myimpact.provsocal.org
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Submission: On February 09 via manual from IN — Scanned from DE
Submission: On February 09 via manual from IN — Scanned from DE
Form analysis 1 forms found in the DOM
POST /#gf_1
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_1" id="gform_1" class="recaptcha-form" action="/#gf_1" novalidate="" aria-live="polite">
<div id="gf_progressbar_wrapper_1" class="gf_progressbar_wrapper">
<p class="gf_progressbar_title">Step <span class="gf_step_current_page">1</span> of <span class="gf_step_page_count">12</span> - Q1 </p>
<div class="gf_progressbar gf_progressbar_blue" aria-hidden="true">
<div class="gf_progressbar_percentage percentbar_blue percentbar_8" style="width:8%;"><span>8%</span></div>
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<div class="gform_body gform-body">
<div id="gform_page_1_1" class="gform_page">
<div class="gform_page_fields">
<div id="gform_fields_1" class="gform_fields top_label form_sublabel_above description_below">
<fieldset id="field_1_74" class="gfield field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_74">
<legend>
<legend class="gfield_label">1) Which of the following Providence medical centers do you feel most connected to?</legend>
</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_74">
<div class="gchoice gchoice_1_74_0">
<input class="gfield-choice-input" name="input_74" type="radio" value="gsurvey7456119067" id="choice_1_74_0" onchange="gformToggleRadioOther( this )">
<label for="choice_1_74_0" id="label_1_74_0">Providence Holy Cross Medical Center</label>
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<div class="gchoice gchoice_1_74_1">
<input class="gfield-choice-input" name="input_74" type="radio" value="gsurvey74c9281614" id="choice_1_74_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_74_1" id="label_1_74_1">Providence Little Company of Mary Medical Center San Pedro</label>
</div>
<div class="gchoice gchoice_1_74_2">
<input class="gfield-choice-input" name="input_74" type="radio" value="gsurvey74bfe55dc1" id="choice_1_74_2" onchange="gformToggleRadioOther( this )">
<label for="choice_1_74_2" id="label_1_74_2">Providence Little Company of Mary Medical Center Torrance</label>
</div>
<div class="gchoice gchoice_1_74_3">
<input class="gfield-choice-input" name="input_74" type="radio" value="gsurvey743659ff28" id="choice_1_74_3" onchange="gformToggleRadioOther( this )">
<label for="choice_1_74_3" id="label_1_74_3">Providence Mission Hospital</label>
</div>
<div class="gchoice gchoice_1_74_4">
<input class="gfield-choice-input" name="input_74" type="radio" value="gsurvey740ec4241a" id="choice_1_74_4" onchange="gformToggleRadioOther( this )">
<label for="choice_1_74_4" id="label_1_74_4">Providence St. Joseph Hospital Orange</label>
</div>
<div class="gchoice gchoice_1_74_5">
<input class="gfield-choice-input" name="input_74" type="radio" value="gsurvey74e69dec5b" id="choice_1_74_5" onchange="gformToggleRadioOther( this )">
<label for="choice_1_74_5" id="label_1_74_5">Providence St. Jude Medical Center</label>
</div>
<div class="gchoice gchoice_1_74_6">
<input class="gfield-choice-input" name="input_74" type="radio" value="gsurvey74e78f3127" id="choice_1_74_6" onchange="gformToggleRadioOther( this )">
<label for="choice_1_74_6" id="label_1_74_6">Providence St. Mary Medical Center</label>
</div>
<div class="gchoice gchoice_1_74_7">
<input class="gfield-choice-input" name="input_74" type="radio" value="gsurvey7433f45e8a" id="choice_1_74_7" onchange="gformToggleRadioOther( this )">
<label for="choice_1_74_7" id="label_1_74_7">Providence Cedars-Sinai Tarzana Medical Center</label>
</div>
<div class="gchoice gchoice_1_74_8">
<input class="gfield-choice-input" name="input_74" type="radio" value="gsurvey74c8e4995b" id="choice_1_74_8" onchange="gformToggleRadioOther( this )">
<label for="choice_1_74_8" id="label_1_74_8">Providence Saint Joseph Medical Center Burbank</label>
</div>
<div class="gchoice gchoice_1_74_9">
<input class="gfield-choice-input" name="input_74" type="radio" value="gsurvey742db16eb0" id="choice_1_74_9" onchange="gformToggleRadioOther( this )">
<label for="choice_1_74_9" id="label_1_74_9">Other</label>
</div>
</div>
</div>
</fieldset>
<div id="field_1_75" class="gfield field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_75" style="display: none;">
<legend><label class="gfield_label" for="input_1_75">Please specify:</label></legend>
<div class="ginput_container ginput_container_text"><input name="input_75" id="input_1_75" type="text" value="" class="medium" aria-invalid="false" disabled="disabled"> </div>
</div>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_next_button_1_55" class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("2"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("2"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Next Question">
</div>
</div>
<div id="gform_page_1_2" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_1_2" class="gform_fields top_label form_sublabel_above description_below">
<fieldset id="field_1_56" class="gfield field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_56">
<legend>
<legend class="gfield_label gfield_label_before_complex">2) In what ways have you engaged with Providence medical centers? Please select all that apply.</legend>
</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_1_56">
<div class="gchoice gchoice_1_56_1">
<input class="gfield-choice-input" name="input_56.1" type="checkbox" value="gsurvey5623620e5c" id="choice_1_56_1">
<label for="choice_1_56_1" id="label_1_56_1">I was treated at a Providence medical center.</label>
</div>
<div class="gchoice gchoice_1_56_2">
<input class="gfield-choice-input" name="input_56.2" type="checkbox" value="gsurvey5601d3f54e" id="choice_1_56_2">
<label for="choice_1_56_2" id="label_1_56_2">A friend or family member was treated at a Providence medical center.</label>
</div>
<div class="gchoice gchoice_1_56_3">
<input class="gfield-choice-input" name="input_56.3" type="checkbox" value="gsurvey56def52091" id="choice_1_56_3">
<label for="choice_1_56_3" id="label_1_56_3">I am a current or former volunteer at a Providence medical center.</label>
</div>
<div class="gchoice gchoice_1_56_4">
<input class="gfield-choice-input" name="input_56.4" type="checkbox" value="gsurvey56545a0fec" id="choice_1_56_4">
<label for="choice_1_56_4" id="label_1_56_4">I am a current or former employee of Providence.</label>
</div>
<div class="gchoice gchoice_1_56_5">
<input class="gfield-choice-input" name="input_56.5" type="checkbox" value="gsurvey569a39e1f1" id="choice_1_56_5">
<label for="choice_1_56_5" id="label_1_56_5">I am a current/former Board Member at a Providence medical center.</label>
</div>
<div class="gchoice gchoice_1_56_6">
<input class="gfield-choice-input" name="input_56.6" type="checkbox" value="gsurvey56798eae3a" id="choice_1_56_6">
