if (window.location.protocol != "https:" && window.location.href.indexOf("formulate") == -1 && "False" === "True") {
    window.location.href = "https:" + window.location.href.substring(window.location.protocol.length);
}

var fbScriptTag = document.getElementsByClassName("213d05f0-8982-429e-806c-8f5d9e983c1c"),
    fbBodyTag = document.body,
    fbHeadTag = document.head,
    fbIsTestResponse = 'False',
    fbEnableInstaMedScript = 'False',
    fbRenderContainer = document.createElement("div"),
    fbRenderedCssContainer = document.createElement("div"),
    fbConfigScript = document.createElement("script"),
    fbRequireJSScript = document.createElement("script"),
    fbInstaMedJSScript = document.createElement("script"),
    fbGeoCaptchaCallback = document.createElement("script"),
    fbGeoReCaptchaCallback = document.createElement("script"),
    fbFormulateRenderer = document.createElement("script"),
    fbRenderedIntegrations = document.createElement("script"),
    fbRenderedScripts = document.createElement("script"),
    fbAutoPopulateFromQueryString = document.createElement("script"),
    fbEmbeddedCss = "",
    renderedScripts = 'var conditionalSectionJs = function () {\
    requirejs([window.formHost + \'/Scripts/require/fbRequire.config.js\'], function (fbRequireConfig) {\
        var fbRequire = fbRequireConfig.fbRequire;\
\
        fbRequire([\'jquery\', \'he\'], function ($, he) {\
            he.encode.options.decimal = true;\
            he.encode.options.allowUnsafeSymbols = true;\
\
            var sectionConditions = JSON.parse(\'[{"ElementName":"FormField9_213d05f0-8982-429e-806c-8f5d9e983c1c","Value":"Additional Gender Category (Other)"}]\');\
            var conditionOperator = \'and\';\
\
            sectionConditions.forEach(function (sectionCondition) {\
                $("select[id=" + sectionCondition.ElementName + "]").addClass(\'conditionalSectionListSelection\');\
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").addClass(\'conditionalSectionListSelection\');\
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").addClass(\'conditionalSectionListSelection\');\
                \
                $("select[id=" + sectionCondition.ElementName + "]").on(\'change\', function () {\
                    checkShowHide();\
                });\
                \
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").on(\'change\', function () {\
                    checkShowHide();\
                });\
                \
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").on(\'change\', function () {\
                    checkShowHide();\
                });\
            });\
            \
            function checkShowHide() {\
                var shouldShowSection = conditionOperator === \'and\'; /* set default to true for AND operation and false for OR operation */\
\
                sectionConditions.forEach(function (sectionCondition) {\
                    checkSelect(sectionCondition);                \
                    checkCheckbox(sectionCondition);                \
                    checkRadio(sectionCondition);                    \
                });\
\
                showHideSection(shouldShowSection);\
\
                function checkSelect(sectionCondition) {\
                    var matchingSelect = $("select[id=" + sectionCondition.ElementName + "]")[0];\
\
                    if (!matchingSelect) {\
                        return;\
                    }\
\
                    if (matchingSelect.type === \'select-multiple\') {\
                        var hasOneMatchingValue = false;\
\
                        for (var i = 0; i < matchingSelect.selectedOptions.length; i++) {\
                            if (encode(matchingSelect.selectedOptions[i].value) === sectionCondition.Value) {\
                                hasOneMatchingValue = true;\
                            }\
                        }\
\
                        shouldShowSection = mergeCondition(shouldShowSection, hasOneMatchingValue, matchingSelect);\
                    } else {\
                        shouldShowSection = mergeCondition(shouldShowSection, encode(matchingSelect.value) === sectionCondition.Value, matchingSelect);\
                    }\
                }\
\
                function checkCheckbox(sectionCondition) {\
                    var matchingCheckboxes = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']");\
                    \
                    for (var i = 0; i < matchingCheckboxes.length; i++) {\
                        if (encode(matchingCheckboxes[i].value) === sectionCondition.Value) {\
                            shouldShowSection = mergeCondition(shouldShowSection, matchingCheckboxes[i].checked, matchingCheckboxes[i]);\
                        }\
                    }\
                }\
\
                function checkRadio(sectionCondition) {\
                    var matchingRadios = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']");\
                    \
                    for (var i = 0; i < matchingRadios.length; i++) {\
                        if (encode(matchingRadios[i].value) === sectionCondition.Value) {\
                            shouldShowSection = mergeCondition(shouldShowSection, matchingRadios[i].checked, matchingRadios[i]);\
                        }\
                    }\
                }\
            }\
\
            function mergeCondition(overallResult, newResult, element) {\
                newResult = newResult && isParentVisible(element);\
\
                if (conditionOperator === \'and\') {\
                    return overallResult && newResult;\
                } else {\
                    return overallResult || newResult;\
                }\
            }\
\
            function isParentVisible(element) {\
                var parentSectionDiv = $(\'#\' + element.id).closest(".fb-section");\
                return parentSectionDiv && !parentSectionDiv.is(":hidden");\
            }\
\
            function encode(myString) {\
                myString = he.encode(he.escape(myString));\
\
                /* Fixes issues with single quote and backtick encoding */\
                var i,\
                    entities = [\
                        [\'&#x27;\', \'&#39;\'],\
                        [\'&#x60;\', \'`\']\
                    ];\
\
                for (i = 0; i < entities.length; i++) {\
                    myString = String(myString).replace(new RegExp(entities[i][0], \'g\'), entities[i][1]);\
                }\
\
                return myString;\
            }\
\
            function showHideSection(showSection) {\
                if (showSection) {\
                    $(\'#FormField10_213d05f0-8982-429e-806c-8f5d9e983c1c\').show();\
                } else {\
                    $(\'#FormField10_213d05f0-8982-429e-806c-8f5d9e983c1c\').hide();\
                }\
\
                $("#FormField10_213d05f0-8982-429e-806c-8f5d9e983c1c .conditionalSectionListSelection").each(function (i, obj) {\
                    if (obj.type === \'radio\' || obj.type === \'checkbox\') {\
                        if (obj.checked) {\
                            $(\'#\' + obj.id).change();\
                        }\
                    } else {\
                        $(\'#\' + obj.id).change();\
                    }\
                });\
            }\
        });\
    });\
};\
\
fbRequireJSScript.addEventListener("load", conditionalSectionJs);var conditionalSectionJs = function () {\
    requirejs([window.formHost + \'/Scripts/require/fbRequire.config.js\'], function (fbRequireConfig) {\
        var fbRequire = fbRequireConfig.fbRequire;\
\
        fbRequire([\'jquery\', \'he\'], function ($, he) {\
            he.encode.options.decimal = true;\
            he.encode.options.allowUnsafeSymbols = true;\
\
            var sectionConditions = JSON.parse(\'[{"ElementName":"FormField16_213d05f0-8982-429e-806c-8f5d9e983c1c","Value":"Yes"}]\');\
            var conditionOperator = \'and\';\
\
            sectionConditions.forEach(function (sectionCondition) {\
                $("select[id=" + sectionCondition.ElementName + "]").addClass(\'conditionalSectionListSelection\');\
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").addClass(\'conditionalSectionListSelection\');\
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").addClass(\'conditionalSectionListSelection\');\
                \
                $("select[id=" + sectionCondition.ElementName + "]").on(\'change\', function () {\
                    checkShowHide();\
                });\
                \
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").on(\'change\', function () {\
                    checkShowHide();\
                });\
                \
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").on(\'change\', function () {\
                    checkShowHide();\
                });\
            });\
            \
            function checkShowHide() {\
                var shouldShowSection = conditionOperator === \'and\'; /* set default to true for AND operation and false for OR operation */\
\
                sectionConditions.forEach(function (sectionCondition) {\
                    checkSelect(sectionCondition);                \
                    checkCheckbox(sectionCondition);                \
                    checkRadio(sectionCondition);                    \
                });\
\
                showHideSection(shouldShowSection);\
\
                function checkSelect(sectionCondition) {\
                    var matchingSelect = $("select[id=" + sectionCondition.ElementName + "]")[0];\
\
                    if (!matchingSelect) {\
                        return;\
                    }\
\
                    if (matchingSelect.type === \'select-multiple\') {\
                        var hasOneMatchingValue = false;\
\
                        for (var i = 0; i < matchingSelect.selectedOptions.length; i++) {\
                            if (encode(matchingSelect.selectedOptions[i].value) === sectionCondition.Value) {\
                                hasOneMatchingValue = true;\
                            }\
                        }\
\
                        shouldShowSection = mergeCondition(shouldShowSection, hasOneMatchingValue, matchingSelect);\
                    } else {\
                        shouldShowSection = mergeCondition(shouldShowSection, encode(matchingSelect.value) === sectionCondition.Value, matchingSelect);\
                    }\
                }\
\
                function checkCheckbox(sectionCondition) {\
                    var matchingCheckboxes = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']");\
                    \
                    for (var i = 0; i < matchingCheckboxes.length; i++) {\
                        if (encode(matchingCheckboxes[i].value) === sectionCondition.Value) {\
                            shouldShowSection = mergeCondition(shouldShowSection, matchingCheckboxes[i].checked, matchingCheckboxes[i]);\
                        }\
                    }\
                }\
\
                function checkRadio(sectionCondition) {\
                    var matchingRadios = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']");\
                    \
                    for (var i = 0; i < matchingRadios.length; i++) {\
                        if (encode(matchingRadios[i].value) === sectionCondition.Value) {\
                            shouldShowSection = mergeCondition(shouldShowSection, matchingRadios[i].checked, matchingRadios[i]);\
                        }\
                    }\
                }\
            }\
\
            function mergeCondition(overallResult, newResult, element) {\
                newResult = newResult && isParentVisible(element);\
\
                if (conditionOperator === \'and\') {\
                    return overallResult && newResult;\
                } else {\
                    return overallResult || newResult;\
                }\
            }\
\
            function isParentVisible(element) {\
                var parentSectionDiv = $(\'#\' + element.id).closest(".fb-section");\
                return parentSectionDiv && !parentSectionDiv.is(":hidden");\
            }\
\
            function encode(myString) {\
                myString = he.encode(he.escape(myString));\
\
                /* Fixes issues with single quote and backtick encoding */\
                var i,\
                    entities = [\
                        [\'&#x27;\', \'&#39;\'],\
                        [\'&#x60;\', \'`\']\
                    ];\
\
                for (i = 0; i < entities.length; i++) {\
                    myString = String(myString).replace(new RegExp(entities[i][0], \'g\'), entities[i][1]);\
                }\
\
                return myString;\
            }\
\
            function showHideSection(showSection) {\
                if (showSection) {\
