Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">PATHFINDER APPLICANT INFORMATION </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Name_First"><i class="fa fa-font"></i><label class="er_fld_label required">First Name:</label><input name="CST_15" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Name_Middle"><i class="fa fa-font"></i><label class="er_fld_label">Middle Name:</label><input name="CST_1" type="text" class="er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;" map_to="CC_Name_Last"><i class="fa fa-font"></i><label class="er_fld_label required">Last Name:</label><input name="CST_16" type="text" class="er_fld_required er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Address_Street_1"><i class="fa fa-font"></i><label class="er_fld_label required">Address:</label><input name="CST_14" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Address_City"><i class="fa fa-font"></i><label class="er_fld_label required">City:</label><input name="CST_2" type="text" class="er_fld_required er_fld_width100" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Address_State"><i class="fa fa-font"></i><label class="er_fld_label required">State:</label><input name="CST_12" type="text" class="er_fld_required er_fld_width50"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;" map_to="CC_Address_Zip"><i class="fa fa-font"></i><label class="er_fld_label required">Zip Code:</label><input name="CST_13" type="text" class="er_fld_width25 er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_EMail"><i class="fa fa-font"></i><label class="er_fld_label required">Email Address:</label><input name="CST_4" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Phone_Mobile"><i class="fa fa-font"></i><label class="er_fld_label required">Phone (Best contact number):</label><input name="CST_5" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Language"> <i class="fa fa-font"></i><label class="er_fld_label">Languages:</label><input name="CST_111" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_DOB"><i class="fa fa-font"></i><label class="er_fld_label required">Date of Birth:</label><input name="CST_7" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col1 er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false" map_to="CC_Gender"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Gender:</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_99" value="M">M</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_99" value="F">F</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_99" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_99_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;" map_to="CC_Race"> <i class="fa fa-font"></i><label class="er_fld_label required">Race/Ethnicity:</label><input name="CST_109" 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 required">Emergency Contact</label><input name="CST_9" 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 required">Relationship:</label><input name="CST_17" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;" map_to="CC_Phone_Mobile_B"><i class="fa fa-font"></i><label class="er_fld_label required">Phone: </label><input name="CST_18" type="text" class="er_fld_required er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CustomField_Value_8"><i class="fa fa-font"></i><label class="er_fld_label required">Name of Home Church (if none, enter N/A):</label><input name="CST_54" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;"><i class="fa fa-font"></i><label class="er_fld_label required">Pastors Name:</label><input name="CST_55" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="CC_ReferralSource_Ref"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Where did you hear about Christian Family Care (CFC)?</label><select name="CST_41" class="er_fld_required er_fld_width50"><option value="N/A" selected="">N/A</option><option value="CFC Website">CFC Website</option><option value="Church Partner">Church Partner</option><option value="Community Partner">Community Partner</option><option value="Google ">Google </option><option value="Facebook ">Facebook </option><option value="CFC Employee">CFC Employee</option><option value="Other">Other</option><option value="Unknown">Unknown</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;" map_to="CC_ReferringWorker_Ref"><i class="fa fa-font"></i><label class="er_fld_label">If Other, please list below:</label><input name="CST_42" 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_warn">ABOUT THE APPLICANT </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">1. Tell us about your journey to become a Christian/where is your faith today?</label><textarea name="CST_112" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Occupation"> <i class="fa fa-font"></i><label class="er_fld_label required">2. What is your occupation?</label><input name="CST_117" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Education"> <i class="fa fa-font"></i><label class="er_fld_label required">3. Education Level and background?</label><input name="CST_114" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">4. Why are you interested in becoming a Pathfinder?</label><textarea name="CST_118" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">5. What special interests or skills do you have that you would like share with at-risk youth/young adults?</label><textarea name="CST_119" style="width:100%;" class="er_fld_required"></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 required">6. While we will accommodate travel by having caseworkers transport youth/young adults to the Exploration Meeting, how far are you willing to travel from your home to your proposed skill/interest activity?</label><textarea name="CST_120" style="width:100%;" class="er_fld_required"></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_warn">APPLICANT AVAILABILITY </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">What is your weekly availability? Check multiple days and times that would potentially work for you when scheduling skill sessions with caseworkers for an at-risk youth/young adult</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">MON.</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_47" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_47" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_47" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_47_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label required">Times Available:</label><input name="CST_102" type="text" value="" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">TUES.</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_44" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" 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 er_fld_required" type="checkbox" name="CST_44" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_44_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label required">Times Available:</label><input name="CST_104" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">WED.</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_46" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_46" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_46" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_46_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label required">Times Available:</label><input name="CST_106" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">THURS.</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_45" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" 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 er_fld_required" type="checkbox" name="CST_45" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_45_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label required">Times Available:</label><input name="CST_108" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">FRI.</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" 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 er_fld_required" type="checkbox" name="CST_35" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_35_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label required">Times Available:</label><input name="CST_107" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">SAT.</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_49" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_49" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_49" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_49_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label required">Times Available:</label><input name="CST_105" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">SUN.</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_50" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_50" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_50" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_50_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label required">Times Available:</label><input name="CST_103" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Signature:</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_100" value="By checking this box, I consent to sign this form electronically:">By checking this box, I consent to sign this form electronically:</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_100" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_100_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 required">Printed Name:</label><input name="CST_101" type="text" class="er_fld_required"></li></ul>
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