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-2846-field_56_3\" name=\"wpforms[fields][56]\" value=\"Trillium Health Partners\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2846-field_56_3\">Trillium Health Partners<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-2846-field_56_4\" name=\"wpforms[fields][56]\" value=\"I don&#039;t have health insurance\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2846-field_56_4\">I don&#8217;t have health insurance<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-2846-field_56_5\" name=\"wpforms[fields][56]\" value=\"Other (Please name insurer below)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2846-field_56_5\">Other (Please name insurer below)<\/label><\/li><\/ul><\/div><div id=\"wpforms-2846-field_57-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_57\">If insurer provider selected is &quot;other&quot; please list insurer<\/label><input type=\"text\" id=\"wpforms-2846-field_57\" class=\"wpforms-field-medium\" name=\"wpforms[fields][57]\" ><\/div><div id=\"wpforms-2846-field_58-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"58\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_58\">What is your insurance ID Number<\/label><input type=\"text\" id=\"wpforms-2846-field_58\" class=\"wpforms-field-medium\" name=\"wpforms[fields][58]\" ><\/div><div id=\"wpforms-2846-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_4\">Allergies <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2846-field_4\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][4]\" required><\/div><div id=\"wpforms-2846-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_20\">Health Concerns <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2846-field_20\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][20]\" required><\/div><div id=\"wpforms-2846-field_5-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_5\">What is the child&#039;s preferred language<\/label><input type=\"number\" id=\"wpforms-2846-field_5\" class=\"wpforms-field-medium\" name=\"wpforms[fields][5]\" step=\"any\" ><\/div><div id=\"wpforms-2846-field_24-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_24\">What are your child&#039;s interests<\/label><textarea id=\"wpforms-2846-field_24\" class=\"wpforms-field-medium\" name=\"wpforms[fields][24]\" ><\/textarea><\/div><div id=\"wpforms-2846-field_26-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"26\"><label class=\"wpforms-field-label\">Personal Care Needs: Is your child independent with feeding<\/label><ul id=\"wpforms-2846-field_26\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2846-field_26_1\" name=\"wpforms[fields][26][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2846-field_26_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2846-field_26_2\" name=\"wpforms[fields][26][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2846-field_26_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-2846-field_27-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_27\">If no, what type of assistance is needed?<\/label><textarea id=\"wpforms-2846-field_27\" class=\"wpforms-field-medium\" name=\"wpforms[fields][27]\" ><\/textarea><\/div><div id=\"wpforms-2846-field_28-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"28\"><label class=\"wpforms-field-label\">Behavioral Needs: Does your child typically have meltdowns<\/label><ul id=\"wpforms-2846-field_28\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2846-field_28_1\" name=\"wpforms[fields][28][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2846-field_28_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2846-field_28_2\" name=\"wpforms[fields][28][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2846-field_28_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-2846-field_29-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"29\"><label class=\"wpforms-field-label\">Do you know what triggers them<\/label><ul id=\"wpforms-2846-field_29\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2846-field_29_1\" name=\"wpforms[fields][29][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2846-field_29_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2846-field_29_2\" name=\"wpforms[fields][29][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2846-field_29_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-2846-field_30-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_30\">Please describe triggers<\/label><textarea id=\"wpforms-2846-field_30\" class=\"wpforms-field-medium\" name=\"wpforms[fields][30]\" ><\/textarea><\/div><div id=\"wpforms-2846-field_32-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_32\">How long do they tend to last<\/label><input type=\"text\" id=\"wpforms-2846-field_32\" class=\"wpforms-field-large\" name=\"wpforms[fields][32]\" ><\/div><div id=\"wpforms-2846-field_33-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_33\">What do you do to stop the behavior?<\/label><textarea id=\"wpforms-2846-field_33\" class=\"wpforms-field-medium\" name=\"wpforms[fields][33]\" ><\/textarea><\/div><div id=\"wpforms-2846-field_31-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"31\"><label class=\"wpforms-field-label\">Does your child typically show physical aggression towards others?