/*jslint nomen:false, debug:true, evil:true, vars:false, browser:true, forin:true, undef:false, white:false */
/**
* Includes a Form with javascript
* @param {Object} formId
* @param {Object} initialHeight
* @param {Object} iframeCode
*/
function FrameBuilder (formId, appendTo, initialHeight, iframeCode){
this.formId = formId;
this.initialHeight = initialHeight;
this.iframeCode = iframeCode;
this.frame = null;
this.timeInterval= 200;
this.appendTo = appendTo || false;
// initialize function for object
this.init = function(){
this.createFrame();
this.addFrameContent(this.iframeCode);
};
// Create the frame
this.createFrame = function(){
var htmlCode = "<"+"iframe src=\"\" allowtransparency=\"true\" frameborder=\"0\" name=\""+this.formId+"\" id=\""+this.formId+"\" style=\"width:100%; height:"+this.initialHeight+"px; border:none;\" scrolling=\"no\">";
if(this.appendTo === false){
document.write(htmlCode);
}else{
var tmp = document.createElement('div');
tmp.innerHTML = htmlCode;
var a = this.appendTo;
document.getElementById(a).appendChild(tmp.firstChild);
}
// also get the frame for future use.
this.frame = document.getElementById(this.formId);
// set the time on the on load event of the frame
this.addEvent(this.frame, 'load', this.bindMethod(this.setTimer, this));
};
// add event function for different browsers
this.addEvent = function( obj, type, fn ) {
if ( obj.attachEvent ) {
obj["e"+type+fn] = fn;
obj[type+fn] = function() { obj["e"+type+fn]( window.event ); };
obj.attachEvent( "on"+type, obj[type+fn] );
}
else{
obj.addEventListener( type, fn, false );
}
};
this.addFrameContent = function (string){
string = string.replace(new RegExp('src\\=\\"[^"]*captcha.php\"><\/scr'+'ipt>', 'gim'), 'src="http://api.recaptcha.net/js/recaptcha_ajax.js"><'+'div id="recaptcha_div"><'+'/div>'+
'<'+'style>#recaptcha_logo{ display:none;} #recaptcha_tagline{display:none;} #recaptcha_table{border:none !important;} .recaptchatable .recaptcha_image_cell, #recaptcha_table{ background-color:transparent !important; } <'+'/style>'+
'<'+'script defer="defer"> window.onload = function(){ Recaptcha.create("6Ld9UAgAAAAAAMon8zjt30tEZiGQZ4IIuWXLt1ky", "recaptcha_div", {theme: "clean",tabindex: 0,callback: function (){'+
'if (document.getElementById("uword")) { document.getElementById("uword").parentNode.removeChild(document.getElementById("uword")); } if (window["validate"] !== undefined) { if (document.getElementById("recaptcha_response_field")){ document.getElementById("recaptcha_response_field").onblur = function(){ validate(document.getElementById("recaptcha_response_field"), "Required"); } } } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_challenge_field")[0].setAttribute("name", "anum"); } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_response_field")[0].setAttribute("name", "qCap"); }}})'+
' }<'+'/script>');
string = string.replace(/(type="text\/javascript">)\s+(validate\(\"[^"]*"\);)/, '$1 jTime = setInterval(function(){if("validate" in window){$2clearTimeout(jTime);}}, 1000);');
var frameDocument = (this.frame.contentWindow) ? this.frame.contentWindow : (this.frame.contentDocument.document) ? this.frame.contentDocument.document : this.frame.contentDocument;
frameDocument.document.open();
frameDocument.document.write(string);
setTimeout( function(){
frameDocument.document.close();
try{
if('JotFormFrameLoaded' in window){
JotFormFrameLoaded();
}
}catch(e){}
},200);
};
this.setTimer = function(){
var self = this;
this.interval = setTimeout(function(){self.changeHeight();},this.timeInterval);
};
this.changeHeight = function (){
var actualHeight = this.getBodyHeight();
var currentHeight = this.getViewPortHeight();
if(actualHeight === undefined){
this.frame.style.height = "100%";
if(!this.frame.style.minHeight){
this.frame.style.minHeight = "300px";
}
}else if (Math.abs(actualHeight - currentHeight) > 18){
this.frame.style.height = (actualHeight)+"px";
}
this.setTimer();
};
this.bindMethod = function(method, scope) {
return function() {
method.apply(scope,arguments);
};
};
this.getBodyHeight = function (){
var height;
var scrollHeight;
var offsetHeight;
try{ // Prevent IE from throw errors
if (this.frame.contentWindow.document.height){
height = this.frame.contentWindow.document.height;
//Emre: to prevent "iframe height" problem (61059)