<label for="choice_1_56_6" id="label_1_56_6">I donate.</label>
</div>
<div class="gchoice gchoice_1_56_7">
<input class="gfield-choice-input" name="input_56.7" type="checkbox" value="gsurvey568a158a9c" id="choice_1_56_7">
<label for="choice_1_56_7" id="label_1_56_7">I have attended events.</label>
</div>
<div class="gchoice gchoice_1_56_8">
<input class="gfield-choice-input" name="input_56.8" type="checkbox" value="gsurvey56077d6d35" id="choice_1_56_8">
<label for="choice_1_56_8" id="label_1_56_8">I follow on social media.</label>
</div>
<div class="gchoice gchoice_1_56_9">
<input class="gfield-choice-input" name="input_56.9" type="checkbox" value="gsurvey5623e0636a" id="choice_1_56_9">
<label for="choice_1_56_9" id="label_1_56_9">I have visited the website.</label>
</div>
<div class="gchoice gchoice_1_56_11">
<input class="gfield-choice-input" name="input_56.11" type="checkbox" value="gsurvey5627e0d913" id="choice_1_56_11">
<label for="choice_1_56_11" id="label_1_56_11">Other</label>
</div>
</div>
</div>
</fieldset>
<div id="field_1_68" class="gfield hideLabel field_sublabel_above field_description_above gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_68" style="display: none;">
<legend><label class="gfield_label" for="input_1_68">2a) Other - Please specify:</label></legend>
<div class="gfield_description" id="gfield_description_1_68"><strong>Please specify:</strong></div>
<div class="ginput_container ginput_container_text"><input name="input_68" id="input_1_68" type="text" value="" class="medium" aria-describedby=" gfield_description_1_68" aria-invalid="false" disabled="disabled"> </div>
</div>
<fieldset id="field_1_57" class="gfield hideLabel field_sublabel_above field_description_above gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_57" style="display: none;">
<legend>
<legend class="gfield_label">2b) How frequently do you engage with Providence medical centers?</legend>
</legend>
<div class="gfield_description" id="gfield_description_1_57">How frequently do you engage with Providence medical centers?</div>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_57">
<div class="gchoice gchoice_1_57_0">
<input class="gfield-choice-input" name="input_57" type="radio" value="gsurvey5457d981f2" id="choice_1_57_0" onchange="gformToggleRadioOther( this )" aria-describedby="gfield_description_1_57" disabled="disabled">
<label for="choice_1_57_0" id="label_1_57_0">Weekly</label>
</div>
<div class="gchoice gchoice_1_57_1">
<input class="gfield-choice-input" name="input_57" type="radio" value="gsurvey54e815aa3a" id="choice_1_57_1" onchange="gformToggleRadioOther( this )" disabled="disabled">
<label for="choice_1_57_1" id="label_1_57_1">Monthly</label>
</div>
<div class="gchoice gchoice_1_57_2">
<input class="gfield-choice-input" name="input_57" type="radio" value="gsurvey5412876d5e" id="choice_1_57_2" onchange="gformToggleRadioOther( this )" disabled="disabled">
<label for="choice_1_57_2" id="label_1_57_2">Every few months</label>
</div>
<div class="gchoice gchoice_1_57_3">
<input class="gfield-choice-input" name="input_57" type="radio" value="gsurvey54494fddbd" id="choice_1_57_3" onchange="gformToggleRadioOther( this )" disabled="disabled">
<label for="choice_1_57_3" id="label_1_57_3">Yearly</label>
</div>
<div class="gchoice gchoice_1_57_4">
<input class="gfield-choice-input" name="input_57" type="radio" value="gsurvey57081c3675" id="choice_1_57_4" onchange="gformToggleRadioOther( this )" disabled="disabled">
<label for="choice_1_57_4" id="label_1_57_4">Rarely or never</label>
</div>
<div class="gchoice gchoice_1_57_5">
<input class="gfield-choice-input" name="input_57" type="radio" value="gsurvey5428477c1b" id="choice_1_57_5" onchange="gformToggleRadioOther( this )" disabled="disabled">
<label for="choice_1_57_5" id="label_1_57_5">Other</label>
</div>
</div>
</div>
</fieldset>
<div id="field_1_58" class="gfield hideLabel field_sublabel_above field_description_above gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_58" style="display: none;">
<legend><label class="gfield_label" for="input_1_58">2b-i) Other - Please specify:</label></legend>
<div class="gfield_description" id="gfield_description_1_58"><strong>Please specify:</strong></div>
<div class="ginput_container ginput_container_text"><input name="input_58" id="input_1_58" type="text" value="" class="medium" aria-describedby=" gfield_description_1_58" aria-invalid="false" disabled="disabled"> </div>
</div>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_1_50" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("1"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("1"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Previous Question"> <input type="button"
id="gform_next_button_1_50" class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("3"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("3"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Next Question">
</div>
</div>
<div id="gform_page_1_3" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_1_3" class="gform_fields top_label form_sublabel_above description_below">
<fieldset id="field_1_70" class="gfield field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_70">
<legend>
<legend class="gfield_label">3) We like to send friends like you occasional emails with updates including videos, stories and information about how we are making an impact on your behalf. Would you like to receive these updates? (You
can opt-out at any time).</legend>
</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_70">
<div class="gchoice gchoice_1_70_0">
<input class="gfield-choice-input" name="input_70" type="radio" value="gsurvey28c2417f3" id="choice_1_70_0" onchange="gformToggleRadioOther( this )">
<label for="choice_1_70_0" id="label_1_70_0">Yes, I want to receive occasional emails with updates.</label>
</div>
<div class="gchoice gchoice_1_70_1">
<input class="gfield-choice-input" name="input_70" type="radio" value="gsurvey531f44b09a" id="choice_1_70_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_70_1" id="label_1_70_1">Not at this time.</label>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_1_54" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("2"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("2"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Previous Question"> <input type="button"
id="gform_next_button_1_54" class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("4"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("4"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Next Question">
</div>
</div>
<div id="gform_page_1_4" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_1_4" class="gform_fields top_label form_sublabel_above description_below">
<fieldset id="field_1_53" class="gfield field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_53">
<legend>
