{"id":27083,"date":"2024-12-13T11:55:55","date_gmt":"2024-12-13T11:55:55","guid":{"rendered":"https:\/\/heartgift.org\/?page_id=27083"},"modified":"2025-03-10T15:14:58","modified_gmt":"2025-03-10T15:14:58","slug":"refer-a-child","status":"publish","type":"page","link":"https:\/\/heartgift.org\/es\/refer-a-child\/","title":{"rendered":"Referir a un ni\u00f1o"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"27083\" class=\"elementor elementor-27083\">\n\t\t\t\t<div class=\"elementor-element elementor-element-17040b56 e-flex e-con-boxed e-con e-parent\" data-id=\"17040b56\" 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<div class=\"elementor-element elementor-element-48cfbe4c e-flex e-con-boxed e-con e-child\" data-id=\"48cfbe4c\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-750d49c5 e-con-full e-flex e-con e-child\" data-id=\"750d49c5\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4f8cbc33 elementor-widget elementor-widget-hub_fancy_heading\" data-id=\"4f8cbc33\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"hub_fancy_heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\n\t\t<div id=\"ld-fancy-heading-69e0a26059412\" class=\"ld-fancy-heading pos-rel\">\n\t\t\t<h1 class=\"ld-fh-element d-inline-block pos-rel  elementor-heading-title lqd-highlight-classic lqd-highlight-grow-left h1\"  > REFER A CHILD<\/h1>\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6042d94f elementor-widget elementor-widget-text-editor\" data-id=\"6042d94f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>If you know a child with a congenital heart defect with limited access to specialized medical care, let us know.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-4f2cc2e6 e-con-full e-flex e-con e-child\" data-id=\"4f2cc2e6\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3755cc7 elementor-widget elementor-widget-image\" data-id=\"3755cc7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"1080\" height=\"1080\" src=\"https:\/\/heartgift.org\/wp-content\/uploads\/2025\/02\/6-1.png\" class=\"attachment-full size-full wp-image-28120\" alt=\"6 1\" srcset=\"https:\/\/heartgift.org\/wp-content\/uploads\/2025\/02\/6-1.png 1080w, https:\/\/heartgift.org\/wp-content\/uploads\/2025\/02\/6-1-300x300.png 300w, https:\/\/heartgift.org\/wp-content\/uploads\/2025\/02\/6-1-1024x1024.png 1024w, https:\/\/heartgift.org\/wp-content\/uploads\/2025\/02\/6-1-150x150.png 150w, https:\/\/heartgift.org\/wp-content\/uploads\/2025\/02\/6-1-320x320.png 320w, https:\/\/heartgift.org\/wp-content\/uploads\/2025\/02\/6-1-760x760.png 760w, https:\/\/heartgift.org\/wp-content\/uploads\/2025\/02\/6-1-400x400.png 400w, https:\/\/heartgift.org\/wp-content\/uploads\/2025\/02\/6-1-600x600.png 600w, https:\/\/heartgift.org\/wp-content\/uploads\/2025\/02\/6-1-500x500.png 500w, https:\/\/heartgift.org\/wp-content\/uploads\/2025\/02\/6-1-12x12.png 12w\" sizes=\"(max-width: 1080px) 100vw, 1080px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-1b8d5ab e-con-full e-flex e-con e-child\" data-id=\"1b8d5ab\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;position&quot;:&quot;absolute&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5a802f0 elementor-widget__width-initial elementor-absolute elementor-widget elementor-widget-hub_fancy_heading\" data-id=\"5a802f0\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_position&quot;:&quot;absolute&quot;}\" data-widget_type=\"hub_fancy_heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\n\t\t<div id=\"ld-fancy-heading-69e0a2605a9e9\" class=\"ld-fancy-heading pos-rel\">\n\t\t\t<h2 class=\"ld-fh-element d-inline-block pos-rel  elementor-heading-title lqd-highlight-classic lqd-highlight-grow-left h2\"  > Morgan | Uganda <br>\nLife saved in 2023<\/h2>\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-7338943 e-flex e-con-boxed e-con e-parent\" data-id=\"7338943\" 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 class=\"elementor-element elementor-element-ce97a68 elementor-widget elementor-widget-shortcode\" data-id=\"ce97a68\" 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 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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_10' ><div id='gf_10' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_10' class='gf_stylespro sp_flat' action='\/es\/wp-json\/wp\/v2\/pages\/27083#gf_10' data-formid='10' novalidate data-trp-original-action=\"\/es\/wp-json\/wp\/v2\/pages\/27083#gf_10\">\n        <div id='gf_progressbar_wrapper_10' 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'>8<\/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_12' style='width:12%;'><span>12%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_10_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_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_10_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_half gf_left o_medium\"  data-field-class=\"gf_half gf_left o_medium\" ><h5>HeartGift's medical selection criteria includes:<\/h5>\n<ul>\n<li>Be under age 14.<\/li>\n<li>Not have undergone previous cardiac surgery.<\/li>\n<li>Have a biventricular condition that can be repaired in one operation which include but may not be limited to the following types of defects:<\/li><ul>\n<li>Patent Ductus Arteriosis (PDA)<\/li>\n<li>Coarctation of the Aorta<\/li>\n<li>Atrial Septal Defect (ASD)<\/li>\n<li>Ventricular Septal Defect (VSD)<\/li>\n<li>Tetrology of Fallot (TOF)<\/li>\n<\/ul>\n<li>Have no chromosomal abnormalities.<\/li>\n<\/ul>\n<\/li><li id=\"field_10_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\"  ><h5>Application Requirements:<\/h5>\nAll requested information must be provided in order for the application to be considered by the Medical Review Committee. Missing information will delay the application until all necessary information is received. \n\nPlease be sure to include the following when filling out the online application:\n<ul>\n<li>Full legal name of the child<\/li>\n<li>Date of birth<\/li>\n<li>Current echocardiogram and report \u2013 Complete echocardiogram, including doppler images, performed within the past 3 months by a pediatric cardiologist or attending physician. We require a moving echocardiogram in DIACOM, MP4, or AVI format. No JPEG or still images will be accepted in place of the echocardiogram. <strong>The medical committee will not review a case without a moving echocardiogram.<\/strong><\/li>\n<li>Photo of Child<\/li>\n<li>Current immunization record<\/li>\n<li>Test results for the following:<\/li>\n<ul>\n<li>TB<\/li>\n<li>Malaria<\/li>\n<li>Hepatitis B&C<\/li>\n<li>HIV<\/li>\n<li>Parasites (may be asked to retake tests before traveling)<\/li>\n<li>Sickle Cell<\/li><\/ul>\n<li>ECG<\/li>\n<li>Chest X-ray<\/li>\n<li>Physicians letter detailing child\u2019s health history and current physical examination.<\/li>\n<li>Any additional medical records you may have that will help the medical committee in reviewing your case.<\/li>\n<\/ul>\n<p>All materials requested must have been generated within the last 3 months.<\/p> \n\nWe have developed this protocol based on the conditions that our medical teams are willing to accept\/treat. Our goal is to ensure a fair evaluation process and provide parents and children with realistic expectations once they submit the necessary information to us.\n<\/li><li id=\"field_10_119\" class=\"gfield gfield--type-text gfield--input-type-text 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_10_119'>Name of Child:<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_10_119' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_166\" class=\"gfield gfield--type-text gfield--input-type-text 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_10_166'>Diagnosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_166' id='input_10_166' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_120\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible o_medium\"  data-field-class=\"o_medium\" ><label class='gfield_label gform-field-label' for='input_10_120'>Name of Care Giver:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_120' id='input_10_120' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_149\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_newline o_medium\"  data-field-class=\"gf_newline o_medium\" ><label class='gfield_label gform-field-label' for='input_10_149'>Phone:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_149' id='input_10_149' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_151\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_newline o_medium\"  data-field-class=\"gf_newline o_medium\" ><label class='gfield_label gform-field-label' for='input_10_151'>Email:<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_151' id='input_10_151' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_10_150\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_newline o_medium\"  data-field-class=\"gf_newline o_medium\" ><label class='gfield_label gform-field-label' for='input_10_150'>Country:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_150' id='input_10_150' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_23\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" ><label class='gfield_label gform-field-label' for='input_10_23'>Language<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_10_23' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_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_10_96'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div ><div id='input_10_96_Container' style='height:180px; width:550px; ' ><input type='hidden' class='gform_hidden' name='input_10_96_valid' id='input_10_96_valid' \/><canvas id='input_10_96' width='550' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_10_5\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_5'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_5' id='input_10_5' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_5_date_format gfield_description_10_5\" aria-invalid=\"false\" \/>\n                            <span id='input_10_5_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_5' class='gform_hidden' value='https:\/\/heartgift.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_10_5'>By signing my legal name above, I acknowledge that I have read and understand the policies as contained herein.