/*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 i90755536198 = new FrameBuilder("90755536198", 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:#fcfcfc;\n }\n\n .form-all{\n margin:0px auto;\n padding-top:0px;\n width:690px;\n background:#fcfcfc;\n color:black !important;\n font-family:Verdana;\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_90755536198\" id=\"90755536198\" accept-charset=\"utf-8\">\n <input type=\"hidden\" name=\"formID\" value=\"90755536198\" \/>\n <div class=\"form-all\">\n <ul class=\"form-section\">\n <li id=\"cid_8\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_8\" class=\"form-header\">\n Southern Hills Medical Release Form\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\"> Last Name of Student: <\/label>\n <div id=\"cid_9\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_9\" name=\"q9_lastName\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_11\">\n <label class=\"form-label-left\" id=\"label_11\" for=\"input_11\"> First Name of Student: <\/label>\n <div id=\"cid_11\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_11\" name=\"q11_firstName\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_10\">\n <label class=\"form-label-left\" id=\"label_10\" for=\"input_10\"> Age: <\/label>\n <div id=\"cid_10\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_10\" name=\"q10_age\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li id=\"cid_12\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_12\" class=\"form-header\">\n Contact 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\"> Father's Name: <\/label>\n <div id=\"cid_20\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_20\" name=\"q20_fathersName\" size=\"20\" 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\"> Mother's Name: <\/label>\n <div id=\"cid_24\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_24\" name=\"q24_mothersName\" 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\"> Address: <\/label>\n <div id=\"cid_21\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_21\" name=\"q21_address\" size=\"20\" maxlength=\"200\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_23\">\n <label class=\"form-label-left\" id=\"label_23\" for=\"input_23\"> City, State, Zip: <\/label>\n <div id=\"cid_23\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_23\" name=\"q23_cityState\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_104\">\n <label class=\"form-label-left\" id=\"label_104\" for=\"input_104\"> Family Email (please give the address that you prefer to be contacted through): <\/label>\n <div id=\"cid_104\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_104\" name=\"q104_familyEmail\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_22\">\n <label class=\"form-label-left\" id=\"label_22\" for=\"input_22\"> Home Phone: <\/label>\n <div id=\"cid_22\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_22\" name=\"q22_homePhone\" 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\"> Work Phone: <\/label>\n <div id=\"cid_15\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_15\" name=\"q15_workPhone\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_19\">\n <label class=\"form-label-left\" id=\"label_19\" for=\"input_19\"> Father's Cell Phone: <\/label>\n <div id=\"cid_19\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_19\" name=\"q19_fathersCell\" size=\"20\" 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\"> Mother's Cell Phone: <\/label>\n <div id=\"cid_18\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_18\" name=\"q18_mothersCell\" 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\"> Friend or Relative (emergency contact): <\/label>\n <div id=\"cid_17\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_17\" name=\"q17_friendOr\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_16\">\n <label class=\"form-label-left\" id=\"label_16\" for=\"input_16\"> Emergency Contact Phone: <\/label>\n <div id=\"cid_16\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_16\" name=\"q16_emergencyContact\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_105\">\n <div id=\"cid_105\" class=\"form-input-wide\">\n <div id=\"text_105\" class=\"form-html\">\n (This is page 1 of 7, please continue by clicking below)\n <\/div>\n <\/div>\n <\/li>\n <li id=\"cid_80\" 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_80\">\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_80\">\n