Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_FirstName"> <i class="fa fa-font"></i><label class="er_fld_label required">First Name:</label><input name="CST_1" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_MiddleInitial"> <i class="fa fa-font"></i><label class="er_fld_label">Middle Name</label><input name="CST_2" 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_LastName"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name: </label><input name="CST_3" 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_Nickname"> <i class="fa fa-font"></i><label class="er_fld_label">Nickname/AKA</label><input name="CST_27" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is this your first time filling out this application? </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_59" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_59" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_59" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_59_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_selected" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Where did you hear about us key: FSA= Fostering Success Act YO Website= Youth Opportunities Website Embark= Embark DFCS/ILS= Department of Family Services/Independent Living Specialist FBFC = FaithBridge Foster Care MAAC= Multi Agency Alliance for Children Other (Friends/Sibling) QFCSO's= Other qualified organizations DJJ= Department of Juvenile Justice </div></li><li class="er_fld_type_radio er_fld_type_radio_col1" style="white-space: normal; width: 50%;" draggable="false" map_to="CC_ReferralSource_Ref"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Where did you hear about us? </label> <label class="er_option"><input class="type_radio" type="radio" name="CST_86" value="FSA">FSA</label><label class="er_option"><input class="type_radio" type="radio" name="CST_86" value="YO Website">YO Website</label><label class="er_option"><input class="type_radio" type="radio" name="CST_86" value="Embark">Embark</label><label class="er_option"><input class="type_radio" type="radio" name="CST_86" value="DFCS/ILS">DFCS/ILS</label><label class="er_option"><input class="type_radio" type="radio" name="CST_86" value="FBFC">FBFC</label><label class="er_option"><input class="type_radio" type="radio" name="CST_86" value="MAAC">MAAC</label><label class="er_option"><input class="type_radio" type="radio" name="CST_86" value="Other (Friend/Sibling)">Other (Friend/Sibling)</label><label class="er_option"><input class="type_radio" type="radio" name="CST_86" value="QFCSOs">QFCSOs</label><label class="er_option"><input class="type_radio" type="radio" name="CST_86" value="DJJ">DJJ</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_86" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_86_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_86" er_fld_condvals="er_fld_showif_values=Other"> <i class="fa fa-font"></i><label class="er_fld_label required">Please specify how you heard about us? </label><input name="CST_87" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Contact Information</label><hr></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">Street 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%;"> <i class="fa fa-font"></i><label class="er_fld_label required">City: </label><input name="CST_5" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">State:</label><select name="CST_34" class="er_fld_required"><option value="AL">AL</option><option value="AK">AK</option><option value="AZ">AZ</option><option value="AR">AR</option><option value="CA">CA</option><option value="CO">CO</option><option value="CT">CT</option><option value="DE">DE</option><option value="DC">DC</option><option value="FL">FL</option><option value="GA" selected="">GA</option><option value="HI">HI</option><option value="ID">ID</option><option value="IL">IL</option><option value="IN">IN</option><option value="IA">IA</option><option value="KS">KS</option><option value="KY">KY</option><option value="LA">LA</option><option value="ME">ME</option><option value="MD">MD</option><option value="MA">MA</option><option value="MI">MI</option><option value="MN">MN</option><option value="MS">MS</option><option value="MO">MO</option><option value="MT">MT</option><option value="NE">NE</option><option value="NV">NV</option><option value="NH">NH</option><option value="NJ">NJ</option><option value="NM">NM</option><option value="NY">NY</option><option value="NC">NC</option><option value="ND">ND</option><option value="OH">OH</option><option value="OK">OK</option><option value="OR">OR</option><option value="PA">PA</option><option value="RI">RI</option><option value="SC">SC</option><option value="SD">SD</option><option value="TN">TN</option><option value="TX">TX</option><option value="UT">UT</option><option value="VT">VT</option><option value="VA">VA</option><option value="WA">WA</option><option value="WV">WV</option><option value="WI">WI</option><option value="WY">WY</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_number" draggable="false" style="width: 50%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Zip Code</label><input name="CST_33" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_number" draggable="false" style="width: 50%;" map_to="CC_PersonalPhone"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Phone Number</label><input name="CST_32" 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_PersonalEmail"> <i class="fa fa-font"></i><label class="er_fld_label required">Email: </label><input name="CST_8" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 50%;" map_to="CC_DOB"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Birth</label><input class="cst_datepicker er_fld_required" name="CST_31" type="text" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Are you a citizen of the United States of America?