{"id":13,"date":"2025-09-17T20:07:28","date_gmt":"2025-09-17T20:07:28","guid":{"rendered":"https:\/\/taonline.org\/v3\/?page_id=13"},"modified":"2025-09-18T21:36:31","modified_gmt":"2025-09-18T21:36:31","slug":"health-form","status":"publish","type":"page","link":"https:\/\/taonline.org\/v3\/health-form\/","title":{"rendered":"Health Form"},"content":{"rendered":"<style id=\"wpforms-css-vars-77-block-33621bfd-9856-4aac-ab5f-3278b95988b2\">\n\t\t\t\t#wpforms-77.wpforms-block-33621bfd-9856-4aac-ab5f-3278b95988b2 {\n\t\t\t\t--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-33621bfd-9856-4aac-ab5f-3278b95988b2 wpforms-render-modern\" id=\"wpforms-77\"><form id=\"wpforms-form-77\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"77\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/v3\/wp-json\/wp\/v2\/pages\/13\" data-token=\"d562875e1903e2552ebde023a7df3eb5\" data-token-time=\"1776292118\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-page-indicator progress\" data-indicator=\"progress\" data-indicator-color=\"#066aab\" data-scroll=\"1\" role=\"progressbar\" aria-valuenow=\"1\" aria-valuemin=\"1\" aria-valuemax=\"3\" tabindex=\"-1\"><span class=\"wpforms-page-indicator-page-title\" data-page-1-title=\"Health Form\">Health Form<\/span><span class=\"wpforms-page-indicator-page-title-sep\" > &#8211; <\/span><span class=\"wpforms-page-indicator-steps\">Step <span class=\"wpforms-page-indicator-steps-current\">1<\/span> of 3<\/span><div class=\"wpforms-page-indicator-page-progress-wrap\"><div class=\"wpforms-page-indicator-page-progress\" style=\"width:33.333333333333%;background-color:#066aab\"><\/div><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-77-field_66-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"66\"><\/div><div id=\"wpforms-77-field_19-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"19\"><div id=\"wpforms-77-field_19\" class=\"wpforms-field-large wpforms-field-row\" aria-errormessage=\"wpforms-77-field_19-error\"><h4>Therapeutic Adventures, Inc.<\/h4>\n<p class=\"p1\"><strong>CONFIDENTIALITY\/PRIVACY NOTICE<\/strong> &#8211; This document contains information that is confidential and\/or legally privileged. The contents provided are intended to provide registered Therapeutic Adventures &#8211; instructors\/adaptive guides with necessary information so that programs can be safely administered.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-77-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-77-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" aria-errormessage=\"wpforms-77-field_0-error\" required><label for=\"wpforms-77-field_0\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-fifth\"><input type=\"text\" id=\"wpforms-77-field_0-middle\" class=\"wpforms-field-name-middle\" name=\"wpforms[fields][0][middle]\" aria-errormessage=\"wpforms-77-field_0-middle-error\" ><label for=\"wpforms-77-field_0-middle\" class=\"wpforms-field-sublabel after\">Middle<\/label><\/div><div class=\"wpforms-field-row-block wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-77-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" aria-errormessage=\"wpforms-77-field_0-last-error\" required><label for=\"wpforms-77-field_0-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-77-field_21-container\" class=\"wpforms-field wpforms-field-divider wpforms-field-divider-hide_line\" data-field-id=\"21\"><h3 id=\"wpforms-77-field_21\" aria-errormessage=\"wpforms-77-field_21-error\">DIAGNOSIS<\/h3><\/div><div id=\"wpforms-77-field_100-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"100\"><label class=\"wpforms-field-label\" for=\"wpforms-77-field_100\">Date of Injury or Onset <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-77-field_100\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][100]\" aria-errormessage=\"wpforms-77-field_100-error\" aria-describedby=\"wpforms-77-field_100-description\" required><\/textarea><div id=\"wpforms-77-field_100-description\" class=\"wpforms-field-description\">(MM\/DD\/YYYY)<\/div><\/div><div id=\"wpforms-77-field_71-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"71\"><label class=\"wpforms-field-label\" for=\"wpforms-77-field_71\">Primary Diagnosis<\/label><textarea id=\"wpforms-77-field_71\" class=\"wpforms-field-small\" name=\"wpforms[fields][71]\" aria-errormessage=\"wpforms-77-field_71-error\" ><\/textarea><\/div><div id=\"wpforms-77-field_72-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"72\"><label class=\"wpforms-field-label\" for=\"wpforms-77-field_72\">Secondary Diagnosis<\/label><textarea