<legend class="gfield_label">4) Which of the following medical center community initiatives is most meaningful to you?</legend>
</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_53">
<div class="gchoice gchoice_1_53_0">
<input class="gfield-choice-input" name="input_53" type="radio" value="gsurvey53da2652da" id="choice_1_53_0" onchange="gformToggleRadioOther( this )">
<label for="choice_1_53_0" id="label_1_53_0">Behavioral Health</label>
</div>
<div class="gchoice gchoice_1_53_1">
<input class="gfield-choice-input" name="input_53" type="radio" value="gsurvey53c514fb57" id="choice_1_53_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_53_1" id="label_1_53_1">Cancer</label>
</div>
<div class="gchoice gchoice_1_53_2">
<input class="gfield-choice-input" name="input_53" type="radio" value="gsurvey532b762f22" id="choice_1_53_2" onchange="gformToggleRadioOther( this )">
<label for="choice_1_53_2" id="label_1_53_2">COVID-19</label>
</div>
<div class="gchoice gchoice_1_53_3">
<input class="gfield-choice-input" name="input_53" type="radio" value="gsurvey534c0b7af0" id="choice_1_53_3" onchange="gformToggleRadioOther( this )">
<label for="choice_1_53_3" id="label_1_53_3">Community Benefit/Health Equity</label>
</div>
<div class="gchoice gchoice_1_53_4">
<input class="gfield-choice-input" name="input_53" type="radio" value="gsurvey53a50dede1" id="choice_1_53_4" onchange="gformToggleRadioOther( this )">
<label for="choice_1_53_4" id="label_1_53_4">Emergency/Trauma</label>
</div>
<div class="gchoice gchoice_1_53_5">
<input class="gfield-choice-input" name="input_53" type="radio" value="gsurvey53b93714b1" id="choice_1_53_5" onchange="gformToggleRadioOther( this )">
<label for="choice_1_53_5" id="label_1_53_5">Heart & Vascular</label>
</div>
<div class="gchoice gchoice_1_53_6">
<input class="gfield-choice-input" name="input_53" type="radio" value="gsurvey53bb1e0b77" id="choice_1_53_6" onchange="gformToggleRadioOther( this )">
<label for="choice_1_53_6" id="label_1_53_6">Homeless</label>
</div>
<div class="gchoice gchoice_1_53_7">
<input class="gfield-choice-input" name="input_53" type="radio" value="gsurvey537339ae2e" id="choice_1_53_7" onchange="gformToggleRadioOther( this )">
<label for="choice_1_53_7" id="label_1_53_7">Neuroscience</label>
</div>
<div class="gchoice gchoice_1_53_8">
<input class="gfield-choice-input" name="input_53" type="radio" value="gsurvey53ee5b28a1" id="choice_1_53_8" onchange="gformToggleRadioOther( this )">
<label for="choice_1_53_8" id="label_1_53_8">Nursing</label>
</div>
<div class="gchoice gchoice_1_53_9">
<input class="gfield-choice-input" name="input_53" type="radio" value="gsurvey53a6a2935e" id="choice_1_53_9" onchange="gformToggleRadioOther( this )">
<label for="choice_1_53_9" id="label_1_53_9">Orthopedics</label>
</div>
<div class="gchoice gchoice_1_53_10">
<input class="gfield-choice-input" name="input_53" type="radio" value="gsurvey53ef020d02" id="choice_1_53_10" onchange="gformToggleRadioOther( this )">
<label for="choice_1_53_10" id="label_1_53_10">Women & Children</label>
</div>
<div class="gchoice gchoice_1_53_11">
<input class="gfield-choice-input" name="input_53" type="radio" value="gsurvey5392fc3336" id="choice_1_53_11" onchange="gformToggleRadioOther( this )">
<label for="choice_1_53_11" id="label_1_53_11">Other</label>
</div>
</div>
</div>
</fieldset>
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<legend><label class="gfield_label" for="input_1_79">Please specify:</label></legend>
<div class="ginput_container ginput_container_text"><input name="input_79" id="input_1_79" type="text" value="" class="medium" aria-invalid="false" disabled="disabled"> </div>
</div>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_1_71" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("3"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("3"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Previous Question"> <input type="button"
id="gform_next_button_1_71" class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("5"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("5"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Next Question">
</div>
</div>
<div id="gform_page_1_5" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_1_5" class="gform_fields top_label form_sublabel_above description_below">
<fieldset id="field_1_51" class="gfield field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_51">
<legend>
<legend class="gfield_label">5) Was there an influential person in your life who inspired your appreciation of the medical center you identified at the beginning of this survey?</legend>
</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_51">
<div class="gchoice gchoice_1_51_0">
<input class="gfield-choice-input" name="input_51" type="radio" value="gsurvey516cc1de7d" id="choice_1_51_0" onchange="gformToggleRadioOther( this )">
<label for="choice_1_51_0" id="label_1_51_0">Yes</label>
</div>
<div class="gchoice gchoice_1_51_1">
<input class="gfield-choice-input" name="input_51" type="radio" value="gsurvey51464f55f4" id="choice_1_51_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_51_1" id="label_1_51_1">No</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_1_59" class="gfield hideLabel field_sublabel_above field_description_above gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_59" style="display: none;">
<legend>
<legend class="gfield_label gfield_label_before_complex">5a) If yes, please indicate their relationship to you.</legend>
</legend>
<div class="gfield_description" id="gfield_description_1_59">If yes, please indicate their relationship to you.</div>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_1_59">
<div class="gchoice gchoice_1_59_1">
<input class="gfield-choice-input" name="input_59.1" type="checkbox" value="gsurvey5991aed26d" id="choice_1_59_1" aria-describedby="gfield_description_1_59" disabled="disabled">
<label for="choice_1_59_1" id="label_1_59_1">Parent/grandparent</label>
</div>
<div class="gchoice gchoice_1_59_2">
<input class="gfield-choice-input" name="input_59.2" type="checkbox" value="gsurvey593d2b66f6" id="choice_1_59_2" disabled="disabled">
<label for="choice_1_59_2" id="label_1_59_2">Spouse/partner/significant other</label>
</div>
<div class="gchoice gchoice_1_59_3">
<input class="gfield-choice-input" name="input_59.3" type="checkbox" value="gsurvey59c34c5cbd" id="choice_1_59_3" disabled="disabled">
<label for="choice_1_59_3" id="label_1_59_3">Child/children</label>
</div>
<div class="gchoice gchoice_1_59_4">
<input class="gfield-choice-input" name="input_59.4" type="checkbox" value="gsurvey59b644a3d9" id="choice_1_59_4" disabled="disabled">
<label for="choice_1_59_4" id="label_1_59_4">Other family member</label>
</div>
<div class="gchoice gchoice_1_59_5">
<input class="gfield-choice-input" name="input_59.5" type="checkbox" value="gsurvey5916972b11" id="choice_1_59_5" disabled="disabled">