Next\n <\/button>\n <\/div>\n <\/div>\n <\/li>\n <\/ul>\n <ul class=\"form-section\" style=\"display:none;\">\n <li id=\"cid_81\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_81\" class=\"form-header\">\n Contact Info Continued (page 2 of 7)\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_14\">\n <label class=\"form-label-left\" id=\"label_14\" for=\"input_14\"> Child's Doctor: <\/label>\n <div id=\"cid_14\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_14\" name=\"q14_childsDoctor\" size=\"20\" 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\"> Doctor's Phone: <\/label>\n <div id=\"cid_25\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_25\" name=\"q25_doctorsPhone\" 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\"> Parents are: <\/label>\n <div id=\"cid_29\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_29_0\" name=\"q29_parentsAre\" value=\"Married\" \/>\n <label for=\"input_29_0\"> Married <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_29_1\" name=\"q29_parentsAre\" value=\"Separated\" \/>\n <label for=\"input_29_1\"> Separated <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_29_2\" name=\"q29_parentsAre\" value=\"Divorced\" \/>\n <label for=\"input_29_2\"> Divorced <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_29_3\" name=\"q29_parentsAre\" value=\"Other\" \/>\n <label for=\"input_29_3\"> Other <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_27\">\n <label class=\"form-label-left\" id=\"label_27\" for=\"input_27\"> Custodial parent is: <\/label>\n <div id=\"cid_27\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_27\" name=\"q27_custodialParent\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_28\">\n <label class=\"form-label-left\" id=\"label_28\" for=\"input_28\"> Child lives at home with: <\/label>\n <div id=\"cid_28\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_28\" name=\"q28_childLives\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li id=\"cid_31\" 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_31\">\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_31\">\n Next\n <\/button>\n <\/div>\n <\/div>\n <\/li>\n <\/ul>\n <ul class=\"form-section\" style=\"display:none;\">\n <li id=\"cid_32\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_32\" class=\"form-header\">\n Medical Information (page 3 of 7)\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_36\">\n <div id=\"cid_36\" class=\"form-input-wide\">\n <div id=\"text_36\" class=\"form-html\">\n Allergies\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\"> Drugs: <\/label>\n <div id=\"cid_33\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_33\" name=\"q33_drugs\" size=\"20\" maxlength=\"200\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_34\">\n <label class=\"form-label-left\" id=\"label_34\" for=\"input_34\"> Foods: <\/label>\n <div id=\"cid_34\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_34\" name=\"q34_foods\" size=\"20\" maxlength=\"200\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_35\">\n <label class=\"form-label-left\" id=\"label_35\" for=\"input_35\"> Latex or other allergies: <\/label>\n <div id=\"cid_35\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_35\" name=\"q35_latexOr\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_37\">\n <div id=\"cid_37\" class=\"form-input-wide\">\n <div id=\"text_37\" class=\"form-html\">\n Vaccines\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_39\">\n <label class=\"form-label-left\" id=\"label_39\" for=\"input_39\"> Tetanus (date): <\/label>\n <div id=\"cid_39\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_39\" name=\"q39_tetanusdate\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_40\">\n <label class=\"form-label-left\" id=\"label_40\" for=\"input_40\"> Hepatitis B (date): <\/label>\n <div id=\"cid_40\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_40\" name=\"q40_hepatitisB\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_41\">\n <div id=\"cid_41\" class=\"form-input-wide\">\n <div id=\"text_41\" class=\"form-html\">\n Medication\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_42\">\n <label class=\"form-label-left\" id=\"label_42\" for=\"input_42\"> Type (dosage, frequency) <\/label>\n <div id=\"cid_42\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_42\" name=\"q42_typedosage\" size=\"20\" maxlength=\"200\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_43\">\n <div id=\"cid_43\" class=\"form-input-wide\">\n <div id=\"text_43\" class=\"form-html\">\n Hospitalizations \/ Surgeries\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_44\">\n <label class=\"form-label-left\" id=\"label_44\" for=\"input_44\"> Please list: <\/label>\n <div id=\"cid_44\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_44\" name=\"q44_pleaseList\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_48\">\n <label class=\"form-label-left\" id=\"label_48\" for=\"input_48\"> Birth date: <\/label>\n <div id=\"cid_48\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_48\" name=\"q48_birthDate\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_47\">\n <label class=\"form-label-left\" id=\"label_47\" for=\"input_47\"> Height: <\/label>\n <div id=\"cid_47\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_47\" name=\"q47_height\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_46\">\n <label class=\"form-label-left\" id=\"label_46\" for=\"input_46\"> Weight: <\/label>\n <div id=\"cid_46\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_46\" name=\"q46_weight\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li id=\"cid_82\" 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_82\">\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_82\">\n Next\n <\/button>\n <\/div>\n <\/div>\n <\/li>\n <\/ul>\n <ul class=\"form-section\" style=\"display:none;\">\n <li id=\"cid_49\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_49\" class=\"form-header\">\n Medications (page 4 of 7)\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_50\">\n <div id=\"cid_50\" class=\"form-input-wide\">\n <div id=\"text_50\" class=\"form-html\">\n Please select any of these over the counter medications your child my receive. Note - these medications will be given by an adult chaperone. We prefer that an adult be notified if your child is traveling with any medicines (over the counter, prescription, etc...).\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_51\">\n <label class=\"form-label-left\" id=\"label_51\" for=\"input_51\"> Check all that apply: <\/label>\n <div id=\"cid_51\" 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_51_0\" name=\"q51_checkAll[]\" value=\"Tylenol (acetaminophen)\" \/>\n <label for=\"input_51_0\"> Tylenol (acetaminophen) <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_51_1\" name=\"q51_checkAll[]\" value=\"Advil \/ Mortrin (ibuprofen)\" \/>\n <label for=\"input_51_1\"> Advil \/ Mortrin (ibuprofen) <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_51_2\" name=\"q51_checkAll[]\" value=\"Benadryl (diphenhydramine)\" \/>\n <label for=\"input_51_2\"> Benadryl (diphenhydramine) <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_51_3\" name=\"q51_checkAll[]\" value=\"Imodium (loperamide hcl)\" \/>\n <label for=\"input_51_3\"> Imodium (loperamide hcl) <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_51_4\" name=\"q51_checkAll[]\" value=\"Sudafed (phenylephrine)\" \/>\n <label for=\"input_51_4\"> Sudafed (phenylephrine) <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_51_5\" name=\"q51_checkAll[]\" value=\"Pepto Bismol (bismuth subsalicylate)\" \/>\n <label for=\"input_51_5\"> Pepto Bismol (bismuth subsalicylate) <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_51_6\" name=\"q51_checkAll[]\" value=\"Mylanta \/ Maalox \/ Tums \/ Rolaids (antacid)\" \/>\n <label for=\"input_51_6\"> Mylanta \/ Maalox \/ Tums \/ Rolaids (antacid) <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_51_7\" name=\"q51_checkAll[]\" value=\"Zantac (ranitidine)\" \/>\n <label for=\"input_51_7\"> Zantac (ranitidine) <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_51_8\" name=\"q51_checkAll[]\" value=\"None of the above\" \/>\n <label for=\"input_51_8\"> None of the above <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_52\">\n <label class=\"form-label-left\" id=\"label_52\" for=\"input_52\"> Any other medications: <\/label>\n <div id=\"cid_52\" class=\"form-input\">\n <textarea id=\"input_52\" class=\"form-textarea\" name=\"q52_anyOther\" cols=\"30\" rows=\"2\"><\/textarea>\n <\/div>\n <\/li>\n <li id=\"cid_54\" 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_54\">\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_54\">\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 Medical History (page 5 of 