if (this.frame.contentWindow.document.body.scrollHeight){
height = scrollHeight = this.frame.contentWindow.document.body.scrollHeight;
}
if (this.frame.contentWindow.document.body.offsetHeight){
height = offsetHeight = this.frame.contentWindow.document.body.offsetHeight;
}
} else if (this.frame.contentWindow.document.body){
if (this.frame.contentWindow.document.body.scrollHeight){
height = scrollHeight = this.frame.contentWindow.document.body.scrollHeight;
}
if (this.frame.contentWindow.document.body.offsetHeight){
height = offsetHeight = this.frame.contentWindow.document.body.offsetHeight;
}
if (scrollHeight && offsetHeight){
height = Math.max(scrollHeight, offsetHeight);
}
}
}catch(e){ }
return height;
};
this.getViewPortHeight = function(){
var height = 0;
try{ // Prevent IE from throw errors
if (this.frame.contentWindow.window.innerHeight)
{
height = this.frame.contentWindow.window.innerHeight - 18;
}
else if ((this.frame.contentWindow.document.documentElement) &&
(this.frame.contentWindow.document.documentElement.clientHeight))
{
height = this.frame.contentWindow.document.documentElement.clientHeight;
}
else if ((this.frame.contentWindow.document.body) &&
(this.frame.contentWindow.document.body.clientHeight))
{
height = this.frame.contentWindow.document.body.clientHeight;
}
}catch(e){ }
return height;
};
this.init();
}
FrameBuilder.get = [];
var i10033129874 = new FrameBuilder("10033129874", false, "", "\n\n\n\n\nForm<\/title>\n<link href=\"http:\/\/max.jotfor.ms\/min\/g=formCss?3.0.2435\" rel=\"stylesheet\" type=\"text\/css\" \/>\n<style type=\"text\/css\">\n .form-label{\n width:150px !important;\n }\n .form-label-left{\n width:150px !important;\n }\n .form-line{\n padding:5px;\n }\n .form-label-right{\n width:150px !important;\n }\n body, html{\n margin:0;\n padding:0;\n background:white;\n }\n\n .form-all{\n margin:0px auto;\n padding-top:0px;\n width:690px;\n background:white;\n color:black !important;\n font-family:Arial;\n font-size:12px;\n }\n<\/style>\n\n<script src=\"http:\/\/max.jotfor.ms\/min\/g=jotform?3.0.2435\" type=\"text\/javascript\"><\/script>\n<script type=\"text\/javascript\">\n var jsTime = setInterval(function(){try{\n JotForm.jsForm = true;\n\n JotForm.init();\n\n clearInterval(jsTime);\n }catch(e){}}, 1000);\n<\/script>\n<\/head>\n<body>\n<form class=\"jotform-form\" action=\"http:\/\/submit.jotform.com\/submit.php\" method=\"post\" name=\"form_10033129874\" id=\"10033129874\" accept-charset=\"utf-8\">\n <input type=\"hidden\" name=\"formID\" value=\"10033129874\" \/>\n <div class=\"form-all\">\n <ul class=\"form-section\">\n <li id=\"cid_54\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_54\" class=\"form-header\">\n Step 1 of 3: Applicant Status & Contact Information\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_9\">\n <label class=\"form-label-left\" id=\"label_9\" for=\"input_9\">\n Indicates Required Fields<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_9\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_9_0\" name=\"q9_indicatesRequired9[]\" value=\"I am a non-smoking female between the ages of 1-40.\" \/>\n <label for=\"input_9_0\"> I am a non-smoking female between the ages of 1-40. <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_9_1\" name=\"q9_indicatesRequired9[]\" value=\"I have given birth and am raising\/have raised at least one child.\" \/>\n <label for=\"input_9_1\"> I have given birth and am raising\/have raised at least one child. <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_9_2\" name=\"q9_indicatesRequired9[]\" value=\"I understand as a surrogate candidate both myself and my husband\/partner will meet with a licensed mental health professional for a psychological evaluation.\" \/>\n <label for=\"input_9_2\"> I understand as a surrogate candidate both myself and my husband\/partner will meet with a licensed mental health professional for a psychological evaluation. <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_9_3\" name=\"q9_indicatesRequired9[]\" value=\"I consent to a background check on both myself and my husband\/partner.\" \/>\n <label for=\"input_9_3\"> I consent to a background check on both myself and my husband\/partner. <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_9_4\" name=\"q9_indicatesRequired9[]\" value=\"I have a reliable car with insurance.