<\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_10_20' 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_10_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_10_2' class='gform_page' data-js='page-field-id-20' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_10_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_10_121\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" ><label class='gfield_label gform-field-label' for='input_10_121'>Name of Caregiver<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_121' id='input_10_121' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_12\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" ><label class='gfield_label gform-field-label' for='input_10_12'>Born On<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_12' id='input_10_12' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_10_12_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_12_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_12' class='gform_hidden' value='https:\/\/heartgift.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_10_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" ><label class='gfield_label gform-field-label' for='input_10_13'>Citizen of<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_10_13' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_11\" class=\"gfield gfield--type-text gfield--input-type-text 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_10_11'>Relationship to Child<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_10_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_118\" 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_left o_medium\"  data-field-class=\"gf_left o_medium\" ><label class='gfield_label gform-field-label' for='input_10_118'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div ><div id='input_10_118_Container' style='height:180px; width:550px; ' ><input type='hidden' class='gform_hidden' name='input_10_118_valid' id='input_10_118_valid' \/><canvas id='input_10_118' width='550' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_10_17\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible o_medium\"  data-field-class=\"o_medium\" ><label class='gfield_label gform-field-label' for='input_10_17'>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_17' id='input_10_17' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_10_17_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_17_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_17' class='gform_hidden' value='https:\/\/heartgift.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_10_19\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >By signing my legal name above, I acknowledge that I have read and understand the policies as contained herein.<\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_10_21' 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_10_21' 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_10_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_10_3' class='gform_page' data-js='page-field-id-21' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_10_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_10_33\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Medical History<\/h2><\/li><li id=\"field_10_122\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" ><label class='gfield_label gform-field-label' for='input_10_122'>Name of Child<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_122' id='input_10_122' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_163\" class=\"gfield gfield--type-text gfield--input-type-text 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_10_163'>Sex of Child<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_163' id='input_10_163' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_65\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" ><label class='gfield_label gform-field-label' for='input_10_65'>Child&#039;s Date of Birth<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_65' id='input_10_65' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_10_65_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_65_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_65' class='gform_hidden' value='https:\/\/heartgift.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_10_24\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" ><label class='gfield_label gform-field-label' for='input_10_24'>Referred 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_24' id='input_10_24' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_25\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" ><label class='gfield_label gform-field-label' for='input_10_25'>Contact Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_25' id='input_10_25' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_26\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" ><label class='gfield_label gform-field-label' for='input_10_26'>Contact Email<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_26' id='input_10_26' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_10_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" ><label class='gfield_label gform-field-label' for='input_10_27'>Primary Diagnosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_10_27' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" ><label class='gfield_label gform-field-label' for='input_10_28'>Referring Physician<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_10_28' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_186\" 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_10_186'>Physician 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_186' id='input_10_186' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_187\" 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_10_187'>Clinic\/Hospital Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_187' id='input_10_187' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_185\" 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_10_185'>Clinic\/Hospital 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_185' id='input_10_185' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_35\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_10_35'>Medical History of Child<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_10_35' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_10_36\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_10_36'>Parent, name, address, phone # &amp; medical history<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_36' id='input_10_36' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_10_154\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_right o_medium\"  data-field-class=\"gf_half gf_right o_medium\" ><label class='gfield_label gform-field-label' for='input_10_154'>Please list any previous hospitalizations, surgeries, or procedures.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_154' id='input_10_154' class='textarea medium'  aria-describedby=\"gfield_description_10_154\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_10_154'>If none, write NONE.<\/div><\/li><li id=\"field_10_42\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_10_42'>Post-op &amp; follow-up care available with physician?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_42' id='input_10_42' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_10_153\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_left o_medium\"  data-field-class=\"gf_half gf_left o_medium\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >KNOWN BIRTH DEFECTS AND\/OR SYNDROMES<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_10_153'><li class='gchoice gchoice_10_153_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_153.1' type='checkbox'  value='Cleft Palate'  id='choice_10_153_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_153_1' id='label_10_153_1' class='gform-field-label gform-field-label--type-inline'>Cleft Palate<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_153_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_153.2' type='checkbox'  value='Trisomy 21'  id='choice_10_153_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_153_2' id='label_10_153_2' class='gform-field-label gform-field-label--type-inline'>Trisomy 21<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_153_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_153.3' type='checkbox'  value='None'  id='choice_10_153_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_153_3' id='label_10_153_3' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_153_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_153.4' type='checkbox'  value='Other (list at right)'  id='choice_10_153_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_153_4' id='label_10_153_4' class='gform-field-label gform-field-label--type-inline'>Other (list at right)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_10_156\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_right o_medium\"  data-field-class=\"gf_half gf_right o_medium\" ><label class='gfield_label gform-field-label' for='input_10_156'>Other Know Birth Defects and\/or Syndromes<\/label><div class='ginput_container ginput_container_text'><input name='input_156' id='input_10_156' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_152\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_left o_medium\"  data-field-class=\"gf_half gf_left o_medium\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Unrelated Cardiac Health Problems<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_10_152'><li class='gchoice gchoice_10_152_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_152.1' type='checkbox'  value='Psychological Problems'  id='choice_10_152_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_152_1' id='label_10_152_1' class='gform-field-label gform-field-label--type-inline'>Psychological Problems<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_152_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_152.2' type='checkbox'  value='Dental Problems'  id='choice_10_152_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_152_2' id='label_10_152_2' class='gform-field-label gform-field-label--type-inline'>Dental Problems<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_152_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_152.3' type='checkbox'  value='Nutritional Problems'  id='choice_10_152_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_152_3' id='label_10_152_3' class='gform-field-label gform-field-label--type-inline'>Nutritional Problems<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_152_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_152.4' type='checkbox'  value='None'  