{"id":3521,"date":"2023-09-29T15:45:57","date_gmt":"2023-09-29T15:45:57","guid":{"rendered":"https:\/\/www.southsideanimalclinic.com\/?page_id=3521"},"modified":"2023-09-29T15:45:57","modified_gmt":"2023-09-29T15:45:57","slug":"canine-and-feline-boarding-form","status":"publish","type":"page","link":"https:\/\/www.southsideanimalclinic.com\/canine-and-feline-boarding-form\/","title":{"rendered":"Canine and Feline Boarding Form"},"content":{"rendered":"<p><script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script><\/p>\n<div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_5' >\n<div class='gform_heading'>\n<h2 class=\"gform_title\">Canine and Feline Boarding Form<\/h2>\n<p class='gform_description'>This is a boarding check-in sheet for all of our canine and feline patients to fill out before boarding with Southside Animal Clinic.<\/p>\n<\/p><\/div>\n<form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/wp-json\/wp\/v2\/pages\/3521\/' data-formid='5' novalidate>\n<div class='gf_invisible ginput_recaptchav3' data-sitekey='6LdZfxInAAAAAGDhjfmQg7QmhadVqjI6NyDa8c0_' data-tabindex='0'><input id=\"input_416e9c570e469f006eac774e58592200\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_416e9c570e469f006eac774e58592200\" value=\"\"\/><\/div>\n<div class='gform-body gform_body'>\n<div id='gform_fields_5' class='gform_fields top_label form_sublabel_above description_below validation_below'>\n<div id=\"field_5_15\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_5_15\" >\n<div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div>\n<h3 class=\"gsection_title\">Next Steps: Sync an Email Add-On<\/h3>\n<div class='gsection_description' id='gfield_description_5_15'>To get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https:\/\/www.gravityforms.com\/the-8-best-email-plugins-for-wordpress-in-2020\/). Important: Delete this tip before you publish the form.<\/div>\n<\/div>\n<div id=\"field_5_7\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_7\" >\n<h3 class=\"gsection_title\">Information About Your Pet<\/h3>\n<\/div>\n<fieldset id=\"field_5_16\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_16\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Your Pet&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_16'>\n<p>                            <span id='input_5_16_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                    <label for='input_5_16_3' class='gform-field-label gform-field-label--type-sub '>First<\/label><br \/>\n                                                    <input type='text' name='input_16.3' id='input_5_16_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/><br \/>\n                                                <\/span><\/p>\n<p>                            <span id='input_5_16_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                            <label for='input_5_16_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label><br \/>\n                                                            <input type='text' name='input_16.6' id='input_5_16_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/><br \/>\n                                                        <\/span><\/p><\/div>\n<\/fieldset>\n<fieldset id=\"field_5_46\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_46\" >\n<legend class='gfield_label gform-field-label' >You Pet&#039;s Species<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_radio'>\n<div class='gfield_radio' id='input_5_46'>\n<div class='gchoice gchoice_5_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Cat'  id='choice_5_46_0' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_46_0' id='label_5_46_0' class='gform-field-label gform-field-label--type-inline'>Cat<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Dog'  id='choice_5_46_1' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_46_1' id='label_5_46_1' class='gform-field-label gform-field-label--type-inline'>Dog<\/label>\n\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"field_5_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_17\" >\n<legend class='gfield_label gform-field-label' >You Pet&#039;s Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_radio'>\n<div class='gfield_radio' id='input_5_17'>\n<div class='gchoice gchoice_5_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Female intact'  id='choice_5_17_0' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_17_0' id='label_5_17_0' class='gform-field-label gform-field-label--type-inline'>Female intact<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Female spayed'  id='choice_5_17_1' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_17_1' id='label_5_17_1' class='gform-field-label gform-field-label--type-inline'>Female spayed<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_17_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Male intact'  id='choice_5_17_2' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_17_2' id='label_5_17_2' class='gform-field-label gform-field-label--type-inline'>Male intact<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_17_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Male neutered'  id='choice_5_17_3' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_17_3' id='label_5_17_3' class='gform-field-label gform-field-label--type-inline'>Male neutered<\/label>\n\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_5_20\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_20\" ><label class='gfield_label gform-field-label' for='input_5_20'>What day are you dropping your pet off?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_20' id='input_5_20' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_20_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/><br \/>\n                            <span id='input_5_20_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_5_20' class='gform_hidden' value='https:\/\/www.southsideanimalclinic.