                    $(\'#FormField18_213d05f0-8982-429e-806c-8f5d9e983c1c\').show();\
                } else {\
                    $(\'#FormField18_213d05f0-8982-429e-806c-8f5d9e983c1c\').hide();\
                }\
\
                $("#FormField18_213d05f0-8982-429e-806c-8f5d9e983c1c .conditionalSectionListSelection").each(function (i, obj) {\
                    if (obj.type === \'radio\' || obj.type === \'checkbox\') {\
                        if (obj.checked) {\
                            $(\'#\' + obj.id).change();\
                        }\
                    } else {\
                        $(\'#\' + obj.id).change();\
                    }\
                });\
            }\
        });\
    });\
};\
\
fbRequireJSScript.addEventListener("load", conditionalSectionJs);var conditionalSectionJs = function () {\
    requirejs([window.formHost + \'/Scripts/require/fbRequire.config.js\'], function (fbRequireConfig) {\
        var fbRequire = fbRequireConfig.fbRequire;\
\
        fbRequire([\'jquery\', \'he\'], function ($, he) {\
            he.encode.options.decimal = true;\
            he.encode.options.allowUnsafeSymbols = true;\
\
            var sectionConditions = JSON.parse(\'[{"ElementName":"FormField34_213d05f0-8982-429e-806c-8f5d9e983c1c","Value":"Other"}]\');\
            var conditionOperator = \'and\';\
\
            sectionConditions.forEach(function (sectionCondition) {\
                $("select[id=" + sectionCondition.ElementName + "]").addClass(\'conditionalSectionListSelection\');\
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").addClass(\'conditionalSectionListSelection\');\
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").addClass(\'conditionalSectionListSelection\');\
                \
                $("select[id=" + sectionCondition.ElementName + "]").on(\'change\', function () {\
                    checkShowHide();\
                });\
                \
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").on(\'change\', function () {\
                    checkShowHide();\
                });\
                \
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").on(\'change\', function () {\
                    checkShowHide();\
                });\
            });\
            \
            function checkShowHide() {\
                var shouldShowSection = conditionOperator === \'and\'; /* set default to true for AND operation and false for OR operation */\
\
                sectionConditions.forEach(function (sectionCondition) {\
                    checkSelect(sectionCondition);                \
                    checkCheckbox(sectionCondition);                \
                    checkRadio(sectionCondition);                    \
                });\
\
                showHideSection(shouldShowSection);\
\
                function checkSelect(sectionCondition) {\
                    var matchingSelect = $("select[id=" + sectionCondition.ElementName + "]")[0];\
\
                    if (!matchingSelect) {\
                        return;\
                    }\
\
                    if (matchingSelect.type === \'select-multiple\') {\
                        var hasOneMatchingValue = false;\
\
                        for (var i = 0; i < matchingSelect.selectedOptions.length; i++) {\
                            if (encode(matchingSelect.selectedOptions[i].value) === sectionCondition.Value) {\
                                hasOneMatchingValue = true;\
                            }\
                        }\
\
                        shouldShowSection = mergeCondition(shouldShowSection, hasOneMatchingValue, matchingSelect);\
                    } else {\
                        shouldShowSection = mergeCondition(shouldShowSection, encode(matchingSelect.value) === sectionCondition.Value, matchingSelect);\
                    }\
                }\
\
                function checkCheckbox(sectionCondition) {\
                    var matchingCheckboxes = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']");\
                    \
                    for (var i = 0; i < matchingCheckboxes.length; i++) {\
                        if (encode(matchingCheckboxes[i].value) === sectionCondition.Value) {\
                            shouldShowSection = mergeCondition(shouldShowSection, matchingCheckboxes[i].checked, matchingCheckboxes[i]);\
                        }\
                    }\
                }\
\
                function checkRadio(sectionCondition) {\
                    var matchingRadios = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']");\
                    \
                    for (var i = 0; i < matchingRadios.length; i++) {\
                        if (encode(matchingRadios[i].value) === sectionCondition.Value) {\
                            shouldShowSection = mergeCondition(shouldShowSection, matchingRadios[i].checked, matchingRadios[i]);\
                        }\
                    }\
                }\
            }\
\
            function mergeCondition(overallResult, newResult, element) {\
                newResult = newResult && isParentVisible(element);\
\
                if (conditionOperator === \'and\') {\
                    return overallResult && newResult;\
                } else {\
                    return overallResult || newResult;\
                }\
            }\
\
            function isParentVisible(element) {\
                var parentSectionDiv = $(\'#\' + element.id).closest(".fb-section");\
                return parentSectionDiv && !parentSectionDiv.is(":hidden");\
            }\
\
            function encode(myString) {\
                myString = he.encode(he.escape(myString));\
\
                /* Fixes issues with single quote and backtick encoding */\
                var i,\
                    entities = [\
                        [\'&#x27;\', \'&#39;\'],\
                        [\'&#x60;\', \'`\']\
                    ];\
\
                for (i = 0; i < entities.length; i++) {\
                    myString = String(myString).replace(new RegExp(entities[i][0], \'g\'), entities[i][1]);\
                }\
\
                return myString;\
            }\
\
            function showHideSection(showSection) {\
                if (showSection) {\
                    $(\'#FormField35_213d05f0-8982-429e-806c-8f5d9e983c1c\').show();\
                } else {\
                    $(\'#FormField35_213d05f0-8982-429e-806c-8f5d9e983c1c\').hide();\
                }\
\
                $("#FormField35_213d05f0-8982-429e-806c-8f5d9e983c1c .conditionalSectionListSelection").each(function (i, obj) {\
                    if (obj.type === \'radio\' || obj.type === \'checkbox\') {\
                        if (obj.checked) {\
                            $(\'#\' + obj.id).change();\
                        }\
                    } else {\
                        $(\'#\' + obj.id).change();\
                    }\
                });\
            }\
        });\
    });\
};\
\
fbRequireJSScript.addEventListener("load", conditionalSectionJs);var conditionalSectionJs = function () {\
    requirejs([window.formHost + \'/Scripts/require/fbRequire.config.js\'], function (fbRequireConfig) {\
        var fbRequire = fbRequireConfig.fbRequire;\
\
        fbRequire([\'jquery\', \'he\'], function ($, he) {\
            he.encode.options.decimal = true;\
            he.encode.options.allowUnsafeSymbols = true;\
\
            var sectionConditions = JSON.parse(\'[{"ElementName":"FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c","Value":"Other"}]\');\
            var conditionOperator = \'and\';\
\
            sectionConditions.forEach(function (sectionCondition) {\
                $("select[id=" + sectionCondition.ElementName + "]").addClass(\'conditionalSectionListSelection\');\
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").addClass(\'conditionalSectionListSelection\');\
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").addClass(\'conditionalSectionListSelection\');\
                \
                $("select[id=" + sectionCondition.ElementName + "]").on(\'change\', function () {\
                    checkShowHide();\
                });\
                \
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").on(\'change\', function () {\
                    checkShowHide();\
                });\
                \
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").on(\'change\', function () {\
                    checkShowHide();\
                });\
            });\
            \
            function checkShowHide() {\
                var shouldShowSection = conditionOperator === \'and\'; /* set default to true for AND operation and false for OR operation */\
\
                sectionConditions.forEach(function (sectionCondition) {\
                    checkSelect(sectionCondition);                \
                    checkCheckbox(sectionCondition);                \
                    checkRadio(sectionCondition);                    \
                });\
\
                showHideSection(shouldShowSection);\
\
                function checkSelect(sectionCondition) {\
                    var matchingSelect = $("select[id=" + sectionCondition.ElementName + "]")[0];\
\
                    if (!matchingSelect) {\
                        return;\
                    }\
\
                    if (matchingSelect.type === \'select-multiple\') {\
                        var hasOneMatchingValue = false;\
\
                        for (var i = 0; i < matchingSelect.selectedOptions.length; i++) {\
                            if (encode(matchingSelect.selectedOptions[i].value) === sectionCondition.Value) {\
                                hasOneMatchingValue = true;\
                            }\
                        }\
\
                        shouldShowSection = mergeCondition(shouldShowSection, hasOneMatchingValue, matchingSelect);\
                    } else {\
                        shouldShowSection = mergeCondition(shouldShowSection, encode(matchingSelect.value) === sectionCondition.Value, matchingSelect);\
                    }\
                }\
\
                function checkCheckbox(sectionCondition) {\
                    var matchingCheckboxes = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']");\
                    \
                    for (var i = 0; i < matchingCheckboxes.length; i++) {\
                        if (encode(matchingCheckboxes[i].value) === sectionCondition.Value) {\
                            shouldShowSection = mergeCondition(shouldShowSection, matchingCheckboxes[i].checked, matchingCheckboxes[i]);\
                        }\
                    }\
                }\
\
                function checkRadio(sectionCondition) {\
                    var matchingRadios = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']");\
                    \
                    for (var i = 0; i < matchingRadios.length; i++) {\
                        if (encode(matchingRadios[i].value) === sectionCondition.Value) {\
                            shouldShowSection = mergeCondition(shouldShowSection, matchingRadios[i].checked, matchingRadios[i]);\
                        }\
                    }\
                }\
            }\
\
            function mergeCondition(overallResult, newResult, element) {\
                newResult = newResult && isParentVisible(element);\
\
                if (conditionOperator === \'and\') {\
                    return overallResult && newResult;\
                } else {\
                    return overallResult || newResult;\
                }\
            }\
\
            function isParentVisible(element) {\
                var parentSectionDiv = $(\'#\' + element.id).closest(".fb-section");\
                return parentSectionDiv && !parentSectionDiv.is(":hidden");\
            }\
\
            function encode(myString) {\
                myString = he.encode(he.escape(myString));\
\
                /* Fixes issues with single quote and backtick encoding */\
                var i,\
                    entities = [\
                        [\'&#x27;\', \'&#39;\'],\
                        [\'&#x60;\', \'`\']\
                    ];\
\
                for (i = 0; i < entities.length; i++) {\
                    myString = String(myString).replace(new RegExp(entities[i][0], \'g\'), entities[i][1]);\
                }\
\
                return myString;\
            }\
\
            function showHideSection(showSection) {\
                if (showSection) {\
                    $(\'#FormField49_213d05f0-8982-429e-806c-8f5d9e983c1c\').show();\
                } else {\
                    $(\'#FormField49_213d05f0-8982-429e-806c-8f5d9e983c1c\').hide();\
                }\
\
                $("#FormField49_213d05f0-8982-429e-806c-8f5d9e983c1c .conditionalSectionListSelection").each(function (i, obj) {\
                    if (obj.type === \'radio\' || obj.type === \'checkbox\') {\