id='choice_10_152_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_152_4' id='label_10_152_4' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_152_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_152.5' type='checkbox'  value='Other (list at right)'  id='choice_10_152_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_152_5' id='label_10_152_5' class='gform-field-label gform-field-label--type-inline'>Other (list at right)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_10_157\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_right o_medium\"  data-field-class=\"gf_half gf_right o_medium\" ><label class='gfield_label gform-field-label' for='input_10_157'>Other Unrelated Cardiac Health Problems<\/label><div class='ginput_container ginput_container_text'><input name='input_157' id='input_10_157' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third gf_left o_medium\"  data-field-class=\"gf_third gf_left o_medium\" ><label class='gfield_label gform-field-label' for='input_10_46'>Height<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_10_46' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_47\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" ><label class='gfield_label gform-field-label' for='input_10_47'>Weight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_10_47' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" ><label class='gfield_label gform-field-label' for='input_10_51'>Oxygen Saturation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_10_51' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_54\" class=\"gfield gfield--type-list gfield--input-type-list field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >IMMUNIZATIONS GIVEN<\/label><style type=\"text\/css\">\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons {\n\t\t\t\t\t\t\tvertical-align: middle !important;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons img {\n\t\t\t\t\t\t\tbackground-color: transparent !important;\n\t\t\t\t\t\t\tbackground-position: 0 0;\n\t\t\t\t\t\t\tbackground-size: 16px 16px !important;\n\t\t\t\t\t\t\tbackground-repeat: no-repeat;\n\t\t\t\t\t\t\tborder: none !important;\n\t\t\t\t\t\t\twidth: 16px !important;\n\t\t\t\t\t\t\theight: 16px !important;\n\t\t\t\t\t\t\topacity: 0.5;\n\t\t\t\t\t\t\ttransition: opacity .5s ease-out;\n\t\t\t\t\t\t    -moz-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -webkit-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -o-transition: opacity .5s ease-out;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons a:hover img {\n\t\t\t\t\t\t\topacity: 1.0;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\t<\/style><div class='ginput_container ginput_container_list ginput_list'><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_54_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_54_col_2' class='gfield_list_col_even' \/><col id='gfield_list_54_col_3' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th scope=\"col\">Immunization Given<\/th><th scope=\"col\">Date<\/th><td>&nbsp;<\/td><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_54_cell1' data-label='Immunization Given'><input aria-invalid='false'   aria-label='Immunization Given, Row 1' data-aria-label-template='Immunization Given, Row {0}' type='text' name='input_54[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_54_cell2' data-label='Date'><input aria-invalid='false'   aria-label='Date, Row 1' data-aria-label-template='Date, Row {0}' type='text' name='input_54[]' value=''   \/><\/td><td class='gfield_list_icons'>   <a href='javascript:void(0);' class='add_list_item' aria-label='Add another row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)'><img src='https:\/\/heartgift.org\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' alt='' title='Add a new row' \/><\/a>   <a href='javascript:void(0);' class='delete_list_item' aria-label='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\"><img src='https:\/\/heartgift.org\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' alt='' title='Remove this row' \/><\/a><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id=\"field_10_169\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Covid-19 Vaccine<\/label><div class='ginput_container ginput_container_list ginput_list'><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_169_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_169_col_2' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th scope=\"col\">Vaccination Date<\/th><td>&nbsp;<\/td><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_169_cell1' data-label='Vaccination Date'><input aria-invalid='false'   aria-label='Vaccination Date, Row 1' data-aria-label-template='Vaccination Date, Row {0}' type='text' name='input_169[]' value=''   \/><\/td><td class='gfield_list_icons'>   <a href='javascript:void(0);' class='add_list_item' aria-label='Add another row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)'><img src='https:\/\/heartgift.org\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' alt='' title='Add a new row' \/><\/a>   <a href='javascript:void(0);' class='delete_list_item' aria-label='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\"><img src='https:\/\/heartgift.org\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' alt='' title='Remove this row' \/><\/a><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id=\"field_10_45\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon 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_10_45'>Today&#039;s 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_45' id='input_10_45' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_10_45_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_45_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_45' class='gform_hidden' value='https:\/\/heartgift.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_10_55\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">TESTED FOR<\/h2><\/li><li id=\"field_10_155\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >TESTED FOR:<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_10_155'><li class='gchoice gchoice_10_155_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_155.1' type='checkbox'  value='TB'  id='choice_10_155_1'   aria-describedby=\"gfield_description_10_155\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_10_155_1' id='label_10_155_1' class='gform-field-label gform-field-label--type-inline'>TB<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_155_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_155.2' type='checkbox'  value='HIV'  id='choice_10_155_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_155_2' id='label_10_155_2' class='gform-field-label gform-field-label--type-inline'>HIV<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_155_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_155.3' type='checkbox'  value='Hepatitis B'  id='choice_10_155_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_155_3' id='label_10_155_3' class='gform-field-label gform-field-label--type-inline'>Hepatitis B<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_155_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_155.4' type='checkbox'  value='Hepatitis C'  id='choice_10_155_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_155_4' id='label_10_155_4' class='gform-field-label gform-field-label--type-inline'>Hepatitis C<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_155_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_155.5' type='checkbox'  value='Scabies'  id='choice_10_155_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_155_5' id='label_10_155_5' class='gform-field-label gform-field-label--type-inline'>Scabies<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_155_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_155.6' type='checkbox'  value='Lice'  id='choice_10_155_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_155_6' id='label_10_155_6' class='gform-field-label gform-field-label--type-inline'>Lice<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_155_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_155.7' type='checkbox'  value='Parasites'  id='choice_10_155_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_155_7' id='label_10_155_7' class='gform-field-label gform-field-label--type-inline'>Parasites<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_155_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_155.8' type='checkbox'  value='Sickle Cell Disease'  id='choice_10_155_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_155_8' id='label_10_155_8' class='gform-field-label gform-field-label--type-inline'>Sickle Cell Disease<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_155_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_155.9' type='checkbox'  value='Malaria'  id='choice_10_155_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_155_9' id='label_10_155_9' class='gform-field-label gform-field-label--type-inline'>Malaria<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_10_155'>*If you check TB, HIV and\/or Hepatitis, test results will need to be attach with all other documentation.<\/div><\/li><li id=\"field_10_58\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" ><label class='gfield_label gform-field-label' for='input_10_58'>Allergies<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_58' id='input_10_58' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_10_59\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" ><label class='gfield_label gform-field-label' for='input_10_59'>Current Medications<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_59' id='input_10_59' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_10_188\" 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 gf_third o_medium\"  data-field-class=\"gf_third o_medium\" ><label class='gfield_label gform-field-label' for='input_10_188'>How is the child developing for their age?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_188' id='input_10_188' class='textarea medium'  aria-describedby=\"gfield_description_10_188\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_10_188'>Are they meeting normal developmental milestones? For example, infants: sitting up, pulling up, crawling; toddlers: walking or walking with assistance, saying words, understanding others; school-age: attending school, any learning difficulties, concentration issues?