id=\"wpforms-77-field_72\" class=\"wpforms-field-small\" name=\"wpforms[fields][72]\" aria-errormessage=\"wpforms-77-field_72-error\" ><\/textarea><\/div><div id=\"wpforms-77-field_95-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"95\"><fieldset><legend class=\"wpforms-field-label\">Please check (\u2714\ufe0f) any that apply and describe below<\/legend><ul id=\"wpforms-77-field_95\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_1\" name=\"wpforms[fields][95][]\" value=\"Amputation (Lower Extremity)\u200e\" aria-errormessage=\"wpforms-77-field_95_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_1\">Amputation (Lower Extremity)\u200e<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_2\" name=\"wpforms[fields][95][]\" value=\"Amputation (Upper Extremity)\u200e\" aria-errormessage=\"wpforms-77-field_95_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_2\">Amputation (Upper Extremity)\u200e<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_3\" name=\"wpforms[fields][95][]\" value=\"Autism - Pervasive Developmental Disorder\u200e\" aria-errormessage=\"wpforms-77-field_95_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_3\">Autism &#8211; Pervasive Developmental Disorder\u200e<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_4\" name=\"wpforms[fields][95][]\" value=\"Blind \/ Visual Impairments\u200e\" aria-errormessage=\"wpforms-77-field_95_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_4\">Blind \/ Visual Impairments\u200e<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_7\" name=\"wpforms[fields][95][]\" value=\"Burns\" aria-errormessage=\"wpforms-77-field_95_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_7\">Burns<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_6\" name=\"wpforms[fields][95][]\" value=\"Cancer\" aria-errormessage=\"wpforms-77-field_95_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_6\">Cancer<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_5\" name=\"wpforms[fields][95][]\" value=\"Cerebral Palsy (CP)\" aria-errormessage=\"wpforms-77-field_95_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_5\">Cerebral Palsy (CP)<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_10\" name=\"wpforms[fields][95][]\" value=\"Chronic Health Impairment (Specify)\u200e\" aria-errormessage=\"wpforms-77-field_95_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_10\">Chronic Health Impairment (Specify)\u200e<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_9\" name=\"wpforms[fields][95][]\" value=\"Deaf \/ Hearing Impairment\" aria-errormessage=\"wpforms-77-field_95_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_9\">Deaf \/ Hearing Impairment<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_8\" name=\"wpforms[fields][95][]\" value=\"Down\u2019s Syndrome\u200e\" aria-errormessage=\"wpforms-77-field_95_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_8\">Down\u2019s Syndrome\u200e<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_12\" name=\"wpforms[fields][95][]\" value=\"Epilepsy \/ Seizure Disorder\u200e\" aria-errormessage=\"wpforms-77-field_95_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_12\">Epilepsy \/ Seizure Disorder\u200e<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_11\" name=\"wpforms[fields][95][]\" value=\"Multiple Sclerosis (MS)\u200e\" aria-errormessage=\"wpforms-77-field_95_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_11\">Multiple Sclerosis (MS)\u200e<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_14\" name=\"wpforms[fields][95][]\" value=\"Parkinson\u2019s Disease\u200e\" aria-errormessage=\"wpforms-77-field_95_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_14\">Parkinson\u2019s Disease\u200e<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_13\" name=\"wpforms[fields][95][]\" value=\"Post Concussion Syndrome (1, 2, 3, or more concussions, please specify)\u200e\" aria-errormessage=\"wpforms-77-field_95_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_13\">Post Concussion Syndrome (1, 2, 3, or more concussions, please specify)\u200e<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_17\" name=\"wpforms[fields][95][]\" value=\"Post Traumatic Stress Disorder (PTSD)\u200e\" aria-errormessage=\"wpforms-77-field_95_17-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_17\">Post Traumatic Stress Disorder (PTSD)\u200e<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_16\" name=\"wpforms[fields][95][]\" value=\"Poly-Trauma i.e.TBI, PTSD, Amputation, etc.\u200e\" aria-errormessage=\"wpforms-77-field_95_16-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_16\">Poly-Trauma i.e.TBI, PTSD, Amputation, etc.