<label for="choice_1_59_5" id="label_1_59_5">Friend</label>
</div>
<div class="gchoice gchoice_1_59_6">
<input class="gfield-choice-input" name="input_59.6" type="checkbox" value="gsurvey59a0eccf3b" id="choice_1_59_6" disabled="disabled">
<label for="choice_1_59_6" id="label_1_59_6">Doctor, nurse or other health care provider</label>
</div>
<div class="gchoice gchoice_1_59_7">
<input class="gfield-choice-input" name="input_59.7" type="checkbox" value="gsurvey59e9148346" id="choice_1_59_7" disabled="disabled">
<label for="choice_1_59_7" id="label_1_59_7">Teacher or professor</label>
</div>
<div class="gchoice gchoice_1_59_8">
<input class="gfield-choice-input" name="input_59.8" type="checkbox" value="gsurvey59259c89c3" id="choice_1_59_8" disabled="disabled">
<label for="choice_1_59_8" id="label_1_59_8">Other</label>
</div>
</div>
</div>
</fieldset>
<div id="field_1_60" class="gfield hideLabel field_sublabel_above field_description_above gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_60" style="display: none;">
<legend><label class="gfield_label" for="input_1_60">5a-i) Other - Please specify:</label></legend>
<div class="gfield_description" id="gfield_description_1_60"><strong>Please specify:</strong></div>
<div class="ginput_container ginput_container_text"><input name="input_60" id="input_1_60" type="text" value="" class="medium" aria-describedby=" gfield_description_1_60" aria-invalid="false" disabled="disabled"> </div>
</div>
<div id="field_1_76" class="gfield field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_76" style="display: none;">
<legend><label class="gfield_label" for="input_1_76">If you feel comfortable, please tell us more about this person.</label></legend>
<div class="ginput_container ginput_container_textarea"><textarea name="input_76" id="input_1_76" class="textarea medium" aria-invalid="false" rows="10" cols="50" disabled="disabled"></textarea></div>
</div>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_1_1" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("4"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("4"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Previous Question"> <input type="button"
id="gform_next_button_1_1" class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("6"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("6"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Next Question">
</div>
</div>
<div id="gform_page_1_6" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_1_6" class="gform_fields top_label form_sublabel_above description_below">
<fieldset id="field_1_3" class="gfield field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_3">
<legend>
<legend class="gfield_label">6) When thinking about future generations, how important is it to you that your preferred Providence medical center remains steadfast in serving all, especially those who are poor and vulnerable?</legend>
</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_3">
<div class="gchoice gchoice_1_3_0">
<input class="gfield-choice-input" name="input_3" type="radio" value="gsurvey35308b86b" id="choice_1_3_0" onchange="gformToggleRadioOther( this )">
<label for="choice_1_3_0" id="label_1_3_0">Of utmost importance</label>
</div>
<div class="gchoice gchoice_1_3_1">
<input class="gfield-choice-input" name="input_3" type="radio" value="gsurvey322cd5a32" id="choice_1_3_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_3_1" id="label_1_3_1">Very important</label>
</div>
<div class="gchoice gchoice_1_3_2">
<input class="gfield-choice-input" name="input_3" type="radio" value="gsurvey3a55caeb3" id="choice_1_3_2" onchange="gformToggleRadioOther( this )">
<label for="choice_1_3_2" id="label_1_3_2">Somewhat important</label>
</div>
<div class="gchoice gchoice_1_3_3">
<input class="gfield-choice-input" name="input_3" type="radio" value="gsurvey3f2fb89a6" id="choice_1_3_3" onchange="gformToggleRadioOther( this )">
<label for="choice_1_3_3" id="label_1_3_3">Not very important</label>
</div>
<div class="gchoice gchoice_1_3_4">
<input class="gfield-choice-input" name="input_3" type="radio" value="gsurvey3fe398e3f" id="choice_1_3_4" onchange="gformToggleRadioOther( this )">
<label for="choice_1_3_4" id="label_1_3_4">Not important at all</label>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_1_21" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("5"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("5"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Previous Question"> <input type="button"
id="gform_next_button_1_21" class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("7"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("7"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Next Question">
</div>
</div>
<div id="gform_page_1_7" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_1_7" class="gform_fields top_label form_sublabel_above description_below">
<div id="field_1_52" class="gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above field_description_below gfield_visibility_visible" data-js-reload="field_1_52">
<legend><label class="gfield_label">7) Supporters often recognize the need to help Providence medical centers continue their important work in our community. Would you consider supporting our shared mission in any of the following
ways?</label></legend>
</div>
<div id="field_1_31" class="gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above field_description_below gfield_visibility_visible" data-js-reload="field_1_31">
<table class="gsurvey-likert" style="float:right">
<tbody>
<tr>
<th scope="col" class="gsurvey-likert-choice-label">I already have</th>
<th scope="col" class="gsurvey-likert-choice-label">I am likely</th>
<th scope="col" class="gsurvey-likert-choice-label">I am somewhat likely</th>
<th scope="col" class="gsurvey-likert-choice-label">I am not likely</th>
</tr>
</tbody>
</table>
</div>
<fieldset id="field_1_33" class="gfield gf_list_4col radioLikert field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_33">
<legend>
<legend class="gfield_label">Talking with a gift officer to learn more about different ways to give</legend>
</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_33">
<div class="gchoice gchoice_1_33_0">
<input class="gfield-choice-input" name="input_33" type="radio" value="gsurvey301f3ee7d5" id="choice_1_33_0" onchange="gformToggleRadioOther( this )">
<label for="choice_1_33_0" id="label_1_33_0">I already have</label>
</div>
<div class="gchoice gchoice_1_33_1">
<input class="gfield-choice-input" name="input_33" type="radio" value="gsurvey309e6d147d" id="choice_1_33_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_33_1" id="label_1_33_1">I am likely</label>
</div>
<div class="gchoice gchoice_1_33_2">
<input class="gfield-choice-input" name="input_33" type="radio" value="gsurvey30027cdd00" id="choice_1_33_2" onchange="gformToggleRadioOther( this )">
