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_content" 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_dropdown" draggable="false" style="width: 100%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">What is your preferred method of contact?</label><select name="CST_89" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Email">Email</option><option value="Text">Text</option><option value="Phone Call">Phone Call</option></select></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 er_fld_selected" style="white-space: normal; width: 100%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Do you have a valid driver's license? </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_101" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_101" 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_101" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_101_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" style="white-space: normal; width: 50%;" draggable="false"><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: 100%;" 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">Are you still in foster care?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_90" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_90" 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_90" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_90_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_90" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Did you remain in care or 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_90" er_fld_condvals="er_fld_showif_values=No"><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" er_fld_condvals="er_fld_showif_values=Yes"> <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_90" er_fld_condvals="er_fld_showif_values=No"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Have you been adopted or placed in a guardianship?</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 or placed in a guardianship?</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" type="radio" name="CST_73" value="I am not currently enrolled in school">I am not currently enrolled in school</label><label class="er_option"><input class="type_radio" type="radio" name="CST_73" value="I am currently completing my high school diploma or GED">I am currently completing my high school diploma or GED</label><label class="er_option"><input class="type_radio" type="radio" name="CST_73" value="I am currently enrolled in college or another educational program">I am currently enrolled in college or another educational program</label><label class="er_option"><input class="type_radio" 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_radio er_fld_showif" style="white-space: normal; width: 100%;" draggable="false" er_fld_condfld="CST_73" er_fld_condvals="er_fld_showif_values=I+am+not+currently+enrolled+in+school"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Have you completed your high school diploma or GED?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_91" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_91" 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_91" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_91_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: 100%;" draggable="false" er_fld_condfld="CST_73" er_fld_condvals="er_fld_showif_values=I+am+not+currently+enrolled+in+school"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Are you interested in continuing your education?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_92" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_92" 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_92" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_92_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_73" er_fld_condvals="er_fld_showif_values=I+am+currently+completing+my+high+school+diploma+or+GED"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Which of these best fits you?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_93" value="I am currently in high school">I am currently in high school</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_93" value="I am currently enrolled in a GED program">I am currently enrolled in a GED program</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_93" value="I am currently enrolled in a Career Plus or Dual Achievement Program">I am currently enrolled in a Career Plus or Dual Achievement Program</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_93" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_93_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_93" er_fld_condvals="er_fld_showif_values=I+am+currently+in+high+school"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Are you dual enrolled?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_94" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_94" 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_94" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_94_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_94" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-caret-down"></i><label class="er_fld_label required">What College/University are you attending?