<\/div><\/li><li id=\"field_10_60\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_left o_medium\"  data-field-class=\"gf_half gf_left o_medium\" ><label class='gfield_label gform-field-label' for='input_10_60'>Completed 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_60' id='input_10_60' type='text' value='' class='large'  aria-describedby=\"gfield_description_10_60\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_10_60'>By signing my legal name below, I acknowledge that I have read and understand the policies as contained herein.<\/div><\/li><li id=\"field_10_99\" 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\"  ><label class='gfield_label gform-field-label' for='input_10_99'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div ><div id='input_10_99_Container' style='height:180px; width:550px; ' ><input type='hidden' class='gform_hidden' name='input_10_99_valid' id='input_10_99_valid' \/><canvas id='input_10_99' width='550' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_10_61\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon 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_10_61'>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_61' id='input_10_61' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_10_61_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_61_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_61' class='gform_hidden' value='https:\/\/heartgift.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_10_62' 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_10_62' 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_10_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_10_4' class='gform_page' data-js='page-field-id-62' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_10_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_10_63\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Social History<\/h2><\/li><li id=\"field_10_165\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_165'>Medical issues of the traveling caregiver and any current medications the caregiver takes, if applicable<\/label><div class='ginput_container ginput_container_text'><input name='input_165' id='input_10_165' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_74\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">FATHER<\/h2><\/li><li id=\"field_10_126\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter o_medium\"  data-field-class=\"gf_quarter o_medium\" ><label class='gfield_label gform-field-label' for='input_10_126'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_126' id='input_10_126' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_76\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter o_medium\"  data-field-class=\"gf_quarter o_medium\" ><label class='gfield_label gform-field-label' for='input_10_76'>Date of Birth<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_76' id='input_10_76' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_10_76_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_76_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_76' class='gform_hidden' value='https:\/\/heartgift.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_10_77\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter o_medium\"  data-field-class=\"gf_quarter o_medium\" ><label class='gfield_label gform-field-label' for='input_10_77'>Occupation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_10_77' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_78\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gf_quarter o_medium\"  data-field-class=\"gf_quarter o_medium\" ><label class='gfield_label gform-field-label' for='input_10_78'>Religious Preference<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_10_78' type='text' value='' class='medium'  aria-describedby=\"gfield_description_10_78\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_10_78'>(This information is used only in matching the child and caregiver with a host family.)<\/div><\/li><li id=\"field_10_79\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">MOTHER<\/h2><\/li><li id=\"field_10_127\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter o_medium\"  data-field-class=\"gf_quarter o_medium\" ><label class='gfield_label gform-field-label' for='input_10_127'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_127' id='input_10_127' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_81\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter o_medium\"  data-field-class=\"gf_quarter o_medium\" ><label class='gfield_label gform-field-label' for='input_10_81'>Date of Birth<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_81' id='input_10_81' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_10_81_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_81_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_81' class='gform_hidden' value='https:\/\/heartgift.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_10_82\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter o_medium\"  data-field-class=\"gf_quarter o_medium\" ><label class='gfield_label gform-field-label' for='input_10_82'>Occupation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_10_82' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_83\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter o_medium\"  data-field-class=\"gf_quarter o_medium\" ><label class='gfield_label gform-field-label' for='input_10_83'>Religious Preference<\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_10_83' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_87\" class=\"gfield gfield--type-list gfield--input-type-list 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 gfield_label_before_complex' >Child will be traveling with (1 caregiver):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_list ginput_list'><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_87_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_87_col_2' class='gfield_list_col_even' \/><col id='gfield_list_87_col_3' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th scope=\"col\">Name<\/th><th scope=\"col\">Relationship to Child<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_87_cell1' data-label='Name'><input aria-invalid='false' aria-required=\"true\"  aria-label='Name, Row 1' data-aria-label-template='Name, Row {0}' type='text' name='input_87[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_87_cell2' data-label='Relationship to Child'><input aria-invalid='false' aria-required=\"true\"  aria-label='Relationship to Child, Row 1' data-aria-label-template='Relationship to Child, Row {0}' type='text' name='input_87[]' value=''   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id=\"field_10_92\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" ><label class='gfield_label gform-field-label' for='input_10_92'>Does the child have any allergies to medication or food?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_92' id='input_10_92' class='textarea medium'  aria-describedby=\"gfield_description_10_92\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_10_92'>If yes, what is the reaction if exposed.<\/div><\/li><li id=\"field_10_128\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-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_10_128'>Completed By Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_128' id='input_10_128' type='text' value='' class='medium'  aria-describedby=\"gfield_description_10_128\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_10_128'>By signing my legal name below, I acknowledge that I have read and understand the policies as contained herein.<\/div><\/li><li id=\"field_10_95\" 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\"  ><label class='gfield_label gform-field-label' for='input_10_95'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div ><div id='input_10_95_Container' style='height:180px; width:550px; ' ><input type='hidden' class='gform_hidden' name='input_10_95_valid' id='input_10_95_valid' \/><canvas id='input_10_95' width='550' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_10_94\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon 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_10_94'>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_94' id='input_10_94' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_10_94_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_94_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_94' class='gform_hidden' value='https:\/\/heartgift.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_10_101' 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_10_101' 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_10_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_10_5' class='gform_page' data-js='page-field-id-101' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_10_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_10_102\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Patient and Caregiver Hold Harmless Agreement<\/h2><\/li><li id=\"field_10_129\" class=\"gfield gfield--type-text gfield--input-type-text 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_10_129'>Child Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_10_129' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_133\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon 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_10_133'>Date of Birth<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_133' id='input_10_133' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_10_133_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_133_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_133' class='gform_hidden' value='https:\/\/heartgift.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_10_130\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >As the legal guardian accompanying (child referenced above) to the United States, the undersigned, on behalf of themselves, the patient and all who may claim through them, release the HeartGift Foundation, its directors, officers, employees, volunteers and attending physicians or other healthcare providers from any and all claims, demands, causes of action and suits, including, but not limited to, claims for negligence, gross negligence, invasion of privacy, defamation, breach of contract or other breach of duty arising out of or in connection with the use of this material.\n<br>\n<br>\nThis information has been read by me or to me in my native language and I understand the contents of this release.