{"id":26854,"date":"2024-09-24T21:11:21","date_gmt":"2024-09-24T21:11:21","guid":{"rendered":"https:\/\/heartgift.org\/?page_id=26854"},"modified":"2024-09-24T21:21:53","modified_gmt":"2024-09-24T21:21:53","slug":"grant-application-form","status":"publish","type":"page","link":"https:\/\/heartgift.org\/es\/grant-application-form\/","title":{"rendered":"Grant Application Form"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"26854\" class=\"elementor elementor-26854\">\n\t\t\t\t<div class=\"elementor-element elementor-element-669338f e-flex e-con-boxed e-con e-parent\" data-id=\"669338f\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div data-custom-animations=\"true\" data-ca-options=\"{&quot;addChildTimelines&quot;:false,&quot;trigger&quot;:&quot;firstChild&quot;,&quot;animationTarget&quot;:&quot;.lqd-split-words 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transform=\"translate(0 0.002)\"\/><\/svg><\/span><\/mark><\/span><\/h1>\t\t<\/div>\n\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<div class=\"elementor-element elementor-element-b6ff69f e-flex e-con-boxed e-con e-parent\" data-id=\"b6ff69f\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-db0726b elementor-widget elementor-widget-shortcode\" data-id=\"db0726b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework gf_stylespro_wrapper sp_flat_wrapper' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_12' ><div id='gf_12' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'>To expand HeartGift's mission and increase access to care for children in Asia, Africa, and Latin America affected by congenital heart defects, we will collaborate with local experts to establish or enhance pediatric cardiac programs. By connecting healthcare professionals, volunteers, and resources, we aim to create sustainable solutions that provide life-saving care to families in need.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_12' class='gf_stylespro sp_flat' action='\/es\/wp-json\/wp\/v2\/pages\/26854#gf_12' data-formid='12' novalidate data-trp-original-action=\"\/es\/wp-json\/wp\/v2\/pages\/26854#gf_12\"><input id=\"partial_entry_id_12\" class=\"partial_entry_id\" type=\"hidden\" name=\"partial_entry_id\" value=\"pending\" data-form_id=\"12\"\/>\n        <div id='gf_progressbar_wrapper_12' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>5<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_20' style='width:20%;'><span>20%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_12_1' class='gform_page' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_12' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_12_6\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_left o_medium\"  data-field-class=\"gf_left o_medium\" ><h3>ORGANIZATION PROFILE<\/h3><\/li><li id=\"field_12_119\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_newline gf_left o_medium\"  data-field-class=\"gf_half gf_newline gf_left o_medium\" ><label class='gfield_label gform-field-label' for='input_12_119'>Name of qualified organization and mission:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_119' id='input_12_119' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_195\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half o_medium\"  data-field-class=\"gf_half o_medium\" ><label class='gfield_label gform-field-label' for='input_12_195'>Contact: Name, Email, Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_195' id='input_12_195' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_269\" class=\"gfield gfield--type-website gfield--input-type-website gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_269'>Organization website:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_website'>\n                    <input name='input_269' id='input_12_269' type='url' value='' class='large'    placeholder='https:\/\/' aria-required=\"true\" aria-invalid=\"false\" \/>\n                <\/div><\/li><li id=\"field_12_271\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_271'>Annual operating budget<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_271' id='input_12_271' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_287\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_287'>Percentage requested to overall budget<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_287' id='input_12_287' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_272\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_272'>Federal incorporation number &amp; year of incorporation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_272' id='input_12_272' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_212\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_212'>Mailing address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_212' id='input_12_212' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_303\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_303'>Number of employees (full\/part-time), Number of volunteers, and Number of board members<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_303' id='input_12_303' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_210\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_210'>Please attach Audited Financials<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='52428800' \/><input name='input_210' id='input_12_210' type='file' class='large' aria-describedby=\"gfield_upload_rules_12_210\" onchange='javascript:gformValidateFileSize( this, 52428800 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_12_210'>Max. file size: 50 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_12_210'><\/div> <\/div><\/li><li id=\"field_12_211\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_211'>Please attach Most Recent Form 990<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='52428800' \/><input name='input_211' id='input_12_211' type='file' class='large' aria-describedby=\"gfield_upload_rules_12_211\" onchange='javascript:gformValidateFileSize( this, 52428800 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_12_211'>Max. file size: 50 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_12_211'><\/div> <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_12_276' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_12_2_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_12_2' class='gform_page' data-js='page-field-id-276' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_12_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_12_170\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>REQUEST:<\/h3><\/li><li id=\"field_12_214\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-seven-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_214'>Grant request:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_214' id='input_12_214' type='text' step='any'   value='' class='large'    placeholder='$' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_12_215\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_215'>Children to be served by grant:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_215' id='input_12_215' type='number' step='any'   value='' class='large'    placeholder='#' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_12_216\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_216'>Location of the program<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_216' id='input_12_216' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_288\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Mission Trip:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_12_288'>\n\t\t\t<li class='gchoice gchoice_12_288_0'>\n\t\t\t\t<input name='input_288' type='radio' value='Yes'  id='choice_12_288_0'    \/>\n\t\t\t\t<label for='choice_12_288_0' id='label_12_288_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_12_288_1'>\n\t\t\t\t<input name='input_288' type='radio' value='No'  id='choice_12_288_1'    \/>\n\t\t\t\t<label for='choice_12_288_1' id='label_12_288_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_12_297\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Training Trip:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_12_297'>\n\t\t\t<li class='gchoice gchoice_12_297_0'>\n\t\t\t\t<input name='input_297' type='radio' value='Yes'  id='choice_12_297_0'    \/>\n\t\t\t\t<label for='choice_12_297_0' id='label_12_297_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_12_297_1'>\n\t\t\t\t<input name='input_297' type='radio' value='No'  id='choice_12_297_1'    \/>\n\t\t\t\t<label for='choice_12_297_1' id='label_12_297_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_12_217\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Direct Surgical Care<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_12_217'>\n\t\t\t<li class='gchoice gchoice_12_217_0'>\n\t\t\t\t<input name='input_217' type='radio' value='Yes'  id='choice_12_217_0'    \/>\n\t\t\t\t<label for='choice_12_217_0' id='label_12_217_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_12_217_1'>\n\t\t\t\t<input name='input_217' type='radio' value='No'  id='choice_12_217_1'    \/>\n\t\t\t\t<label for='choice_12_217_1' id='label_12_217_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_12_298\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Other<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_12_298'>\n\t\t\t<li class='gchoice gchoice_12_298_0'>\n\t\t\t\t<input name='input_298' type='radio' value='Yes'  id='choice_12_298_0'    \/>\n\t\t\t\t<label for='choice_12_298_0' id='label_12_298_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_12_298_1'>\n\t\t\t\t<input name='input_298' type='radio' value='No'  id='choice_12_298_1'    \/>\n\t\t\t\t<label for='choice_12_298_1' id='label_12_298_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_12_221\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_221'>Please outline training trip programs, estimate number of hours, and number of medical professionals being trained:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_221' id='input_12_221' class='textarea large'  aria-describedby=\"gfield_description_12_221\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_12_221'>Describe the need to be addressed by your program and how your program will address that need with the requested funding.<\/div><\/li><li id=\"field_12_218\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Funding for an existing program:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_12_218'>\n\t\t\t<li class='gchoice gchoice_12_218_0'>\n\t\t\t\t<input name='input_218' type='radio' value='Yes'  id='choice_12_218_0'    \/>\n\t\t\t\t<label for='choice_12_218_0' id='label_12_218_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_12_218_1'>\n\t\t\t\t<input name='input_218' type='radio' value='No'  id='choice_12_218_1'    \/>\n\t\t\t\t<label for='choice_12_218_1' id='label_12_218_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_12_289\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_289'>PROGRAM REQUEST:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_289' id='input_12_289' class='textarea large'  aria-describedby=\"gfield_description_12_289\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_12_289'>Describe the need to be addressed by your program and how your program will address that need with the requested funding.<\/div><\/li><li id=\"field_12_299\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_299'>If Mission Trip, detail hospital, sustainability plan:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_299' id='input_12_299' class='textarea large'  aria-describedby=\"gfield_description_12_299\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_12_299'>Fill with N\/A if not applicable.<\/div><\/li><li id=\"field_12_300\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_300'>If Training Trip, detail training plan, total hours, staff, etc:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_300' id='input_12_300' class='textarea large'  aria-describedby=\"gfield_description_12_300\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_12_300'>Fill with N\/A if not applicable.<\/div><\/li><li id=\"field_12_302\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_302'>If Direct Surgical Care, detail existing hospital care capabilities:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_302' id='input_12_302' class='textarea large'  aria-describedby=\"gfield_description_12_302\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_12_302'>Fill with N\/A if not applicable.<\/div><\/li><li id=\"field_12_301\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_301'>If Other, outline request of need in detail:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_301' id='input_12_301' class='textarea large'  aria-describedby=\"gfield_description_12_301\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_12_301'>Fill with N\/A if not applicable.<\/div><\/li><li id=\"field_12_222\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_222'>Stakeholder Support:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_222' id='input_12_222' class='textarea large'  aria-describedby=\"gfield_description_12_222\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_12_222'>Describe stakeholder support and how the project may impact the priority of increasing surgical care to children.