\u200e<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_15\" name=\"wpforms[fields][95][]\" value=\"Severe Childhood Trauma\u200e\" aria-errormessage=\"wpforms-77-field_95_15-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_15\">Severe Childhood Trauma\u200e<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_19\" name=\"wpforms[fields][95][]\" value=\"Stroke (CVA)\u200e\" aria-errormessage=\"wpforms-77-field_95_19-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_19\">Stroke (CVA)\u200e<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_18\" name=\"wpforms[fields][95][]\" value=\"Traumatic Brain Injury (TBI)\u200e\" aria-errormessage=\"wpforms-77-field_95_18-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_18\">Traumatic Brain Injury (TBI)\u200e<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_20\" name=\"wpforms[fields][95][]\" value=\"Traumatic Spinal Cord Injury (paraplegia, quadriplegia)\u200e\" aria-errormessage=\"wpforms-77-field_95_20-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_20\">Traumatic Spinal Cord Injury (paraplegia, quadriplegia)\u200e<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_95_21\" name=\"wpforms[fields][95][]\" value=\"Other (specify)\u200e\" aria-errormessage=\"wpforms-77-field_95_21-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_95_21\">Other (specify)\u200e<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-77-field_46-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-77-field_46\">Please Describe (if Other):<\/label><textarea id=\"wpforms-77-field_46\" class=\"wpforms-field-medium\" name=\"wpforms[fields][46]\" aria-errormessage=\"wpforms-77-field_46-error\" ><\/textarea><\/div><div id=\"wpforms-77-field_74-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"74\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"1\" data-formid=\"77\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-77-field_76-container\" class=\"wpforms-field wpforms-field-divider wpforms-field-divider-hide_line\" data-field-id=\"76\"><h3 id=\"wpforms-77-field_76\" aria-errormessage=\"wpforms-77-field_76-error\">OTHER HEALTH \/ MEDICAL NEEDS THAT MAY REQUIRE SPECIAL ATTENTION<\/h3><\/div><div id=\"wpforms-77-field_96-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"96\"><fieldset><legend class=\"wpforms-field-label\">Please check (\u2714\ufe0f) any that apply and describe below<\/legend><ul id=\"wpforms-77-field_96\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_1\" name=\"wpforms[fields][96][]\" value=\"Allergies\" aria-errormessage=\"wpforms-77-field_96_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_1\">Allergies<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_2\" name=\"wpforms[fields][96][]\" value=\"Allergy to Bees (I carry Epi-Pen \/ Bee sting kit)\" aria-errormessage=\"wpforms-77-field_96_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_2\">Allergy to Bees (I carry Epi-Pen \/ Bee sting kit)<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_4\" name=\"wpforms[fields][96][]\" value=\"Cognitive or developmental delay\" aria-errormessage=\"wpforms-77-field_96_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_4\">Cognitive or developmental delay<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_7\" name=\"wpforms[fields][96][]\" value=\"Diabetes\" aria-errormessage=\"wpforms-77-field_96_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_7\">Diabetes<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_6\" name=\"wpforms[fields][96][]\" value=\"Difficulty remembering or following directions\" aria-errormessage=\"wpforms-77-field_96_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_6\">Difficulty remembering or following directions<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_5\" name=\"wpforms[fields][96][]\" value=\"Difficulty speaking or communicating\" aria-errormessage=\"wpforms-77-field_96_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_5\">Difficulty speaking or communicating<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_8\" name=\"wpforms[fields][96][]\" value=\"Difficulty with Balance\" aria-errormessage=\"wpforms-77-field_96_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_8\">Difficulty with Balance<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_10\" name=\"wpforms[fields][96][]\" value=\"Emotional &amp; behavioral concerns we should know about\" aria-errormessage=\"wpforms-77-field_96_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_10\">Emotional &amp; behavioral concerns we should know