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div>\n<fieldset id=\"field_5_22\" class=\"gfield gfield--type-time gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_22\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Drop Off Time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class=\"ginput_container ginput_complex gform-grid-row\">\n<div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_5_22'>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_5_22_1'>Hours<\/label><br \/>\n                            <input type='number' maxlength='2' name='input_22[]' id='input_5_22_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='true'   \/>\n                        <\/div>\n<div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n<div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_5_22_2'>Minutes<\/label><br \/>\n                            <input type='number' maxlength='2' name='input_22[]' id='input_5_22_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='true'  \/>\n                        <\/div>\n<div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n<p>                                <select name='input_22[]' id='input_5_22_3'  ><option value='am' >AM<\/option><option value='pm' >PM<\/option><\/select><br \/>\n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_5_22_3'>AM\/PM<\/label>\n                           <\/div>\n<\/p><\/div>\n<\/fieldset>\n<div id=\"field_5_21\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_21\" ><label class='gfield_label gform-field-label' for='input_5_21'>What day are you picking your pet up?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_21' id='input_5_21' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_21_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/><br \/>\n                            <span id='input_5_21_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_5_21' class='gform_hidden' value='https:\/\/www.southsideanimalclinic.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div>\n<fieldset id=\"field_5_23\" class=\"gfield gfield--type-time gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_23\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Pick Up Time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class=\"ginput_container ginput_complex gform-grid-row\">\n<div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_5_23'>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_5_23_1'>Hours<\/label><br \/>\n                            <input type='number' maxlength='2' name='input_23[]' id='input_5_23_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='true'   \/>\n                        <\/div>\n<div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n<div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_5_23_2'>Minutes<\/label><br \/>\n                            <input type='number' maxlength='2' name='input_23[]' id='input_5_23_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='true'  \/>\n                        <\/div>\n<div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n<p>                                <select name='input_23[]' id='input_5_23_3'  ><option value='am' >AM<\/option><option value='pm' >PM<\/option><\/select><br \/>\n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_5_23_3'>AM\/PM<\/label>\n                           <\/div>\n<\/p><\/div>\n<\/fieldset>\n<div id=\"field_5_19\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_19\" ><label class='gfield_label gform-field-label' for='input_5_19'>What type of heartworm and flea treatment is your pet on?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_19' id='input_5_19' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_19\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<div class='gfield_description' id='gfield_description_5_19'>If fleas are seen on pet, Capstar, flea treatment, will be administered and will incur a small additional cost.<\/div>\n<\/div>\n<fieldset id=\"field_5_48\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_48\" >\n<legend class='gfield_label gform-field-label' >Is your pet on any medications?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_radio'>\n<div class='gfield_radio' id='input_5_48'>\n<div class='gchoice gchoice_5_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Yes'  id='choice_5_48_0' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_48_0' id='label_5_48_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='No'  id='choice_5_48_1' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_48_1' id='label_5_48_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_5_26\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_26\" ><label class='gfield_label gform-field-label' for='input_5_26'>If your pet is on any medications, please tell us what medication, how often they are given, and when the last dose given.<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_26' id='input_5_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div>\n<\/div>\n<div id=\"field_5_24\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_24\" ><label class='gfield_label gform-field-label' for='input_5_24'>How much and how often does your pet eat?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_24' id='input_5_24' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<\/div>\n<fieldset id=\"field_5_28\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_28\" >\n<legend class='gfield_label gform-field-label' >Did your pet already eat today?<\/legend>\n<div class='ginput_container ginput_container_radio'>\n<div class='gfield_radio' id='input_5_28'>\n<div class='gchoice gchoice_5_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Yes'  id='choice_5_28_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_28\"   \/><br \/>\n\t\t\t\t\t<label for='choice_5_28_0' id='label_5_28_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='No'  id='choice_5_28_1' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_28_1' id='label_5_28_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n<\/div>\n<\/div>\n<div class='gfield_description' id='gfield_description_5_28'>Applies if you are dropping off same-day you are filling this form out.