<\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_12_277' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_12_277' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_12_3_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_12_3' class='gform_page' data-js='page-field-id-277' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_12_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_12_223\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>PROGRAM DETAILS<\/h3>\n<p>If the request is for an ESTABLISHED PROGRAM, provide the following:<\/p><\/li><li id=\"field_12_225\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_225'>How long has program been established:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_225' id='input_12_225' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_226\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_226'>Name of in-country surgeon:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_226' id='input_12_226' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_227\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_227'>Name of in-country cardiologist:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_227' id='input_12_227' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_290\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_290'>In-country program coordinator name, email, phone number:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_290' id='input_12_290' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_228\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_228'>If medical mission trip, list name of surgeon(s) and cardiologist(s) attending trip:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_228' id='input_12_228' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_291\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_291'>Total number of medical professionals traveling:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_291' id='input_12_291' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_292\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_292'>Number of medical professional to be trained on medical mission trip:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_292' id='input_12_292' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_293\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_293'>Estimated of total number of training hours on medical mission trip:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_293' id='input_12_293' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_233\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>If the request is for a MISSION TRIP provide the following:<\/p><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_12_283' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_12_283' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_12_4_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_12_4' class='gform_page' data-js='page-field-id-283' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_12_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_12_240\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>GOALS & OVERSIGHT:<\/h3><\/li><li id=\"field_12_242\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_242'>How will you measure progress and success of the program?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_242' id='input_12_242' class='textarea large'  aria-describedby=\"gfield_description_12_242\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_12_242'>State the goals, objectives, and evaluation plan.<\/div><\/li><li id=\"field_12_244\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>PROGRAM IMPACT:<\/h3><\/li><li id=\"field_12_246\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_246'>What is the impact your program has on the community it serves?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_246' id='input_12_246' class='textarea large'  aria-describedby=\"gfield_description_12_246\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_12_246'>Explain country demographics, region served, and the impact this program will have on this region. (e.g., number of children on a waiting list, expected long-term changes that will occur as a result of this work).<\/div><\/li><li id=\"field_12_247\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_247'>What is the sustainability plan for this program?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_247' id='input_12_247' class='textarea large'  aria-describedby=\"gfield_description_12_247\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_12_247'>Provide a detailed plan on how this program is\/will be sustainable.<\/div><\/li><li id=\"field_12_248\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_248'>COLLABORATION: List other NGO&#039;s\/NPO&#039;s you are working with.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_248' id='input_12_248' class='textarea large'  aria-describedby=\"gfield_description_12_248\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_12_248'>What partnerships currently exist or need to be established to implement this program?<\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_12_278' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_12_278' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_12_5_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_12_5' class='gform_page' data-js='page-field-id-278' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_12_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_12_249\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>USE OF FUNDS:<\/h3>\n<p>HeartGift will NOT fund the following:<\/p>\n<ul class=\"two-column-list\">\n    <li>Lobbying, Political, or Religious Efforts<\/li>\n    <li>Cellphone, Internet, Roaming<\/li>\n    <li>Photography, Videography<\/li>\n    <li>Scrubs, Shirts, and Clothing for medical teams<\/li>\n    <li>Upgraded flights, hotel incidentals<\/li>\n    <li>Expedited or Late Fees of any kind, fees for travel documents<\/li>\n    <li>Vaccinations<\/li>\n    <li>Compensation of any kind to staff or medical professionals<\/li>\n    <li>Multi-year requests<\/li>\n    <li>Food\/Beverage\/Meals<\/li>\n    <li>Care for Rheumatic Heart Disease<\/li>\n    <li>Children served over 14<\/li>\n    <li>Intra-country airfare<\/li>\n<\/ul>\n<\/li><li id=\"field_12_250\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >\n<p>Allowable funds requested based on annual revenue: <\/p>\n<ul class=\"two-column-list\">\n    <li>$1 - $200,000: <span>request not to exceed 50% of budget<\/span><\/li>\n    <li>$200,001 - $800,000: <span>request not to exceed 45% of budget<\/span><\/li>\n    <li>$800,001+: <span>request not to exceed 25% of budget<\/span><\/li>\n<\/ul>\n<\/li><li id=\"field_12_251\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >\n<p>Specify how funds will be used.