about<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_9\" name=\"wpforms[fields][96][]\" value=\"Expressive or Receptive Asphasia\" aria-errormessage=\"wpforms-77-field_96_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_9\">Expressive or Receptive Asphasia<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_13\" name=\"wpforms[fields][96][]\" value=\"Heart Cardiac Condition\" aria-errormessage=\"wpforms-77-field_96_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_13\">Heart Cardiac Condition<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_12\" name=\"wpforms[fields][96][]\" value=\"Heart Murmur\" aria-errormessage=\"wpforms-77-field_96_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_12\">Heart Murmur<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_11\" name=\"wpforms[fields][96][]\" value=\"High Blood Pressure\" aria-errormessage=\"wpforms-77-field_96_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_11\">High Blood Pressure<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_16\" name=\"wpforms[fields][96][]\" value=\"Limited Range of Motion in any limbs\" aria-errormessage=\"wpforms-77-field_96_16-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_16\">Limited Range of Motion in any limbs<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_15\" name=\"wpforms[fields][96][]\" value=\"Personal care or independence concerns (ADL)\" aria-errormessage=\"wpforms-77-field_96_15-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_15\">Personal care or independence concerns (ADL)<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_14\" name=\"wpforms[fields][96][]\" value=\"Respiratory Condition\" aria-errormessage=\"wpforms-77-field_96_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_14\">Respiratory Condition<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_18\" name=\"wpforms[fields][96][]\" value=\"Reactions to Medications \/ Drugs\" aria-errormessage=\"wpforms-77-field_96_18-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_18\">Reactions to Medications \/ Drugs<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_17\" name=\"wpforms[fields][96][]\" value=\"Sensitivity to hot or cold\" aria-errormessage=\"wpforms-77-field_96_17-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_17\">Sensitivity to hot or cold<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_20\" name=\"wpforms[fields][96][]\" value=\"Sensitivity to light\" aria-errormessage=\"wpforms-77-field_96_20-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_20\">Sensitivity to light<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_19\" name=\"wpforms[fields][96][]\" value=\"Special Dietary Needs\" aria-errormessage=\"wpforms-77-field_96_19-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_19\">Special Dietary Needs<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_22\" name=\"wpforms[fields][96][]\" value=\"Wear a device for spinal stabilization\" aria-errormessage=\"wpforms-77-field_96_22-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_22\">Wear a device for spinal stabilization<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_96_21\" name=\"wpforms[fields][96][]\" value=\"Other (specify)\" aria-errormessage=\"wpforms-77-field_96_21-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_96_21\">Other (specify)<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-77-field_78-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"78\"><label class=\"wpforms-field-label\" for=\"wpforms-77-field_78\">Please Describe (if Other):<\/label><textarea id=\"wpforms-77-field_78\" class=\"wpforms-field-medium\" name=\"wpforms[fields][78]\" aria-errormessage=\"wpforms-77-field_78-error\" ><\/textarea><\/div><div id=\"wpforms-77-field_57-container\" class=\"wpforms-field wpforms-field-divider wpforms-field-divider-hide_line\" data-field-id=\"57\"><h3 id=\"wpforms-77-field_57\" aria-errormessage=\"wpforms-77-field_57-error\">LIMITATIONS FOR ACTIVITY<\/h3><\/div><div id=\"wpforms-77-field_55-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"55\"><fieldset><legend class=\"wpforms-field-label\">Has any physician advised you to limit your activity? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-77-field_55\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_55_1\" name=\"wpforms[fields][55][]\" value=\"Yes\" aria-errormessage=\"wpforms-77-field_55_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_55_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_55_2\" name=\"wpforms[fields][55][]\" value=\"No\" aria-errormessage=\"wpforms-77-field_55_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_55_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-77-field_56-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-77-field_56\">If YES, please describe:<\/label><textarea id=\"wpforms-77-field_56\" class=\"wpforms-field-medium\" name=\"wpforms[fields][56]\" aria-errormessage=\"wpforms-77-field_56-error\" ><\/textarea><\/div><div id=\"wpforms-77-field_60-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"60\"><label class=\"wpforms-field-label\" for=\"wpforms-77-field_60\">Please indicate the contraindications for activity that will require special attention?<\/label><textarea id=\"wpforms-77-field_60\" class=\"wpforms-field-medium\" name=\"wpforms[fields][60]\" aria-errormessage=\"wpforms-77-field_60-error\" ><\/textarea><\/div><div id=\"wpforms-77-field_80-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"80\"><fieldset><legend class=\"wpforms-field-label\">Do you have a Hx of any back, shoulder, knee, or other joint problems? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-77-field_80\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_80_1\" name=\"wpforms[fields][80][]\" value=\"Yes\" aria-errormessage=\"wpforms-77-field_80_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_80_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_80_2\" name=\"wpforms[fields][80][]\" value=\"No\" aria-errormessage=\"wpforms-77-field_80_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_80_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-77-field_82-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"82\"><label class=\"wpforms-field-label\" for=\"wpforms-77-field_82\">If YES, please describe:<\/label><textarea id=\"wpforms-77-field_82\" class=\"wpforms-field-medium\" name=\"wpforms[fields][82]\" aria-errormessage=\"wpforms-77-field_82-error\" ><\/textarea><\/div><div id=\"wpforms-77-field_81-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"81\"><fieldset><legend class=\"wpforms-field-label\">Any surgery in the last 6 months? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-77-field_81\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_81_1\" name=\"wpforms[fields][81][]\" value=\"Yes\" aria-errormessage=\"wpforms-77-field_81_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_81_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_81_2\" name=\"wpforms[fields][81][]\" value=\"No\" aria-errormessage=\"wpforms-77-field_81_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_81_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-77-field_83-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"83\"><label class=\"wpforms-field-label\" for=\"wpforms-77-field_83\">If YES, please describe:<\/label><textarea id=\"wpforms-77-field_83\" class=\"wpforms-field-medium\" name=\"wpforms[fields][83]\" aria-errormessage=\"wpforms-77-field_83-error\" ><\/textarea><\/div><div id=\"wpforms-77-field_84-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"84\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"2\" data-formid=\"77\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"2\" data-formid=\"77\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3 last \" data-page=\"3\" style=\"display:none;\"><div id=\"wpforms-77-field_85-container\" class=\"wpforms-field wpforms-field-divider wpforms-field-divider-hide_line\" data-field-id=\"85\"><h3 id=\"wpforms-77-field_85\" aria-errormessage=\"wpforms-77-field_85-error\">PRESCRIPTION MEDICATIONS<\/h3><\/div><div id=\"wpforms-77-field_86-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"86\"><fieldset><legend class=\"wpforms-field-label\">Currently taking any medications? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-77-field_86\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_86_1\" name=\"wpforms[fields][86][]\" value=\"Yes\" aria-errormessage=\"wpforms-77-field_86_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_86_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_86_2\" name=\"wpforms[fields][86][]\" value=\"No\" aria-errormessage=\"wpforms-77-field_86_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_86_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-77-field_87-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"87\"><label class=\"wpforms-field-label\" for=\"wpforms-77-field_87\">Please list any medication that will be taken during the program \/ event:<\/label><textarea id=\"wpforms-77-field_87\" class=\"wpforms-field-medium\" name=\"wpforms[fields][87]\" aria-errormessage=\"wpforms-77-field_87-error\" aria-describedby=\"wpforms-77-field_87-description\" ><\/textarea><div