                        if (obj.checked) {\
                            $(\'#\' + obj.id).change();\
                        }\
                    } else {\
                        $(\'#\' + obj.id).change();\
                    }\
                });\
            }\
        });\
    });\
};\
\
fbRequireJSScript.addEventListener("load", conditionalSectionJs);var conditionalSectionJs = function () {\
    requirejs([window.formHost + \'/Scripts/require/fbRequire.config.js\'], function (fbRequireConfig) {\
        var fbRequire = fbRequireConfig.fbRequire;\
\
        fbRequire([\'jquery\', \'he\'], function ($, he) {\
            he.encode.options.decimal = true;\
            he.encode.options.allowUnsafeSymbols = true;\
\
            var sectionConditions = JSON.parse(\'[{"ElementName":"FormField59_213d05f0-8982-429e-806c-8f5d9e983c1c","Value":"Yes"}]\');\
            var conditionOperator = \'and\';\
\
            sectionConditions.forEach(function (sectionCondition) {\
                $("select[id=" + sectionCondition.ElementName + "]").addClass(\'conditionalSectionListSelection\');\
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").addClass(\'conditionalSectionListSelection\');\
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").addClass(\'conditionalSectionListSelection\');\
                \
                $("select[id=" + sectionCondition.ElementName + "]").on(\'change\', function () {\
                    checkShowHide();\
                });\
                \
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").on(\'change\', function () {\
                    checkShowHide();\
                });\
                \
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").on(\'change\', function () {\
                    checkShowHide();\
                });\
            });\
            \
            function checkShowHide() {\
                var shouldShowSection = conditionOperator === \'and\'; /* set default to true for AND operation and false for OR operation */\
\
                sectionConditions.forEach(function (sectionCondition) {\
                    checkSelect(sectionCondition);                \
                    checkCheckbox(sectionCondition);                \
                    checkRadio(sectionCondition);                    \
                });\
\
                showHideSection(shouldShowSection);\
\
                function checkSelect(sectionCondition) {\
                    var matchingSelect = $("select[id=" + sectionCondition.ElementName + "]")[0];\
\
                    if (!matchingSelect) {\
                        return;\
                    }\
\
                    if (matchingSelect.type === \'select-multiple\') {\
                        var hasOneMatchingValue = false;\
\
                        for (var i = 0; i < matchingSelect.selectedOptions.length; i++) {\
                            if (encode(matchingSelect.selectedOptions[i].value) === sectionCondition.Value) {\
                                hasOneMatchingValue = true;\
                            }\
                        }\
\
                        shouldShowSection = mergeCondition(shouldShowSection, hasOneMatchingValue, matchingSelect);\
                    } else {\
                        shouldShowSection = mergeCondition(shouldShowSection, encode(matchingSelect.value) === sectionCondition.Value, matchingSelect);\
                    }\
                }\
\
                function checkCheckbox(sectionCondition) {\
                    var matchingCheckboxes = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']");\
                    \
                    for (var i = 0; i < matchingCheckboxes.length; i++) {\
                        if (encode(matchingCheckboxes[i].value) === sectionCondition.Value) {\
                            shouldShowSection = mergeCondition(shouldShowSection, matchingCheckboxes[i].checked, matchingCheckboxes[i]);\
                        }\
                    }\
                }\
\
                function checkRadio(sectionCondition) {\
                    var matchingRadios = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']");\
                    \
                    for (var i = 0; i < matchingRadios.length; i++) {\
                        if (encode(matchingRadios[i].value) === sectionCondition.Value) {\
                            shouldShowSection = mergeCondition(shouldShowSection, matchingRadios[i].checked, matchingRadios[i]);\
                        }\
                    }\
                }\
            }\
\
            function mergeCondition(overallResult, newResult, element) {\
                newResult = newResult && isParentVisible(element);\
\
                if (conditionOperator === \'and\') {\
                    return overallResult && newResult;\
                } else {\
                    return overallResult || newResult;\
                }\
            }\
\
            function isParentVisible(element) {\
                var parentSectionDiv = $(\'#\' + element.id).closest(".fb-section");\
                return parentSectionDiv && !parentSectionDiv.is(":hidden");\
            }\
\
            function encode(myString) {\
                myString = he.encode(he.escape(myString));\
\
                /* Fixes issues with single quote and backtick encoding */\
                var i,\
                    entities = [\
                        [\'&#x27;\', \'&#39;\'],\
                        [\'&#x60;\', \'`\']\
                    ];\
\
                for (i = 0; i < entities.length; i++) {\
                    myString = String(myString).replace(new RegExp(entities[i][0], \'g\'), entities[i][1]);\
                }\
\
                return myString;\
            }\
\
            function showHideSection(showSection) {\
                if (showSection) {\
                    $(\'#FormField66_213d05f0-8982-429e-806c-8f5d9e983c1c\').show();\
                } else {\
                    $(\'#FormField66_213d05f0-8982-429e-806c-8f5d9e983c1c\').hide();\
                }\
\
                $("#FormField66_213d05f0-8982-429e-806c-8f5d9e983c1c .conditionalSectionListSelection").each(function (i, obj) {\
                    if (obj.type === \'radio\' || obj.type === \'checkbox\') {\
                        if (obj.checked) {\
                            $(\'#\' + obj.id).change();\
                        }\
                    } else {\
                        $(\'#\' + obj.id).change();\
                    }\
                });\
            }\
        });\
    });\
};\
\
fbRequireJSScript.addEventListener("load", conditionalSectionJs);var conditionalSectionJs = function () {\
    requirejs([window.formHost + \'/Scripts/require/fbRequire.config.js\'], function (fbRequireConfig) {\
        var fbRequire = fbRequireConfig.fbRequire;\
\
        fbRequire([\'jquery\', \'he\'], function ($, he) {\
            he.encode.options.decimal = true;\
            he.encode.options.allowUnsafeSymbols = true;\
\
            var sectionConditions = JSON.parse(\'[{"ElementName":"FormField60_213d05f0-8982-429e-806c-8f5d9e983c1c","Value":"Yes"}]\');\
            var conditionOperator = \'and\';\
\
            sectionConditions.forEach(function (sectionCondition) {\
                $("select[id=" + sectionCondition.ElementName + "]").addClass(\'conditionalSectionListSelection\');\
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").addClass(\'conditionalSectionListSelection\');\
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").addClass(\'conditionalSectionListSelection\');\
                \
                $("select[id=" + sectionCondition.ElementName + "]").on(\'change\', function () {\
                    checkShowHide();\
                });\
                \
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").on(\'change\', function () {\
                    checkShowHide();\
                });\
                \
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").on(\'change\', function () {\
                    checkShowHide();\
                });\
            });\
            \
            function checkShowHide() {\
                var shouldShowSection = conditionOperator === \'and\'; /* set default to true for AND operation and false for OR operation */\
\
                sectionConditions.forEach(function (sectionCondition) {\
                    checkSelect(sectionCondition);                \
                    checkCheckbox(sectionCondition);                \
                    checkRadio(sectionCondition);                    \
                });\
\
                showHideSection(shouldShowSection);\
\
                function checkSelect(sectionCondition) {\
                    var matchingSelect = $("select[id=" + sectionCondition.ElementName + "]")[0];\
\
                    if (!matchingSelect) {\
                        return;\
                    }\
\
                    if (matchingSelect.type === \'select-multiple\') {\
                        var hasOneMatchingValue = false;\
\
                        for (var i = 0; i < matchingSelect.selectedOptions.length; i++) {\
                            if (encode(matchingSelect.selectedOptions[i].value) === sectionCondition.Value) {\
                                hasOneMatchingValue = true;\
                            }\
                        }\
\
                        shouldShowSection = mergeCondition(shouldShowSection, hasOneMatchingValue, matchingSelect);\
                    } else {\
                        shouldShowSection = mergeCondition(shouldShowSection, encode(matchingSelect.value) === sectionCondition.Value, matchingSelect);\
                    }\
                }\
\
                function checkCheckbox(sectionCondition) {\
                    var matchingCheckboxes = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']");\
                    \
                    for (var i = 0; i < matchingCheckboxes.length; i++) {\
                        if (encode(matchingCheckboxes[i].value) === sectionCondition.Value) {\
                            shouldShowSection = mergeCondition(shouldShowSection, matchingCheckboxes[i].checked, matchingCheckboxes[i]);\
                        }\
                    }\
                }\
\
                function checkRadio(sectionCondition) {\
                    var matchingRadios = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']");\
                    \
                    for (var i = 0; i < matchingRadios.length; i++) {\
                        if (encode(matchingRadios[i].value) === sectionCondition.Value) {\
                            shouldShowSection = mergeCondition(shouldShowSection, matchingRadios[i].checked, matchingRadios[i]);\
                        }\
                    }\
                }\
            }\
\
            function mergeCondition(overallResult, newResult, element) {\
                newResult = newResult && isParentVisible(element);\
\
                if (conditionOperator === \'and\') {\
                    return overallResult && newResult;\
                } else {\
                    return overallResult || newResult;\
                }\
            }\
\
            function isParentVisible(element) {\
                var parentSectionDiv = $(\'#\' + element.id).closest(".fb-section");\
                return parentSectionDiv && !parentSectionDiv.is(":hidden");\
            }\
\
            function encode(myString) {\
                myString = he.encode(he.escape(myString));\
\
                /* Fixes issues with single quote and backtick encoding */\
                var i,\
                    entities = [\
                        [\'&#x27;\', \'&#39;\'],\
                        [\'&#x60;\', \'`\']\
                    ];\
\
                for (i = 0; i < entities.length; i++) {\
                    myString = String(myString).replace(new RegExp(entities[i][0], \'g\'), entities[i][1]);\
                }\
\
                return myString;\
            }\
\
            function showHideSection(showSection) {\
                if (showSection) {\
                    $(\'#FormField61_213d05f0-8982-429e-806c-8f5d9e983c1c\').show();\
                } else {\
                    $(\'#FormField61_213d05f0-8982-429e-806c-8f5d9e983c1c\').hide();\
                }\
\
                $("#FormField61_213d05f0-8982-429e-806c-8f5d9e983c1c .conditionalSectionListSelection").each(function (i, obj) {\
                    if (obj.type === \'radio\' || obj.type === \'checkbox\') {\
                        if (obj.checked) {\
                            $(\'#\' + obj.id).change();\
                        }\
                    } else {\
                        $(\'#\' + obj.id).change();\
                    }\
                });\
            }\
        });\
    });\
};\
\
fbRequireJSScript.addEventListener("load", conditionalSectionJs);';

