{"id":4867,"date":"2025-11-24T10:08:35","date_gmt":"2025-11-24T16:08:35","guid":{"rendered":"https:\/\/alabamarespite.wpenginepowered.com\/?page_id=4867"},"modified":"2025-11-27T06:32:07","modified_gmt":"2025-11-27T12:32:07","slug":"2025-2026-respite-application-packet-spanish","status":"publish","type":"page","link":"https:\/\/alabamarespite.org\/es\/apply-for-respite\/2025-2026-respite-application-packet-spanish\/","title":{"rendered":"2025-2026 Respite Application Packet Spanish"},"content":{"rendered":"\r\n<p><strong>About the Alabama Lifespan Respite Reimbursement Program<br \/>What is Respite?<\/strong> A temporary short break to give relief to family caregivers from the extraordinary intensive demands of providing ongoing care in the home for a loved one with special needs.<\/p>\r\n<p><strong>Who is a Primary Caregiver?<\/strong> A person who provides full-time (40 or more hours per week) unpaid care to assist with activities of daily living (bathing, dressing, feeding, medication management, errands, chores, etc.) for a parent, spouse\/partner, child, sibling, grandparent, or other family member who requires full-time care due to a disability or chronic illness.<\/p>\r\n<p><strong>Who is a Care Recipient?<\/strong> A family member who requires full-time care due to a disability or chronic illness (proof of diagnosis required).<\/p>\r\n<p><strong>Who is a Respite Provider? <\/strong>A person hired by the Primary Caregiver to give them a short break (respite) from daily caregiving duties. Respite provision at onsite, fee-based respite day\/evening<br \/>programs and camps are also eligible for reimbursement. What is Respite Reimbursement? Alabama Lifespan Respite does not employ Respite Providers. Therefore, Caregivers are responsible for identifying, hiring, and training Respite Providers (or enrolling their Care Recipient in a day\/evening program or camp) to receive respite and will be reimbursed for services rendered based on timesheet guidelines. Reimbursement is not income and should not affect SSI benefits.<\/p>\r\n<p><strong>What are Timesheets?<\/strong> Timesheets are simply a paper form that documents when and how long respite took place and who provided the respite (Respite Provider).<\/p>\r\n<p><strong>How the program works:<\/strong> Once a Caregiver applies and is qualified for the respite reimbursement program, the Caregiver will receive a welcome packet with instructions and atimesheet indicating the amount of reimbursement award they will receive for a specific period of time. Caregivers may choose anyone they wish to provide respite and may require training (such as<br \/>CPR or basic First Aid), if they so choose, but the level of training is at the discretion of the Caregiver. The Respite Provider must be at least age 18 and may not live in the same home as<br \/>the Care Recipient. More than one Respite Provider may provide respite during the dates listed on the timesheet and be recorded as such. Caregivers\/Respite Providers mutually determine a<br \/>rate of pay. When respite service is completed, the Respite Provider signs the timesheet to confirm the date and time respite was received. The Caregiver will pay the Respite Provider out-of-pocket and submit the completed\/signed timesheet to Alabama Lifespan Respite, who will issue a check to reimburse the Caregiver (based on award amount that must be utilized during the specified time<br \/>frame). Once Alabama Lifespan Respite receives the completed\/signed timesheet and verifies information, reimbursement will be issued to the Caregiver within 30 days.<\/p>\r\n\r\n\r\n\r\n<p class=\"has-text-align-center\"><strong>STOP! Please read the following information fully before completing your application.<br \/>Sign and return this page with your competed application.<\/strong><\/p>\r\n\r\n\r\n\r\n<p>Are you a full-time, unpaid, family caregiver for a loved one of any age with a chronic illness or disability that requires around-the-clock care? Do you need a break (also known as respite)? If so, you are invited to *apply for the Alabama Lifespan Respite Reimbursement program.<\/p>\r\n<p>*If you have applied for and received respite reimbursement from Alabama Lifespan Respite after <strong>July 1, 2025, there is no need to reapply. <\/strong>Re-enrollment information will be sent to<br \/>recipients annually. <strong>NOTICE:<\/strong> The completion of this application does not guarantee the awarding of financial assistance from Alabama Lifespan Respite. Please note that while Alabama Lifespan Respite wishes we could help all qualified individuals who seek assistance, regrettably we only have limited funds to meet the needs of qualified caregivers. Therefore, we can only respond to<br \/>requests based on our available resources.<\/p>\r\n\r\n\r\n<style id=\"wpforms-css-vars-4802-block-1e4d5b25-d9fd-4f06-a0e1-eb2ac6288d96\">\n\t\t\t\t#wpforms-4802.wpforms-block-1e4d5b25-d9fd-4f06-a0e1-eb2ac6288d96 {\n\t\t\t\t--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-1e4d5b25-d9fd-4f06-a0e1-eb2ac6288d96 wpforms-render-modern\" id=\"wpforms-4802\"><form id=\"wpforms-form-4802\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"4802\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/es\/wp-json\/wp\/v2\/pages\/4867?wpforms_form_id=4802\" data-token=\"d0c776b290892ca9102bab2514ed0afa\" data-token-time=\"1776691903\"><noscript class=\"wpforms-error-noscript\">Por favor, activa JavaScript en tu navegador para completar este formulario.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Por favor, activa JavaScript en tu navegador para completar este formulario.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-4802-field_4-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"4\"><fieldset><legend class=\"wpforms-field-label\">Please mark that you have read and understand each of the following guidelines before applying for the Alabama Lifespan Respite Reimbursement Program.  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4802-field_4\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_4_1\" name=\"wpforms[fields][4][]\" value=\"I understand that I cannot currently be receiving respite services through any other program in order to qualify for the Alabama Lifespan Respite reimbursement program\" aria-errormessage=\"wpforms-4802-field_4_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_4_1\">I understand that I cannot currently be receiving respite services through any other program in order to qualify for the Alabama Lifespan Respite reimbursement program<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_4_2\" name=\"wpforms[fields][4][]\" value=\"I understand that only one caregiver per household is eligible to apply.