</label><select name="CST_95" class="er_fld_required"><option value="-Not Specified-" selected="">-Not Specified-</option><option value="Albany State University">Albany State University</option><option value="Albany Technical College">Albany Technical College</option><option value="American Intercontinental University">American Intercontinental University</option><option value="American International University">American International University</option><option value="American Public University">American Public University</option><option value="Athens Technical College">Athens Technical College</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 Metropolitan State College">Atlanta Metropolitan State College</option><option value="Atlanta School of Massage">Atlanta School of Massage</option><option value="Atlanta Technical College">Atlanta Technical College</option><option value="Augusta School of Massage">Augusta School of Massage</option><option value="Augusta Technical College">Augusta Technical College</option><option value="Augusta University">Augusta University</option><option value="Aviation Institute of Maintenance">Aviation Institute of Maintenance</option><option value="Barry University, FL">Barry University, FL</option><option value="Berry College, GA">Berry College, GA</option><option value="Brenau University">Brenau University</option><option value="Bryant and Stratton">Bryant and Stratton</option><option value="Cambridge Institute of Allied Health & Technology Gwinnett College">Cambridge Institute of Allied Health & Technology Gwinnett College</option><option value="Central Georgia Technical">Central Georgia Technical</option><option value="Chamberlain University: College of Nursing">Chamberlain University: College of Nursing</option><option value="Chattahoochee Technical College">Chattahoochee Technical College</option><option value="Clayton State University">Clayton State University</option><option value="Coastal Pines Technical College">Coastal Pines Technical College</option><option value="Coastal Plains High School">Coastal Plains High School</option><option value="College of Coastal Georgia">College of Coastal Georgia</option><option value="Columbus State University">Columbus State University</option><option value="Columbus Technical College">Columbus Technical College</option><option value="Dalton State College">Dalton State College</option><option value="DeVry University ">DeVry University </option><option value="DeVry University (Sandy Springs)">DeVry University (Sandy Springs)</option><option value="East Georgia State College">East Georgia State College</option><option value="Elaine Sterling Institute">Elaine Sterling Institute</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="Flight School">Flight School</option><option value="Forest Hill High School">Forest Hill High School</option><option value="Fort Valley State University">Fort Valley State University</option><option value="Fortis College ">Fortis College </option><option value="Full Sail University">Full Sail University</option><option value="Georgia Building Trades Academy (GABATA)">Georgia Building Trades Academy (GABATA)</option><option value="Georgia Career Institute ">Georgia Career Institute </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 Institute of Emergency Medicine">Georgia Institute of Emergency Medicine</option><option value="Georgia Institute of Technology (GA Tech)">Georgia Institute of Technology (GA Tech)</option><option value="Georgia Military College">Georgia Military College</option><option value="Georgia Northwestern Technical College">Georgia Northwestern Technical College</option><option value="Georgia Perimeter Technical College">Georgia Perimeter Technical College</option><option value="Georgia Piedmont Technical College">Georgia Piedmont Technical 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="Gulf Coast State College ">Gulf Coast State College </option><option value="Gwinnett Technical College">Gwinnett Technical College</option><option value="Health and Style Institute">Health and Style Institute</option><option value="Herzing University">Herzing University</option><option value="Hillendell Medical Training">Hillendell Medical Training</option><option value="Jefferson High School">Jefferson High School</option><option value="Jump Start Automotive Training Center">Jump Start Automotive Training Center</option><option value="Kennesaw State University">Kennesaw State University</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="Mercer University">Mercer University</option><option value="Middle Georgia State University">Middle Georgia State University</option><option value="Monroe Community College">Monroe Community College</option><option value="Morris Brown College">Morris Brown College</option><option value="North Carolina A&T State University">North Carolina A&T State University</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="Paul Mitchell Hair & Beauty School">Paul Mitchell Hair & Beauty School</option><option value="Perry Learning Center">Perry Learning Center</option><option value="Philadelphia College of Osteopathic Medicine">Philadelphia College of Osteopathic Medicine</option><option value="Philander Smith University">Philander Smith University</option><option value="Piedmont University">Piedmont University</option><option value="Point University">Point University</option><option value="Reinhardt University">Reinhardt University</option><option value="SAE Institute of Technology-Atlanta">SAE Institute of Technology-Atlanta</option><option value="Savannah Atlanta’s John Marshall Law School">Savannah Atlanta’s John Marshall Law School</option><option value="Savannah College of Art and Design (SCAD)">Savannah College of Art and Design (SCAD)</option><option value="Savannah Miller-Motte Technical College">Savannah Miller-Motte Technical College</option><option value="Savannah State University">Savannah State University</option><option value="Savannah Technical College">Savannah Technical College</option><option value="South Georgia State College">South Georgia State College</option><option value="South Georgia Technical College">South Georgia Technical College</option><option value="South University ">South University </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="Southern University and A&M College">Southern University and A&M College</option><option value="Southwestern University">Southwestern University</option><option value="Strayer University">Strayer University</option><option value="Toccoa Falls College">Toccoa Falls College</option><option