\" \/>\n <label for=\"input_9_4\"> I have a reliable car with insurance. <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_9_5\" name=\"q9_indicatesRequired9[]\" value=\"I have access to previous obstetrical medical records, and am comfortable sharing this information with Simple Surrogacy.\" \/>\n <label for=\"input_9_5\"> I have access to previous obstetrical medical records, and am comfortable sharing this information with Simple Surrogacy. <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_9_6\" name=\"q9_indicatesRequired9[]\" value=\"I have not had any major complications with pregnancy.\" \/>\n <label for=\"input_9_6\"> I have not had any major complications with pregnancy. <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_9_7\" name=\"q9_indicatesRequired9[]\" value=\"I have not received psychiatric care for mental illness in the last 10 years.\" \/>\n <label for=\"input_9_7\"> I have not received psychiatric care for mental illness in the last 10 years. <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_9_8\" name=\"q9_indicatesRequired9[]\" value=\"I am not receiving any state or federal financial assistance (welfare).\" \/>\n <label for=\"input_9_8\"> I am not receiving any state or federal financial assistance (welfare). <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_9_9\" name=\"q9_indicatesRequired9[]\" value=\"I will consent to a full medical examination which will include a vaginal ultrasound, pelvic examination, communicable disease testing, and drug testing.\" \/>\n <label for=\"input_9_9\"> I will consent to a full medical examination which will include a vaginal ultrasound, pelvic examination, communicable disease testing, and drug testing. <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_9_10\" name=\"q9_indicatesRequired9[]\" value=\"I understand that I must have a BMI between 18-33.\" \/>\n <label for=\"input_9_10\"> I understand that I must have a BMI between 18-33. <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_9_11\" name=\"q9_indicatesRequired9[]\" value=\"I have a supportive spouse\/partner (if applicable) who knows of my plans to become a surrogate mother.\" \/>\n <label for=\"input_9_11\"> I have a supportive spouse\/partner (if applicable) who knows of my plans to become a surrogate mother. <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_9_12\" name=\"q9_indicatesRequired9[]\" value=\"I understand I must act responsibly and understand that the intended parents will depend on me to take my medications as directed by a physician, to attend all doctor appointments, and to take care of myself emotionally and physically.\" \/>\n <label for=\"input_9_12\"> I understand I must act responsibly and understand that the intended parents will depend on me to take my medications as directed by a physician, to attend all doctor appointments, and to take care of myself emotionally and physically. <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_56\">\n <div id=\"cid_56\" class=\"form-input-wide\">\n <div id=\"text_56\" class=\"form-html\">\n Click to edit this text...\n <\/div>\n <\/div>\n <\/li>\n <li id=\"cid_55\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h3 id=\"header_55\" class=\"form-header\">\n Contact Information\n <\/h3>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_11\">\n <label class=\"form-label-left\" id=\"label_11\" for=\"input_11\">\n First Name<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_11\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_11\" name=\"q11_firstName11\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_12\">\n <label class=\"form-label-left\" id=\"label_12\" for=\"input_12\">\n Last Name<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_12\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_12\" name=\"q12_lastName\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_50\">\n <label class=\"form-label-left\" id=\"label_50\" for=\"input_50\">\n Phone<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_50\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_50\" name=\"q50_phone50\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_14\">\n <label class=\"form-label-left\" id=\"label_14\" for=\"input_14\">\n