<label for="choice_1_33_2" id="label_1_33_2">I am somewhat likely</label>
</div>
<div class="gchoice gchoice_1_33_3">
<input class="gfield-choice-input" name="input_33" type="radio" value="gsurvey307eb30447" id="choice_1_33_3" onchange="gformToggleRadioOther( this )">
<label for="choice_1_33_3" id="label_1_33_3">I am not likely</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_1_35" class="gfield gf_list_4col radioLikert field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_35">
<legend>
<legend class="gfield_label">Donating from a Donor-Advised Fund or Family Foundation</legend>
</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_35">
<div class="gchoice gchoice_1_35_0">
<input class="gfield-choice-input" name="input_35" type="radio" value="gsurvey301f3ee7d5" id="choice_1_35_0" onchange="gformToggleRadioOther( this )">
<label for="choice_1_35_0" id="label_1_35_0">I already have</label>
</div>
<div class="gchoice gchoice_1_35_1">
<input class="gfield-choice-input" name="input_35" type="radio" value="gsurvey309e6d147d" id="choice_1_35_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_35_1" id="label_1_35_1">I am likely</label>
</div>
<div class="gchoice gchoice_1_35_2">
<input class="gfield-choice-input" name="input_35" type="radio" value="gsurvey30027cdd00" id="choice_1_35_2" onchange="gformToggleRadioOther( this )">
<label for="choice_1_35_2" id="label_1_35_2">I am somewhat likely</label>
</div>
<div class="gchoice gchoice_1_35_3">
<input class="gfield-choice-input" name="input_35" type="radio" value="gsurvey307eb30447" id="choice_1_35_3" onchange="gformToggleRadioOther( this )">
<label for="choice_1_35_3" id="label_1_35_3">I am not likely</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_1_37" class="gfield gf_list_4col radioLikert field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_37">
<legend>
<legend class="gfield_label">Giving appreciated assets (such as personal or business stocks or bonds, land or rental real estate, etc.)</legend>
</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_37">
<div class="gchoice gchoice_1_37_0">
<input class="gfield-choice-input" name="input_37" type="radio" value="gsurvey301f3ee7d5" id="choice_1_37_0" onchange="gformToggleRadioOther( this )">
<label for="choice_1_37_0" id="label_1_37_0">I already have</label>
</div>
<div class="gchoice gchoice_1_37_1">
<input class="gfield-choice-input" name="input_37" type="radio" value="gsurvey309e6d147d" id="choice_1_37_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_37_1" id="label_1_37_1">I am likely</label>
</div>
<div class="gchoice gchoice_1_37_2">
<input class="gfield-choice-input" name="input_37" type="radio" value="gsurvey30027cdd00" id="choice_1_37_2" onchange="gformToggleRadioOther( this )">
<label for="choice_1_37_2" id="label_1_37_2">I am somewhat likely</label>
</div>
<div class="gchoice gchoice_1_37_3">
<input class="gfield-choice-input" name="input_37" type="radio" value="gsurvey307eb30447" id="choice_1_37_3" onchange="gformToggleRadioOther( this )">
<label for="choice_1_37_3" id="label_1_37_3">I am not likely</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_1_38" class="gfield gf_list_4col radioLikert field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_38">
<legend>
<legend class="gfield_label">Donating a portion of my Individual Retirement Account or Required Minimum Distribution</legend>
</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_38">
<div class="gchoice gchoice_1_38_0">
<input class="gfield-choice-input" name="input_38" type="radio" value="gsurvey301f3ee7d5" id="choice_1_38_0" onchange="gformToggleRadioOther( this )">
<label for="choice_1_38_0" id="label_1_38_0">I already have</label>
</div>
<div class="gchoice gchoice_1_38_1">
<input class="gfield-choice-input" name="input_38" type="radio" value="gsurvey309e6d147d" id="choice_1_38_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_38_1" id="label_1_38_1">I am likely</label>
</div>
<div class="gchoice gchoice_1_38_2">
<input class="gfield-choice-input" name="input_38" type="radio" value="gsurvey30027cdd00" id="choice_1_38_2" onchange="gformToggleRadioOther( this )">
<label for="choice_1_38_2" id="label_1_38_2">I am somewhat likely</label>
</div>
<div class="gchoice gchoice_1_38_3">
<input class="gfield-choice-input" name="input_38" type="radio" value="gsurvey307eb30447" id="choice_1_38_3" onchange="gformToggleRadioOther( this )">
<label for="choice_1_38_3" id="label_1_38_3">I am not likely</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_1_39" class="gfield gf_list_4col radioLikert field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_39">
<legend>
<legend class="gfield_label">Making a charitable gift that provides a lifetime income to me or my loved ones</legend>
</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_39">
<div class="gchoice gchoice_1_39_0">
<input class="gfield-choice-input" name="input_39" type="radio" value="gsurvey301f3ee7d5" id="choice_1_39_0" onchange="gformToggleRadioOther( this )">
<label for="choice_1_39_0" id="label_1_39_0">I already have</label>
</div>
<div class="gchoice gchoice_1_39_1">
<input class="gfield-choice-input" name="input_39" type="radio" value="gsurvey309e6d147d" id="choice_1_39_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_39_1" id="label_1_39_1">I am likely</label>
</div>
<div class="gchoice gchoice_1_39_2">
<input class="gfield-choice-input" name="input_39" type="radio" value="gsurvey30027cdd00" id="choice_1_39_2" onchange="gformToggleRadioOther( this )">
<label for="choice_1_39_2" id="label_1_39_2">I am somewhat likely</label>
</div>
<div class="gchoice gchoice_1_39_3">
<input class="gfield-choice-input" name="input_39" type="radio" value="gsurvey307eb30447" id="choice_1_39_3" onchange="gformToggleRadioOther( this )">
<label for="choice_1_39_3" id="label_1_39_3">I am not likely</label>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_1_29" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("6"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("6"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Previous Question"> <input type="button"
id="gform_next_button_1_29" class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("8"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("8"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Next Question">
</div>
</div>
<div id="gform_page_1_8" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_1_8" class="gform_fields top_label form_sublabel_above description_below">
<fieldset id="field_1_41" class="gfield field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_41">
<legend>
<legend class="gfield_label">8) Many people like to include a gift to charity in their will, trust or other estate plans to support causes that are important in their life. Would you consider creating a legacy at the medical center?