<\/div>\n<\/fieldset>\n<fieldset id=\"field_5_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_49\" >\n<legend class='gfield_label gform-field-label' >Does your pet have any allergies or food and treat sensitivities?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_radio'>\n<div class='gfield_radio' id='input_5_49'>\n<div class='gchoice gchoice_5_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Yes'  id='choice_5_49_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_49\"   \/><br \/>\n\t\t\t\t\t<label for='choice_5_49_0' id='label_5_49_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='No'  id='choice_5_49_1' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_49_1' id='label_5_49_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n<\/div>\n<\/div>\n<div class='gfield_description' id='gfield_description_5_49'>If pet develops any symptoms during stay, you could be called to discuss the need for testing and\/or treatments.<\/div>\n<\/fieldset>\n<div id=\"field_5_50\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_50\" ><label class='gfield_label gform-field-label' for='input_5_50'>If your pet does have any allergies or food and treat sensitivities, please list them below.<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_50' id='input_5_50' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div>\n<\/div>\n<div id=\"field_5_27\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_27\" ><label class='gfield_label gform-field-label' for='input_5_27'>What is  being left with your pet during their stay (leash\/collar, bed, toys, food, treats, etc.)? Please be specific with what items you are leaving and a description of each item below.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_27' id='input_5_27' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_27\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<div class='gfield_description' id='gfield_description_5_27'>We cannot guarantee you will receive items back in the same condition in which they arrived or at all.<\/div>\n<\/div>\n<fieldset id=\"field_5_39\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_39\" >\n<legend class='gfield_label gform-field-label' >If leaving multiple pets for boarding, can pets be housed in the same suite during stay?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_radio'>\n<div class='gfield_radio' id='input_5_39'>\n<div class='gchoice gchoice_5_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Yes'  id='choice_5_39_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_39\"   \/><br \/>\n\t\t\t\t\t<label for='choice_5_39_0' id='label_5_39_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='No'  id='choice_5_39_1' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_39_1' id='label_5_39_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_39_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Not Applicable to My Pet'  id='choice_5_39_2' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_39_2' id='label_5_39_2' class='gform-field-label gform-field-label--type-inline'>Not Applicable to My Pet<\/label>\n\t\t\t<\/div>\n<\/div>\n<\/div>\n<div class='gfield_description' id='gfield_description_5_39'>Pets are left unattended during the night and staff will be unaware of any events that may occur between pets until the following morning.<\/div>\n<\/fieldset>\n<fieldset id=\"field_5_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_36\" >\n<legend class='gfield_label gform-field-label' >Does your pet need a bath and\/or nail trim during stay?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_radio'>\n<div class='gfield_radio' id='input_5_36'>\n<div class='gchoice gchoice_5_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Bath'  id='choice_5_36_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_36\"   \/><br \/>\n\t\t\t\t\t<label for='choice_5_36_0' id='label_5_36_0' class='gform-field-label gform-field-label--type-inline'>Bath<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Nail Trim'  id='choice_5_36_1' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_36_1' id='label_5_36_1' class='gform-field-label gform-field-label--type-inline'>Nail Trim<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_36_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Bath and Nail Trim'  id='choice_5_36_2' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_36_2' id='label_5_36_2' class='gform-field-label gform-field-label--type-inline'>Bath and Nail Trim<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_36_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Does Not Need a Bath or Nail Trim'  id='choice_5_36_3' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_36_3' id='label_5_36_3' class='gform-field-label gform-field-label--type-inline'>Does Not Need a Bath or Nail Trim<\/label>\n\t\t\t<\/div>\n<\/div>\n<\/div>\n<div class='gfield_description' id='gfield_description_5_36'>Additional charges apply.<\/div>\n<\/fieldset>\n<fieldset id=\"field_5_38\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_38\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Would you like your pet to participate in daycare while here for boarding?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox' id='input_5_38'>\n<div class='gchoice gchoice_5_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='Monday'  id='choice_5_38_1'   aria-describedby=\"gfield_description_5_38\"\/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_1' id='label_5_38_1' class='gform-field-label gform-field-label--type-inline'>Monday<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_5_38_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.2' type='checkbox'  value='Tuesday'  id='choice_5_38_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_2' id='label_5_38_2' class='gform-field-label gform-field-label--type-inline'>Tuesday<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_5_38_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.3' type='checkbox'  value='Wednesday'  id='choice_5_38_3'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_3' id='label_5_38_3' class='gform-field-label