id=\"wpforms-77-field_87-description\" class=\"wpforms-field-description\">Name of Medication \/ Purpose \/ Amount \/ Frequency \/ Time<\/div><\/div><div id=\"wpforms-77-field_88-container\" class=\"wpforms-field wpforms-field-divider wpforms-field-divider-hide_line\" data-field-id=\"88\"><h3 id=\"wpforms-77-field_88\" aria-errormessage=\"wpforms-77-field_88-error\">ASSISTIVE DEVICES \/ MOBILITY EQUIPMENT USED<\/h3><\/div><div id=\"wpforms-77-field_97-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"97\"><fieldset><legend class=\"wpforms-field-label\">Please check (\u2714\ufe0f) any that apply and describe below<\/legend><ul id=\"wpforms-77-field_97\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_97_1\" name=\"wpforms[fields][97][]\" value=\"Cane(s)\" aria-errormessage=\"wpforms-77-field_97_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_97_1\">Cane(s)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_97_2\" name=\"wpforms[fields][97][]\" value=\"Electric Wheelchair\u200e\" aria-errormessage=\"wpforms-77-field_97_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_97_2\">Electric Wheelchair\u200e<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_97_3\" name=\"wpforms[fields][97][]\" value=\"Manual Wheelchair\u200e\" aria-errormessage=\"wpforms-77-field_97_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_97_3\">Manual Wheelchair\u200e<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_97_5\" name=\"wpforms[fields][97][]\" value=\"Forearm Crutches\" aria-errormessage=\"wpforms-77-field_97_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_97_5\">Forearm Crutches<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_97_4\" name=\"wpforms[fields][97][]\" value=\"Lower Extremity Orthotic\" aria-errormessage=\"wpforms-77-field_97_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_97_4\">Lower Extremity Orthotic<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_97_7\" name=\"wpforms[fields][97][]\" value=\"Lower Extremity Prosthesis\" aria-errormessage=\"wpforms-77-field_97_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_97_7\">Lower Extremity Prosthesis<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_97_6\" name=\"wpforms[fields][97][]\" value=\"Upper Extremity Orthotic\u200e\" aria-errormessage=\"wpforms-77-field_97_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_97_6\">Upper Extremity Orthotic\u200e<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_97_9\" name=\"wpforms[fields][97][]\" value=\"Upper Extremity Prosthesis\" aria-errormessage=\"wpforms-77-field_97_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_97_9\">Upper Extremity Prosthesis<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_97_8\" name=\"wpforms[fields][97][]\" value=\"Segway\" aria-errormessage=\"wpforms-77-field_97_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_97_8\">Segway<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_97_11\" name=\"wpforms[fields][97][]\" value=\"Walker\" aria-errormessage=\"wpforms-77-field_97_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_97_11\">Walker<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_97_10\" name=\"wpforms[fields][97][]\" value=\"Other (specify)\" aria-errormessage=\"wpforms-77-field_97_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_97_10\">Other (specify)<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-77-field_90-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"90\"><label class=\"wpforms-field-label\" for=\"wpforms-77-field_90\">Please Describe (if Other): <\/label><textarea id=\"wpforms-77-field_90\" class=\"wpforms-field-medium\" name=\"wpforms[fields][90]\" aria-errormessage=\"wpforms-77-field_90-error\" ><\/textarea><\/div><div id=\"wpforms-77-field_91-container\" class=\"wpforms-field wpforms-field-divider wpforms-field-divider-hide_line\" data-field-id=\"91\"><h3 id=\"wpforms-77-field_91\" aria-errormessage=\"wpforms-77-field_91-error\">FUNCTIONAL MOBILITY<\/h3><\/div><div id=\"wpforms-77-field_98-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"98\"><fieldset><legend class=\"wpforms-field-label\">Please check (\u2714\ufe0f) any that apply and describe below<\/legend><ul id=\"wpforms-77-field_98\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_98_1\" name=\"wpforms[fields][98][]\" value=\"Requires assistance for some walking: ascending\/descending moderate inclines, uneven or rough terrain\u200e\" aria-errormessage=\"wpforms-77-field_98_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_98_1\">Requires assistance for some walking: ascending\/descending moderate inclines, uneven or rough