7)\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_68\">\n <label class=\"form-label-left\" id=\"label_68\" for=\"input_68\"> Eyes: <\/label>\n <div id=\"cid_68\" 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_68_0\" name=\"q68_eyes[]\" value=\"Contacts\" \/>\n <label for=\"input_68_0\"> Contacts <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_68_1\" name=\"q68_eyes[]\" value=\"Glasses\" \/>\n <label for=\"input_68_1\"> Glasses <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_74\">\n <label class=\"form-label-left\" id=\"label_74\" for=\"input_74\"> Ear, Nose, and Throat: <\/label>\n <div id=\"cid_74\" 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_74_0\" name=\"q74_earNose[]\" value=\"TMJ\" \/>\n <label for=\"input_74_0\"> TMJ <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_74_1\" name=\"q74_earNose[]\" value=\"Other (type in below)\" \/>\n <label for=\"input_74_1\"> Other (type in below) <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_75\">\n <label class=\"form-label-left\" id=\"label_75\" for=\"input_75\"> .... <\/label>\n <div id=\"cid_75\" class=\"form-input\">\n <textarea id=\"input_75\" class=\"form-textarea\" name=\"q75_75\" cols=\"30\" rows=\"2\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_72\">\n <label class=\"form-label-left\" id=\"label_72\" for=\"input_72\"> Heart: <\/label>\n <div id=\"cid_72\" 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_72_0\" name=\"q72_heart[]\" value=\"Heart Murmur\" \/>\n <label for=\"input_72_0\"> Heart Murmur <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_72_1\" name=\"q72_heart[]\" value=\"Mitral valve prolapse\" \/>\n <label for=\"input_72_1\"> Mitral valve prolapse <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_72_2\" name=\"q72_heart[]\" value=\"Family history of sudden death\" \/>\n <label for=\"input_72_2\"> Family history of sudden death <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_72_3\" name=\"q72_heart[]\" value=\"Other (type in below)\" \/>\n <label for=\"input_72_3\"> Other (type in below) <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_78\">\n <label class=\"form-label-left\" id=\"label_78\" for=\"input_78\"> .... <\/label>\n <div id=\"cid_78\" class=\"form-input\">\n <textarea id=\"input_78\" class=\"form-textarea\" name=\"q78_78\" cols=\"30\" rows=\"2\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_73\">\n <label class=\"form-label-left\" id=\"label_73\" for=\"input_73\"> Lung: <\/label>\n <div id=\"cid_73\" 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_73_0\" name=\"q73_lung[]\" value=\"Asthma (list medications)\" \/>\n <label for=\"input_73_0\"> Asthma (list medications) <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_73_1\" name=\"q73_lung[]\" value=\"Other (type in below)\" \/>\n <label for=\"input_73_1\"> Other (type in below) <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_79\">\n <label class=\"form-label-left\" id=\"label_79\" for=\"input_79\"> .... <\/label>\n <div id=\"cid_79\" class=\"form-input\">\n <textarea id=\"input_79\" class=\"form-textarea\" name=\"q79_79\" cols=\"30\" rows=\"2\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_71\">\n <label class=\"form-label-left\" id=\"label_71\" for=\"input_71\"> Gastrointestinal: <\/label>\n <div id=\"cid_71\" 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_71_0\" name=\"q71_gastrointestinal[]\" value=\"Reflux\" \/>\n <label for=\"input_71_0\"> Reflux <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_71_1\" name=\"q71_gastrointestinal[]\" value=\"Irritable Bowel Syndrome\" \/>\n <label for=\"input_71_1\"> Irritable Bowel Syndrome <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_71_2\" name=\"q71_gastrointestinal[]\" value=\"Other (type in below)\" \/>\n <label for=\"input_71_2\"> Other (type in below) <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_83\">\n <label class=\"form-label-left\" id=\"label_83\" for=\"input_83\"> .... <\/label>\n <div id=\"cid_83\" class=\"form-input\">\n <textarea id=\"input_83\" class=\"form-textarea\" name=\"q83_83\" cols=\"30\" rows=\"2\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_69\">\n <label class=\"form-label-left\" id=\"label_69\" for=\"input_69\"> Neurological: <\/label>\n <div id=\"cid_69\" 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_69_0\" name=\"q69_neurological[]\" value=\"Seizures\" \/>\n <label for=\"input_69_0\"> Seizures <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_69_1\" name=\"q69_neurological[]\" value=\"Fainting Spells\" \/>\n <label for=\"input_69_1\"> Fainting Spells <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_69_2\" name=\"q69_neurological[]\" value=\"ADD \/ ADHD\" \/>\n <label for=\"input_69_2\"> ADD \/ ADHD <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_69_3\" name=\"q69_neurological[]\" value=\"Eating Disorders\" \/>\n <label for=\"input_69_3\"> Eating Disorders <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_69_4\" name=\"q69_neurological[]\" value=\"Other (type in below)\" \/>\n <label for=\"input_69_4\"> Other (type in below) <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_84\">\n <label class=\"form-label-left\" id=\"label_84\" for=\"input_84\"> .... <\/label>\n <div id=\"cid_84\" class=\"form-input\">\n <textarea id=\"input_84\" class=\"form-textarea\" name=\"q84_84\" cols=\"30\" rows=\"2\"><\/textarea>\n <\/div>\n <\/li>\n <li id=\"cid_97\" 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_97\">\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_97\">\n Next\n <\/button>\n <\/div>\n <\/div>\n <\/li>\n <\/ul>\n <ul class=\"form-section\" style=\"display:none;\">\n <li id=\"cid_99\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_99\" class=\"form-header\">\n Medical History Continued (page 6 of 7)\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_70\">\n <label class=\"form-label-left\" id=\"label_70\" for=\"input_70\"> Orthopedic <\/label>\n <div id=\"cid_70\" 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_70_0\" name=\"q70_orthopedic[]\" value=\"Chronic bone \/ joint problems\" \/>\n <label for=\"input_70_0\"> Chronic bone \/ joint problems <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_70_1\" name=\"q70_orthopedic[]\" value=\"Previously broken bones (list as necessary)\" \/>\n <label for=\"input_70_1\"> Previously broken bones (list as necessary) <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_70_2\" name=\"q70_orthopedic[]\" value=\"Other (type in below)\" \/>\n <label for=\"input_70_2\"> Other (type in below) <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_85\">\n <label class=\"form-label-left\" id=\"label_85\" for=\"input_85\"> .... <\/label>\n <div id=\"cid_85\" class=\"form-input\">\n <textarea id=\"input_85\" class=\"form-textarea\" name=\"q85_85\" cols=\"30\" rows=\"2\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_65\">\n <label class=\"form-label-left\" id=\"label_65\" for=\"input_65\"> Hematological: <\/label>\n <div id=\"cid_65\" 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_65_0\" name=\"q65_hematological[]\" value=\"Anemia\" \/>\n <label for=\"input_65_0\"> Anemia <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_65_1\" name=\"q65_hematological[]\" value=\"Free Bleeding\" \/>\n <label for=\"input_65_1\"> Free Bleeding <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_65_2\" name=\"q65_hematological[]\" value=\"ITP\" \/>\n <label for=\"input_65_2\"> ITP <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_65_3\" name=\"q65_hematological[]\" value=\"Leukemia \/ Cancer\" \/>\n <label for=\"input_65_3\"> Leukemia \/ Cancer <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_65_4\" name=\"q65_hematological[]\" value=\"Other (type in below)\" \/>\n <label for=\"input_65_4\"> Other (type in below) <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_86\">\n <label class=\"form-label-left\" id=\"label_86\" for=\"input_86\"> .... <\/label>\n <div id=\"cid_86\" class=\"form-input\">\n <textarea id=\"input_86\" class=\"form-textarea\" name=\"q86_86\" cols=\"30\" rows=\"2\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_67\">\n <label class=\"form-label-left\" id=\"label_67\" for=\"input_67\"> Endocrine: <\/label>\n <div id=\"cid_67\" 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_67_0\" name=\"q67_endocrine[]\" value=\"Diabetes\" \/>\n <label for=\"input_67_0\"> Diabetes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_67_1\" name=\"q67_endocrine[]\" value=\"Thyroid\" \/>\n <label for=\"input_67_1\"> Thyroid <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_67_2\" name=\"q67_endocrine[]\" value=\"Other (type in below)\" \/>\n <label for=\"input_67_2\"> Other (type in below) <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_88\">\n <label class=\"form-label-left\" id=\"label_88\" for=\"input_88\"> .... <\/label>\n <div