</legend>
</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_41">
<div class="gchoice gchoice_1_41_0">
<input class="gfield-choice-input" name="input_41" type="radio" value="gsurvey41b8a8653f" id="choice_1_41_0" onchange="gformToggleRadioOther( this )">
<label for="choice_1_41_0" id="label_1_41_0"><strong>I have included a gift</strong> in my will, trust, or by beneficiary designation.</label>
</div>
<div class="gchoice gchoice_1_41_1">
<input class="gfield-choice-input" name="input_41" type="radio" value="gsurvey41e07ac16b" id="choice_1_41_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_41_1" id="label_1_41_1"><strong>I am interested</strong> in making this type of gift.</label>
</div>
<div class="gchoice gchoice_1_41_2">
<input class="gfield-choice-input" name="input_41" type="radio" value="gsurvey418565a23d" id="choice_1_41_2" onchange="gformToggleRadioOther( this )">
<label for="choice_1_41_2" id="label_1_41_2"><strong>Not now, but in the future I <u>would definitely</u> be interested</strong> in making this type of gift.</label>
</div>
<div class="gchoice gchoice_1_41_3">
<input class="gfield-choice-input" name="input_41" type="radio" value="gsurvey413fc3e423" id="choice_1_41_3" onchange="gformToggleRadioOther( this )">
<label for="choice_1_41_3" id="label_1_41_3"><strong>Not now, but in the future I <u>might possibly</u> be interested</strong> in making this type of gift.</label>
</div>
<div class="gchoice gchoice_1_41_4">
<input class="gfield-choice-input" name="input_41" type="radio" value="gsurvey4144770816" id="choice_1_41_4" onchange="gformToggleRadioOther( this )">
<label for="choice_1_41_4" id="label_1_41_4"><strong>I am not interested</strong> in this type of gift.</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_1_42" class="gfield hideLabel field_sublabel_above field_description_above gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_42" style="display: none;">
<legend>
<legend class="gfield_label gfield_label_before_complex">8a) If you feel comfortable sharing, which of the following organizations are a beneficiary of your intended gift?</legend>
</legend>
<div class="gfield_description" id="gfield_description_1_42"><strong>If you feel comfortable sharing, which of the following organizations are a beneficiary of your intended gift?</strong></div>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_1_42">
<div class="gchoice gchoice_1_42_1">
<input class="gfield-choice-input" name="input_42.1" type="checkbox" value="gsurvey42763d4ec6" id="choice_1_42_1" aria-describedby="gfield_description_1_42" disabled="disabled">
<label for="choice_1_42_1" id="label_1_42_1">Providence Holy Cross Foundation</label>
</div>
<div class="gchoice gchoice_1_42_2">
<input class="gfield-choice-input" name="input_42.2" type="checkbox" value="gsurvey426b88b2d6" id="choice_1_42_2" disabled="disabled">
<label for="choice_1_42_2" id="label_1_42_2">Providence Little Company of Mary Foundation</label>
</div>
<div class="gchoice gchoice_1_42_3">
<input class="gfield-choice-input" name="input_42.3" type="checkbox" value="gsurvey42db0379b2" id="choice_1_42_3" disabled="disabled">
<label for="choice_1_42_3" id="label_1_42_3">Providence Mission Hospital Foundation</label>
</div>
<div class="gchoice gchoice_1_42_4">
<input class="gfield-choice-input" name="input_42.4" type="checkbox" value="gsurvey42ede7846a" id="choice_1_42_4" disabled="disabled">
<label for="choice_1_42_4" id="label_1_42_4">Providence St. Joseph Hospital Foundation Orange</label>
</div>
<div class="gchoice gchoice_1_42_5">
<input class="gfield-choice-input" name="input_42.5" type="checkbox" value="gsurvey42a18e1e6b" id="choice_1_42_5" disabled="disabled">
<label for="choice_1_42_5" id="label_1_42_5">Providence St. Jude Memorial Foundation</label>
</div>
<div class="gchoice gchoice_1_42_6">
<input class="gfield-choice-input" name="input_42.6" type="checkbox" value="gsurvey4299148a32" id="choice_1_42_6" disabled="disabled">
<label for="choice_1_42_6" id="label_1_42_6">Providence St. Mary Medical Center Foundation</label>
</div>
<div class="gchoice gchoice_1_42_7">
<input class="gfield-choice-input" name="input_42.7" type="checkbox" value="gsurvey4215591f59" id="choice_1_42_7" disabled="disabled">
<label for="choice_1_42_7" id="label_1_42_7">Providence Tarzana Foundation</label>
</div>
<div class="gchoice gchoice_1_42_8">
<input class="gfield-choice-input" name="input_42.8" type="checkbox" value="gsurvey42d9fc8b07" id="choice_1_42_8" disabled="disabled">
<label for="choice_1_42_8" id="label_1_42_8">Providence Saint Joseph Foundation Burbank</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_1_78" class="gfield hideLabel field_sublabel_above field_description_above gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_78" style="display: none;">
<legend>
<legend class="gfield_label gfield_label_before_complex">8a-i) Please tell us about your gift:</legend>
</legend>
<div class="gfield_description" id="gfield_description_1_78"><strong>Please tell us about your gift:</strong></div>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_1_78">
<div class="gchoice gchoice_1_78_1">
<input class="gfield-choice-input" name="input_78.1" type="checkbox" value="gsurvey42a31caef0" id="choice_1_78_1" aria-describedby="gfield_description_1_78" disabled="disabled">
<label for="choice_1_78_1" id="label_1_78_1">I made this gift to honor or in memory of someone.</label>
</div>
<div class="gchoice gchoice_1_78_2">
<input class="gfield-choice-input" name="input_78.2" type="checkbox" value="gsurvey42763d4ec6" id="choice_1_78_2" disabled="disabled">
<label for="choice_1_78_2" id="label_1_78_2">I made this gift for a specific purpose.</label>
</div>
<div class="gchoice gchoice_1_78_3">
<input class="gfield-choice-input" name="input_78.3" type="checkbox" value="gsurvey426b88b2d6" id="choice_1_78_3" disabled="disabled">
<label for="choice_1_78_3" id="label_1_78_3">The organization may use my gift where it will do the most good.</label>
</div>
</div>
</div>
</fieldset>
<div id="field_1_43" class="gfield hideLabel field_sublabel_above field_description_above gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_43" style="display: none;">
<legend><label class="gfield_label" for="input_1_43">8a-ii) Please provide the name of and/or association with this person:</label></legend>
<div class="gfield_description" id="gfield_description_1_43"><strong>Please provide the name of and/or association with this person:</strong></div>
<div class="ginput_container ginput_container_text"><input name="input_43" id="input_1_43" type="text" value="" class="medium" aria-describedby=" gfield_description_1_43" aria-invalid="false" disabled="disabled"> </div>
</div>