terrain\u200e<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_98_2\" name=\"wpforms[fields][98][]\" value=\"Requires assistance for some wheelchair mobility: ascending\/descending moderate inclines, uneven or rough terrain, transfers\u200e\" aria-errormessage=\"wpforms-77-field_98_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_98_2\">Requires assistance for some wheelchair mobility: ascending\/descending moderate inclines, uneven or rough terrain, transfers\u200e<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-77-field_98_3\" name=\"wpforms[fields][98][]\" value=\"Other (specify)\" aria-errormessage=\"wpforms-77-field_98_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-77-field_98_3\">Other (specify)<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-77-field_93-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"93\"><label class=\"wpforms-field-label\" for=\"wpforms-77-field_93\">Please Describe (if Other):<\/label><textarea id=\"wpforms-77-field_93\" class=\"wpforms-field-medium\" name=\"wpforms[fields][93]\" aria-errormessage=\"wpforms-77-field_93-error\" ><\/textarea><\/div>\t\t<div id=\"wpforms-77-field_1-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"1\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-77-field_1\" >check Please list<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-77-field_1\" class=\"wpforms-field-medium\" name=\"wpforms[fields][1]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-77-field_40-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"40\"><fieldset><legend class=\"wpforms-field-label\">Name of Participant <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-77-field_40\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][40][first]\" aria-errormessage=\"wpforms-77-field_40-error\" required><label for=\"wpforms-77-field_40\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-77-field_40-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][40][last]\" aria-errormessage=\"wpforms-77-field_40-last-error\" required><label for=\"wpforms-77-field_40-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-77-field_5-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-77-field_5\">Date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-77-field_5\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-small\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][5][date]\" aria-errormessage=\"wpforms-77-field_5-error\" aria-describedby=\"wpforms-77-field_5-description\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><div id=\"wpforms-77-field_5-description\" class=\"wpforms-field-description\">MM\/DD\/YYYY<\/div><\/div><div id=\"wpforms-77-field_67-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"67\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"3\" data-formid=\"77\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><\/div><\/div><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-77-field_1-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-77-field_1-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-77-field_1-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-recaptcha-container wpforms-is-recaptcha wpforms-is-recaptcha-type-v2\" style=\"display:none;\"><div class=\"g-recaptcha\" data-sitekey=\"6LcWcdsrAAAAALa0EAsXIjgMDjXocwF5kaGapUvY\"><\/div><input type=\"text\" name=\"g-recaptcha-hidden\" class=\"wpforms-recaptcha-hidden\" style=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\" data-rule-recaptcha=\"1\"><\/div><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"77\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/taonline.org\/v3\/wp-json\/wp\/v2\/pages\/13\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-77\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/taonline.org\/v3\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-13","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/taonline.org\/v3\/wp-json\/wp\/v2\/pages\/13","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/taonline.org\/v3\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/taonline.org\/v3\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/taonline.org\/v3\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/taonline.org\/v3\/wp-json\/wp\/v2\/comments?post=13"}],"version-history":[{"count":2,"href":"https:\/\/taonline.org\/v3\/wp-json\/wp\/v2\/pages\/13\/revisions"}],"predecessor-version":[{"id":93,"href":"https:\/\/taonline.org\/v3\/wp-json\/wp\/v2\/pages\/13\/revisions\/93"}],"wp:attachment":[{"href":"https:\/\/taonline.org\/v3\/wp-json\/wp\/v2\/media?parent=13"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}