\" aria-errormessage=\"wpforms-4802-field_4_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_4_2\">I understand that only one caregiver per household is eligible to apply.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_4_3\" name=\"wpforms[fields][4][]\" value=\"I understand that only one individual per household may be listed as the care recipient. (If you are caring for multiple individuals with special needs, please only list the individual who requires the most care.)\" aria-errormessage=\"wpforms-4802-field_4_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_4_3\">I understand that only one individual per household may be listed as the care recipient. (If you are caring for multiple individuals with special needs, please only list the individual who requires the most care.)<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_4_4\" name=\"wpforms[fields][4][]\" value=\"I understand that I cannot be listed as both the Primary Caregiver and the Respite Provider, and that the intent of this program is to reimburse me after I have paid a third-party for respite.\" aria-errormessage=\"wpforms-4802-field_4_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_4_4\">I understand that I cannot be listed as both the Primary Caregiver and the Respite Provider, and that the intent of this program is to reimburse me after I have paid a third-party for respite.<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_4_8\" name=\"wpforms[fields][4][]\" value=\"I understand that I must submit a proof of diagnosis for my care recipient, which is required to process my application.\" aria-errormessage=\"wpforms-4802-field_4_8-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_4_8\">I understand that I must submit a proof of diagnosis for my care recipient, which is required to process my application.<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_4_7\" name=\"wpforms[fields][4][]\" value=\"I understand that I am responsible for selecting and training a trustworthy respite provider(s) who is at least 18 years of age and who lives outside of the care recipient\u2019s home. Neither Alabama Lifespan Respite nor UCP Huntsville will be held responsible for any actions taken by my selected respite provider.\" aria-errormessage=\"wpforms-4802-field_4_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_4_7\">I understand that I am responsible for selecting and training a trustworthy respite provider(s) who is at least 18 years of age and who lives outside of the care recipient\u2019s home. Neither Alabama Lifespan Respite nor UCP Huntsville will be held responsible for any actions taken by my selected respite provider.<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_4_6\" name=\"wpforms[fields][4][]\" value=\"I understand there is a 30 day processing period before I will receive reimbursement in the form of a check. If I cannot wait 30 days for reimbursement, I understand that this program does not fit my needs and I will not apply to the program.\" aria-errormessage=\"wpforms-4802-field_4_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_4_6\">I understand there is a 30 day processing period before I will receive reimbursement in the form of a check. If I cannot wait 30 days for reimbursement, I understand that this program does not fit my needs and I will not apply to the program.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_4_5\" name=\"wpforms[fields][4][]\" value=\"I agree to use respite reimbursement funds only for respite care.\" aria-errormessage=\"wpforms-4802-field_4_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_4_5\">I agree to use respite reimbursement funds only for respite care.<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_4_9\" name=\"wpforms[fields][4][]\" value=\"I understand both the caregiver and care recipient must be residents of Alabama\" aria-errormessage=\"wpforms-4802-field_4_9-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_4_9\">I understand both the caregiver and care recipient must be residents of Alabama<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-4802-field_11-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"11\"><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-4802-field_10-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_10\">Signature <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4802-field_10\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][10]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-4802-field_10-error\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-4802-field_10-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4802-field_12-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_12\">Date  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4802-field_12\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][12][date]\" aria-errormessage=\"wpforms-4802-field_12-error\" required><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><\/div><\/div><\/div><div id=\"wpforms-4802-field_16-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"16\"><div id=\"wpforms-4802-field_16\" aria-errormessage=\"wpforms-4802-field_16-error\"><h2 style=\"text-align:center;\">Alabama Respite Application<\/h2>\r\n<\/div><\/div><div id=\"wpforms-4802-field_18-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"18\"><div id=\"wpforms-4802-field_18\" aria-errormessage=\"wpforms-4802-field_18-error\"><h3 style=\"margin-bottom:10px;\">Primary Caregiver:<\/h3>\r\n<p style=\"font-size:14px;\">(This name must be used consistently on all documentation for this program moving forward.)