if(fbScriptTag.length === 0) {
    fbScriptTag = document.querySelector("script[src*='213d05f0-8982-429e-806c-8f5d9e983c1c']");
} else {
    fbScriptTag = fbScriptTag[0];
}

fbRenderContainer.id = "formRenderContainer";
fbRenderContainer.className = " fbRenderContainer fbRenderContainer_213d05f0-8982-429e-806c-8f5d9e983c1c";
fbRenderedCssContainer.id = "fbRenderedCssContainer";

fbConfigScript.type = "text/javascript";
fbRequireJSScript.type = "text/javascript";
fbInstaMedJSScript.type = "text/javascript";
fbGeoCaptchaCallback.type = "text/javascript";
fbGeoReCaptchaCallback.type = "text/javascript";
fbFormulateRenderer.type = "text/javascript";
fbRenderedIntegrations.type = "text/javascript";
fbRenderedScripts.type = "text/javascript";
fbAutoPopulateFromQueryString.type = "text/javascript";

fbRequireJSScript.src = "https://formulate.geonetric.com/Scripts/require.min.js";
fbInstaMedJSScript.src = "https://formulate.geonetric.com/Scripts/vendor/instamed/token.js";
fbInstaMedJSScript.id = "instamed-sdk";
fbGeoCaptchaCallback.src = "https://formulate.geonetric.com/Scripts/geo-captcha-callback.js";
fbGeoReCaptchaCallback.src = "https://www.google.com/recaptcha/api.js?onload=geoFbCaptchaCallback&render=6LdxkTEpAAAAAMKbkhz8-INpQis_mvSaIXnoyC2V";
fbFormulateRenderer.src = "https://formulate.geonetric.com/Scripts/require/formulate-renderer.js?embeddedCssType=0&isTestResponse=False&hasGoogleAnalytics=False";
fbFormulateRenderer.id = "formulateRendererScript";
fbAutoPopulateFromQueryString.src = "https://formulate.geonetric.com/Scripts/auto-populate-from-query-string.js";

if (fbEnableInstaMedScript === 'True') {
    fbInstaMedJSScript.setAttribute("data-displaymode", "embedded");
    fbInstaMedJSScript.setAttribute("data-environment", "UAT");
    fbInstaMedJSScript.setAttribute("data-mobiledisplaymode", "embedded");
}

fbGeoCaptchaCallback.onload = function() {
    if(document.querySelectorAll('.geo-fb-recaptcha').length > 0)
    {
        fbBodyTag.appendChild(fbGeoReCaptchaCallback);
    }
}

fbRequireJSScript.addEventListener("load", function() {
    fbBodyTag.appendChild(fbFormulateRenderer);
    fbBodyTag.appendChild(fbAutoPopulateFromQueryString);
});

fbFormulateRenderer.addEventListener("load", function () {
    initFormBuilderForm();
});

var embeddedCssType = 0
switch (embeddedCssType) {
    case 1:
        fbEmbeddedCss = '<link href=\"https://formulate.geonetric.com/Content/bootstrap.min.css\" rel=\"stylesheet\"><link href=\"https://formulate.geonetric.com/Content/embedded/font-awesome/css/font-awesome.min.css\" rel=\"stylesheet\"><link href=\"https://formulate.geonetric.com/Content/embedded/embedded.css\" rel=\"stylesheet\">';
        break;
    case 2:
        fbEmbeddedCss = '';
        break;
    default:
        fbEmbeddedCss = '<link href=\"https://formulate.geonetric.com/Content/embedded/font-awesome/css/font-awesome.min.css\" rel=\"stylesheet\"><link href=\"https://formulate.geonetric.com/Content/embedded/embedded.css\" rel=\"stylesheet\">';
}

if (fbIsTestResponse === 'True') {
    fbRenderContainer.setAttribute('data-test-mode', 'true');
} else {
    fbRenderContainer.setAttribute('data-test-mode', 'false');
}

