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("b0b89650-034b-473a-9ec7-ab5b6fba297b"), 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":"FormField35_ba8c7b08-5368-4433-b64c-aa2fa92b071c","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 = [\ [\''\', \''\'],\ [\'`\', \'`\']\ ];\ \ 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) {\ $(\'#FormField36_ba8c7b08-5368-4433-b64c-aa2fa92b071c\').show();\ } else {\ $(\'#FormField36_ba8c7b08-5368-4433-b64c-aa2fa92b071c\').hide();\ }\ \ $("#FormField36_ba8c7b08-5368-4433-b64c-aa2fa92b071c .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":"FormField38_ba8c7b08-5368-4433-b64c-aa2fa92b071c","Value":"No"}]\');\ 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 = [\ [\''\', \''\'],\ [\'`\', \'`\']\ ];\ \ 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) {\ $(\'#FormField39_ba8c7b08-5368-4433-b64c-aa2fa92b071c\').show();\ } else {\ $(\'#FormField39_ba8c7b08-5368-4433-b64c-aa2fa92b071c\').hide();\ }\ \ $("#FormField39_ba8c7b08-5368-4433-b64c-aa2fa92b071c .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*='b0b89650-034b-473a-9ec7-ab5b6fba297b']"); } else { fbScriptTag = fbScriptTag[0]; } fbRenderContainer.id = "formRenderContainer"; fbRenderContainer.className = " fbRenderContainer fbRenderContainer_b0b89650-034b-473a-9ec7-ab5b6fba297b"; 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 = ''; break; case 2: fbEmbeddedCss = ''; break; default: fbEmbeddedCss = ''; } if (fbIsTestResponse === 'True') { fbRenderContainer.setAttribute('data-test-mode', 'true'); } else { fbRenderContainer.setAttribute('data-test-mode', 'false'); } fbRenderContainer.innerHTML = "
\

Required fields are marked with *

\ \ \ \ \ \ \ \ \ \
\ Name of Applicant\ \
\ \
\ \ \
\
\
\ \
\ \ \
\
\
\
\ Your Name\ \
\ \
\ \ \
\
\
\ \
\ \ \
\
\
\ \
\ \
\ \
\ \
\
\
\ \
\ \

Please select the rating you would apply to this person:

\ \
\ \
\ \

Terms and Conditions

Users are advised that the information submitted through this form may be transmitted over unsecured email and releases EvergreenHealth and its employees, agents, and subcontractors from all responsibility or liability for any claims or damages arising from the content of the Email Form or the transmission thereof.  By selecting the "I agree to Terms and Conditions" checkbox user acknowledges these terms and conditions and consents to transmission of the form.

If you would like to speak to us confidentially about this person, please call 425.899.1040 and ask to speak with one of the hospice volunteer coordinators.

The following fields are required or invalid.

\ \
\
\
"; fbConfigScript.innerHTML = "window.formHost = 'https://formulate.geonetric.com'; window.submissionHost = 'https://formulate.geonetric.com/';"; fbRenderedScripts.innerHTML = renderedScripts.replace(/