<\/p>\r\n<\/div><\/div><div id=\"wpforms-4802-field_17-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"17\"><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-4802-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_1\">Last Name: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4802-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" aria-errormessage=\"wpforms-4802-field_1-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-4802-field_19-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_19\">First Name, MI: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4802-field_19\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][19]\" aria-errormessage=\"wpforms-4802-field_19-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-4802-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_21\">Caregiver Mailing Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4802-field_21\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][21]\" aria-errormessage=\"wpforms-4802-field_21-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-4802-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_23\">City <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4802-field_23\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][23]\" aria-errormessage=\"wpforms-4802-field_23-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-4802-field_88-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"88\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_88\">State <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4802-field_88\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][88]\" aria-errormessage=\"wpforms-4802-field_88-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-4802-field_87-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"87\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_87\">Zip <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4802-field_87\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][87]\" aria-errormessage=\"wpforms-4802-field_87-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-4802-field_25-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_25\">County: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4802-field_25\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][25]\" aria-errormessage=\"wpforms-4802-field_25-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-4802-field_26-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_26\">Caregiver DOB: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4802-field_26\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][26]\" aria-errormessage=\"wpforms-4802-field_26-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><\/div><\/div><\/div><\/div><div id=\"wpforms-4802-field_83-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"83\"><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-4802-field_27-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"27\"><fieldset><legend class=\"wpforms-field-label\">Caregiver Gender: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4802-field_27\" class=\"wpforms-randomize wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_27_1\" name=\"wpforms[fields][27][]\" value=\"Female\" aria-errormessage=\"wpforms-4802-field_27_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_27_1\">Female<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_27_2\" name=\"wpforms[fields][27][]\" value=\"Male\" aria-errormessage=\"wpforms-4802-field_27_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_27_2\">Male<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_27_3\" name=\"wpforms[fields][27][]\" value=\"Other\" aria-errormessage=\"wpforms-4802-field_27_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_27_3\">Other<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4802-field_28-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"28\"><fieldset><legend class=\"wpforms-field-label\">Preferred Method of Contact: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4802-field_28\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_28_1\" name=\"wpforms[fields][28][]\" value=\"Email\" aria-errormessage=\"wpforms-4802-field_28_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_28_1\">Email<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_28_2\" name=\"wpforms[fields][28][]\" value=\"Postal Mail\" aria-errormessage=\"wpforms-4802-field_28_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_28_2\">Postal Mail<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4802-field_29-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_29\">Email Address: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-4802-field_29\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][29]\" spellcheck=\"false\" aria-errormessage=\"wpforms-4802-field_29-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4802-field_31-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_31\">Phone number with area code: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-4802-field_31\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][31]\" aria-label=\"Phone number with area code:\" aria-errormessage=\"wpforms-4802-field_31-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4802-field_32-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"32\"><fieldset><legend class=\"wpforms-field-label\">Is your gross monthly income above $1,500? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4802-field_32\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_32_1\" name=\"wpforms[fields][32][]\" value=\"Yes\" aria-errormessage=\"wpforms-4802-field_32_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_32_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_32_2\" name=\"wpforms[fields][32][]\" value=\"No\" aria-errormessage=\"wpforms-4802-field_32_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_32_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><div id=\"wpforms-4802-field_33-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"33\"><fieldset><legend class=\"wpforms-field-label\">1. How are you (Primary Caregiver) related to the Care Recipient? I am their&#8230; <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4802-field_33\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_33_1\" name=\"wpforms[fields][33][]\" value=\"Parent\" aria-errormessage=\"wpforms-4802-field_33_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_33_1\">Parent<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_33_2\" name=\"wpforms[fields][33][]\" value=\"Spouse or partner\" aria-errormessage=\"wpforms-4802-field_33_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_33_2\">Spouse or partner<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_33_3\" name=\"wpforms[fields][33][]\" value=\"Child\" aria-errormessage=\"wpforms-4802-field_33_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_33_3\">Child<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_33_6\" name=\"wpforms[fields][33][]\" value=\"Court