fbRenderContainer.innerHTML = "<div id=\'formContainer_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'fbFormContainer fbFormContainer_213d05f0-8982-429e-806c-8f5d9e983c1c BlockLabels hidden\'>\
<p>Required fields are marked with <span class=\'fb-required\'>*</span></p>\
<input type=\'hidden\' name=\'formId\' id=\'formId\' value=\'213d05f0-8982-429e-806c-8f5d9e983c1c\' />\
<input type=\'hidden\' name=\'formName\' id=\'formName\' value=\'Patient and Family Advisory Council Application\' />\
<input type=\'hidden\' name=\'formVersion\' value=\'43\' id=\'formVersion\' />\
<input type=\'hidden\' name=\'organizationId\' id=\'organizationId\' value=\'1572f4b7-20b2-4588-b567-38b685c688cd\' />\
<input type=\'hidden\' name=\'responseId\' id=\'responseId\' value=\'10ef2a1f-0bbf-4f22-96e2-97f5379f2021\' />\
<input type=\'hidden\' name=\'formBaseUrl\' id=\'formBaseUrl\' value=\'https://formulate.geonetric.com\' />\
\
\
<div class=\'fb-section\'><p><u><span style=\'font-size: 24px;\'><strong>Applicant Information</strong></span></u></p>\
                        <fieldset class=\'fb-fieldset \'>\
                            <legend class=\'fb-legend hidden\'>First and Last Name</legend>\
                            \
                            <div class=\'row\'>\
                                <div class=\'col-sm-6\'>\
                                    \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label  \' for=\'FormField3_213d05f0-8982-429e-806c-8f5d9e983c1cFirst\'>First Name<span class=\'fb-required\'>*</span></label>\
                    <div >\
                        <input class=\'fb-name-field form-control input-medium\' id=\'FormField3_213d05f0-8982-429e-806c-8f5d9e983c1cFirst\' name=\'FormField3_213d05f0-8982-429e-806c-8f5d9e983c1cFirst\' type=\'text\' data-export-label=\'First_and_Last_Name_First_Name\'  integration-export-label=\'\' placeholder=\'\' required data-msg-required=\'First Name is required.\' />\
                        \
                    </div>\
                </div>\
                                </div>\
                                <div class=\'col-sm-6\'>\
                                    \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label  \' for=\'FormField3_213d05f0-8982-429e-806c-8f5d9e983c1cLast\'>Last Name<span class=\'fb-required\'>*</span></label>\
                    <div >\
                        <input class=\'fb-name-field form-control input-medium\' id=\'FormField3_213d05f0-8982-429e-806c-8f5d9e983c1cLast\' name=\'FormField3_213d05f0-8982-429e-806c-8f5d9e983c1cLast\' type=\'text\' data-export-label=\'First_and_Last_Name_Last_Name\'  integration-export-label=\'\' placeholder=\'\' required data-msg-required=\'Last Name is required.\' />\
                        \
                    </div>\
                </div>\
                                </div>\
                            </div>\
                        </fieldset><div class=\'form-group\'><label for=\'FormField4_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Preferred First Name</label><div>\
<input type=\'text\' name=\'FormField4_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField4_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-medium \' value=\'\'   data-export-label=\'Preferred_First_Name\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField5_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Date of Birth<span class=\'fb-required\'>*</span></label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField5_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField5_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-medium isDatePicker\' required data-msg-required=\'Date of Birth is required.\' data-format=\'mm/dd/yy\' data-export-label=\'Date_of_Birth\'  data-rule-dateFormat=\'MM/DD/YYYY\' style=\'float: left;\' /></div></div></div>\
                <fieldset class=\'fb-fieldset \'>\
                    <legend class=\'fb-legend \'>Address</legend>\
                    \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label \' for=\'FormField6_213d05f0-8982-429e-806c-8f5d9e983c1c_Line1\'>Line 1<span class=\'fb-required\'>*</span></label>\
                    <div >\
                        <input class=\'form-control\' id=\'FormField6_213d05f0-8982-429e-806c-8f5d9e983c1c_Line1\' name=\'FormField6_213d05f0-8982-429e-806c-8f5d9e983c1c_Line1\' type=\'text\' data-export-label=\'Address_Line1\'  required data-msg-required=\'Address Line 1 is required.\' autocomplete=\'street-address\'  />\
                    </div>\
                </div>\
                    \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label \' for=\'FormField6_213d05f0-8982-429e-806c-8f5d9e983c1c_Line2\'>Line 2</label>\
                    <div >\
                        <input class=\'form-control\' id=\'FormField6_213d05f0-8982-429e-806c-8f5d9e983c1c_Line2\' name=\'FormField6_213d05f0-8982-429e-806c-8f5d9e983c1c_Line2\' type=\'text\' data-export-label=\'Address_Line2\'     />\
                    </div>\
                </div>\
                    <div class=\'row\'>\
                        <div class=\'col-sm-4\'>\
                            \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label \' for=\'FormField6_213d05f0-8982-429e-806c-8f5d9e983c1c_City\'>City<span class=\'fb-required\'>*</span></label>\
                    <div >\
                        <input class=\'form-control\' id=\'FormField6_213d05f0-8982-429e-806c-8f5d9e983c1c_City\' name=\'FormField6_213d05f0-8982-429e-806c-8f5d9e983c1c_City\' type=\'text\' data-export-label=\'Address_City\'  required data-msg-required=\'Address City is required.\' autocomplete=\'locality\'  />\
                    </div>\
                </div>\
                        </div>\
                        <div class=\'col-sm-4\'>\
                            \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label \' for=\'FormField6_213d05f0-8982-429e-806c-8f5d9e983c1c_State\'>State<span class=\'fb-required\'>*</span></label>\
                    <div >\
                        <select class=\'form-control\' name=\'FormField6_213d05f0-8982-429e-806c-8f5d9e983c1c_State\' id=\'FormField6_213d05f0-8982-429e-806c-8f5d9e983c1c_State\' autocomplete=\'region\' required=\'required\' data-msg-required=\'Address State is required.\' data-export-label=\'Address_State\' >\
                            <option value=\'\'>( Please Select )</option>\
                            <option value=\'AL\'>Alabama</option>\
                            <option value=\'AK\'>Alaska</option>\
                            <option value=\'AZ\'>Arizona</option>\
                            <option value=\'AR\'>Arkansas</option>\
                            <option value=\'CA\'>California</option>\
                            <option value=\'CO\'>Colorado</option>\
                            <option value=\'CT\'>Connecticut</option>\
                            <option value=\'DE\'>Delaware</option>\
                            <option value=\'DC\'>District Of Columbia</option>\
                            <option value=\'FL\'>Florida</option>\
                            <option value=\'GA\'>Georgia</option>\
                            <option value=\'HI\'>Hawaii</option>\
                            <option value=\'ID\'>Idaho</option>\
                            <option value=\'IL\'>Illinois</option>\
                            <option value=\'IN\'>Indiana</option>\
                            <option value=\'IA\'>Iowa</option>\
                            <option value=\'KS\'>Kansas</option>\
                            <option value=\'KY\'>Kentucky</option>\
                            <option value=\'LA\'>Louisiana</option>\
                            <option value=\'ME\'>Maine</option>\
                            <option value=\'MD\'>Maryland</option>\
                            <option value=\'MA\'>Massachusetts</option>\
                            <option value=\'MI\'>Michigan</option>\
                            <option value=\'MN\'>Minnesota</option>\
                            <option value=\'MS\'>Mississippi</option>\
                            <option value=\'MO\'>Missouri</option>\
                            <option value=\'MT\'>Montana</option>\
                            <option value=\'NE\'>Nebraska</option>\
                            <option value=\'NV\'>Nevada</option>\
                            <option value=\'NH\'>New Hampshire</option>\
                            <option value=\'NJ\'>New Jersey</option>\
                            <option value=\'NM\'>New Mexico</option>\
                            <option value=\'NY\'>New York</option>\
                            <option value=\'NC\'>North Carolina</option>\
                            <option value=\'ND\'>North Dakota</option>\
                            <option value=\'OH\'>Ohio</option>\
                            <option value=\'OK\'>Oklahoma</option>\
                            <option value=\'OR\'>Oregon</option>\
                            <option value=\'PA\'>Pennsylvania</option>\
                            <option value=\'RI\'>Rhode Island</option>\
                            <option value=\'SC\'>South Carolina</option>\
                            <option value=\'SD\'>South Dakota</option>\
                            <option value=\'TN\'>Tennessee</option>\
                            <option value=\'TX\'>Texas</option>\
                            <option value=\'UT\'>Utah</option>\
                            <option value=\'VT\'>Vermont</option>\
                            <option value=\'VA\'>Virginia</option>\
                            <option value=\'WA\'>Washington</option>\
                            <option value=\'WV\'>West Virginia</option>\
                            <option value=\'WI\'>Wisconsin</option>\
                            <option value=\'WY\'>Wyoming</option>\
                        </select>\
                    </div>\
                </div>\
                \
                        </div>\
                        <div class=\'col-sm-4\'>\
                            \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label \' for=\'FormField6_213d05f0-8982-429e-806c-8f5d9e983c1c_Zip\'>Zip<span class=\'fb-required\'>*</span></label>\
                    <div >\
                        <input class=\'form-control\' id=\'FormField6_213d05f0-8982-429e-806c-8f5d9e983c1c_Zip\' name=\'FormField6_213d05f0-8982-429e-806c-8f5d9e983c1c_Zip\' type=\'text\' data-export-label=\'Address_Zip\'  required data-msg-required=\'Address Zip is required.\' autocomplete=\'postal-code\' data-rule-zipCode=\'true\' />\
                    </div>\
                </div>\
                        </div>\
                    </div>\
                </fieldset><div class=\'form-group\'><label for=\'FormField7_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Phone Number<span class=\'fb-required\'>*</span></label><div><input type=\'text\' name=\'FormField7_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField7_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-medium \' value=\'\' required data-msg-required=\'Phone Number is required.\' data-export-label=\'Phone_Number\'  data-rule-phoneUS=\'true\' data-msg-phoneUS=\'Please specify a valid phone number.\' />\
</div></div><div class=\'form-group\'><label for=\'FormField8_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Email<span class=\'fb-required\'>*</span></label><div><input type=\'email\' name=\'FormField8_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField8_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-medium \' value=\'\' required data-msg-required=\'Email is required.\' data-export-label=\'Email\'  data-msg-email=\'Please specify a valid email.\' />\
</div></div></div><div class=\'form-group\'><label for=\'FormField9_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Gender<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField9_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField9_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'Gender is required.\' data-export-label=\'Gender\' ><option value=\'\' selected>( Please Select )</option><option value=\'Female\'>Female</option><option value=\'Male\'>Male</option><option value=\'Transgender Man/Trans Man\'>Transgender Man/Trans Man</option><option value=\'Transgender Woman/Trans Woman\'>Transgender Woman/Trans Woman</option><option value=\'Genderqueer/Gender nonconforming neither Male or Female\'>Genderqueer/Gender nonconforming neither Male or Female</option><option value=\'Additional Gender Category (Other)\'>Additional Gender Category (Other)</option><option value=\'Decline to Answer\'>Decline to Answer</option></select></div></div><div class=\'fb-section\' style=\'display: none;\' id=\'FormField10_213d05f0-8982-429e-806c-8f5d9e983c1c\'><div class=\'form-group\'><label for=\'FormField11_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>If Additional Gender Category (Other), please describe.<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField11_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField11_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'If Additional Gender Category (Other), please describe. is required.\' data-export-label=\'If_Additional_Gender_Category_Other\'  placeholder=\'\'  />\
</div></div></div><div class=\'form-group\'><label for=\'FormField12_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Race/Ethnicity (optional)</label><div>\
<input type=\'text\' name=\'FormField12_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField12_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-medium \' value=\'\'   data-export-label=\'Race_Ethnicity_optional\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField13_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>What language(s) do you speak?<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField13_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField13_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'What language(s) do you speak? is required.\' data-export-label=\'What_languages__do_you_speak\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField14_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Are you a veteran?</label><div><select  name=\'FormField14_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField14_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control \' style=\'width: auto\'  data-export-label=\'Are_you_a_veteran\' ><option value=\'\' selected>( Please Select )</option><option value=\'Yes\'>Yes</option><option value=\'No\'>No</option></select></div></div><div class=\'form-group\'><label for=\'FormField16_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Have you ever worked or volunteered at MyMichigan Health?<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField16_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField16_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'Have you ever worked or volunteered at MyMichigan Health? is required.\' data-export-label=\'Worked_or_volunteered_at_MyMichigan_Health\' ><option value=\'\' selected>( Please Select )</option><option value=\'Yes\'>Yes</option><option value=\'No\'>No</option></select></div></div><div class=\'fb-section\' style=\'display: none;\' id=\'FormField18_213d05f0-8982-429e-806c-8f5d9e983c1c\'><div class=\'form-group\'><label for=\'FormField21_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>If yes, in what capacity and when?<span class=\'fb-required\'>*</span></label><div>\
<textarea rows=\'10\' name=\'FormField21_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField21_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control textarea-medium\' required data-msg-required=\'If yes, in what capacity and when? is required.\'  data-export-label=\'If_yes_what_capacity_and_when\'  placeholder=\'\'></textarea>\
</div></div></div><p><u><span style=\'font-size: 24px;\'><strong>Employment History (Optional)</strong></span></u></p><p><span style=\'font-size: 14px;\'><strong>Please list information for your two most recent employers.</strong></span></p><div class=\'form-group\'><label for=\'FormField23_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>1st Employer Name</label><div>\
