Online Inquiry
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<ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Connected Inquiry</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 100%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold er_fld_noprint">Thank you for your interest in serving with Connected. The first step in our pathway to helping children and families is to fill out this inquiry. Once you fill out this inquiry, click submit. We will send you a confirmation email with details about our next Information Meeting that includes requirements and next steps. If you have any questions or special information you want us to know about, please let us know below. If you need additional assistance, please email somer.colbert@arkansasfamilies.org. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Contact Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Name_First_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Your First Name</label><input name="CST_2" type="text" class="er_fld_required er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Name_Last_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Your Last Name</label><input name="CST_3" type="text" class="er_fld_required er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Address_City"> <i class="fa fa-font"></i><label class="er_fld_label required">City</label><input name="CST_17" type="text" class="er_fld_width100 er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Address_Zip"> <i class="fa fa-font"></i><label class="er_fld_label required">Zip Code</label><input name="CST_18" type="text" class="er_fld_required er_fld_width100"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="FH_Address_County"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Your County</label><select name="CST_13" class="er_fld_required er_fld_copypre er_fld_width100"><option value="Arkansas" selected="">Arkansas</option><option value="Ashley">Ashley</option><option value="Baxter">Baxter</option><option value="Benton">Benton</option><option value="Boone">Boone</option><option value="Bradley">Bradley</option><option value="Calhoun">Calhoun</option><option value="Carroll">Carroll</option><option value="Chicot">Chicot</option><option value="Clark">Clark</option><option value="Clay">Clay</option><option value="Cleburne">Cleburne</option><option value="Cleveland">Cleveland</option><option value="Columbia">Columbia</option><option value="Conway">Conway</option><option value="Craighead">Craighead</option><option value="Crawford">Crawford</option><option value="Crittenden">Crittenden</option><option value="Cross">Cross</option><option value="Dallas">Dallas</option><option value="Desha">Desha</option><option value="Drew">Drew</option><option value="Faulkner">Faulkner</option><option value="Franklin">Franklin</option><option value="Fulton">Fulton</option><option value="Garland">Garland</option><option value="Grant">Grant</option><option value="Greene">Greene</option><option value="Hempstead">Hempstead</option><option value="Hot Spring">Hot Spring</option><option value="Howard">Howard</option><option value="Independence">Independence</option><option value="Izard">Izard</option><option value="Jackson">Jackson</option><option value="Jefferson">Jefferson</option><option value="Johnson">Johnson</option><option value="Lafayette">Lafayette</option><option value="Lawrence">Lawrence</option><option value="Lee">Lee</option><option value="Lincoln">Lincoln</option><option value="Little River">Little River</option><option value="Logan">Logan</option><option value="Lonoke">Lonoke</option><option value="Madison">Madison</option><option value="Marion">Marion</option><option value="Miller">Miller</option><option value="Mississippi">Mississippi</option><option value="Monroe">Monroe</option><option value="Montgomery">Montgomery</option><option value="Nevada">Nevada</option><option value="Newton">Newton</option><option value="Ouachita">Ouachita</option><option value="Perry">Perry</option><option value="Phillips">Phillips</option><option value="Pike">Pike</option><option value="Poinsett">Poinsett</option><option value="Polk">Polk</option><option value="Pope">Pope</option><option value="Prairie">Prairie</option><option value="Pulaski">Pulaski</option><option value="Randolph">Randolph</option><option value="Saline">Saline</option><option value="Scott">Scott</option><option value="Searcy">Searcy</option><option value="Sebastian">Sebastian</option><option value="Sevier">Sevier</option><option value="Sharp">Sharp</option><option value="St. Francis">St. Francis</option><option value="Stone">Stone</option><option value="Union">Union</option><option value="Van Buren">Van Buren</option><option value="Washington">Washington</option><option value="White">White</option><option value="Woodruff">Woodruff</option><option value="Yell">Yell</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Phone_Mobile"> <i class="fa fa-font"></i><label class="er_fld_label required">Mobile Phone (Ex: 000-000-0000)</label><input name="CST_14" type="text" value="" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_EMail"> <i class="fa fa-font"></i><label class="er_fld_label required">Your Email</label><input name="CST_5" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Church"> <i class="fa fa-font"></i><label class="er_fld_label required">Your Church</label><input name="CST_6" type="text" class="er_fld_width100 er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Quick Survey</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false" map_to="FH_Interest"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">What are you interested in?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_7" value="Fostering">Fostering</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_7" value="Adopting">Adopting</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_7" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_7_Other" type="text"></label></li><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn er_fld_noprint">Interested in adoption? Private adoption is different from adopting foster children in DCFS custody. In order to adopt a child privately (not in DCFS custody) with our agency, you must be a licensed foster family with our agency.</div></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Would you like to be contacted about our adoption process and services?</label><select name="CST_15" class="er_fld_required"><option value="Select One" selected="">Select One</option><option value="Yes">Yes</option><option value="No">No</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false" map_to="FH_Inquiry_How_Referred"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">How did you hear about us?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Website">Website</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Facebook/Instagram">Facebook/Instagram</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Church/Pastor">Church/Pastor</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Meeting/Conference">Meeting/Conference</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Friend">Friend</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_8" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_8_Other" type="text"></label></li><li class="er_fld_type_paragraph er_fld_type_paragraph_large" draggable="false" style="width: 50%;" map_to="FH_Inquiry_Comments"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Any other comments or questions for us?</label><textarea name="CST_10" style="width:100%;" class=""></textarea></li></ul>
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