<\/label><ul id=\"wpforms-2846-field_31\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2846-field_31_1\" name=\"wpforms[fields][31][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2846-field_31_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2846-field_31_2\" name=\"wpforms[fields][31][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2846-field_31_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-2846-field_34-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_34\">If yes, please describe triggers<\/label><textarea id=\"wpforms-2846-field_34\" class=\"wpforms-field-medium\" name=\"wpforms[fields][34]\" ><\/textarea><div class=\"wpforms-field-description\">Boredom, Frustration, Communication, Other Trigger<\/div><\/div><div id=\"wpforms-2846-field_35-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"35\"><label class=\"wpforms-field-label\">Does your child typically show physical aggression toward themself?<\/label><ul id=\"wpforms-2846-field_35\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2846-field_35_1\" name=\"wpforms[fields][35][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2846-field_35_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2846-field_35_2\" name=\"wpforms[fields][35][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2846-field_35_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-2846-field_36-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_36\">If yes, please describe triggers<\/label><textarea id=\"wpforms-2846-field_36\" class=\"wpforms-field-medium\" name=\"wpforms[fields][36]\" ><\/textarea><\/div><div id=\"wpforms-2846-field_37-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_37\">What do you do to stop the behavior?<\/label><textarea id=\"wpforms-2846-field_37\" class=\"wpforms-field-medium\" name=\"wpforms[fields][37]\" ><\/textarea><\/div><div id=\"wpforms-2846-field_38-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"38\"><label class=\"wpforms-field-label\">Are there ongoing conflicts with siblings that we should know about?<\/label><ul id=\"wpforms-2846-field_38\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2846-field_38_1\" name=\"wpforms[fields][38][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2846-field_38_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2846-field_38_2\" name=\"wpforms[fields][38][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2846-field_38_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-2846-field_39-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_39\">If yes, please describe triggers<\/label><textarea id=\"wpforms-2846-field_39\" class=\"wpforms-field-medium\" name=\"wpforms[fields][39]\" ><\/textarea><\/div><div id=\"wpforms-2846-field_40-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_40\">What do you do to stop the behavior?<\/label><textarea id=\"wpforms-2846-field_40\" class=\"wpforms-field-medium\" name=\"wpforms[fields][40]\" ><\/textarea><\/div>\t\t<div id=\"wpforms-2846-field_2-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"2\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-2846-field_2\" >that What to<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-2846-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-2846-field_41-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_41\">What strategies help your child to avoid negative behavior(s)?<\/label><textarea id=\"wpforms-2846-field_41\" class=\"wpforms-field-medium\" name=\"wpforms[fields][41]\" ><\/textarea><\/div><div id=\"wpforms-2846-field_42-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_42\">At what point do you think we should notify you and\/or ask for your assistance?<\/label><textarea id=\"wpforms-2846-field_42\" class=\"wpforms-field-medium\" name=\"wpforms[fields][42]\" ><\/textarea><\/div><div id=\"wpforms-2846-field_45-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"45\"><h3 id=\"wpforms-2846-field_45\">Parent\/Guardian Information  and Emergency Contact<\/h3><\/div><div id=\"wpforms-2846-field_12-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"12\"><label class=\"wpforms-field-label\">Parent\/Guardian Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-2846-field_12\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][12][first]\" required><label for=\"wpforms-2846-field_12\" class=\"wpforms-field-sublabel after\">Nombre<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-2846-field_12-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][12][last]\" required><label for=\"wpforms-2846-field_12-last\" class=\"wpforms-field-sublabel after\">Apellidos<\/label><\/div><\/div><\/div><div id=\"wpforms-2846-field_64-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"64\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2846-field_65-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"65\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_65\">Gender<\/label><input type=\"text\" id=\"wpforms-2846-field_65\" class=\"wpforms-field-medium\" name=\"wpforms[fields][65]\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2846-field_66-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"66\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_66\">Ethnicity<\/label><input