{"id":2013,"date":"2024-03-28T15:36:11","date_gmt":"2024-03-28T15:36:11","guid":{"rendered":"https:\/\/caregivingtn.com\/?page_id=2013"},"modified":"2024-04-02T20:06:34","modified_gmt":"2024-04-02T20:06:34","slug":"contact-information-demographic-form","status":"publish","type":"page","link":"https:\/\/tncaregiver.org\/es\/contact-information-demographic-form\/","title":{"rendered":"Contact Information &#038; Demographic Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2013\" class=\"elementor elementor-2013\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-d374a08 e-flex e-con-boxed e-con e-parent\" data-id=\"d374a08\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[],&quot;background_background&quot;:&quot;classic&quot;,&quot;shape_divider_bottom&quot;:&quot;waves&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-shape elementor-shape-bottom\" aria-hidden=\"true\" data-negative=\"false\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 1000 100\" preserveAspectRatio=\"none\">\n\t<path class=\"elementor-shape-fill\" d=\"M421.9,6.5c22.6-2.5,51.5,0.4,75.5,5.3c23.6,4.9,70.9,23.5,100.5,35.7c75.8,32.2,133.7,44.5,192.6,49.7\n\tc23.6,2.1,48.7,3.5,103.4-2.5c54.7-6,106.2-25.6,106.2-25.6V0H0v30.3c0,0,72,32.6,158.4,30.5c39.2-0.7,92.8-6.7,134-22.4\n\tc21.2-8.1,52.2-18.2,79.7-24.2C399.3,7.9,411.6,7.5,421.9,6.5z\"\/>\n<\/svg>\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-c8e2df4 elementor-widget elementor-widget-text-editor\" data-id=\"c8e2df4\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Contact Information &amp; Demographic Form<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-c7a7157 e-flex e-con-boxed e-con e-parent\" data-id=\"c7a7157\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-42a853f elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"42a853f\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"New Form\" aria-label=\"New Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"2013\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"42a853f\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Contact Information &#038; Demographic Form\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"2013\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-70\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_878f781 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_878f781\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of Birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_878f781]\" id=\"form-field-field_878f781\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field elementor-use-native\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_48d64c5 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_48d64c5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStreet Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_48d64c5]\" id=\"form-field-field_48d64c5\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Street Address\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a40a4ad elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a40a4ad\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCity\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a40a4ad]\" id=\"form-field-field_a40a4ad\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_21fbf29 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_21fbf29\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tState\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_21fbf29]\" id=\"form-field-field_21fbf29\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_0daf4c5 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0daf4c5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tZIP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_0daf4c5]\" id=\"form-field-field_0daf4c5\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_81d6b31 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_81d6b31\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tContact Phone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_81d6b31]\" id=\"form-field-field_81d6b31\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-email elementor-col-40 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPersonal Email Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5bed2fa elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5bed2fa\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPronouns\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5bed2fa]\" id=\"form-field-field_5bed2fa\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_c8e2d22 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c8e2d22\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmergency Contact Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_c8e2d22]\" id=\"form-field-field_c8e2d22\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f48894c elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f48894c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmergency Contact Phone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f48894c]\" id=\"form-field-field_f48894c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_d781299 elementor-col-100\">\n\t\t\t\t\t<strong>Check all that Apply:<\/strong>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_0f57506 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0f57506\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEthnicity\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\" Not Hispanic\" id=\"form-field-field_0f57506-0\" name=\"form_fields[field_0f57506][]\"> <label for=\"form-field-field_0f57506-0\">No, not of Hispanic, Latinx, or Spanish origin <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\" Hispanic\" id=\"form-field-field_0f57506-1\" name=\"form_fields[field_0f57506][]\"> <label for=\"form-field-field_0f57506-1\">Yes, of