Appointed Legal Guardian\" aria-errormessage=\"wpforms-4802-field_33_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_33_6\">Court Appointed Legal Guardian<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_33_5\" name=\"wpforms[fields][33][]\" value=\"Sibling\" aria-errormessage=\"wpforms-4802-field_33_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_33_5\">Sibling<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_33_4\" name=\"wpforms[fields][33][]\" value=\"Grandparent\" aria-errormessage=\"wpforms-4802-field_33_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_33_4\">Grandparent<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_33_7\" name=\"wpforms[fields][33][]\" value=\"Other\" aria-errormessage=\"wpforms-4802-field_33_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_33_7\">Other<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-4802-field_34-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"34\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_34\">Please describe <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4802-field_34\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][34]\" aria-errormessage=\"wpforms-4802-field_34-error\" required><\/div><div id=\"wpforms-4802-field_84-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"84\"><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-4802-field_35-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"35\"><fieldset><legend class=\"wpforms-field-label\">2. Please specify military status: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4802-field_35\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_35_1\" name=\"wpforms[fields][35][]\" value=\"Served\" aria-errormessage=\"wpforms-4802-field_35_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_35_1\">Served<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_35_2\" name=\"wpforms[fields][35][]\" value=\"Never served\" aria-errormessage=\"wpforms-4802-field_35_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_35_2\">Never served<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4802-field_36-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"36\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Active or Retired <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4802-field_36\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_36_1\" name=\"wpforms[fields][36][]\" value=\"Active\" aria-errormessage=\"wpforms-4802-field_36_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_36_1\">Active<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_36_2\" name=\"wpforms[fields][36][]\" value=\"Retired\" aria-errormessage=\"wpforms-4802-field_36_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_36_2\">Retired<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-4802-field_37-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"37\"><fieldset><legend class=\"wpforms-field-label\">3. Please select your race: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4802-field_37\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_37_1\" name=\"wpforms[fields][37][]\" value=\"Asian or Asian American\" aria-errormessage=\"wpforms-4802-field_37_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_37_1\">Asian or Asian American<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_37_2\" name=\"wpforms[fields][37][]\" value=\"Biracial or Multiracial\" aria-errormessage=\"wpforms-4802-field_37_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_37_2\">Biracial or Multiracial<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_37_3\" name=\"wpforms[fields][37][]\" value=\"Black or African American\" aria-errormessage=\"wpforms-4802-field_37_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_37_3\">Black or African American<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_37_4\" name=\"wpforms[fields][37][]\" value=\"Native Hawaiian or Pacific Islander\" aria-errormessage=\"wpforms-4802-field_37_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_37_4\">Native Hawaiian or Pacific Islander<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_37_5\" name=\"wpforms[fields][37][]\" value=\"White\" aria-errormessage=\"wpforms-4802-field_37_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_37_5\">White<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_37_6\" name=\"wpforms[fields][37][]\" value=\"Other\" aria-errormessage=\"wpforms-4802-field_37_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_37_6\">Other<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-4802-field_38-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"38\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_38\">Please describe  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4802-field_38\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][38]\" aria-errormessage=\"wpforms-4802-field_38-error\" required><\/div><div id=\"wpforms-4802-field_85-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"85\"><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-4802-field_41-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"41\"><fieldset><legend class=\"wpforms-field-label\">4. Please identify your ethnicity. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4802-field_41\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_41_1\" name=\"wpforms[fields][41][]\" value=\"Hispanic or Latino\" aria-errormessage=\"wpforms-4802-field_41_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_41_1\">Hispanic or Latino<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_41_2\" name=\"wpforms[fields][41][]\" value=\"Not Hispanic or Latino\" aria-errormessage=\"wpforms-4802-field_41_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_41_2\">Not Hispanic or Latino<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4802-field_42-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"42\"><fieldset><legend class=\"wpforms-field-label\">5. Do you (Primary Caregiver) and the Care Recipient live in the same household? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4802-field_42\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_42_1\" name=\"wpforms[fields][42][]\" value=\"Yes\" aria-errormessage=\"wpforms-4802-field_42_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_42_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_42_2\" name=\"wpforms[fields][42][]\" value=\"No\" aria-errormessage=\"wpforms-4802-field_42_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_42_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4802-field_43-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"43\"><fieldset><legend class=\"wpforms-field-label\">6. How many hours of care do you provide in a week (please estimate)? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4802-field_43\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_43_1\" name=\"wpforms[fields][43][]\" value=\"Less than 40 hours\" aria-errormessage=\"wpforms-4802-field_43_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_43_1\">Less than 40 hours<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_43_2\" name=\"wpforms[fields][43][]\" value=\"Between 40-60 hours\" aria-errormessage=\"wpforms-4802-field_43_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_43_2\">Between 40-60 hours<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_43_5\" name=\"wpforms[fields][43][]\" value=\"Between 60-80 hours\" aria-errormessage=\"wpforms-4802-field_43_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_43_5\">Between 60-80 hours<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_43_4\" name=\"wpforms[fields][43][]\" value=\"80+ hours\" aria-errormessage=\"wpforms-4802-field_43_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_43_4\">80+ hours<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4802-field_44-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"44\"><fieldset><legend class=\"wpforms-field-label\">7. Are you interested in receiving information about free caregiver mental health counseling, education, and supports?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4802-field_44\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_44_1\" name=\"wpforms[fields][44][]\" value=\"Yes\" aria-errormessage=\"wpforms-4802-field_44_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_44_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_44_2\" name=\"wpforms[fields][44][]\" value=\"No\" aria-errormessage=\"wpforms-4802-field_44_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_44_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-4802-field_46-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_46\">8. On a scale of 1 to 10 (1 being little to no stress and 10 being very stressed), please determine your stress level at this time. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4802-field_46\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][46]\" aria-errormessage=\"wpforms-4802-field_46-error\" required><\/div><div id=\"wpforms-4802-field_48-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"48\"><div id=\"wpforms-4802-field_48\" aria-errormessage=\"wpforms-4802-field_48-error\"><p style=\"font-size:16px; color:black;\">\r\n. Please check any respite services you are currently receiving from the list below. If you are currently on a waiting list for any services below, please record the date you applied. If none, proceed to the next question.\r\n<\/p>\r\n<\/div><\/div><div id=\"wpforms-4802-field_49-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"49\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4802-field_50-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-id=\"50\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Medicaid Waiver Home Based Services<\/legend><ul id=\"wpforms-4802-field_50\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_50_1\" name=\"wpforms[fields][50][]\" value=\"Medicaid Waiver Home Based Services (respite only, not health insurance)\" aria-errormessage=\"wpforms-4802-field_50_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_50_1\">Medicaid Waiver Home Based Services (respite only, not health insurance)<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4802-field_52-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-id=\"52\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Alabama Cares<\/legend><ul id=\"wpforms-4802-field_52\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_52_1\" name=\"wpforms[fields][52][]\" value=\"Alabama Cares\" aria-errormessage=\"wpforms-4802-field_52_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_52_1\">Alabama Cares<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4802-field_53-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-id=\"53\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">HEARTS<\/legend><ul id=\"wpforms-4802-field_53\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_53_1\" name=\"wpforms[fields][53][]\" value=\"HEARTS\" aria-errormessage=\"wpforms-4802-field_53_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_53_1\">HEARTS<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4802-field_54-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-id=\"54\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Alabama Head Injury Foundation<\/legend><ul id=\"wpforms-4802-field_54\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_54_1\" name=\"wpforms[fields][54][]\" value=\"Alabama Head Injury Foundation\" aria-errormessage=\"wpforms-4802-field_54_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_54_1\">Alabama Head Injury Foundation<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4802-field_51-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"51\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_51\">Date:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4802-field_51\" 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][51][date]\" aria-errormessage=\"wpforms-4802-field_51-error\" ><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><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4802-field_55-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"55\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_55\">Date:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4802-field_55\" 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][55][date]\" aria-errormessage=\"wpforms-4802-field_55-error\" ><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><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4802-field_56-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"56\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_56\">Date:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4802-field_56\" 