type=\"text\" id=\"wpforms-2846-field_66\" class=\"wpforms-field-medium\" name=\"wpforms[fields][66]\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2846-field_67-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"67\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_67\">Preferred Language<\/label><input type=\"text\" id=\"wpforms-2846-field_67\" class=\"wpforms-field-medium\" name=\"wpforms[fields][67]\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2846-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_1\">Parent\/Guardian Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-2846-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-2846-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_17\">Parent\/Guardian Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2846-field_17\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][17]\" required><\/div><div id=\"wpforms-2846-field_44-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"44\"><label class=\"wpforms-field-label\">Home Address <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-2846-field_44\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][44][address1]\" required><label for=\"wpforms-2846-field_44\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-2846-field_44-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][44][address2]\" ><label for=\"wpforms-2846-field_44-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-2846-field_44-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][44][city]\" required><label for=\"wpforms-2846-field_44-city\" class=\"wpforms-field-sublabel after\">Ciudad<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-2846-field_44-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][44][state]\" required><option class=\"placeholder\" value=\"\" selected disabled>&#8212; Select state &#8212;<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >Distrito de Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawai<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Luisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >M\u00edchigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Misisip\u00ed<\/option><option value=\"MO\" >Misuri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >Nuevo Hampshire<\/option><option value=\"NJ\" >Nueva Jersey<\/option><option value=\"NM\" >Nuevo M\u00e9xico<\/option><option value=\"NY\" >Nueva York<\/option><option value=\"NC\" >Carolina del norte<\/option><option value=\"ND\" >Dakota del norte<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oreg\u00f3n<\/option><option value=\"PA\" >Pensilvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >Carolina del Sur<\/option><option value=\"SD\" >Dakota del Sur<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >Virginia Occidental<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-2846-field_44-state\" class=\"wpforms-field-sublabel after\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-2846-field_44-postal\" class=\"wpforms-field-address-postal wpforms-field-required wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][44][postal]\" required><label for=\"wpforms-2846-field_44-postal\" class=\"wpforms-field-sublabel after\">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-2846-field_46-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"46\"><h3 id=\"wpforms-2846-field_46\">Emergency Contact and Pick-Up Authorization (Required)<\/h3><div class=\"wpforms-field-description\">The following people are to contact in case of emergency, only if parent\/guardian cannot be reached AND are authorized to pick-up the child. (The emergency contact&#8217;s name MUST match the name on their photo ID.)<\/div><\/div><div id=\"wpforms-2846-field_47-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"47\"><label class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-2846-field_47\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][47][first]\" required><label for=\"wpforms-2846-field_47\" class=\"wpforms-field-sublabel after\">Nombre<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-2846-field_47-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][47][last]\" required><label for=\"wpforms-2846-field_47-last\" class=\"wpforms-field-sublabel after\">Apellidos<\/label><\/div><\/div><\/div><div id=\"wpforms-2846-field_68-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"68\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2846-field_69-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"69\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_69\">Preferred Language<\/label><input type=\"text\" id=\"wpforms-2846-field_69\" class=\"wpforms-field-medium\" name=\"wpforms[fields][69]\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2846-field_48-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_48\">Relationship to child<\/label><input type=\"text\" id=\"wpforms-2846-field_48\" class=\"wpforms-field-medium\" name=\"wpforms[fields][48]\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2846-field_50-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_50\">Phone<\/label><input type=\"tel\" id=\"wpforms-2846-field_50\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][50]\" aria-label=\"Phone\" ><\/div><div id=\"wpforms-2846-field_51-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"51\"><label class=\"wpforms-field-label\">Name  <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-2846-field_51\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][51][first]\" required><label for=\"wpforms-2846-field_51\" class=\"wpforms-field-sublabel after\">Nombre<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-2846-field_51-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][51][last]\" required><label for=\"wpforms-2846-field_51-last\" class=\"wpforms-field-sublabel after\">Apellidos<\/label><\/div><\/div><\/div><div id=\"wpforms-2846-field_70-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"70\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2846-field_71-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"71\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_71\">Preferred Language<\/label><input type=\"text\" id=\"wpforms-2846-field_71\" class=\"wpforms-field-medium\" name=\"wpforms[fields][71]\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2846-field_72-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"72\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_72\">Relationship to child<\/label><input type=\"text\" id=\"wpforms-2846-field_72\" class=\"wpforms-field-medium\" name=\"wpforms[fields][72]\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2846-field_53-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_53\">Phone<\/label><input type=\"tel\" id=\"wpforms-2846-field_53\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][53]\" aria-label=\"Phone\" ><\/div><div id=\"wpforms-2846-field_15-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"15\"><label class=\"wpforms-field-label\">Parent\/Guardian Authorization <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-2846-field_15\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2846-field_15_1\" name=\"wpforms[fields][15][]\" value=\"I agree and give my permission\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2846-field_15_1\">I agree and give my permission<\/label><\/li><\/ul><div class=\"wpforms-field-description wpforms-disclaimer-description\">I acknowledge that this information on the OFSN Tell Us About Your Child and the OFSN Parent\/Guardian Information and Emergency Contact is true and accurate. <br \/>\n<br \/>\nI authorize that my and my child(ren&#8217;s) information can be shared with the Family Support Specialist and other OFSN staff and volunteers involved in the care of my child during Parent&#8217;s Night Out Respite.<br \/>\n<br \/>\nI understand that Parent&#8217;s Night out Respite is from _____________________PM to ____________________PM, and that I, as the parent will pick-up my child at _______________________PM. If an emergency arises, my emergency contact on this form will be contacted in the order listed to pick-up my child and will show proof of ID at the time of pick-up<\/div><\/div><div id=\"wpforms-2846-field_54-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"54\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_54\">Parent\/Guardian Signature<\/label><input type=\"text\" id=\"wpforms-2846-field_54\" class=\"wpforms-field-medium\" name=\"wpforms[fields][54]\" ><\/div><div id=\"wpforms-2846-field_55-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-2846-field_55\">Date<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-2846-field_55\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-small\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][55][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-2846-field_2-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-2846-field_2-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-2846-field_2-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"2846\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/ofsn.org\/es\/wp-json\/wp\/v2\/pages\/3139\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-2846\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/ofsn.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Cargando\"><\/div><\/form><\/div>  <!-- .wpforms-container -->","protected":false},"excerpt":{"rendered":"<p><span class=\"more-link\"><a href=\"https:\/\/ofsn.org\/es\/about-your-child-form\/\">Sigue leyendo<\/a><\/span><\/p>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"template\/page\/left-sidebar.php","meta":{"bgseo_title":"","bgseo_description":"","bgseo_robots_index":"index","bgseo_robots_follow":"follow","_uf_show_specific_survey":0,"_uf_disable_surveys":false,"footnotes":""},"class_list":["entry","author-dev_3nd40j","post-3139","page","type-page","status-publish"],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/ofsn.org\/es\/wp-json\/wp\/v2\/pages\/3139","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/ofsn.org\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/ofsn.org\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/ofsn.org\/es\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/ofsn.org\/es\/wp-json\/wp\/v2\/comments?post=3139"}],"version-history":[{"count":1,"href":"https:\/\/ofsn.org\/es\/wp-json\/wp\/v2\/pages\/3139\/revisions"}],"predecessor-version":[{"id":3140,"href":"https:\/\/ofsn.org\/es\/wp-json\/wp\/v2\/pages\/3139\/revisions\/3140"}],"wp:attachment":[{"href":"https:\/\/ofsn.org\/es\/wp-json\/wp\/v2\/media?parent=3139"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}