value="Troy University ">Troy University </option><option value="Ultimate Medical Academy">Ultimate Medical Academy</option><option value="University of Georgia">University of Georgia</option><option value="University of Kansas">University of Kansas</option><option value="University of Kentucky">University of Kentucky</option><option value="University of Maryland ">University of Maryland </option><option value="University of New Hampshire">University of New Hampshire</option><option value="University of North Georgia">University of North Georgia</option><option value="University of Phoenix">University of Phoenix</option><option value="University of West Georgia">University of West Georgia</option><option value="Valdosta State University">Valdosta State University</option><option value="Voorhees University">Voorhees University</option><option value="Walden University">Walden University</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="Young Harris College">Young Harris College</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: 100%;" er_fld_condfld="CST_95" er_fld_condvals="er_fld_showif_values=Other"> <i class="fa fa-font"></i><label class="er_fld_label required">You checked ohter for school name. Please list college/university you are attending:</label><input name="CST_98" 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+am+currently+enrolled+in+college+or+another+educational+program"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Which of these best fits you?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_96" value="I am currently enrolled in college/university">I am currently enrolled in college/university</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_96" value="I am currently enrolled in technical school">I am currently enrolled in technical school</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_96" 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_96" value="I am currently enrolled in an Apprenticeship/Pre-Apprenticeship program">I am currently enrolled in an Apprenticeship/Pre-Apprenticeship program</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_96" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_96_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%;" map_to="CC_School_Name" er_fld_condfld="CST_96" er_fld_condvals="er_fld_showif_values=I+am+currently+enrolled+in+college%2Funiversity&er_fld_showif_values=I+am+currently+enrolled+in+technical+school&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 College/University are you attending? </label><select name="CST_49" class="er_fld_required"><option value="-Not Specified-" selected="">-Not Specified-</option><option value="Albany State University">Albany State University</option><option value="Albany Technical College">Albany Technical College</option><option value="American Intercontinental University">American Intercontinental University</option><option value="American International University">American International University</option><option value="American Public University">American Public University</option><option value="Athens Technical College">Athens Technical College</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 Metropolitan State College">Atlanta Metropolitan State College</option><option value="Atlanta School of Massage">Atlanta School of Massage</option><option value="Atlanta Technical College">Atlanta Technical College</option><option value="Augusta School of Massage">Augusta School of Massage</option><option value="Augusta Technical College">Augusta Technical College</option><option value="Augusta University">Augusta University</option><option value="Aviation Institute of Maintenance">Aviation Institute of Maintenance</option><option value="Barry University, FL">Barry University, FL</option><option value="Berry College, GA">Berry College, GA</option><option value="Brenau University">Brenau University</option><option value="Bryant and Stratton">Bryant and Stratton</option><option value="Cambridge Institute of Allied Health & Technology Gwinnett College">Cambridge Institute of Allied Health & Technology Gwinnett College</option><option value="Central Georgia Technical">Central Georgia Technical</option><option value="Chamberlain University: College of Nursing">Chamberlain University: College of Nursing</option><option value="Chattahoochee Technical College">Chattahoochee Technical College</option><option value="Clayton State University">Clayton State University</option><option value="Coastal Pines Technical College">Coastal Pines Technical College</option><option value="Coastal Plains High School">Coastal Plains High School</option><option value="College of Coastal Georgia">College of Coastal Georgia</option><option value="Columbus State University">Columbus State University</option><option value="Columbus Technical College">Columbus Technical College</option><option value="Dalton State College">Dalton State College</option><option value="DeVry University ">DeVry University </option><option value="DeVry University (Sandy Springs)">DeVry University (Sandy Springs)</option><option value="East Georgia State College">East Georgia State College</option><option value="Elaine Sterling Institute">Elaine Sterling Institute</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="Flight School">Flight School</option><option value="Forest Hill High School">Forest Hill High School</option><option value="Fort Valley State University">Fort Valley State University</option><option value="Fortis College ">Fortis College </option><option value="Full Sail University">Full Sail University</option><option value="Georgia Building Trades Academy (GABATA)">Georgia Building Trades Academy (GABATA)</option><option value="Georgia Career Institute ">Georgia Career Institute </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 Institute of Emergency Medicine">Georgia Institute of