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_70" value="Yes, I am a United States Citizen">Yes, I am a United States Citizen</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_70" value="No, I am not a citizen of the United States">No, I am not a citizen of the United States</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_70" value="No, but I have a Visa/Green Card">No, but I have a Visa/Green Card</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_70" value="No, I am seeking to obtain a valid Green Card">No, I am seeking to obtain a valid Green Card</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_70" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_70_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false" map_to="CC_Gender"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Gender</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_71" value="Male">Male</label><label class="er_option"><input class="type_radio" type="radio" name="CST_71" value="Female">Female</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_71" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_71_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>History of Foster Care in Georgia</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio sortable-chosen" style="white-space: normal; width: 50%;" draggable="true"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Were you ever in foster care in the state of Georgia? </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_61" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_61" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_61" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_61_Other" type="text"></label> </li><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_61" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-caret-down"></i><label class="er_fld_label required">What county were you in foster care? </label><select name="CST_88" class="er_fld_required"><option value="-not specified-" selected="">-not specified-</option><option value="Appling">Appling</option><option value="Atkinson">Atkinson</option><option value="Bacon">Bacon</option><option value="Baker">Baker</option><option value="Baldwin">Baldwin</option><option value="Banks">Banks</option><option value="Barrow">Barrow</option><option value="Bartow">Bartow</option><option value="Ben Hill">Ben Hill</option><option value="Berrien">Berrien</option><option value="Bibb">Bibb</option><option value="Bleckley">Bleckley</option><option value="Brantley">Brantley</option><option value="Brooks">Brooks</option><option value="Bryan">Bryan</option><option value="Bulloch">Bulloch</option><option value="Burke">Burke</option><option value="Butts">Butts</option><option value="Calhoun">Calhoun</option><option value="Camden">Camden</option><option value="Candler">Candler</option><option value="Carroll">Carroll</option><option value="Catoosa">Catoosa</option><option value="Charlton">Charlton</option><option value="Chatham">Chatham</option><option value="Chattahoochee">Chattahoochee</option><option value="Chattooga">Chattooga</option><option value="Cherokee">Cherokee</option><option value="Clarke">Clarke</option><option value="Clay">Clay</option><option value="Clayton">Clayton</option><option value="Clinch">Clinch</option><option value="Cobb">Cobb</option><option value="Coffee">Coffee</option><option value="Colquitt">Colquitt</option><option value="Columbia">Columbia</option><option value="Cook">Cook</option><option value="Coweta">Coweta</option><option value="Crawford">Crawford</option><option value="Crisp">Crisp</option><option value="Dade">Dade</option><option value="Dawson">Dawson</option><option value="Decatur">Decatur</option><option value="DeKalb">DeKalb</option><option value="Dodge">Dodge</option><option value="Dooly">Dooly</option><option value="Dougherty">Dougherty</option><option value="Douglas">Douglas</option><option value="Early">Early</option><option value="Echols">Echols</option><option value="Effingham">Effingham</option><option value="Elbert">Elbert</option><option value="Emanuel">Emanuel</option><option value="Evans">Evans</option><option value="Fannin">Fannin</option><option value="Fayette">Fayette</option><option value="Floyd">Floyd</option><option value="Forsyth">Forsyth</option><option value="Franklin">Franklin</option><option value="Fulton">Fulton</option><option value="Gilmer">Gilmer</option><option value="Glascock">Glascock</option><option value="Glynn">Glynn</option><option value="Gordon">Gordon</option><option value="Grady">Grady</option><option value="Greene">Greene</option><option value="Gwinnett">Gwinnett</option><option