<\/li><li id=\"field_10_131\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_left o_medium\"  data-field-class=\"gf_half gf_left o_medium\" ><label class='gfield_label gform-field-label' for='input_10_131'>Parent\/Guardian or Legal Representative Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_131' id='input_10_131' type='text' value='' class='large'  aria-describedby=\"gfield_description_10_131\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_10_131'>By signing my legal name below, I acknowledge that I have read and understand the policies as contained herein.<\/div><\/li><li id=\"field_10_104\" 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_half gf_left o_medium\"  data-field-class=\"gf_half gf_left o_medium\" ><label class='gfield_label gform-field-label' for='input_10_104'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div ><div id='input_10_104_Container' style='height:180px; width:550px; ' ><input type='hidden' class='gform_hidden' name='input_10_104_valid' id='input_10_104_valid' \/><canvas id='input_10_104' width='550' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_10_106\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_left o_medium\"  data-field-class=\"gf_half gf_left o_medium\" ><label class='gfield_label gform-field-label' for='input_10_106'>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_106' id='input_10_106' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_10_106_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_106_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_106' class='gform_hidden' value='https:\/\/heartgift.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_10_148\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >[vc_empty_space]<\/li><li id=\"field_10_132\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_left o_medium\"  data-field-class=\"gf_half gf_left o_medium\" ><label class='gfield_label gform-field-label' for='input_10_132'>Witnessed \/ Interpreter Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_10_132' type='text' value='' class='large'  aria-describedby=\"gfield_description_10_132\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_10_132'>By signing my legal name below, I acknowledge that I have read and understand the policies as contained herein.<\/div><\/li><li id=\"field_10_109\" class=\"gfield gfield--type-signature gfield--input-type-signature field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_left o_medium\"  data-field-class=\"gf_half gf_left o_medium\" ><label class='gfield_label gform-field-label' for='input_10_109'>Witnessed \/Interpreter Signature<\/label><div ><div id='input_10_109_Container' style='height:180px; width:550px; ' ><input type='hidden' class='gform_hidden' name='input_10_109_valid' id='input_10_109_valid' \/><canvas id='input_10_109' width='550' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_10_134\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_left o_medium\"  data-field-class=\"gf_half gf_left o_medium\" ><label class='gfield_label gform-field-label' for='input_10_134'>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_134' id='input_10_134' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_10_134_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_134_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_134' class='gform_hidden' value='https:\/\/heartgift.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_10_135' 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_10_135' 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_10_6_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_10_6' class='gform_page' data-js='page-field-id-135' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_10_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_10_136\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Certification of Patient Condition By Referring Physician<\/h2><\/li><li id=\"field_10_137\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-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_10_137'>I am referring:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_137' id='input_10_137' type='text' value='' class='large'  aria-describedby=\"gfield_description_10_137\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_10_137'>Name of Child<\/div><\/li><li id=\"field_10_139\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-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_10_139'>Diagnosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_10_139' type='text' value='' class='large'  aria-describedby=\"gfield_description_10_139\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_10_139'>Defect<\/div><\/li><li id=\"field_10_138\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h5>HeartGift's medical selection criteria includes:<\/h5>\n<ul>\n<li>Be under age 14.<\/li>\n<li>Not have undergone previous cardiac surgery.<\/li>\n<li>Have a biventricular condition that can be repaired in one operation which include but may not be limited to the following types of defects:<\/li><ul>\n<li>Patent Ductus Arteriosis (PDA)<\/li>\n<li>Coarctation of the Aorta<\/li>\n<li>Atrial Septal Defect (ASD)<\/li>\n<li>Ventricular Septal Defect (VSD)<\/li>\n<li>Tetrology of Fallot (TOF)<\/li>\n<\/ul>\n<li>Have no chromosomal abnormalities.<\/li>\n<\/ul>\n\nI hereby certify that all known and\/or discernible health conditions are disclosed in the referring documents, e.g. suspected chromosomal disorders or other syndromes, immune deficiency, and any other diseases.<\/li><li id=\"field_10_140\" class=\"gfield gfield--type-text gfield--input-type-text 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_10_140'>Physician Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_140' id='input_10_140' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_178\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_178'>Phone Number<\/label><div class='ginput_container ginput_container_number'><input name='input_178' id='input_10_178' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_10_179\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_179'>Patient Clinic or Hospital Name, Phone<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_179' id='input_10_179' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_10_141\" 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\"  ><label class='gfield_label gform-field-label' for='input_10_141'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div ><div id='input_10_141_Container' style='height:180px; width:550px; ' ><input type='hidden' class='gform_hidden' name='input_10_141_valid' id='input_10_141_valid' \/><canvas id='input_10_141' width='550' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_10_142\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_inline o_medium\"  data-field-class=\"gf_inline o_medium\" ><label class='gfield_label gform-field-label' for='input_10_142'>Country of Origin<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_142' id='input_10_142' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_143\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_inline o_medium\"  data-field-class=\"gf_inline o_medium\" ><label class='gfield_label gform-field-label' for='input_10_143'>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_143' id='input_10_143' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_10_143_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_143_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_143' class='gform_hidden' value='https:\/\/heartgift.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_10_112' 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_10_112' 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_10_7_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_10_7' class='gform_page' data-js='page-field-id-112' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_10_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_10_113\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Child Information Uploads<\/h2><\/li><li id=\"field_10_114\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Your referral will not be complete until you provide HeartGift with a picture and copy of an echocardiogram study for the child you are referring. If you prefer, you may mail the picture and echocardiogram study to HeartGift Foundation.\n\n<h5>Medical Documentation<\/h5>\n<ul>\n<li>Full legal name of the child<\/li>\n<li>Date of birth<\/li>\n<li>Current echocardiogram and report \u2013 DVD of a complete echocardiogram, including doppler images, performed within the past 3 months by a pediatric cardiologist or attending physician. We require a moving echocardiogram in DIACOM, MP4, or AVI format. No JPEG or still images will be accepted in place of the echocardiogram. <strong>The medical committee will not review a case without a moving echocardiogram.<\/strong><\/li>\n<li>Photo of Child<\/li>\n<li>Current immunization record<\/li>\n<li>Test results for the following:<\/li>\n<ul>\n<li>TB<\/li>\n<li>Malaria<\/li>\n<li>Hepatitis B&C<\/li>\n<li>HIV<\/li>\n<li>Parasites (may be asked to retake tests before traveling)<\/li>\n<li>Sickle Cell<\/li><\/ul>\n<li>ECG<\/li>\n<li>Chest X-ray<\/li>\n<li>Physicians letter detailing child\u2019s health history and current physical examination.<\/li>\n<li>Any additional medical records you may have that will help the medical committee in reviewing your case. (this one not mandatory)<\/li>\n<\/ul>\n<p>All materials requested must have been generated within the last 3 months.<\/p> \n\nIf child is able to walk or crawl, please attach a video of them being active.