Email<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_14\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required, Email]\" id=\"input_14\" name=\"q14_email\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_15\">\n <label class=\"form-label-left\" id=\"label_15\" for=\"input_15\"> Address <\/label>\n <div id=\"cid_15\" class=\"form-input\">\n <textarea id=\"input_15\" class=\"form-textarea\" name=\"q15_address\" cols=\"30\" rows=\"2\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_16\">\n <label class=\"form-label-left\" id=\"label_16\" for=\"input_16\">\n City<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_16\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_16\" name=\"q16_city\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_17\">\n <label class=\"form-label-left\" id=\"label_17\" for=\"input_17\">\n State<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_17\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_17\" name=\"q17_state\" size=\"10\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_18\">\n <label class=\"form-label-left\" id=\"label_18\" for=\"input_18\"> Zip Code <\/label>\n <div id=\"cid_18\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_18\" name=\"q18_zipCode\" size=\"10\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li id=\"cid_51\" class=\"form-input-wide\">\n <div class=\"form-pagebreak\">\n <div class=\"form-pagebreak-back-container form-label-left\">\n <button type=\"button\" class=\"form-pagebreak-back\" id=\"form-pagebreak-back_51\">\n Back\n <\/button>\n <\/div>\n <div class=\"form-pagebreak-next-container\">\n <button type=\"button\" class=\"form-pagebreak-next\" id=\"form-pagebreak-next_51\">\n Next\n <\/button>\n <\/div>\n <\/div>\n <\/li>\n <\/ul>\n <ul class=\"form-section\" style=\"display:none;\">\n <li id=\"cid_19\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_19\" class=\"form-header\">\n Step 2 of 3: Personal Information\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_20\">\n <label class=\"form-label-left\" id=\"label_20\" for=\"input_20\">\n I am applying to be a:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_20\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_20_0\" name=\"q20_iAm[]\" value=\"Traditional Surrogate\" \/>\n <label for=\"input_20_0\"> Traditional Surrogate <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_20_1\" name=\"q20_iAm[]\" value=\"Gestational Surrogate\" \/>\n <label for=\"input_20_1\"> Gestational Surrogate <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_49\">\n <label class=\"form-label-left\" id=\"label_49\" for=\"input_49\">\n DOB: MM\/DD\/YY<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_49\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_49\" name=\"q49_dobMmddyy\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_21\">\n <label class=\"form-label-left\" id=\"label_21\" for=\"input_21\">\n Marital Status<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_21\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_21\" name=\"q21_maritalStatus\">\n <option> <\/option>\n <option value=\"Married\"> Married <\/option>\n <option value=\"Single\"> Single <\/option>\n <option value=\"Divorced\"> Divorced <\/option>\n <option value=\"Widowed\"> Widowed <\/option>\n <option value=\"Separated\"> Separated <\/option>\n <option value=\"Living Together\"> Living Together <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_23\">\n <label class=\"form-label-left\" id=\"label_23\" for=\"input_23\">\n Number of Surrogacies<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_23\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_23\" name=\"q23_numberOf\" size=\"10\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_24\">\n <label class=\"form-label-left\" id=\"label_24\" for=\"input_24\">\n Height<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_24\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_24\" name=\"q24_height\" size=\"10\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_25\">\n <label class=\"form-label-left\" id=\"label_25\" for=\"input_25\">\n Weight<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_25\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_25\" name=\"q25_weight\" size=\"10\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_27\">\n <label class=\"form-label-left\" id=\"label_27\" for=\"input_27\">\n Hair