value="Habersham">Habersham</option><option value="Hall">Hall</option><option value="Hancock">Hancock</option><option value="Haralson">Haralson</option><option value="Harris">Harris</option><option value="Hart">Hart</option><option value="Heard">Heard</option><option value="Henry">Henry</option><option value="Houston">Houston</option><option value="Irwin">Irwin</option><option value="Jackson">Jackson</option><option value="Jasper">Jasper</option><option value="Jeff Davis">Jeff Davis</option><option value="Jefferson">Jefferson</option><option value="Jenkins">Jenkins</option><option value="Johnson">Johnson</option><option value="Jones">Jones</option><option value="Lamar">Lamar</option><option value="Lanier">Lanier</option><option value="Laurens">Laurens</option><option value="Lee">Lee</option><option value="Liberty">Liberty</option><option value="Lincoln">Lincoln</option><option value="Long">Long</option><option value="Lowndes">Lowndes</option><option value="Lumpkin">Lumpkin</option><option value="Macon">Macon</option><option value="Madison">Madison</option><option value="Marion">Marion</option><option value="McDuffie">McDuffie</option><option value="McIntosh">McIntosh</option><option value="Meriwether">Meriwether</option><option value="Miller">Miller</option><option value="Mitchell">Mitchell</option><option value="Monroe">Monroe</option><option value="Montgomery">Montgomery</option><option value="Morgan">Morgan</option><option value="Murray">Murray</option><option value="Muscogee">Muscogee</option><option value="Newton">Newton</option><option value="Oconee">Oconee</option><option value="Oglethorpe">Oglethorpe</option><option value="Paulding">Paulding</option><option value="Peach">Peach</option><option value="Pickens">Pickens</option><option value="Pierce">Pierce</option><option value="Pike">Pike</option><option value="Polk">Polk</option><option value="Pulaski">Pulaski</option><option value="Putnam">Putnam</option><option value="Quitman">Quitman</option><option value="Rabun">Rabun</option><option value="Randolph">Randolph</option><option value="Richmond">Richmond</option><option value="Rockdale">Rockdale</option><option value="Schley">Schley</option><option value="Screven">Screven</option><option value="Seminole">Seminole</option><option value="Spalding">Spalding</option><option value="Stephens">Stephens</option><option value="Stewart">Stewart</option><option value="Sumter">Sumter</option><option value="Talbot">Talbot</option><option value="Taliaferro">Taliaferro</option><option value="Tattnall">Tattnall</option><option value="Taylor">Taylor</option><option value="Telfair">Telfair</option><option value="Terrell">Terrell</option><option value="Thomas">Thomas</option><option value="Tift">Tift</option><option value="Toombs">Toombs</option><option value="Towns">Towns</option><option value="Treutlen">Treutlen</option><option value="Troup">Troup</option><option value="Turner">Turner</option><option value="Twiggs">Twiggs</option><option value="Union">Union</option><option value="Upson">Upson</option><option value="Walker">Walker</option><option value="Walton">Walton</option><option value="Ware">Ware</option><option value="Warren">Warren</option><option value="Washington">Washington</option><option value="Wayne">Wayne</option><option value="Webster">Webster</option><option value="Wheeler">Wheeler</option><option value="White">White</option><option value="Whitfield">Whitfield</option><option value="Wilcox">Wilcox</option><option value="Wilkes">Wilkes</option><option value="Wilkinson">Wilkinson</option><option value="Worth">Worth</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_61" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">What age did you go into Georgia Foster Care? </label><input name="CST_35" type="text" class="er_fld_required er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_61" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Were you in foster care until your 18th birthday? </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_62" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_62" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_62" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_62_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_61" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Did you remain/sign back into care after your 18th birthday?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_63" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_63" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_63" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_63_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_61" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Were you reunified with your biological family?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_64" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_64" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_64" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_64_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_64"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">What age were you reunified? </label><input name="CST_41" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_61" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Have you been adopted?