Online Inquiry
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<ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Name_First_A"> <i class="fa fa-font"></i><label class="er_fld_label required">First Name</label><input name="CST_1" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Name_Middle_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Middle Name</label><input name="CST_2" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Name_Last_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name</label><input name="CST_3" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Name_First_B"> <i class="fa fa-font"></i><label class="er_fld_label">Adult #2 First Name</label><input name="CST_7" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Adult #2 Middle Name</label><input name="CST_8" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Adult #2 Last Name</label><input name="CST_9" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Home Street Address</label><input name="CST_4" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">City</label><input name="CST_5" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">County</label><input name="CST_6" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_selected" draggable="false" style="width: 50%;" map_to="FH_Address_State"> <i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_10" type="text" value="Arkansas"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Zip Code</label><input name="CST_11" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false"><i class="fa fa-caret-down"></i><label class="er_fld_label required">How did you hear about us?</label><select name="CST_12" class="er_fld_required"><option value="Facebook" selected="">Facebook</option><option value="Yard Sign">Yard Sign</option><option value="Friend">Friend</option><option value="Family">Family</option><option value="Billboard" selected="">Billboard</option><option value="Church">Church</option><option value="Foster Parent">Foster Parent</option><option value="Recruiting Event">Recruiting Event</option><option value="Other">Other</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false"><i class="fa fa-caret-down"></i><label class="er_fld_label">What is your preferred method of contact?</label><select name="CST_13"><option value="Email">Email</option><option value="Cell Phone">Cell Phone</option><option value="Work Phone">Work Phone</option><option value="Mail">Mail</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Best Number to Reach You at</label><input name="CST_14" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Primary Email Address</label><input name="CST_15" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large" draggable="false"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Motivation for Fostering</label><textarea name="CST_16" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Vision Statement: The vision of Free Will Baptist Family Ministries is to be nationally recognized as a model of excellence in faith-based family, adult, adolescent, and child care services which strengthen and preserve the family and provide dignity to those we serve. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Mission Statement: The mission of Free Will Baptist Family Ministries is to serve and share Christ in order to strengthen and preserve families and provide a loving, caring, and secure environment in which to live, work, and grow in the Lord. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Do you attend church?</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_17" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_17" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_17" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_17_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">If so, where?</label><input name="CST_18" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Can you agree to uphold the Mission and Vision of FWBFM?</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_19" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_19" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_19" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_19_Other" type="text"></label></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Have you ever had your parental rights terminated?</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_20" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_20" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_20" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_20_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Have you ever been closed in bad standing with another agency?</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_21" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_21" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_21" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_21_Other" type="text"></label></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Do you drink alcohol or use illegal substance?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_22" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_22" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_22" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_22_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Have you received the influenza and pertussis vaccines?</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_23" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_23" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_23" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_23_Other" type="text"></label></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">If not, are you willing to be vaccinated?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_24" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_24" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_24" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_24_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Do you use tobacco products?</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_25" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_25" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_25" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_25_Other" type="text"></label></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">If yes, are you willing to uphold DCS policy in regards to tobacco use?</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_26" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_26" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_26" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_26_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Have you ever been denied or deferred by any child care or private provider agnecy?</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_27" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_27" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_27" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_27_Other" type="text"></label></li><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 33.3333%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">If yes, provide details</label><textarea name="CST_28" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Have you ever been convicted of a crime?</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_29" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_29" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_29" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_29_Other" type="text"></label></li><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">If yes, provide details</label><textarea name="CST_30" style="width:100%;"></textarea></li></ul>
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