Color<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_27\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_27\" name=\"q27_hairColor\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_29\">\n <label class=\"form-label-left\" id=\"label_29\" for=\"input_29\">\n Eye Color<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_29\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_29\" name=\"q29_eyeColor\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_30\">\n <label class=\"form-label-left\" id=\"label_30\" for=\"input_30\">\n Ethnicity<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_30\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_30\" name=\"q30_ethnicity\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_31\">\n <label class=\"form-label-left\" id=\"label_31\" for=\"input_31\">\n Highest Level Of Education<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_31\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_31\" name=\"q31_highestLevel\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_32\">\n <label class=\"form-label-left\" id=\"label_32\" for=\"input_32\">\n Do you have medical insurance?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_32\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_32_0\" name=\"q32_doYou[]\" value=\"Yes\" \/>\n <label for=\"input_32_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_32_1\" name=\"q32_doYou[]\" value=\"No\" \/>\n <label for=\"input_32_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_33\">\n <label class=\"form-label-left\" id=\"label_33\" for=\"input_33\">\n Do it exclude Surrogacy<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_33\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_33_0\" name=\"q33_doIt[]\" value=\"Yes\" \/>\n <label for=\"input_33_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_33_1\" name=\"q33_doIt[]\" value=\"No\" \/>\n <label for=\"input_33_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_34\">\n <label class=\"form-label-left\" id=\"label_34\" for=\"input_34\">\n Do you smoke or use tobacco?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_34\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_34_0\" name=\"q34_doYou34[]\" value=\"Yes\" \/>\n <label for=\"input_34_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_34_1\" name=\"q34_doYou34[]\" value=\"No\" \/>\n <label for=\"input_34_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_36\">\n <label class=\"form-label-left\" id=\"label_36\" for=\"input_36\">\n Have you ever abused alcohol or illegal drugs?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_36\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_36_0\" name=\"q36_haveYou[]\" value=\"Yes\" \/>\n <label for=\"input_36_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_36_1\" name=\"q36_haveYou[]\" value=\"No\" \/>\n <label for=\"input_36_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_37\">\n <label class=\"form-label-left\" id=\"label_37\" for=\"input_37\"> Are you taking any medications? <\/label>\n <div id=\"cid_37\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_37_0\" name=\"q37_areYou[]\" value=\"Yes\" \/>\n <label for=\"input_37_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_37_1\" name=\"q37_areYou[]\" value=\"No\" \/>\n <label for=\"input_37_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_38\">\n <label class=\"form-label-left\" id=\"label_38\" for=\"input_38\"> If yes, please list: <\/label>\n <div id=\"cid_38\" class=\"form-input\">\n <textarea id=\"input_38\" class=\"form-textarea\" name=\"q38_ifYes\" cols=\"30\" rows=\"2\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_39\">\n <label class=\"form-label-left\" id=\"label_39\" for=\"input_39\"> Reasons for medications: <\/label>\n <div id=\"cid_39\" class=\"form-input\">\n <textarea id=\"input_39\" class=\"form-textarea\" name=\"q39_reasonsFor\" cols=\"30\" rows=\"2\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_40\">\n <label class=\"form-label-left\" id=\"label_40\" for=\"input_40\">\n Do you or any member of your family receive any form of Government assistance?