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_65" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_65" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_65" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_65_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_65" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">What age were you adopted? </label><input name="CST_43" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Current Living Situation</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Are you currently living in Georgia?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_66" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_66" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_66" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_66_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Do you have children of your own?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_67" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_67" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_67" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_67_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_67" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Do your children live with you?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_68" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_68" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_68" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_68_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">What is your current living status? </label> <label class="er_option"><input class="type_radio" type="radio" name="CST_72" value="I am still in foster care/ ILP">I am still in foster care/ ILP</label><label class="er_option"><input class="type_radio" type="radio" name="CST_72" value="I live on my own">I live on my own</label><label class="er_option"><input class="type_radio" type="radio" name="CST_72" value="I live with my biological family">I live with my biological family</label><label class="er_option"><input class="type_radio" type="radio" name="CST_72" value="I live with friends">I live with friends</label><label class="er_option"><input class="type_radio" type="radio" name="CST_72" value="I live with extended relatives">I live with extended relatives</label><label class="er_option"><input class="type_radio" type="radio" name="CST_72" value="I am homeless/not in stable housing">I am homeless/not in stable housing</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_72" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_72_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Education/Vocational Status</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">What educational status best describes your current situation?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_73" value="I have not finished my high school diploma or GED">I have not finished my high school diploma or GED</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_73" value="I am currently enrolled in high school">I am currently enrolled in high school</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_73" value="I completed high school & received my High School Diploma">I completed high school & received my High School Diploma</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_73" value="I completed a GED program & received my GED Certificate">I completed a GED program & received my GED Certificate</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_73" value="I am currently enrolled in a GED, CareerPlus, or Dual Achievement Program">I am currently enrolled in a GED, CareerPlus, or Dual Achievement Program</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_73" value="I am currently enrolled in a Technical School">I am currently enrolled in a Technical School</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_73" value="I am currently enrolled in a Trade School">I am currently enrolled in a Trade School</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_73" value="I am currently enrolled in a College/University">I am currently enrolled in a College/University</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_73" value="I earned a Bachelor's Degree">I earned a Bachelor's Degree</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_73" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_73_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_73" map_to="CC_School_Name" er_fld_condvals="er_fld_showif_values=I+am+currently+enrolled+in+a+Technical+School"><i class="fa fa-caret-down"></i><label class="er_fld_label required">What Technical school are you attending? </label><select name="CST_29" class="er_fld_required"><option value="-Not Specified-" selected="">-Not Specified-</option><option value="Albany Technical College">Albany Technical College</option><option value="Athens Technical College">Athens Technical College</option><option value="Atlanta Technical College">Atlanta Technical College</option><option value="Augusta Technical College">Augusta Technical College</option><option value="Cambridge Institute of Allied Health & Technology Gwinnett College">Cambridge Institute of Allied Health & Technology Gwinnett College</option><option