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][56][date]\" aria-errormessage=\"wpforms-4802-field_56-error\" ><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><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4802-field_57-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"57\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_57\">Date:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4802-field_57\" 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][57][date]\" aria-errormessage=\"wpforms-4802-field_57-error\" ><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><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4802-field_58-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"58\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Veteran\u2019s Administration (Aid and Attendance)<\/legend><ul id=\"wpforms-4802-field_58\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_58_1\" name=\"wpforms[fields][58][]\" value=\"Veteran\u2019s Administration (Aid and Attendance)\" aria-errormessage=\"wpforms-4802-field_58_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_58_1\">Veteran\u2019s Administration (Aid and Attendance)<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4802-field_59-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"59\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Autism Society of AL<\/legend><ul id=\"wpforms-4802-field_59\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_59_1\" name=\"wpforms[fields][59][]\" value=\"Autism Society of AL\" aria-errormessage=\"wpforms-4802-field_59_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_59_1\">Autism Society of AL<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4802-field_60-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"60\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">ALS<\/legend><ul id=\"wpforms-4802-field_60\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_60_1\" name=\"wpforms[fields][60][]\" value=\"ALS\" aria-errormessage=\"wpforms-4802-field_60_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_60_1\">ALS<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4802-field_61-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"61\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Other <\/legend><ul id=\"wpforms-4802-field_61\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_61_1\" name=\"wpforms[fields][61][]\" value=\"Other\" aria-errormessage=\"wpforms-4802-field_61_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_61_1\">Other<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4802-field_62-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"62\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_62\">Date:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4802-field_62\" 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][62][date]\" aria-errormessage=\"wpforms-4802-field_62-error\" ><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><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4802-field_63-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"63\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_63\">Date:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4802-field_63\" 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][63][date]\" aria-errormessage=\"wpforms-4802-field_63-error\" ><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><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4802-field_64-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"64\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_64\">Date:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4802-field_64\" 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][64][date]\" aria-errormessage=\"wpforms-4802-field_64-error\" ><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><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4802-field_66-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"66\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_66\">Name of Program<\/label><input type=\"text\" id=\"wpforms-4802-field_66\" class=\"wpforms-field-medium\" name=\"wpforms[fields][66]\" aria-errormessage=\"wpforms-4802-field_66-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4802-field_65-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"65\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_65\">Date:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4802-field_65\" 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][65][date]\" aria-errormessage=\"wpforms-4802-field_65-error\" ><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><\/div><\/div><\/div><div id=\"wpforms-4802-field_68-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"68\"><fieldset><legend class=\"wpforms-field-label\">10. \u00bfPrefieres recibir informaci\u00f3n en ingl\u00e9s o espa\u00f1ol?<\/legend><ul id=\"wpforms-4802-field_68\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_68_1\" name=\"wpforms[fields][68][]\" value=\"Espa\u00f1ol\" aria-errormessage=\"wpforms-4802-field_68_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_68_1\">Espa\u00f1ol<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_68_2\" name=\"wpforms[fields][68][]\" value=\"Inglesa\" aria-errormessage=\"wpforms-4802-field_68_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_68_2\">Inglesa<\/label><\/li><\/ul><\/fieldset><\/div>\t\t<div id=\"wpforms-4802-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-4802-field_2\" >in 10 Caregiver<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-4802-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-4802-field_67-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"67\"><div id=\"wpforms-4802-field_67\" aria-errormessage=\"wpforms-4802-field_67-error\"><h2 style=\"text-align:center;\">Care Recipient Information<\/h2>\r\n<\/div><\/div><div id=\"wpforms-4802-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-4802-field_69-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"69\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_69\">Last Name: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4802-field_69\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][69]\" aria-errormessage=\"wpforms-4802-field_69-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4802-field_71-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"71\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_71\">First