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_40\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_40_0\" name=\"q40_doYou40[]\" value=\"Yes\" \/>\n <label for=\"input_40_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_40_1\" name=\"q40_doYou40[]\" value=\"No\" \/>\n <label for=\"input_40_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_41\">\n <label class=\"form-label-left\" id=\"label_41\" for=\"input_41\">\n Have you ever been convicted of a crime or had trouble with the law?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_41\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_41_0\" name=\"q41_haveYou41[]\" value=\"Yes\" \/>\n <label for=\"input_41_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_41_1\" name=\"q41_haveYou41[]\" value=\"No\" \/>\n <label for=\"input_41_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_43\">\n <label class=\"form-label-left\" id=\"label_43\" for=\"input_43\"> If Yes, please describe: <\/label>\n <div id=\"cid_43\" class=\"form-input\">\n <textarea id=\"input_43\" class=\"form-textarea\" name=\"q43_ifYes43\" cols=\"30\" rows=\"2\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_44\">\n <label class=\"form-label-left\" id=\"label_44\" for=\"input_44\">\n Who would you consider for your IP\/s: (please check next to each you would consider)<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_44\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_44_0\" name=\"q44_whoWould[]\" value=\"Single Woman\" \/>\n <label for=\"input_44_0\"> Single Woman <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_44_1\" name=\"q44_whoWould[]\" value=\"Single Man\" \/>\n <label for=\"input_44_1\"> Single Man <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_44_2\" name=\"q44_whoWould[]\" value=\"Gay or Lesbian Couple\" \/>\n <label for=\"input_44_2\"> Gay or Lesbian Couple <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_44_3\" name=\"q44_whoWould[]\" value=\"Heterosexual Couple\" \/>\n <label for=\"input_44_3\"> Heterosexual Couple <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_44_4\" name=\"q44_whoWould[]\" value=\"Unmarried Couple\" \/>\n <label for=\"input_44_4\"> Unmarried Couple <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li id=\"cid_52\" class=\"form-input-wide\">\n <div class=\"form-pagebreak\">\n <div class=\"form-pagebreak-back-container form-label-left\">\n <button type=\"button\" class=\"form-pagebreak-back\" id=\"form-pagebreak-back_52\">\n Back\n <\/button>\n <\/div>\n <div class=\"form-pagebreak-next-container\">\n <button type=\"button\" class=\"form-pagebreak-next\" id=\"form-pagebreak-next_52\">\n Next\n <\/button>\n <\/div>\n <\/div>\n <\/li>\n <\/ul>\n <ul class=\"form-section\" style=\"display:none;\">\n <li id=\"cid_53\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_53\" class=\"form-header\">\n Step 3 of 3: Closing Comments\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_45\">\n <label class=\"form-label-left\" id=\"label_45\" for=\"input_45\"> Comments or Questions: <\/label>\n <div id=\"cid_45\" class=\"form-input\">\n <textarea id=\"input_45\" class=\"form-textarea\" name=\"q45_commentsOr\" cols=\"30\" rows=\"5\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_57\">\n <label class=\"form-label-top\" id=\"label_57\" for=\"input_57\"> I would like to receive Simple Surrogacy\u2019s monthly newsletter <\/label>\n <div id=\"cid_57\" class=\"form-input-wide\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_57_0\" name=\"q57_iWould[]\" value=\"Yes\" \/>\n <label for=\"input_57_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_47\">\n <label class=\"form-label-left\" id=\"label_47\" for=\"input_47\">\n How did you hear about us?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_47\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_47\" name=\"q47_howDid\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_1\">\n <div id=\"cid_1\" class=\"form-input-wide\">\n <div style=\"margin-left:156px\" class=\"form-buttons-wrapper\">\n <button id=\"input_1\" type=\"submit\" class=\"form-submit-button\">\n Submit\n <\/button>\n <\/div>\n <\/div>\n <\/li>\n <li style=\"display:none\">\n Should be Empty:\n <input type=\"text\" name=\"website\" value=\"\" \/>\n <\/li>\n <\/ul>\n <\/div>\n <input type=\"hidden\" id=\"simple_spc\" name=\"simple_spc\" value=\"10033129874\" \/>\n <script type=\"text\/javascript\">\n document.getElementById(\"si\" + \"mple\" + \"_spc\").value = \"10033129874-10033129874\";\n <\/script>\n<\/form><\/body>\n<\/html>\n");