value="Central Georgia Tech">Central Georgia Tech</option><option value="Central Georgia Technical">Central Georgia Technical</option><option value="Chattahoochee Technical College">Chattahoochee Technical College</option><option value="Coastal Pines Technical College">Coastal Pines Technical College</option><option value="College South Georgia Technical College">College South Georgia Technical College</option><option value="Columbus Technical College">Columbus Technical College</option><option value="Georgia Institute of Technology">Georgia Institute of Technology</option><option value="Georgia Northwestern Technical College">Georgia Northwestern Technical College</option><option value="Georgia Piedmont Technical College">Georgia Piedmont Technical College</option><option value="Gwinnett Technical College">Gwinnett Technical College</option><option value="Lanier Technical College">Lanier Technical College</option><option value="Lincoln Tech">Lincoln Tech</option><option value="Lincoln Tech-Marietta">Lincoln Tech-Marietta</option><option value="North Georgia Technical College">North Georgia Technical College</option><option value="Oconee Fall Line Technical College">Oconee Fall Line Technical College</option><option value="Ogeechee Technical College">Ogeechee Technical College</option><option value="Perimeter Technical College">Perimeter Technical College</option><option value="SAE Institute of Technology-Atlanta,">SAE Institute of Technology-Atlanta,</option><option value="Savannah Miller-Motte Technical College,">Savannah Miller-Motte Technical College,</option><option value="Savannah Technical College">Savannah Technical College</option><option value="Southeastern Technical College">Southeastern Technical College</option><option value="Southern Crescent Technical College">Southern Crescent Technical College</option><option value="Southern Regional Technical College">Southern Regional Technical College</option><option value="Taccoa Technical College">Taccoa Technical College</option><option value="West Georgia Technical College">West Georgia Technical College</option><option value="Wiregrass Georgia Technical College">Wiregrass Georgia Technical College</option><option value="Other">Other</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_73" map_to="CC_School_Name" er_fld_condvals="er_fld_showif_values=I+am+currently+enrolled+in+a+Trade+School"><i class="fa fa-caret-down"></i><label class="er_fld_label required">What Trade school are you attending? </label><select name="CST_48" class="er_fld_required"><option value="-Not Specified-" selected="">-Not Specified-</option><option value="Atlanta Beauty & Barber Academy">Atlanta Beauty & Barber Academy</option><option value="Atlanta Elaine Sterling Institute International School of Skin, Nailcare & Massage Therapy">Atlanta Elaine Sterling Institute International School of Skin, Nailcare & Massage Therapy</option><option value="Atlanta Georgia Institute of Cosmetology">Atlanta Georgia Institute of Cosmetology</option><option value="Atlanta Institute of Music and Media">Atlanta Institute of Music and Media</option><option value="Atlanta School of Massage">Atlanta School of Massage</option><option value="Empire Beauty School">Empire Beauty School</option><option value="Empire Beauty School-Dunwoody">Empire Beauty School-Dunwoody</option><option value="Empire Beauty School-Gwinnett">Empire Beauty School-Gwinnett</option><option value="Empire Beauty School-Kennesaw">Empire Beauty School-Kennesaw</option><option value="Empire Beauty School-Morrow">Empire Beauty School-Morrow</option><option value="Fortis College Augusta School of Massage">Fortis College Augusta School of Massage</option><option value="Georgia Career Institute Aviation Institute of Maintenance">Georgia Career Institute Aviation Institute of Maintenance</option><option value="Health and Style Institute">Health and Style Institute</option><option value="Lilburn Chamberlain College of Nursing">Lilburn Chamberlain College of Nursing</option><option value="Paul Mitchell the School-Atlanta">Paul Mitchell the School-Atlanta</option><option value="Savannah Atlanta’s John Marshall Law School">Savannah Atlanta’s John Marshall Law School</option><option value="Other">Other</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_73" map_to="CC_School_Name" er_fld_condvals="er_fld_showif_values=I+am+currently+enrolled+in+a+College%2FUniversity"><i class="fa fa-caret-down"></i><label class="er_fld_label required">What College/University are you attending? </label><select name="CST_49" class="er_fld_required"><option value="-Not Specified-" selected="">-Not Specified-</option><option value="Abraham Baldwin Agricultural College">Abraham Baldwin Agricultural College</option><option value="Albany State University">Albany State University</option><option value="Atlanta Metropolitan State College">Atlanta Metropolitan State College</option><option value="Augusta University">Augusta University</option><option value="Clayton State University">Clayton State University</option><option value="College of Coastal Georgia">College of Coastal Georgia</option><option value="Columbus State University">Columbus State University</option><option value="Dalton State College">Dalton