<div id="field_1_44" class="gfield hideLabel field_sublabel_above field_description_above gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_44" style="display: none;">
<legend><label class="gfield_label" for="input_1_44">8a-iii) Please describe the intended purpose:</label></legend>
<div class="gfield_description" id="gfield_description_1_44"><strong>Please describe the intended purpose:</strong></div>
<div class="ginput_container ginput_container_text"><input name="input_44" id="input_1_44" type="text" value="" class="medium" aria-describedby=" gfield_description_1_44" aria-invalid="false" disabled="disabled"> </div>
</div>
<fieldset id="field_1_77" class="gfield hideLabel field_sublabel_above field_description_above gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_77" style="display: none;">
<legend>
<legend class="gfield_label gfield_label_before_complex">8b) If you feel comfortable sharing, are you considering such a gift to any of the following organizations?</legend>
</legend>
<div class="gfield_description" id="gfield_description_1_77"><strong>If you feel comfortable sharing, are you considering such a gift to any of the following organizations?</strong></div>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_1_77">
<div class="gchoice gchoice_1_77_1">
<input class="gfield-choice-input" name="input_77.1" type="checkbox" value="gsurvey42763d4ec6" id="choice_1_77_1" aria-describedby="gfield_description_1_77" disabled="disabled">
<label for="choice_1_77_1" id="label_1_77_1">Providence Holy Cross Foundation</label>
</div>
<div class="gchoice gchoice_1_77_2">
<input class="gfield-choice-input" name="input_77.2" type="checkbox" value="gsurvey426b88b2d6" id="choice_1_77_2" disabled="disabled">
<label for="choice_1_77_2" id="label_1_77_2">Providence Little Company of Mary Foundation</label>
</div>
<div class="gchoice gchoice_1_77_3">
<input class="gfield-choice-input" name="input_77.3" type="checkbox" value="gsurvey42db0379b2" id="choice_1_77_3" disabled="disabled">
<label for="choice_1_77_3" id="label_1_77_3">Providence Mission Hospital Foundation</label>
</div>
<div class="gchoice gchoice_1_77_4">
<input class="gfield-choice-input" name="input_77.4" type="checkbox" value="gsurvey42ede7846a" id="choice_1_77_4" disabled="disabled">
<label for="choice_1_77_4" id="label_1_77_4">Providence St. Joseph Hospital Foundation Orange</label>
</div>
<div class="gchoice gchoice_1_77_5">
<input class="gfield-choice-input" name="input_77.5" type="checkbox" value="gsurvey42a18e1e6b" id="choice_1_77_5" disabled="disabled">
<label for="choice_1_77_5" id="label_1_77_5">Providence St. Jude Memorial Foundation</label>
</div>
<div class="gchoice gchoice_1_77_6">
<input class="gfield-choice-input" name="input_77.6" type="checkbox" value="gsurvey4299148a32" id="choice_1_77_6" disabled="disabled">
<label for="choice_1_77_6" id="label_1_77_6">Providence St. Mary Medical Center Foundation</label>
</div>
<div class="gchoice gchoice_1_77_7">
<input class="gfield-choice-input" name="input_77.7" type="checkbox" value="gsurvey4215591f59" id="choice_1_77_7" disabled="disabled">
<label for="choice_1_77_7" id="label_1_77_7">Providence Tarzana Foundation</label>
</div>
<div class="gchoice gchoice_1_77_8">
<input class="gfield-choice-input" name="input_77.8" type="checkbox" value="gsurvey42d9fc8b07" id="choice_1_77_8" disabled="disabled">
<label for="choice_1_77_8" id="label_1_77_8">Providence Saint Joseph Foundation Burbank</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_1_45" class="gfield hideLabel field_sublabel_above field_description_above gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_45">
<legend>
<legend class="gfield_label gfield_label_before_complex">Guides</legend>
</legend>
<div class="gfield_description" id="gfield_description_1_45"> </div>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_1_45">
<div class="gchoice gchoice_1_45_1">
<input class="gfield-choice-input" name="input_45.1" type="checkbox" value="gsurvey4566317982" id="choice_1_45_1" aria-describedby="gfield_description_1_45">
<label for="choice_1_45_1" id="label_1_45_1"><strong>Please send me more information to help with my decision.</strong></label>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_1_47" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("7"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("7"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Previous Question"> <input type="button"
id="gform_next_button_1_47" class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("9"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("9"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Next Question">
</div>
</div>
<div id="gform_page_1_9" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_1_9" class="gform_fields top_label form_sublabel_above description_below">
<fieldset id="field_1_48" class="gfield field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_48">
<legend>
<legend class="gfield_label">9) How does the Providence medical center you identified at the beginning of this survey rank in comparison to other charitable causes?</legend>
</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_48">
<div class="gchoice gchoice_1_48_0">
<input class="gfield-choice-input" name="input_48" type="radio" value="gsurvey482806e6d3" id="choice_1_48_0" onchange="gformToggleRadioOther( this )">
<label for="choice_1_48_0" id="label_1_48_0">My top choice</label>
</div>
<div class="gchoice gchoice_1_48_1">
<input class="gfield-choice-input" name="input_48" type="radio" value="gsurvey48e9b5a034" id="choice_1_48_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_48_1" id="label_1_48_1">Near the top of my list</label>
</div>
<div class="gchoice gchoice_1_48_2">
<input class="gfield-choice-input" name="input_48" type="radio" value="gsurvey48ae8803a4" id="choice_1_48_2" onchange="gformToggleRadioOther( this )">
<label for="choice_1_48_2" id="label_1_48_2">Middle of my list</label>
</div>
<div class="gchoice gchoice_1_48_3">
<input class="gfield-choice-input" name="input_48" type="radio" value="gsurvey48c2fae602" id="choice_1_48_3" onchange="gformToggleRadioOther( this )">
<label for="choice_1_48_3" id="label_1_48_3">Bottom of my list</label>
</div>
<div class="gchoice gchoice_1_48_4">
<input class="gfield-choice-input" name="input_48" type="radio" value="gsurvey48263bb56c" id="choice_1_48_4" onchange="gformToggleRadioOther( this )">
<label for="choice_1_48_4" id="label_1_48_4">Not on my list</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_1_49" class="gfield hideLabel field_sublabel_above field_description_above gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_49" style="display: none;">
<legend>
<legend class="gfield_label">9a) Do you have any friends/colleagues/family members with similar interests who would consider supporting the mission and vision of Providence?</legend>