<input type=\'text\' name=\'FormField23_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField23_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-large \' value=\'\'   data-export-label=\'1st_Employer_Name\'  placeholder=\'\'  />\
</div></div><div class=\'fb-section\'><div class=\'form-group\'><label for=\'FormField76_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>1st Employer Address (List Address, City, State, Zip Code)</label><div>\
<input type=\'text\' name=\'FormField76_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField76_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-large \' value=\'\'   data-export-label=\'1st_Employer_Address\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField25_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Date of Employment</label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField25_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField25_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-medium isDatePicker\'  data-format=\'mm/dd/yy\' data-export-label=\'1_Date_of_Employment\'  data-rule-dateFormat=\'MM/DD/YYYY\' style=\'float: left;\' /></div></div></div><div class=\'form-group\'><label for=\'FormField26_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Job Title</label><div>\
<input type=\'text\' name=\'FormField26_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField26_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-large \' value=\'\'   data-export-label=\'1_Job_Title\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField27_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>What type of work did you do?</label><div>\
<textarea rows=\'10\' name=\'FormField27_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField27_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control textarea-medium\'   data-export-label=\'1_Type_of_Work\'  placeholder=\'\'></textarea>\
</div></div></div><div class=\'fb-section\'><div class=\'form-group\'><label for=\'FormField75_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>2nd Employer Address (List Address, City, State, Zip Code)</label><div>\
<input type=\'text\' name=\'FormField75_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField75_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-large \' value=\'\'   data-export-label=\'2nd_Employer_Address\'  placeholder=\'\'  />\
<div class=\'formHelp\'>List Address, City, State, Zip Code</div></div></div><div class=\'form-group\'><label for=\'FormField30_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Date of Employment</label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField30_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField30_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-medium isDatePicker\'  data-format=\'mm/dd/yy\' data-export-label=\'2_Date_of_Employment\'  data-rule-dateFormat=\'MM/DD/YYYY\' style=\'float: left;\' /></div></div></div><div class=\'form-group\'><label for=\'FormField31_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Job Title</label><div>\
<input type=\'text\' name=\'FormField31_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField31_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-large \' value=\'\'   data-export-label=\'2_Job_Title\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField32_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>What type of work did you do?</label><div>\
<textarea rows=\'10\' name=\'FormField32_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField32_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control textarea-medium\'   data-export-label=\'2_Type_of_Work\'  placeholder=\'\'></textarea>\
</div></div></div><p><u><strong><span style=\'font-size: 24px;\'>Education (Optional)</span></strong></u></p><div class=\'form-group\'><label for=\'FormField34_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Highest Level of Education Completed</label><div><select  name=\'FormField34_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField34_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control \' style=\'width: auto\'  data-export-label=\'Highest_Level_of_Education_Completed\' ><option value=\'\' selected>( Please Select )</option><option value=\'High School Diploma\'>High School Diploma</option><option value=\'GED\'>GED</option><option value=\'Some College\'>Some College</option><option value=\'Technical School\'>Technical School</option><option value=\'Undergraduate\'>Undergraduate</option><option value=\'Graduate\'>Graduate</option><option value=\'Other\'>Other</option></select></div></div><div class=\'fb-section\' style=\'display: none;\' id=\'FormField35_213d05f0-8982-429e-806c-8f5d9e983c1c\'><div class=\'form-group\'><label for=\'FormField36_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>If education Other, please list.</label><div>\
<input type=\'text\' name=\'FormField36_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField36_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-large \' value=\'\'   data-export-label=\'If_education_Other_please_list\'  placeholder=\'\'  />\
</div></div></div><div class=\'form-group\'><label for=\'FormField37_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>High School</label><div>\
<input type=\'text\' name=\'FormField37_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField37_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-large \' value=\'\'   data-export-label=\'High_School\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField38_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>City/State/Zip Code</label><div>\
<input type=\'text\' name=\'FormField38_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField38_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-large \' value=\'\'   data-export-label=\'City_State_Zip_Code\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField39_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>College</label><div>\
<input type=\'text\' name=\'FormField39_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField39_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-large \' value=\'\'   data-export-label=\'College\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField40_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Degree/Major</label><div>\
<input type=\'text\' name=\'FormField40_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField40_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-large \' value=\'\'   data-export-label=\'Degree_Major\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField41_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Other Professional Training</label><div>\
<textarea rows=\'10\' name=\'FormField41_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField41_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control textarea-medium\'   data-export-label=\'Other_Professional_Training\'  placeholder=\'\'></textarea>\
</div></div><p><u><span style=\'font-size: 24px;\'><strong>Skills and Scheduling</strong></span></u></p><div class=\'form-group\'><label  class=\'control-label  \'>Which Patient and Family Advisory Council (PFAC) are you interested in, Midland or Regional? (select one area of interest)</label><div class=\'Chkbx\'><div><fieldset class=\'RadioGroup\'><div class=\'separate\'><input type=\'radio\' value=\'Cardiovascular (Midland)\'  name=\'checkbox43\' id=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_1\' class=\'right\' data-export-label=\'Midland_or_Regional\' ><label for=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_1\'>Cardiovascular (Midland)</label></div><div class=\'separate\'><input type=\'radio\' value=\'Musculoskeletal (Midland)\'  name=\'checkbox43\' id=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_2\' class=\'right\' data-export-label=\'Midland_or_Regional\' ><label for=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_2\'>Musculoskeletal (Midland)</label></div><div class=\'separate\'><input type=\'radio\' value=\'Oncology (Midland)\'  name=\'checkbox43\' id=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_3\' class=\'right\' data-export-label=\'Midland_or_Regional\' ><label for=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_3\'>Oncology (Midland)</label></div><div class=\'separate\'><input type=\'radio\' value=\'Neuroscience (Midland)\'  name=\'checkbox43\' id=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_4\' class=\'right\' data-export-label=\'Midland_or_Regional\' ><label for=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_4\'>Neuroscience (Midland)</label></div><div class=\'separate\'><input type=\'radio\' value=\'Behavioral Health (Midland)\'  name=\'checkbox43\' id=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_5\' class=\'right\' data-export-label=\'Midland_or_Regional\' ><label for=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_5\'>Behavioral Health (Midland)</label></div><div class=\'separate\'><input type=\'radio\' value=\'Pediatrics (Midland)\'  name=\'checkbox43\' id=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_6\' class=\'right\' data-export-label=\'Midland_or_Regional\' ><label for=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_6\'>Pediatrics (Midland)</label></div><div class=\'separate\'><input type=\'radio\' value=\'Outpatient Providers Practices/Virtual Care (Midland)\'  name=\'checkbox43\' id=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_7\' class=\'right\' data-export-label=\'Midland_or_Regional\' ><label for=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_7\'>Outpatient Providers Practices/Virtual Care (Midland)</label></div><div class=\'separate\'><input type=\'radio\' value=\'Alpena Region\'  name=\'checkbox43\' id=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_8\' class=\'right\' data-export-label=\'Midland_or_Regional\' ><label for=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_8\'>Alpena Region</label></div><div class=\'separate\'><input type=\'radio\' value=\'Alma, Clare, Mt. Pleasant Region\'  name=\'checkbox43\' id=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_9\' class=\'right\' data-export-label=\'Midland_or_Regional\' ><label for=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_9\'>Alma, Clare, Mt. Pleasant Region</label></div><div class=\'separate\'><input type=\'radio\' value=\'Gladwin, West Branch Region\'  name=\'checkbox43\' id=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_10\' class=\'right\' data-export-label=\'Midland_or_Regional\' ><label for=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_10\'>Gladwin, West Branch Region</label></div><div class=\'separate\'><input type=\'radio\' value=\'Sault Ste. Marie Region\'  name=\'checkbox43\' id=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_11\' class=\'right\' data-export-label=\'Midland_or_Regional\' ><label for=\'FormField43_213d05f0-8982-429e-806c-8f5d9e983c1c_11\'>Sault Ste. Marie Region</label></div></fieldset></div></div></div><div class=\'form-group\'><label for=\'FormField45_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Have you or a family member received care at MyMichigan Health, or have you been an advocate for a relative or friend who received care?<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField45_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField45_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'Have you or a family member received care at MyMichigan Health, or have you been an advocate for a relative or friend who received care? is required.\' data-export-label=\'Received_Care\' ><option value=\'\' selected>( Please Select )</option><option value=\'Yes\'>Yes</option><option value=\'No\'>No</option></select></div></div><div class=\'form-group\'><label  class=\'control-label  \'>My care is/was provided by: (check all that apply)<span class=\'fb-required\'>*</span></label><div><div><fieldset class=\'CheckboxGroup\'><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Hospitalization (inpatient)\' required data-msg-required=\'My care is/was provided by: (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField46_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_46\' id=\'FormField46_213d05f0-8982-429e-806c-8f5d9e983c1c_1\' class=\'fo-right-margin-5\' data-export-label=\'Care_Provided_By\' ><label for=\'FormField46_213d05f0-8982-429e-806c-8f5d9e983c1c_1\'>Hospitalization (inpatient)</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Clinic Visit (outpatient)\' required data-msg-required=\'My care is/was provided by: (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField46_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_46\' id=\'FormField46_213d05f0-8982-429e-806c-8f5d9e983c1c_2\' class=\'fo-right-margin-5\' data-export-label=\'Care_Provided_By\' ><label for=\'FormField46_213d05f0-8982-429e-806c-8f5d9e983c1c_2\'>Clinic Visit (outpatient)</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Both inpatient and outpatient\' required data-msg-required=\'My care is/was provided by: (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField46_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_46\' id=\'FormField46_213d05f0-8982-429e-806c-8f5d9e983c1c_3\' class=\'fo-right-margin-5\' data-export-label=\'Care_Provided_By\' ><label for=\'FormField46_213d05f0-8982-429e-806c-8f5d9e983c1c_3\'>Both inpatient and outpatient</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Emergency Department\' required data-msg-required=\'My care is/was provided by: (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField46_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_46\' id=\'FormField46_213d05f0-8982-429e-806c-8f5d9e983c1c_4\' class=\'fo-right-margin-5\' data-export-label=\'Care_Provided_By\' ><label for=\'FormField46_213d05f0-8982-429e-806c-8f5d9e983c1c_4\'>Emergency Department</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Other departments or services\' required data-msg-required=\'My care is/was provided by: (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField46_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_46\' id=\'FormField46_213d05f0-8982-429e-806c-8f5d9e983c1c_5\' class=\'fo-right-margin-5\' data-export-label=\'Care_Provided_By\' ><label for=\'FormField46_213d05f0-8982-429e-806c-8f5d9e983c1c_5\'>Other departments or services</label></div></fieldset></div></div></div><div class=\'form-group\'><label  class=\'control-label  \'>The dates of my care experience at MyMichigan Health include: (check only one)<span class=\'fb-required\'>*</span></label><div class=\'Chkbx\'><div><fieldset class=\'RadioGroup\'><div class=\'flow\'><input type=\'radio\' value=\'Within the past 2 years\' required data-msg-required=\'The dates of my care experience at MyMichigan Health include: (check only one) is required.\' name=\'checkbox47\' id=\'FormField47_213d05f0-8982-429e-806c-8f5d9e983c1c_1\' class=\'right\' data-export-label=\'Dates_of_Care\' ><label for=\'FormField47_213d05f0-8982-429e-806c-8f5d9e983c1c_1\'>Within the past 2 years</label></div><div class=\'flow\'><input type=\'radio\' value=\'More than 2 years ago\' required data-msg-required=\'The dates of my care experience at MyMichigan Health include: (check only one) is required.\' name=\'checkbox47\' id=\'FormField47_213d05f0-8982-429e-806c-8f5d9e983c1c_2\' class=\'right\' data-export-label=\'Dates_of_Care\' ><label for=\'FormField47_213d05f0-8982-429e-806c-8f5d9e983c1c_2\'>More than 2 years ago</label></div><div class=\'flow\'><input type=\'radio\' value=\'More than 5 years ago\' required data-msg-required=\'The dates of my care experience at MyMichigan Health include: (check only one) is required.