Name, MI.: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4802-field_71\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][71]\" aria-errormessage=\"wpforms-4802-field_71-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4802-field_72-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"72\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_72\">Date of Birth <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4802-field_72\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][72][date]\" aria-errormessage=\"wpforms-4802-field_72-error\" required><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><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4802-field_73-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"73\"><fieldset><legend class=\"wpforms-field-label\">Gender:  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4802-field_73\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_73_1\" name=\"wpforms[fields][73][]\" value=\"Female\" aria-errormessage=\"wpforms-4802-field_73_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_73_1\">Female<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_73_2\" name=\"wpforms[fields][73][]\" value=\"Male\" aria-errormessage=\"wpforms-4802-field_73_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_73_2\">Male<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4802-field_73_3\" name=\"wpforms[fields][73][]\" value=\"Other\" aria-errormessage=\"wpforms-4802-field_73_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4802-field_73_3\">Other<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4802-field_74-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"74\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_74\">Race:  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4802-field_74\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][74]\" aria-errormessage=\"wpforms-4802-field_74-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4802-field_75-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"75\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_75\">Primary Diagnosis: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4802-field_75\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][75]\" aria-errormessage=\"wpforms-4802-field_75-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4802-field_86-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"86\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_86\">Attach Proof of Diagnoses <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader wpforms-field-required\"\n\t\tdata-field-id=\"86\"\n\t\tdata-form-id=\"4802\"\n\t\tdata-input-name=\"wpforms_4802_86\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\"\n\t\tdata-max-size=\"52428800\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"52428800\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-4802-field_86\"\n\t\tname=\"wpforms_4802_86\" required\t\tvalue=\"\">\n<\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><div id=\"wpforms-4802-field_79-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"79\"><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-4802-field_80-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"80\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_80\">Primary Caregiver Signature: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4802-field_80\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][80]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-4802-field_80-error\" aria-describedby=\"wpforms-4802-field_80-description\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-4802-field_80-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><div id=\"wpforms-4802-field_80-description\" class=\"wpforms-field-description\">Your typed\nname may serve as your signature and\nconfirmation that all above information is correct: <\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4802-field_81-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"81\"><label class=\"wpforms-field-label\" for=\"wpforms-4802-field_81\">Date: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4802-field_81\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][81][date]\" aria-errormessage=\"wpforms-4802-field_81-error\" required><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><\/div><\/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-4802-field_2-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 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src=\"data:image\/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==\" data-layzr=\"https:\/\/alabamarespite.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>About the Alabama Lifespan Respite Reimbursement ProgramWhat is Respite? A temporary short break to give relief to family caregivers from the extraordinary intensive demands of providing ongoing care in the home for a loved one with special needs. Who is a Primary Caregiver? A person who provides full-time (40 or more hours per week) unpaid &hellip; <\/p>","protected":false},"author":4,"featured_media":0,"parent":556,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_price":"","_stock":"","_tribe_ticket_header":"","_tribe_default_ticket_provider":"","_tribe_ticket_capacity":"0","_ticket_start_date":"","_ticket_end_date":"","_tribe_ticket_show_description":"","_tribe_ticket_show_not_going":false,"_tribe_ticket_use_global_stock":"","_tribe_ticket_global_stock_level":"","_global_stock_mode":"","_global_stock_cap":"","_tribe_rsvp_for_event":"","_tribe_ticket_going_count":"","_tribe_ticket_not_going_count":"","_tribe_tickets_list":"[]","_tribe_ticket_has_attendee_info_fields":false,"footnotes":""},"class_list":["post-4867","page","type-page","status-publish","hentry","latest_post"],"_links":{"self":[{"href":"https:\/\/alabamarespite.org\/es\/wp-json\/wp\/v2\/pages\/4867","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/alabamarespite.org\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/alabamarespite.org\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/alabamarespite.org\/es\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/alabamarespite.org\/es\/wp-json\/wp\/v2\/comments?post=4867"}],"version-history":[{"count":0,"href":"https:\/\/alabamarespite.org\/es\/wp-json\/wp\/v2\/pages\/4867\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/alabamarespite.org\/es\/wp-json\/wp\/v2\/pages\/556"}],"wp:attachment":[{"href":"https:\/\/alabamarespite.org\/es\/wp-json\/wp\/v2\/media?parent=4867"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}