State College</option><option value="East Georgia State College">East Georgia State College</option><option value="Fort Valley State University">Fort Valley State University</option><option value="Georgia College & State University">Georgia College & State University</option><option value="Georgia Gwinnett College">Georgia Gwinnett College</option><option value="Georgia Herzing University">Georgia Herzing University</option><option value="Georgia Highlands College">Georgia Highlands College</option><option value="Georgia Military College">Georgia Military College</option><option value="Georgia Southern University">Georgia Southern University</option><option value="Georgia Southwestern State University">Georgia Southwestern State University</option><option value="Georgia State University">Georgia State University</option><option value="Gordon State College">Gordon State College</option><option value="Kennesaw State University">Kennesaw State University</option><option value="Mercer">Mercer</option><option value="Middle Georgia State University">Middle Georgia State University</option><option value="Sandy Springs DeVry University">Sandy Springs DeVry University</option><option value="Savannah State University">Savannah State University</option><option value="SCAD">SCAD</option><option value="South Georgia State College">South Georgia State College</option><option value="Strayer University">Strayer University</option><option value="Toccoa Falls">Toccoa Falls</option><option value="University of Georgia">University of Georgia</option><option value="University of North Georgia">University of North Georgia</option><option value="University of West Georgia">University of West Georgia</option><option value="Valdosta State University">Valdosta State University</option><option value="Other">Other</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_48" er_fld_condvals="er_fld_showif_values=Other" map_to="CC_School_Name"> <i class="fa fa-font"></i><label class="er_fld_label required">You checked other for school name. Please list trade school you are attending: </label><input name="CST_57" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_29" er_fld_condvals="er_fld_showif_values=Other" map_to="CC_School_Name"> <i class="fa fa-font"></i><label class="er_fld_label required">You checked other for school name. Please list techincal school you are attending:</label><input name="CST_56" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" map_to="CC_School_Name" er_fld_condfld="CST_49" er_fld_condvals="er_fld_showif_values=Other"> <i class="fa fa-font"></i><label class="er_fld_label required">You checked other for school name. Please list college/university you are attending:</label><input name="CST_58" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_73" er_fld_condvals="er_fld_showif_values=I+have+not+finished+my+high+school+diploma+or+GED&er_fld_showif_values=I+am+currently+enrolled+in+high+school&er_fld_showif_values=I+completed+high+school+%26+received+my+High+School+Diploma&er_fld_showif_values=I+completed+a+GED+program+%26+received+my+GED+Certificate&er_fld_showif_values=I+am+currently+enrolled+in+a+GED%2C+CareerPlus%2C+or+Dual+Achievement+Program&er_fld_showif_values=I+earned+a+Bachelor's+Degree"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Are you interested in applying and continuing your education?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_69" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_69" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_69" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_69_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false" map_to="CC_Employ_Status"><i class="fa fa-circle-o"></i><label class="er_fld_label">What is your current employment status?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_74" value="Not employed">Not employed</label><label class="er_option"><input class="type_radio" type="radio" name="CST_74" value="Employed Full-time">Employed Full-time</label><label class="er_option"><input class="type_radio" type="radio" name="CST_74" value="Employed Part-time">Employed Part-time</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_74" value="Other:">Other:<input class="cst_Other" name="CST_74_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_74" map_to="CC_Employ_Employer" er_fld_condvals="er_fld_showif_values=Employed+Full-time&er_fld_showif_values=Employed+Part-time"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Employer:</label><input name="CST_52" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label></label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 50%;" map_to="CC_School_Comments"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Please share anything about yourself or your current situation that you feel is important for us to know. </label><textarea name="CST_53" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Thank you for taking the time to answer these questions. Once you submit this application, the Youth Opportunities Intake Coordinator will contact you within 48 hours to discuss the next steps. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label></label><hr></li></ul>
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