Hispanic, Latinx, or Spanish origin<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Prefer not to report\" id=\"form-field-field_0f57506-2\" name=\"form_fields[field_0f57506][]\"> <label for=\"form-field-field_0f57506-2\">Prefer not to report<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_e93bbb1 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e93bbb1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRace\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\" White \/ Caucasian\" id=\"form-field-field_e93bbb1-0\" name=\"form_fields[field_e93bbb1][]\"> <label for=\"form-field-field_e93bbb1-0\">White or Caucasian <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Black \/ African American\" id=\"form-field-field_e93bbb1-1\" name=\"form_fields[field_e93bbb1][]\"> <label for=\"form-field-field_e93bbb1-1\">Black or African American<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Asian\" id=\"form-field-field_e93bbb1-2\" name=\"form_fields[field_e93bbb1][]\"> <label for=\"form-field-field_e93bbb1-2\">Asian or Asian American<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"American Indian \/ Alaskan Native\" id=\"form-field-field_e93bbb1-3\" name=\"form_fields[field_e93bbb1][]\"> <label for=\"form-field-field_e93bbb1-3\">American Indian or Alaska Native<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Native Hawaiian or Other Pacific Islander\" id=\"form-field-field_e93bbb1-4\" name=\"form_fields[field_e93bbb1][]\"> <label for=\"form-field-field_e93bbb1-4\">Native Hawaiian or Other Pacific Islander<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Two or more races\" id=\"form-field-field_e93bbb1-5\" name=\"form_fields[field_e93bbb1][]\"> <label for=\"form-field-field_e93bbb1-5\">Two or more races<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Prefer not to report\" id=\"form-field-field_e93bbb1-6\" name=\"form_fields[field_e93bbb1][]\"> <label for=\"form-field-field_e93bbb1-6\">Prefer not to report<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_c87d983 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c87d983\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tGender\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Male\" id=\"form-field-field_c87d983-0\" name=\"form_fields[field_c87d983][]\"> <label for=\"form-field-field_c87d983-0\">Male<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Female\" id=\"form-field-field_c87d983-1\" name=\"form_fields[field_c87d983][]\"> <label for=\"form-field-field_c87d983-1\">Female<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Gender Fluid\" id=\"form-field-field_c87d983-2\" name=\"form_fields[field_c87d983][]\"> <label for=\"form-field-field_c87d983-2\">Gender Fluid \/ Does Not Identify as Male or Female<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Prefer not to report\" id=\"form-field-field_c87d983-3\" name=\"form_fields[field_c87d983][]\"> <label for=\"form-field-field_c87d983-3\">Prefer not to report<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_332c9ed elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_332c9ed\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSexuality\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"LGBTQIA+\" id=\"form-field-field_332c9ed-0\" name=\"form_fields[field_332c9ed][]\"> <label for=\"form-field-field_332c9ed-0\">Identifies as a member of the LGBTQIA+ community<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Not LGBTQIA+\" id=\"form-field-field_332c9ed-1\" name=\"form_fields[field_332c9ed][]\"> <label for=\"form-field-field_332c9ed-1\">Does not identify as a member of the LGBTQIA+ community<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Prefer not to report\" id=\"form-field-field_332c9ed-2\" name=\"form_fields[field_332c9ed][]\"> <label for=\"form-field-field_332c9ed-2\">Prefer not to report<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_768d2d1 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_768d2d1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDisability\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Identifies as a member of the Disability community\" id=\"form-field-field_768d2d1-0\" name=\"form_fields[field_768d2d1][]\"> <label for=\"form-field-field_768d2d1-0\">Identifies as a member of the Disability community<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Does not identify as a member of the Disability community\" id=\"form-field-field_768d2d1-1\" name=\"form_fields[field_768d2d1][]\"> <label for=\"form-field-field_768d2d1-1\">Does not identify as a member of the Disability community<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Prefer not to report\" id=\"form-field-field_768d2d1-2\" name=\"form_fields[field_768d2d1][]\"> <label for=\"form-field-field_768d2d1-2\">Prefer not to report<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_4734d60 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4734d60\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tVeteran Status\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Is a veteran\" id=\"form-field-field_4734d60-0\" name=\"form_fields[field_4734d60][]\"> <label for=\"form-field-field_4734d60-0\">Is a veteran<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Is not a veteran\" id=\"form-field-field_4734d60-1\" name=\"form_fields[field_4734d60][]\"> <label for=\"form-field-field_4734d60-1\">Is not a veteran<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Prefer not to report\" id=\"form-field-field_4734d60-2\" name=\"form_fields[field_4734d60][]\"> <label for=\"form-field-field_4734d60-2\">Prefer not to report<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Send<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Contact Information &amp; Demographic 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