\' name=\'checkbox47\' id=\'FormField47_213d05f0-8982-429e-806c-8f5d9e983c1c_3\' class=\'right\' data-export-label=\'Dates_of_Care\' ><label for=\'FormField47_213d05f0-8982-429e-806c-8f5d9e983c1c_3\'>More than 5 years ago</label></div></fieldset></div></div></div><div class=\'form-group\'><label  class=\'control-label  \'>Within the past two years, what care services have you or your family members used? (check all that apply)<span class=\'fb-required\'>*</span></label><div><div><fieldset class=\'CheckboxGroup\'><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Behavioral Health\' required data-msg-required=\'Within the past two years, what care services have you or your family members used? (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_48\' id=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_1\' class=\'fo-right-margin-5\' data-export-label=\'Care_Services_Used\' ><label for=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_1\'>Behavioral Health</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Cancer\' required data-msg-required=\'Within the past two years, what care services have you or your family members used? (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_48\' id=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_2\' class=\'fo-right-margin-5\' data-export-label=\'Care_Services_Used\' ><label for=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_2\'>Cancer</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Cardiology\' required data-msg-required=\'Within the past two years, what care services have you or your family members used? (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_48\' id=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_3\' class=\'fo-right-margin-5\' data-export-label=\'Care_Services_Used\' ><label for=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_3\'>Cardiology</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Ear, Nose and Throat\' required data-msg-required=\'Within the past two years, what care services have you or your family members used? (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_48\' id=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_4\' class=\'fo-right-margin-5\' data-export-label=\'Care_Services_Used\' ><label for=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_4\'>Ear, Nose and Throat</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Endocrinology\' required data-msg-required=\'Within the past two years, what care services have you or your family members used? (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_48\' id=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_5\' class=\'fo-right-margin-5\' data-export-label=\'Care_Services_Used\' ><label for=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_5\'>Endocrinology</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Gastroenterology/GI\' required data-msg-required=\'Within the past two years, what care services have you or your family members used? (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_48\' id=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_6\' class=\'fo-right-margin-5\' data-export-label=\'Care_Services_Used\' ><label for=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_6\'>Gastroenterology/GI</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Intensive Care Unit (ICU)\' required data-msg-required=\'Within the past two years, what care services have you or your family members used? (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_48\' id=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_7\' class=\'fo-right-margin-5\' data-export-label=\'Care_Services_Used\' ><label for=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_7\'>Intensive Care Unit (ICU)</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Infectious Disease\' required data-msg-required=\'Within the past two years, what care services have you or your family members used? (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_48\' id=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_8\' class=\'fo-right-margin-5\' data-export-label=\'Care_Services_Used\' ><label for=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_8\'>Infectious Disease</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Nephrology\' required data-msg-required=\'Within the past two years, what care services have you or your family members used? (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_48\' id=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_9\' class=\'fo-right-margin-5\' data-export-label=\'Care_Services_Used\' ><label for=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_9\'>Nephrology</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Diabetes/Nutrition\' required data-msg-required=\'Within the past two years, what care services have you or your family members used? (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_48\' id=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_10\' class=\'fo-right-margin-5\' data-export-label=\'Care_Services_Used\' ><label for=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_10\'>Diabetes/Nutrition</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Orthopedics\' required data-msg-required=\'Within the past two years, what care services have you or your family members used? (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_48\' id=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_11\' class=\'fo-right-margin-5\' data-export-label=\'Care_Services_Used\' ><label for=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_11\'>Orthopedics</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Maternal Child Health\' required data-msg-required=\'Within the past two years, what care services have you or your family members used? (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_48\' id=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_12\' class=\'fo-right-margin-5\' data-export-label=\'Care_Services_Used\' ><label for=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_12\'>Maternal Child Health</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Rehabilitation\' required data-msg-required=\'Within the past two years, what care services have you or your family members used? (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_48\' id=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_13\' class=\'fo-right-margin-5\' data-export-label=\'Care_Services_Used\' ><label for=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_13\'>Rehabilitation</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Surgery\' required data-msg-required=\'Within the past two years, what care services have you or your family members used? (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_48\' id=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_14\' class=\'fo-right-margin-5\' data-export-label=\'Care_Services_Used\' ><label for=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_14\'>Surgery</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Urology\' required data-msg-required=\'Within the past two years, what care services have you or your family members used? (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_48\' id=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_15\' class=\'fo-right-margin-5\' data-export-label=\'Care_Services_Used\' ><label for=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_15\'>Urology</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Other\' required data-msg-required=\'Within the past two years, what care services have you or your family members used? (check all that apply) is required.\' name=\'39293543-a4fc-4e72-ad5b-69dfaf571138_FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_checkbox_48\' id=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_16\' class=\'fo-right-margin-5\' data-export-label=\'Care_Services_Used\' ><label for=\'FormField48_213d05f0-8982-429e-806c-8f5d9e983c1c_16\'>Other</label></div></fieldset></div></div></div><div class=\'fb-section\' style=\'display: none;\' id=\'FormField49_213d05f0-8982-429e-806c-8f5d9e983c1c\'><div class=\'form-group\'><label for=\'FormField50_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>If other services used, please describe<span class=\'fb-required\'>*</span></label><div>\
<textarea rows=\'10\' name=\'FormField50_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField50_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control textarea-medium\' required data-msg-required=\'If other services used, please describe is required.\'  data-export-label=\'Describe_other_services_used\'  placeholder=\'\'></textarea>\
</div></div></div><div class=\'form-group\'><label for=\'FormField51_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>What motivates you to consider serving as a MyMichigan Health Patient and Family advisor?<span class=\'fb-required\'>*</span></label><div>\
<textarea rows=\'10\' name=\'FormField51_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField51_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control textarea-large\' required data-msg-required=\'What motivates you to consider serving as a MyMichigan Health Patient and Family advisor? is required.\'  data-export-label=\'What_motivates_you_to_serve\'  placeholder=\'\'></textarea>\
</div></div><div class=\'form-group\'><label for=\'FormField53_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>What would you like to gain from serving as a Patient and Family advisor?<span class=\'fb-required\'>*</span></label><div>\
<textarea rows=\'10\' name=\'FormField53_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField53_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control textarea-large\' required data-msg-required=\'What would you like to gain from serving as a Patient and Family advisor? is required.\'  data-export-label=\'What_would_you_like_to_gain\'  placeholder=\'\'></textarea>\
</div></div><div class=\'form-group\'><label for=\'FormField54_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>If you have experience as an advisor, volunteer member, or public speaker for other organizations, please briefly describe it.<span class=\'fb-required\'>*</span></label><div>\
<textarea rows=\'10\' name=\'FormField54_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField54_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control textarea-large\' required data-msg-required=\'If you have experience as an advisor, volunteer member, or public speaker for other organizations, please briefly describe it. is required.\'  data-export-label=\'Describe_experience_of_prior_serving\'  placeholder=\'\'></textarea>\
</div></div><div class=\'form-group\'><label for=\'FormField55_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Tell us about you or your family&#39;s care experience at MyMichigan Health. What would you have improved about this experience? What impressed you about this experience?</label><div>\
<textarea rows=\'10\' name=\'FormField55_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField55_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control textarea-large\'   data-export-label=\'Familys_experience\'  placeholder=\'\'></textarea>\
</div></div><div class=\'form-group\'><label for=\'FormField56_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Is there anything else you would like us to know related to your experiences at MyMichigan Health?</label><div>\
<textarea rows=\'10\' name=\'FormField56_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField56_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control textarea-large\'   data-export-label=\'Anything_else_related_experiences\'  placeholder=\'\'></textarea>\
</div></div><p><span style=\'font-size: 24px;\'><u><strong>Additional Information</strong></u></span></p><div class=\'form-group\'><label for=\'FormField58_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Is there any additional information or comments you would like to share with us?</label><div>\
<textarea rows=\'10\' name=\'FormField58_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField58_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control textarea-large\'   data-export-label=\'Additional_Information_Comments\'  placeholder=\'\'></textarea>\
</div></div><div class=\'form-group\'><label for=\'FormField59_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Have you ever been convicted of a crime, including a misdemeanor?<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField59_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField59_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'Have you ever been convicted of a crime, including a misdemeanor? is required.\' data-export-label=\'Convicted_of_Crime\' ><option value=\'\' selected>( Please Select )</option><option value=\'Yes\'>Yes</option><option value=\'No\'>No</option></select></div></div><div class=\'fb-section\' style=\'display: none;\' id=\'FormField66_213d05f0-8982-429e-806c-8f5d9e983c1c\'><div class=\'form-group\'><label for=\'FormField67_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>If yes, please explain<span class=\'fb-required\'>*</span></label><div>\
<textarea rows=\'10\' name=\'FormField67_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField67_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control textarea-medium\' required data-msg-required=\'If yes, please explain is required.\'  data-export-label=\'If_yes_please_explain_crime_charges\'  placeholder=\'\'></textarea>\
</div></div></div><div class=\'form-group\'><label for=\'FormField60_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Are there any legal charges pending against you?<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField60_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField60_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'Are there any legal charges pending against you? is required.\' data-export-label=\'Pending_Charges\' ><option value=\'\' selected>( Please Select )</option><option value=\'Yes\'>Yes</option><option value=\'No\'>No</option></select></div></div><div class=\'fb-section\' style=\'display: none;\' id=\'FormField61_213d05f0-8982-429e-806c-8f5d9e983c1c\'><div class=\'form-group\'><label for=\'FormField62_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>If yes (legal charges pending) please explain:<span class=\'fb-required\'>*</span></label><div>\
<textarea rows=\'10\' name=\'FormField62_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField62_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control textarea-large\' required data-msg-required=\'If yes (legal charges pending) please explain: is required.\'  data-export-label=\'Explain_Pending_Charges\'  placeholder=\'\'></textarea>\
</div></div></div><p><span style=\'font-size: 24px;\'><u><strong>Authorization and Signature</strong></u></span></p><p><span style=\'font-size: 14px;\'>I certify that the responses on this application are true to the best of my knowledge. I agree that this information may be verified. I authorize MyMichigan Health to perform all necessary background checks and understand my date of birth is necessary for these checks. If accepted for one of the Patient and Family Advisory Councils or any volunteer service, I will comply with the values, policies and procedures of MyMichigan Health in effect or revisions which may be issued in the future. Misrepresentation of facts constitutes cause for separation from volunteer placement. I understand that the position that I am applying for is an unpaid volunteer position. </span></p><div class=\'form-group\'><label for=\'FormField64_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Signature - My typed name will act as my written signature.<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField64_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField64_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-large \' value=\'\'  required data-msg-required=\'Signature - My typed name will act as my written signature. is required.\' data-export-label=\'Signature\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField65_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'control-label  \'>Date Signed<span class=\'fb-required\'>*</span></label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField65_213d05f0-8982-429e-806c-8f5d9e983c1c\' id=\'FormField65_213d05f0-8982-429e-806c-8f5d9e983c1c\' class=\'form-control input-medium isDatePicker\' required data-msg-required=\'Date Signed is required.\' data-format=\'mm/dd/yy\' data-export-label=\'Date_Signed\'  data-rule-dateFormat=\'MM/DD/YYYY\' style=\'float: left;\' /></div></div></div><div class=\'validationSummary\'><p><i class=\'fa fa-exclamation-triangle\'></i> The following fields are required or invalid.</p><ul></ul></div>\
\
<div id=\'form-errors\' class=\'alert alert-danger fade in\' role=\'alert\' style=\'display:none\'></div>\
<div class=\'form-group ignore\'><div class=\'form-group ButtonHolder\'><div class=\'col-sm-4 col-sm-offset-2\'><button id=\'fb-submitButton\' type=\'button\' class=\'btn btn-primary Button\' value=\'Submit\'>Submit</button></div></div></div>\
</div>";