\n<\/li><li id=\"field_10_115\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload 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='gform_browse_button_10_115'>Photo of Child<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_10_115' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_10_115&quot;,&quot;container&quot;:&quot;gform_multifile_upload_10_115&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_10_115&quot;,&quot;filelist&quot;:&quot;gform_preview_10_115&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/heartgift.org\\\/?gf_page=1f932de83207a1e&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/heartgift.org\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/heartgift.org\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,jpeg,gif,png,pdf,tiff&quot;}],&quot;max_file_size&quot;:&quot;52428800b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:10,&quot;field_id&quot;:115,&quot;_gform_file_upload_nonce_10_115&quot;:&quot;714c64c26d&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_10_115&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_10_115' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_10_115' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_10_115\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_10_115'>Accepted file types: jpg, jpeg, gif, png, pdf, tiff, Max. file size: 50 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_10_115'><\/ul> <div id='gform_preview_10_115' class='ginput_preview_list'><\/div><\/div><\/li><li id=\"field_10_189\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload 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='gform_browse_button_10_189'>Video of Child in Everyday Life<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_10_189' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_10_189&quot;,&quot;container&quot;:&quot;gform_multifile_upload_10_189&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_10_189&quot;,&quot;filelist&quot;:&quot;gform_preview_10_189&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/heartgift.org\\\/?gf_page=1f932de83207a1e&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/heartgift.org\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/heartgift.org\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;mov,mp4,wmv&quot;}],&quot;max_file_size&quot;:&quot;52428800b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:10,&quot;field_id&quot;:189,&quot;_gform_file_upload_nonce_10_189&quot;:&quot;afa8808c54&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_10_189&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_10_189' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_10_189' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_10_189 gfield_description_10_189\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_10_189'>Accepted file types: mov, mp4, wmv, Max. file size: 50 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_10_189'><\/ul> <div id='gform_preview_10_189' class='ginput_preview_list'><\/div><\/div><div class='gfield_description' id='gfield_description_10_189'>Please include a video of the child meeting developmental milestones. \nInfants: standing up, pulling up, crawling; Toddlers: walking or walking with assistance; saying words, understanding others; School-age: attending school, doing homework, playing outside.<\/div><\/li><li id=\"field_10_160\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload 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='gform_browse_button_10_160'>Medical Documentation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_10_160' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_10_160&quot;,&quot;container&quot;:&quot;gform_multifile_upload_10_160&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_10_160&quot;,&quot;filelist&quot;:&quot;gform_preview_10_160&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/heartgift.org\\\/?gf_page=1f932de83207a1e&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/heartgift.org\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/heartgift.org\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,doc,docx,jpeg&quot;}],&quot;max_file_size&quot;:&quot;52428800b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:10,&quot;field_id&quot;:160,&quot;_gform_file_upload_nonce_10_160&quot;:&quot;d2e3d69cac&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_10_160&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_10_160' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_10_160' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_10_160 gfield_description_10_160\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_10_160'>Accepted file types: jpg, gif, png, pdf, doc, docx, jpeg, Max. file size: 50 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_10_160'><\/ul> <div id='gform_preview_10_160' class='ginput_preview_list'><\/div><\/div><div class='gfield_description' id='gfield_description_10_160'>Please attach the following:\n\u2022 Current echocardiogram and report (a moving video taken within the last 3 months - REQUIRED)\n\u2022 Photo of Child\n\u2022 Current immunization record\n\u2022 Test results for the following:\n-TB\n-Malaria\n-Hepatitis B&C\n-HIV\n-Parasites (may be asked to retake tests before traveling)\n-Sickle Cell\n\u2022 ECG\n\u2022 Chest X-ray\n\u2022 Physicians letter detailing child\u2019s health history and current physical examination.\n\u2022 Any additional medical records you may have that will help the medical committee in reviewing your case. <\/div><\/li><li id=\"field_10_145\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >You can also share the Echocardiogram to skeeling@heartgift.org through Dropbox or Google Drive.<\/li><li id=\"field_10_161\" 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\"  ><label class='gfield_label gform-field-label' for='input_10_161'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div ><div id='input_10_161_Container' style='height:180px; width:550px; ' ><input type='hidden' class='gform_hidden' name='input_10_161_valid' id='input_10_161_valid' \/><canvas id='input_10_161' width='550' height='180'><\/canvas><\/div><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_10_172' 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_10_172' 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_10_8_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_10_8' class='gform_page' data-js='page-field-id-172' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_10_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_10_171\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Conditions for Caregivers<\/h2><\/li><li id=\"field_10_173\" 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\"  >If child is selected for treatment in the United States, we pledge to provide all necessary medical care related to his or her heart condition as well as housing, meals, and translation services for the child and caregiver as a gift.\n\nIn return for this gift we expect both the child and caregiver to honor the time, belongings and rules of HeartGift staff, physicians, host families, and volunteers.\n<\/li><li id=\"field_10_175\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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 gfield_label_before_complex' >Conditions for Caregivers<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_10_175'><li class='gchoice gchoice_10_175_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.1' type='checkbox'  value='I will return to my country immediately upon completion of the child\u2019s medical treatment and under no circumstances will the child or I attempt to stay in the United States beyond the time needed for medical care.'  id='choice_10_175_1'   aria-describedby=\"gfield_description_10_175\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_10_175_1' id='label_10_175_1' class='gform-field-label gform-field-label--type-inline'>I will return to my country immediately upon completion of the child\u2019s medical treatment and under no circumstances will the child or I attempt to stay in the United States beyond the time needed for medical care.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_175_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.2' type='checkbox'  value='I certify that I am not pregnant'  id='choice_10_175_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_175_2' id='label_10_175_2' class='gform-field-label gform-field-label--type-inline'>I certify that I am not pregnant<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_175_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.3' type='checkbox'  value='I certify that I am in good health, and that I will not seek medical treatment for myself while in the U.S.'  id='choice_10_175_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_175_3' id='label_10_175_3' class='gform-field-label gform-field-label--type-inline'>I certify that I am in good health, and that I will not seek medical treatment for myself while in the U.S.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_175_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.4' type='checkbox'  value='I and the child will treat HeartGift staff, physicians, host families, and volunteers with respect and courtesy.'  id='choice_10_175_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_175_4' id='label_10_175_4' class='gform-field-label gform-field-label--type-inline'>I and the child will treat HeartGift staff, physicians, host families, and volunteers with respect and courtesy.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_175_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.5' type='checkbox'  value='I and the child agree not to travel apart from the host family, HeartGift staff, and\/or volunteers.'  id='choice_10_175_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_175_5' id='label_10_175_5' class='gform-field-label gform-field-label--type-inline'>I and the child agree not to travel apart from the host family, HeartGift staff, and\/or volunteers.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_175_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.6' type='checkbox'  value='Neither I nor the child will engage in any other outside personal activities, including visits to or by friends or family in the United States, Canada and Mexico.'  id='choice_10_175_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_175_6' id='label_10_175_6' class='gform-field-label gform-field-label--type-inline'>Neither I nor the child will engage in any other outside personal activities, including visits to or by friends or family in the United States, Canada and Mexico.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_175_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.7' type='checkbox'  value='I and the child understand that I am not permitted to communicate with any family members or friends living in the United States, Canada and Mexico without the express permission of HeartGift staff.'  id='choice_10_175_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_175_7' id='label_10_175_7' class='gform-field-label gform-field-label--type-inline'>I and the child understand that I am not permitted to communicate with any family members or friends living in the United States, Canada and Mexico without the express permission of HeartGift staff.