id=\"cid_88\" class=\"form-input\">\n <textarea id=\"input_88\" class=\"form-textarea\" name=\"q88_88\" cols=\"30\" rows=\"2\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_87\">\n <label class=\"form-label-left\" id=\"label_87\" for=\"input_87\"> Diabetes details:(How long? list of insulin type, dose, frequency, years) <\/label>\n <div id=\"cid_87\" class=\"form-input\">\n <textarea id=\"input_87\" class=\"form-textarea\" name=\"q87_diabetesDetailshow\" cols=\"30\" rows=\"2\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_66\">\n <label class=\"form-label-left\" id=\"label_66\" for=\"input_66\"> Kidney: <\/label>\n <div id=\"cid_66\" 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_66_0\" name=\"q66_kidney[]\" value=\"Kidney problems\" \/>\n <label for=\"input_66_0\"> Kidney problems <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_89\">\n <label class=\"form-label-left\" id=\"label_89\" for=\"input_89\"> Other health problems not listed: <\/label>\n <div id=\"cid_89\" class=\"form-input\">\n <textarea id=\"input_89\" class=\"form-textarea\" name=\"q89_otherHealth\" cols=\"30\" rows=\"5\"><\/textarea>\n <\/div>\n <\/li>\n <li id=\"cid_98\" 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_98\">\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_98\">\n Next\n <\/button>\n <\/div>\n <\/div>\n <\/li>\n <\/ul>\n <ul class=\"form-section\" style=\"display:none;\">\n <li id=\"cid_90\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_90\" class=\"form-header\">\n Insurance (page 7 of 7)\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_91\">\n <label class=\"form-label-left\" id=\"label_91\" for=\"input_91\"> Name of Subscriber: <\/label>\n <div id=\"cid_91\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_91\" name=\"q91_nameOf\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_94\">\n <label class=\"form-label-left\" id=\"label_94\" for=\"input_94\"> Company: <\/label>\n <div id=\"cid_94\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_94\" name=\"q94_company\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_95\">\n <label class=\"form-label-left\" id=\"label_95\" for=\"input_95\"> ID Number: <\/label>\n <div id=\"cid_95\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_95\" name=\"q95_idNumber\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_96\">\n <label class=\"form-label-left\" id=\"label_96\" for=\"input_96\"> Group number: <\/label>\n <div id=\"cid_96\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_96\" name=\"q96_groupNumber\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_93\">\n <label class=\"form-label-left\" id=\"label_93\" for=\"input_93\"> Subscriber: <\/label>\n <div id=\"cid_93\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_93\" name=\"q93_subscriber\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_92\">\n <label class=\"form-label-left\" id=\"label_92\" for=\"input_92\"> Subscriber birth date: <\/label>\n <div id=\"cid_92\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_92\" name=\"q92_subscriberBirth\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_100\">\n <div id=\"cid_100\" class=\"form-input-wide\">\n <div id=\"text_100\" class=\"form-html\">\n I understand that this information will be released to Matthew Savage and\/or other agents of Southern Hills Church of Christ. I authorize Matthew Savage or other agents of Southern Hills Church of Christ to seek emergent or non-emergent medical care on behalf of my child as deemed necessary. I also allow them to receive information regarding the treatment, care, and condition of my child.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_101\">\n <label class=\"form-label-left\" id=\"label_101\" for=\"input_101\"> Online signature: <\/label>\n <div id=\"cid_101\" 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_101_0\" name=\"q101_onlineSignature[]\" value=\"I agree to the terms above.\" \/>\n <label for=\"input_101_0\"> I agree to the terms above. <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_102\">\n <div id=\"cid_102\" class=\"form-input-wide\">\n <div style=\"margin-left:156px\" class=\"form-buttons-wrapper\">\n <button id=\"input_102\" 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=\"90755536198\" \/>\n <script type=\"text\/javascript\">\n document.getElementById(\"si\" + \"mple\" + \"_spc\").value = \"90755536198-90755536198\";\n <\/script>\n<\/form><\/body>\n<\/html>\n");