fbConfigScript.innerHTML = "window.formHost = 'https://formulate.geonetric.com'; window.submissionHost = 'https://formulate.geonetric.com/';";
fbRenderedScripts.innerHTML = renderedScripts.replace(/<script>/ig, '\n').replace(/<\/script>/ig, '').replace(/\s{4}/ig, "");
fbRenderedIntegrations.innerHTML = "";
fbRenderedCssContainer.innerHTML = '<link href="//maxcdn.bootstrapcdn.com/font-awesome/4.2.0/css/font-awesome.min.css" rel="stylesheet" /><link rel="stylesheet" href="https://formulate.geonetric.com/Content/themes/base/all.css" />';

fbScriptTag.parentNode.insertBefore(fbRenderContainer, fbScriptTag.nextSibling);

fbBodyTag.appendChild(fbConfigScript);
fbBodyTag.appendChild(fbRequireJSScript);
if (fbEnableInstaMedScript === 'True')
    fbHeadTag.appendChild(fbInstaMedJSScript);
fbBodyTag.insertAdjacentHTML('beforeend', fbEmbeddedCss);
fbBodyTag.appendChild(fbGeoCaptchaCallback);
fbBodyTag.appendChild(fbRenderedIntegrations);
fbBodyTag.appendChild(fbRenderedCssContainer);
fbBodyTag.appendChild(fbRenderedScripts);


fbScriptTag.parentNode.removeChild(fbScriptTag);