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_175_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.8' type='checkbox'  value='I and the child will leave all original travel documents including my passport, visa, and tickets with a HeartGift staff person until medical treatment is complete and it is time to return home.'  id='choice_10_175_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_175_8' id='label_10_175_8' class='gform-field-label gform-field-label--type-inline'>I and the child will leave all original travel documents including my passport, visa, and tickets with a HeartGift staff person until medical treatment is complete and it is time to return home.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_175_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.9' type='checkbox'  value='Neither I nor the child will not change the status of my visa in any manner nor seek asylum while I am in the United States'  id='choice_10_175_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_175_9' id='label_10_175_9' class='gform-field-label gform-field-label--type-inline'>Neither I nor the child will not change the status of my visa in any manner nor seek asylum while I am in the United States<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_175_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.11' type='checkbox'  value='I understand that the child and I must abide by all State, U.S. Immigration Laws, Criminal Laws, and Civil Laws while in the United States.'  id='choice_10_175_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_175_11' id='label_10_175_11' class='gform-field-label gform-field-label--type-inline'>I understand that the child and I must abide by all State, U.S. Immigration Laws, Criminal Laws, and Civil Laws while in the United States.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_175_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.12' type='checkbox'  value='Should any of these conditions be violated, I understand that the child and I will be disqualified for the HeartGift program and will be sent home immediately.'  id='choice_10_175_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_175_12' id='label_10_175_12' class='gform-field-label gform-field-label--type-inline'>Should any of these conditions be violated, I understand that the child and I will be disqualified for the HeartGift program and will be sent home immediately.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_175_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.13' type='checkbox'  value='If at any time I become incapacitated for any reason, then I and the child may have to return to my country immediately even if it means that the child will not receive treatment.'  id='choice_10_175_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_175_13' id='label_10_175_13' class='gform-field-label gform-field-label--type-inline'>If at any time I become incapacitated for any reason, then I and the child may have to return to my country immediately even if it means that the child will not receive treatment.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_175_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.14' type='checkbox'  value='I acknowledge that all of the conditions in this Agreement have been read to me through an interpreter in my native tongue and I understand each condition and I accept all of the conditions.'  id='choice_10_175_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_175_14' id='label_10_175_14' class='gform-field-label gform-field-label--type-inline'>I acknowledge that all of the conditions in this Agreement have been read to me through an interpreter in my native tongue and I understand each condition and I accept all of the conditions.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_10_175'>Please read and check all the boxes to agree to the conditions in this Agreement. <\/div><\/li><li id=\"field_10_192\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have any relatives that live in the United States?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_192'>\n\t\t\t<li class='gchoice gchoice_10_192_0'>\n\t\t\t\t<input name='input_192' type='radio' value='Yes'  id='choice_10_192_0'    \/>\n\t\t\t\t<label for='choice_10_192_0' id='label_10_192_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_10_192_1'>\n\t\t\t\t<input name='input_192' type='radio' value='No'  id='choice_10_192_1'    \/>\n\t\t\t\t<label for='choice_10_192_1' id='label_10_192_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_10_174\" class=\"gfield gfield--type-signature gfield--input-type-signature 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_10_174'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div ><div id='input_10_174_Container' style='height:180px; width:550px; ' ><input type='hidden' class='gform_hidden' name='input_10_174_valid' id='input_10_174_valid' \/><canvas id='input_10_174' width='550' height='180'><\/canvas><\/div><\/div><div class='gfield_description' id='gfield_description_10_174'>By signing below, I hereby testify that I have read, understood and agree to these conditions.<\/div><\/li><li id=\"field_10_183\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Emergency Contact of someone in home country:<\/h2><\/li><li id=\"field_10_180\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_10_180'>\n                            \n                            <span id='input_10_180_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_180.3' id='input_10_180_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_10_180_3' class='gform-field-label gform-field-label--type-sub'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_10_180_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_180.6' id='input_10_180_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_10_180_6' class='gform-field-label gform-field-label--type-sub'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_10_181\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_181'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_181' id='input_10_181' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_10_182\" class=\"gfield gfield--type-phone gfield--input-type-phone 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class=\"elementor-element elementor-element-4b93886 e-flex e-con-boxed e-con e-child\" data-id=\"4b93886\" 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-0b03ba5 elementor-widget elementor-widget-heading\" data-id=\"0b03ba5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">HeartGift's medical selection criteria includes:<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-4936771 elementor-position-inline-start elementor-view-default elementor-mobile-position-block-start elementor-widget elementor-widget-icon-box\" data-id=\"4936771\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<span  class=\"elementor-icon\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"17\" height=\"17\" viewbox=\"0 0 17 17\" fill=\"none\"><path d=\"M10.9795 3.54169H7.79199L11.3337 8.50002L7.79199 13.4584H10.9795L14.5212 8.50002L10.9795 3.54169Z\" fill=\"#C92026\"><\/path><path d=\"M6.02051 3.54169H2.83301L6.37468 8.50002L2.83301 13.4584H6.02051L9.56218 8.50002L6.02051 3.54169Z\" fill=\"#C92026\"><\/path><\/svg>\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tBe under age 14.\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-37a3fb6 elementor-position-inline-start elementor-view-default elementor-mobile-position-block-start elementor-widget elementor-widget-icon-box\" data-id=\"37a3fb6\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<span  class=\"elementor-icon\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"17\" height=\"17\" viewbox=\"0 0 17 17\" fill=\"none\"><path d=\"M10.9795 3.54169H7.79199L11.3337 8.50002L7.79199 13.4584H10.9795L14.5212 8.50002L10.9795 3.54169Z\" fill=\"#C92026\"><\/path><path d=\"M6.02051 3.54169H2.83301L6.37468 8.50002L2.83301 13.4584H6.02051L9.56218 8.50002L6.02051 3.54169Z\" fill=\"#C92026\"><\/path><\/svg>\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tNot have undergone previous cardiac surgery.\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-23a1b1f elementor-position-inline-start elementor-view-default elementor-mobile-position-block-start elementor-widget elementor-widget-icon-box\" data-id=\"23a1b1f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<span  class=\"elementor-icon\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"17\" height=\"17\" viewbox=\"0 0 17 17\" fill=\"none\"><path d=\"M10.9795 3.54169H7.79199L11.3337 8.50002L7.79199 13.4584H10.9795L14.5212 8.50002L10.9795 3.54169Z\" fill=\"#C92026\"><\/path><path d=\"M6.02051 3.54169H2.83301L6.37468 8.50002L2.83301 13.4584H6.02051L9.56218 8.50002L6.02051 3.54169Z\" fill=\"#C92026\"><\/path><\/svg>\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tHave a biventricular condition that can be repaired in one operation which include but may not be limited to the following types of defects:\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b7bb8b9 elementor-widget elementor-widget-text-editor\" data-id=\"b7bb8b9\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<ul><li>Patent Ductus Arteriosis (PDA)<\/li><li>Coarctation of the Aorta<\/li><li>Atrial Septal Defect (ASD)<\/li><li>Ventricular Septal Defect (VSD)<\/li><li>Tetrology of Fallot (TOF)<\/li><\/ul>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-61b7498 elementor-position-inline-start elementor-view-default elementor-mobile-position-block-start elementor-widget elementor-widget-icon-box\" data-id=\"61b7498\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<span  class=\"elementor-icon\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"17\" height=\"17\" viewbox=\"0 0 17 17\" fill=\"none\"><path d=\"M10.9795 3.54169H7.79199L11.3337 8.50002L7.79199 13.4584H10.9795L14.5212 8.50002L10.9795 3.54169Z\" fill=\"#C92026\"><\/path><path d=\"M6.02051 3.54169H2.83301L6.37468 8.50002L2.83301 13.4584H6.02051L9.56218 8.50002L6.02051 3.54169Z\" fill=\"#C92026\"><\/path><\/svg>\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tHave no chromosomal abnormalities.\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0b12524 elementor-widget elementor-widget-text-editor\" data-id=\"0b12524\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tI hereby certify that all known and\/or discernible health conditions are disclosed in the referring documents, e.g. suspected chromosomal disorders or other syndromes, immune deficiency, and any other diseases.