Online Inquiry
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<ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Name_Last_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name</label><input name="CST_2" type="text" class="er_fld_required er_fld_width100"><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Name_First_A"> <i class="fa fa-font"></i><label class="er_fld_label required">First Name</label><input name="CST_1" type="text" class="er_fld_required er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="FH_Phone_Home" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone Number</label><input name="CST_7" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" map_to="FH_EMail" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Email Address</label><input name="CST_5" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;" map_to="FH_Address_County"><i class="fa fa-caret-down"></i><label class="er_fld_label required">County </label><select name="CST_10" class="er_fld_required er_fld_width100"><option value=""></option><option value="Banks">Banks</option><option value="Barrow">Barrow</option><option value="Butts">Butts</option><option value="Carroll">Carroll</option><option value="Cherokee">Cherokee</option><option value="Clarke">Clarke</option><option value="Clayton">Clayton</option><option value="Cobb">Cobb</option><option value="Columbia">Columbia</option><option value="Coweta">Coweta</option><option value="Dawson">Dawson</option><option value="De Kalb">De Kalb</option><option value="Douglas">Douglas</option><option value="Fayette">Fayette</option><option value="Forsyth">Forsyth</option><option value="Franklin">Franklin</option><option value="Fulton">Fulton</option><option value="Gwinnett">Gwinnett</option><option value="Habersham">Habersham</option><option value="Hall">Hall</option><option value="Hancock">Hancock</option><option value="Heard">Heard</option><option value="Henry">Henry</option><option value="Jackson">Jackson</option><option value="Lincoln">Lincoln</option><option value="Lumpkin">Lumpkin</option><option value="McDuffie">McDuffie</option><option value="Meriwether">Meriwether</option><option value="Newton">Newton</option><option value="Oconee">Oconee</option><option value="Oglethorpe">Oglethorpe</option><option value="Paulding">Paulding</option><option value="Pike">Pike</option><option value="Richmond">Richmond</option><option value="Rockdale">Rockdale</option><option value="Spalding">Spalding</option><option value="Stephens">Stephens</option><option value="Taliaferro">Taliaferro</option><option value="Troup">Troup</option><option value="Walton">Walton</option><option value="Warren">Warren</option><option value="White">White</option><option value="Wilkes">Wilkes</option></select></li><li class="er_fld_type_text" draggable="false" map_to="FH_Address_Zip" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Zip Code</label><input name="CST_9" type="text" class="er_fld_required er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_selected" draggable="false" style="width: 50%;" map_to="FH_ReferralSource"><i class="fa fa-caret-down"></i><label class="er_fld_label required">How were you referred to us?</label><select name="CST_11" class="er_fld_width100 er_fld_required"><option value=""></option><option value="Community Event">Community Event</option><option value="Church">Church</option><option value="Radio/TV advertisement">Radio/TV advertisement</option><option value="Social Media">Social Media</option><option value="Wellroot Employee">Wellroot Employee</option><option value="Wellroot Foster Parent">Wellroot Foster Parent</option><option value="Other Agency or DFCS Foster Parent">Other Agency or DFCS Foster Parent</option><option value="Wellroot Supporter">Wellroot Supporter</option><option value="Wellroot Website ">Wellroot Website </option><option value="DFCS Employee">DFCS Employee</option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" map_to="FH_Inquiry_How_Referred" er_fld_condfld="CST_11" er_fld_condvals="er_fld_showif_values=Other"> <i class="fa fa-font"></i><label class="er_fld_label required">Other</label><input name="CST_12" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_normal">Only Georgia Counties Served By Our Foster Care Office Are Listed.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Interested in Mentoring?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_14" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_14" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_14" value="Other:">Other:<input class="cst_Other" name="CST_14_Other" type="text"></label> </li><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Interested in Adopting?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_13" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_13" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_13" value="Other:">Other:<input class="cst_Other" name="CST_13_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Interested in Fostering</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_15" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_15" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_15" value="Other:">Other:<input class="cst_Other" name="CST_15_Other" type="text"></label> </li><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Interested in attending a recruitment event?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_16" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_16" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_16" value="Other:">Other:<input class="cst_Other" name="CST_16_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">What age child(ren) are you interested in fostering?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_17" value="0-5 years">0-5 years</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_17" value="6-12 years">6-12 years</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_17" value="13+ years">13+ years</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_17" value="Not applicable">Not applicable</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_17" value="Other:">Other:<input class="cst_Other" name="CST_17_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Are you willing to foster siblings?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_18" value="Yes">Yes</label><label class="er_option"><input class="type_radio" type="radio" name="CST_18" value="No">No</label><label class="er_option"><input class="type_radio" type="radio" name="CST_18" value="Maybe">Maybe</label><label class="er_option"><input class="type_radio" type="radio" name="CST_18" value="Not applicable">Not applicable</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_18" value="Other:">Other:<input class="cst_Other" name="CST_18_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Dropdown</label><select name="CST_19"><option value="I am interested in learning more about becoming a foster or adoptive parent.">I am interested in learning more about becoming a foster or adoptive parent.</option><option value="I have questions and would like to speak with someone.">I have questions and would like to speak with someone.</option><option value="Let's go! I am ready to get started. ">Let's go! I am ready to get started. </option><option value="I am only interested in mentoring right now.">I am only interested in mentoring right now.</option><option value="Not applicable. ">Not applicable. </option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Preferred form of contact?</label><select name="CST_20"><option value="Text">Text</option><option value="Call">Call</option><option value="Email">Email</option></select></li></ul>
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