Emergency Medicine</option><option value="Georgia Institute of Technology (GA Tech)">Georgia Institute of Technology (GA Tech)</option><option value="Georgia Military College">Georgia Military College</option><option value="Georgia Northwestern Technical College">Georgia Northwestern Technical College</option><option value="Georgia Perimeter Technical College">Georgia Perimeter Technical College</option><option value="Georgia Piedmont Technical College">Georgia Piedmont Technical 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="Gulf Coast State College ">Gulf Coast State College </option><option value="Gwinnett Technical College">Gwinnett Technical College</option><option value="Health and Style Institute">Health and Style Institute</option><option value="Herzing University">Herzing University</option><option value="Hillendell Medical Training">Hillendell Medical Training</option><option value="Jefferson High School">Jefferson High School</option><option value="Jump Start Automotive Training Center">Jump Start Automotive Training Center</option><option value="Kennesaw State University">Kennesaw State University</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="Mercer University">Mercer University</option><option value="Middle Georgia State University">Middle Georgia State University</option><option value="Monroe Community College">Monroe Community College</option><option value="Morris Brown College">Morris Brown College</option><option value="North Carolina A&T State University">North Carolina A&T State University</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="Paul Mitchell Hair & Beauty School">Paul Mitchell Hair & Beauty School</option><option value="Perry Learning Center">Perry Learning Center</option><option value="Philadelphia College of Osteopathic Medicine">Philadelphia College of Osteopathic Medicine</option><option value="Philander Smith University">Philander Smith University</option><option value="Piedmont University">Piedmont University</option><option value="Point University">Point University</option><option value="Reinhardt University">Reinhardt University</option><option value="SAE Institute of Technology-Atlanta">SAE Institute of Technology-Atlanta</option><option value="Savannah Atlanta’s John Marshall Law School">Savannah Atlanta’s John Marshall Law School</option><option value="Savannah College of Art and Design (SCAD)">Savannah College of Art and Design (SCAD)</option><option value="Savannah Miller-Motte Technical College">Savannah Miller-Motte Technical College</option><option value="Savannah State University">Savannah State University</option><option value="Savannah Technical College">Savannah Technical College</option><option value="South Georgia State College">South Georgia State College</option><option value="South Georgia Technical College">South Georgia Technical College</option><option value="South University ">South University </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="Southern University and A&M College">Southern University and A&M College</option><option value="Southwestern University">Southwestern University</option><option value="Strayer University">Strayer University</option><option value="Toccoa Falls College">Toccoa Falls College</option><option value="Troy University ">Troy University </option><option value="Ultimate Medical Academy">Ultimate Medical Academy</option><option value="University of Georgia">University of Georgia</option><option value="University of Kansas">University of Kansas</option><option value="University of Kentucky">University of Kentucky</option><option value="University of Maryland ">University of Maryland </option><option value="University of New Hampshire">University of New Hampshire</option><option value="University of North Georgia">University of North Georgia</option><option value="University of Phoenix">University of Phoenix</option><option value="University of West Georgia">University of West Georgia</option><option value="Valdosta State University">Valdosta State University</option><option value="Voorhees University">Voorhees University</option><option value="Walden University">Walden University</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="Young Harris College">Young Harris College</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: 100%;" 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_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_96" er_fld_condvals="er_fld_showif_values=I+am+currently+enrolled+in+an+Apprenticeship%2FPre-Apprenticeship+program"> <i class="fa fa-font"></i><label class="er_fld_label required">What program are you currently enrolled in?</label><input name="CST_97" 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+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_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">If you are working with or receiving services from another organization (i.e. Bloom, MAAC, Nsoro, etc.) please list organization(s) name:</label><input name="CST_99" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 100%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Have you applied for or are you receiving services from the following:</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_100" value="Food Stamps">Food Stamps</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_100" value="Medicaid">Medicaid</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_100" value="CAPS">CAPS</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_100" value="WIC">WIC</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_100" value="None of the above">None of the above</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_100" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_100_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_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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