gform-field-label--type-inline'>Wednesday<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_5_38_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.4' type='checkbox'  value='Thursday'  id='choice_5_38_4'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_4' id='label_5_38_4' class='gform-field-label gform-field-label--type-inline'>Thursday<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_5_38_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.5' type='checkbox'  value='Friday'  id='choice_5_38_5'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_5' id='label_5_38_5' class='gform-field-label gform-field-label--type-inline'>Friday<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_5_38_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.6' type='checkbox'  value='Does Not Need Daycare'  id='choice_5_38_6'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_6' id='label_5_38_6' class='gform-field-label gform-field-label--type-inline'>Does Not Need Daycare<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<div class='gfield_description' id='gfield_description_5_38'>To participate, this is an additional fee of $15\/day.     <\/div>\n<\/fieldset>\n<fieldset id=\"field_5_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_41\" >\n<legend class='gfield_label gform-field-label' >Do we have permission to behaviorally assess your pet to allow them to participate in daycare during their stay?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_radio'>\n<div class='gfield_radio' id='input_5_41'>\n<div class='gchoice gchoice_5_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Yes'  id='choice_5_41_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_41\"   \/><br \/>\n\t\t\t\t\t<label for='choice_5_41_0' id='label_5_41_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='No'  id='choice_5_41_1' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_41_1' id='label_5_41_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_41_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='My pet has already been assessed through Southside.'  id='choice_5_41_2' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_41_2' id='label_5_41_2' class='gform-field-label gform-field-label--type-inline'>My pet has already been assessed through Southside.<\/label>\n\t\t\t<\/div>\n<\/div>\n<\/div>\n<div class='gfield_description' id='gfield_description_5_41'>If your pet has not previously had a behavior assessment there will be a $30 assessment for existing patients and $45 for new patients. This includes a physical exam by the veterinarian. <\/div>\n<\/fieldset>\n<fieldset id=\"field_5_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_33\" >\n<legend class='gfield_label gform-field-label' >Does your pet need to be examined or treated by a veterinarian during their stay?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_radio'>\n<div class='gfield_radio' id='input_5_33'>\n<div class='gchoice gchoice_5_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Yes'  id='choice_5_33_0' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_33_0' id='label_5_33_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='No'  id='choice_5_33_1' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_33_1' id='label_5_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_5_40\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_40\" ><label class='gfield_label gform-field-label' for='input_5_40'>If your pet needs to be examined or treated by a veterinarian during their stay, please list problems or concerns.<\/label><\/p>\n<div class='ginput_container ginput_container_textarea'><textarea name='input_40' id='input_5_40' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div>\n<\/div>\n<fieldset id=\"field_5_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_42\" >\n<legend class='gfield_label gform-field-label' >If any issues are noted (ie., diarrhea, vomiting, anxiety) during your pets stay do we have permission to treat?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_radio'>\n<div class='gfield_radio' id='input_5_42'>\n<div class='gchoice gchoice_5_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Yes'  id='choice_5_42_0' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_42_0' id='label_5_42_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='No'  id='choice_5_42_1' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_42_1' id='label_5_42_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_5_43\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_43\" ><label class='gfield_label gform-field-label' for='input_5_43'>If your pet has any medical issues during their stay, you agreed above that we can treat them, and you are unreachable, is there a budget that needs to be honored and up to how much?<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_43' id='input_5_43' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div>\n<\/div>\n<div id=\"field_5_10\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_10\" >\n<h3 class=\"gsection_title\">Your Contact Information<\/h3>\n<\/div>\n<fieldset id=\"field_5_1\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_1\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Your Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_1'>\n<p>                            <span id='input_5_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                    <label for='input_5_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label><br \/>\n                                                    <input type='text' name='input_1.3' id='input_5_1_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/><br \/>\n                                                <\/span><\/p>\n<p>                            <span id='input_5_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                            <label for='input_5_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label><br \/>\n                                                            <input type='text' name='input_1.6' id='input_5_1_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/><br \/>\n                                                        <\/span><\/p><\/div>\n<\/fieldset>\n<fieldset id=\"field_5_2\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_2\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_5_2_container'>\n                                <span id='input_5_2_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'><br \/>\n                                    <label for='input_5_2' class='gform-field-label gform-field-label--type-sub '>Email Address<\/label><br \/>\n                                    <input class='' type='email' name='input_2' id='input_5_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/><br \/>\n                                <\/span><br \/>\n                                <span id='input_5_2_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'><br \/>\n                                    <label for='input_5_2_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email Address<\/label><br \/>\n                                    <input class='' type='email' name='input_2_2' id='input_5_2_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/><br \/>\n                                <\/span><\/p>\n<div class='gf_clear gf_clear_complex'><\/div>\n<\/p><\/div>\n<\/fieldset>\n<div id=\"field_5_5\" class=\"gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_5\" ><label class='gfield_label gform-field-label' for='input_5_5'>Primary Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_phone'><input name='input_5' id='input_5_5' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"tel\" \/><\/div>\n<\/div>\n<div id=\"field_5_44\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_44\" ><label class='gfield_label gform-field-label' for='input_5_44'>Secondary Phone<\/label><\/p>\n<div class='ginput_container ginput_container_phone'><input name='input_44' id='input_5_44' type='tel' value='' class='medium'    aria-invalid=\"false\"  autocomplete=\"tel\" \/><\/div>\n<\/div>\n<fieldset id=\"field_5_47\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_47\" >\n<legend class='gfield_label gform-field-label' >Did you want our team to text you pictures and updates regarding your pet during their boarding stay?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_radio'>\n<div class='gfield_radio' id='input_5_47'>\n<div class='gchoice gchoice_5_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Yes'  id='choice_5_47_0' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_47_0' id='label_5_47_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='No'  id='choice_5_47_1' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_47_1' id='label_5_47_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"field_5_4\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_4\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Your Address<\/legend>\n<div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_5_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_4_1_container' ><br \/>\n                                        <label for='input_5_4_1' id='input_5_4_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label><br \/>\n                                        <input type='text' name='input_4.1' id='input_5_4_1' value=''    aria-required='false'   autocomplete=\"address-line1\" \/><br \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_4_2_container' ><br \/>\n                                        <label for='input_5_4_2' id='input_5_4_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label><br \/>\n                                        <input type='text' name='input_4.2' id='input_5_4_2' value=''    autocomplete=\"address-line2\" aria-required='false'   \/><br \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_4_3_container' ><br \/>\n                                    <label for='input_5_4_3' id='input_5_4_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label><br \/>\n                                    <input type='text' name='input_4.3' id='input_5_4_3' value=''    aria-required='false'   autocomplete=\"address-level2\" \/><br \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_4_4_container' ><br \/>\n                                        <label for='input_5_4_4' id='input_5_4_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label><br \/>\n                                        <select name='input_4.4' id='input_5_4_4'     aria-required='false'   autocomplete=\"address-level1\" ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' selected='selected'>Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select><br \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_4_5_container' ><br \/>\n                  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class='gform-field-label gform-field-label--type-sub '>Last<\/label><br \/>\n                                                            <input type='text' name='input_31.6' id='input_5_31_6' value=''   aria-required='true'     \/><br \/>\n                                                        <\/span><\/p><\/div>\n<\/fieldset>\n<div id=\"field_5_32\" class=\"gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_32\" ><label class='gfield_label gform-field-label' for='input_5_32'>Emergency Contact&#039;s Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_phone'><input name='input_32' id='input_5_32' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<fieldset id=\"field_5_30\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_30\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent to Board<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_consent'><input name='input_30.1' id='input_5_30_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_30_1' >I agree that I have answered everything on this form to the best of my abilities and agree to pay any additional charges that I have selected above.<\/label><input 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HiddenNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. 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