\u2028\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-2304508 e-con-full elementor-hidden-desktop elementor-hidden-tablet elementor-hidden-mobile e-flex e-con e-parent\" data-id=\"2304508\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-b53fa6f e-flex e-con-boxed e-con e-child\" data-id=\"b53fa6f\" 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<div class=\"elementor-element elementor-element-93b1380 e-con-full e-flex e-con e-child\" data-id=\"93b1380\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;position&quot;:&quot;absolute&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-56e3b90 elementor-widget elementor-widget-heading\" data-id=\"56e3b90\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Application Requirements:<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-10ba8bd elementor-widget elementor-widget-text-editor\" data-id=\"10ba8bd\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tAll requested information must be provided in order for the application to be considered by the Medical Review Committee. Missing information will delay the application until all necessary information is received. Please be sure to include the following when filling out the online application:\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-72fed8c elementor-position-inline-start elementor-view-default elementor-mobile-position-block-start elementor-widget elementor-widget-icon-box\" data-id=\"72fed8c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<span  class=\"elementor-icon\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"17\" height=\"17\" viewbox=\"0 0 17 17\" fill=\"none\"><path d=\"M10.979 3.54163H7.7915L11.3332 8.49996L7.7915 13.4583H10.979L14.5207 8.49996L10.979 3.54163Z\" fill=\"white\"><\/path><path d=\"M6.021 3.54163H2.8335L6.37516 8.49996L2.8335 13.4583H6.021L9.56266 8.49996L6.021 3.54163Z\" fill=\"white\"><\/path><\/svg>\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tFull legal name of the child\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-dd3a9b7 elementor-position-inline-start elementor-view-default elementor-mobile-position-block-start elementor-widget elementor-widget-icon-box\" data-id=\"dd3a9b7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<span  class=\"elementor-icon\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"17\" height=\"17\" viewbox=\"0 0 17 17\" fill=\"none\"><path d=\"M10.979 3.54163H7.7915L11.3332 8.49996L7.7915 13.4583H10.979L14.5207 8.49996L10.979 3.54163Z\" fill=\"white\"><\/path><path d=\"M6.021 3.54163H2.8335L6.37516 8.49996L2.8335 13.4583H6.021L9.56266 8.49996L6.021 3.54163Z\" fill=\"white\"><\/path><\/svg>\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tCurrent echocardiogram and report \u2013 Complete echocardiogram, including doppler images, performed within the past 3 months by a pediatric cardiologist or attending physician. We require a moving echocardiogram in DIACOM, MP4, or AVI format. No JPEG or still images will be accepted in place of the echocardiogram.\u00a0The medical committee will not review a case without a moving echocardiogram.\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-9fb7bc4 elementor-position-inline-start elementor-view-default elementor-mobile-position-block-start elementor-widget elementor-widget-icon-box\" data-id=\"9fb7bc4\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<span  class=\"elementor-icon\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"17\" height=\"17\" viewbox=\"0 0 17 17\" fill=\"none\"><path d=\"M10.979 3.54163H7.7915L11.3332 8.49996L7.7915 13.4583H10.979L14.5207 8.49996L10.979 3.54163Z\" fill=\"white\"><\/path><path d=\"M6.021 3.54163H2.8335L6.37516 8.49996L2.8335 13.4583H6.021L9.56266 8.49996L6.021 3.54163Z\" fill=\"white\"><\/path><\/svg>\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tPhoto of Child\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-4626d9c elementor-position-inline-start elementor-view-default elementor-mobile-position-block-start elementor-widget elementor-widget-icon-box\" data-id=\"4626d9c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<span  class=\"elementor-icon\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"17\" height=\"17\" viewbox=\"0 0 17 17\" fill=\"none\"><path d=\"M10.979 3.54163H7.7915L11.3332 8.49996L7.7915 13.4583H10.979L14.5207 8.49996L10.979 3.54163Z\" fill=\"white\"><\/path><path d=\"M6.021 3.54163H2.8335L6.37516 8.49996L2.8335 13.4583H6.021L9.56266 8.49996L6.021 3.54163Z\" fill=\"white\"><\/path><\/svg>\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tCurrent immunization record\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-bb00474 elementor-position-inline-start elementor-view-default elementor-mobile-position-block-start elementor-widget elementor-widget-icon-box\" data-id=\"bb00474\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<span  class=\"elementor-icon\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"17\" height=\"17\" viewbox=\"0 0 17 17\" fill=\"none\"><path d=\"M10.979 3.54163H7.7915L11.3332 8.49996L7.7915 13.4583H10.979L14.5207 8.49996L10.979 3.54163Z\" fill=\"white\"><\/path><path d=\"M6.021 3.54163H2.8335L6.37516 8.49996L2.8335 13.4583H6.021L9.56266 8.49996L6.021 3.54163Z\" fill=\"white\"><\/path><\/svg>\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tTest results for the following:\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-73ce302 elementor-widget elementor-widget-text-editor\" data-id=\"73ce302\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<ul><li>TB<\/li><li>Malaria<\/li><li>Hepatitis B&amp;C<\/li><li>HIV<\/li><li>Parasites (may be asked to<br \/>retake tests before traveling)<\/li><li>Sickle Cell<\/li><\/ul>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2c98722 elementor-position-inline-start elementor-view-default elementor-mobile-position-block-start elementor-widget elementor-widget-icon-box\" data-id=\"2c98722\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<span  class=\"elementor-icon\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"17\" height=\"17\" viewbox=\"0 0 17 17\" fill=\"none\"><path d=\"M10.979 3.54163H7.7915L11.3332 8.49996L7.7915 13.4583H10.979L14.5207 8.49996L10.979 3.54163Z\" fill=\"white\"><\/path><path d=\"M6.021 3.54163H2.8335L6.37516 8.49996L2.8335 13.4583H6.021L9.56266 8.49996L6.021 3.54163Z\" fill=\"white\"><\/path><\/svg>\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tECG\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-80c5c47 elementor-position-inline-start elementor-view-default elementor-mobile-position-block-start elementor-widget elementor-widget-icon-box\" data-id=\"80c5c47\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<span  class=\"elementor-icon\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"17\" height=\"17\" viewbox=\"0 0 17 17\" fill=\"none\"><path d=\"M10.979 3.54163H7.7915L11.3332 8.49996L7.7915 13.4583H10.979L14.5207 8.49996L10.979 3.54163Z\" fill=\"white\"><\/path><path d=\"M6.021 3.54163H2.8335L6.37516 8.49996L2.8335 13.4583H6.021L9.56266 8.49996L6.021 3.54163Z\" fill=\"white\"><\/path><\/svg>\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tChest X-ray\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3289f4f elementor-position-inline-start elementor-view-default elementor-mobile-position-block-start elementor-widget elementor-widget-icon-box\" data-id=\"3289f4f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<span  class=\"elementor-icon\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"17\" height=\"17\" viewbox=\"0 0 17 17\" fill=\"none\"><path d=\"M10.979 3.54163H7.7915L11.3332 8.49996L7.7915 13.4583H10.979L14.5207 8.49996L10.979 3.54163Z\" fill=\"white\"><\/path><path d=\"M6.021 3.54163H2.8335L6.37516 8.49996L2.8335 13.4583H6.021L9.56266 8.49996L6.021 3.54163Z\" fill=\"white\"><\/path><\/svg>\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tPhysicians letter detailing child\u2019s health history and current physical examination.\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-62c983b elementor-position-inline-start elementor-view-default elementor-mobile-position-block-start elementor-widget elementor-widget-icon-box\" data-id=\"62c983b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<span  class=\"elementor-icon\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"17\" height=\"17\" viewbox=\"0 0 17 17\" fill=\"none\"><path d=\"M10.979 3.54163H7.7915L11.3332 8.49996L7.7915 13.4583H10.979L14.5207 8.49996L10.979 3.54163Z\" fill=\"white\"><\/path><path d=\"M6.021 3.54163H2.8335L6.37516 8.49996L2.8335 13.4583H6.021L9.56266 8.49996L6.021 3.54163Z\" fill=\"white\"><\/path><\/svg>\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tAny additional medical records you may have that will help the medical committee in reviewing your case.\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3e3ad58 elementor-widget elementor-widget-text-editor\" data-id=\"3e3ad58\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tAll materials requested must have been generated within the last 3 months.\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e2e6c3b elementor-widget elementor-widget-text-editor\" data-id=\"e2e6c3b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tWe have developed this protocol based on the conditions that our medical teams are willing to accept\/treat. Our goal is to ensure a fair evaluation process and provide parents and children with realistic expectations once they submit the necessary information to us.\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-df2e14e e-flex e-con-boxed e-con e-parent\" data-id=\"df2e14e\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"<p>REFER A CHILD If you know a child with a congenital heart defect with limited access to specialized medical care, let us know. Morgan | Uganda Life saved in 2023 HeartGift&#8217;s medical selection criteria includes: Be under age 14. Not have undergone previous cardiac surgery. Have a biventricular condition that can be repaired in one [&hellip;]<\/p>","protected":false},"author":11,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-27083","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.5 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Refer a child - HeartGift<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/heartgift.org\/es\/refer-a-child\/\" \/>\n<meta property=\"og:locale\" content=\"es_MX\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Refer a child - HeartGift\" \/>\n<meta property=\"og:description\" content=\"REFER A CHILD If you know a child with a congenital heart defect with limited access to specialized medical care, let us know. Morgan | Uganda Life saved in 2023 HeartGift&#8217;s medical selection criteria includes: Be under age 14. Not have undergone previous cardiac surgery. 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