<\/p><\/li><li id=\"field_12_252\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_252'>Total amount requested for surgical cases:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_252' id='input_12_252' type='text' step='any'   value='' class='large'    placeholder='$0.00' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_12_295\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_295'>Total Surgeries Provided:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_295' id='input_12_295' type='number' step='any'   value='' class='large'    placeholder='#' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_12_253\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_253'>Total amount requested for catheterization cases:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_253' id='input_12_253' type='text' step='any'   value='' class='large'    placeholder='$0.00' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_12_296\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_296'>Total Catheterization&#039;s Provided:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_296' id='input_12_296' type='number' step='any'   value='' class='large'    placeholder='#' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_12_255\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_255'>Patient Insurance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_255' id='input_12_255' type='text' step='any'   value='' class='large'    placeholder='$0.00' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_12_256\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_256'>Patient Housing<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_256' id='input_12_256' type='text' step='any'   value='' class='large'    placeholder='$0.00' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_12_257\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_257'>Patient Travel<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_257' id='input_12_257' type='text' step='any'   value='' class='large'    placeholder='$0.00' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_12_258\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_258'>Screening<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_258' id='input_12_258' type='text' step='any'   value='' class='large'    placeholder='$0.00' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_12_259\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_259'>Medications<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_259' id='input_12_259' type='text' step='any'   value='' class='large'    placeholder='$0.00' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_12_260\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_260'>Follow up care<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_260' id='input_12_260' type='text' step='any'   value='' class='large'    placeholder='$0.00' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_12_261\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_261'>Consumables<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_261' id='input_12_261' type='text' step='any'   value='' class='large'    placeholder='$0.00' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_12_262\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_262'>Medical Team Airfare<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_262' id='input_12_262' type='text' step='any'   value='' class='large'    placeholder='$0.00' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_12_263\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_263'>Medical Team Ground Transportation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_263' id='input_12_263' type='text' step='any'   value='' class='large'    placeholder='$0.00' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_12_264\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_264'>Medical Team Lodging<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_264' id='input_12_264' type='text' step='any'   value='' class='large'    placeholder='$0.00' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_12_265\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_265'>Shipment for Supplies<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_265' id='input_12_265' type='text' step='any'   value='' class='large'    placeholder='$0.00' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_12_96\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_newline gf_left o_medium\"  data-field-class=\"gf_newline gf_left o_medium\" ><label class='gfield_label gform-field-label' for='input_12_96'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div ><div id='input_12_96_Container' style='height:180px; width:550px; ' ><input type='hidden' class='gform_hidden' name='input_12_96_valid' id='input_12_96_valid' \/><canvas id='input_12_96' width='550' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_12_279\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_279'>Submitted By<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_279' id='input_12_279' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_281\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_281'>Correo electr\u00f3nico<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_281' id='input_12_281' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_12_282\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_282'>Tel\u00e9fono<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_282' id='input_12_282' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_5\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_5'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_5' id='input_12_5' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_12_5_date_format gfield_description_12_5\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_12_5_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_12_5' class='gform_hidden' value='https:\/\/heartgift.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_12_5'>By signing my legal name above, I acknowledge that I have read and understand the policies as contained herein.<\/div><\/li><\/ul><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_12' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_12' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Enviar'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_12_footer_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_12' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_12' id='gform_theme_12' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' 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