</legend>
<div class="gfield_description" id="gfield_description_1_49"><strong>Do you have any friends/colleagues/family members with similar interests who would consider supporting the mission and vision of Providence?</strong></div>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_49">
<div class="gchoice gchoice_1_49_0">
<input class="gfield-choice-input" name="input_49" type="radio" value="gsurvey482806e6d3" id="choice_1_49_0" onchange="gformToggleRadioOther( this )" aria-describedby="gfield_description_1_49" disabled="disabled">
<label for="choice_1_49_0" id="label_1_49_0">Yes</label>
</div>
<div class="gchoice gchoice_1_49_1">
<input class="gfield-choice-input" name="input_49" type="radio" value="gsurvey48e9b5a034" id="choice_1_49_1" onchange="gformToggleRadioOther( this )" disabled="disabled">
<label for="choice_1_49_1" id="label_1_49_1">No</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_1_62" class="gfield hideLabel field_sublabel_above field_description_above gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_62" style="display: none;">
<legend>
<legend class="gfield_label">9a-i) Please let us know the most convenient way to connect:</legend>
</legend>
<div class="gfield_description" id="gfield_description_1_62"><strong>Please let us know the most convenient way to connect:</strong></div>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_62">
<div class="gchoice gchoice_1_62_0">
<input class="gfield-choice-input" name="input_62" type="radio" value="gsurvey62aebd4e43" id="choice_1_62_0" onchange="gformToggleRadioOther( this )" aria-describedby="gfield_description_1_62" disabled="disabled">
<label for="choice_1_62_0" id="label_1_62_0">I would like to introduce the person(s) to Providence on my own.</label>
</div>
<div class="gchoice gchoice_1_62_1">
<input class="gfield-choice-input" name="input_62" type="radio" value="gsurvey6280e6b456" id="choice_1_62_1" onchange="gformToggleRadioOther( this )" disabled="disabled">
<label for="choice_1_62_1" id="label_1_62_1">I would like Providence to provide me with resources to share with the person(s).</label>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_1_64" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("8"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("8"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Previous Question"> <input type="button"
id="gform_next_button_1_64" class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("10"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("10"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Next Question">
</div>
</div>
<div id="gform_page_1_10" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_1_10" class="gform_fields top_label form_sublabel_above description_below">
<div id="field_1_65" class="gfield field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_65">
<legend><label class="gfield_label" for="input_1_65">10) We would love to hear your story. If you would like, please share a memory or experience from your involvement with the Providence medical center you identified at the beginning of
this survey.</label></legend>
<div class="ginput_container ginput_container_textarea"><textarea name="input_65" id="input_1_65" class="textarea medium" maxlength="16000" aria-invalid="false" rows="10" cols="50"></textarea>
<div class="charleft ginput_counter" aria-live="polite">0 of 16000 max characters</div>
</div>
</div>
<fieldset id="field_1_80" class="gfield field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_80">
<legend>
<legend class="gfield_label screen-reader-text gfield_label_before_complex"></legend>
</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_1_80">
<div class="gchoice gchoice_1_80_1">
<input class="gfield-choice-input" name="input_80.1" type="checkbox" value="gsurvey8067a4fdbe" id="choice_1_80_1">
<label for="choice_1_80_1" id="label_1_80_1">I prefer to tell you my story directly.</label>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_1_40" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("9"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("9"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Previous Question"> <input type="button"
id="gform_next_button_1_40" class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("11"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("11"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Next Question">
</div>
</div>
<div id="gform_page_1_11" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_1_11" class="gform_fields top_label form_sublabel_above description_below">
<div id="field_1_63" class="gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above field_description_below gfield_visibility_visible" data-js-reload="field_1_63">
<legend><label class="gfield_label">11) About You (optional)</label></legend>
</div>
<fieldset id="field_1_22" class="gfield gf_list_4col field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_22">
<legend>
<legend class="gfield_label">Age</legend>
</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_22">
<div class="gchoice gchoice_1_22_0">
<input class="gfield-choice-input" name="input_22" type="radio" value="gsurvey222f4d7a17" id="choice_1_22_0" onchange="gformToggleRadioOther( this )">
<label for="choice_1_22_0" id="label_1_22_0">Under 40</label>
</div>
<div class="gchoice gchoice_1_22_1">
<input class="gfield-choice-input" name="input_22" type="radio" value="gsurvey22abd12bbf" id="choice_1_22_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_22_1" id="label_1_22_1">40 - 49</label>
</div>
<div class="gchoice gchoice_1_22_2">
<input class="gfield-choice-input" name="input_22" type="radio" value="gsurvey220ec95f71" id="choice_1_22_2" onchange="gformToggleRadioOther( this )">
<label for="choice_1_22_2" id="label_1_22_2">50 - 59</label>
</div>
<div class="gchoice gchoice_1_22_3">
<input class="gfield-choice-input" name="input_22" type="radio" value="gsurvey2292051d4d" id="choice_1_22_3" onchange="gformToggleRadioOther( this )">
<label for="choice_1_22_3" id="label_1_22_3">60 - 69</label>
</div>
<div class="gchoice gchoice_1_22_4">
<input class="gfield-choice-input" name="input_22" type="radio" value="gsurvey223724e037" id="choice_1_22_4" onchange="gformToggleRadioOther( this )">
<label for="choice_1_22_4" id="label_1_22_4">70 - 79</label>
</div>
<div class="gchoice gchoice_1_22_5">
<input class="gfield-choice-input" name="input_22" type="radio" value="gsurvey22aef1e623" id="choice_1_22_5" onchange="gformToggleRadioOther( this )">
<label for="choice_1_22_5" id="label_1_22_5">80 - 89</label>
</div>
<div class="gchoice gchoice_1_22_6">
<input class="gfield-choice-input" name="input_22" type="radio" value="gsurvey2272153849" id="choice_1_22_6" onchange="gformToggleRadioOther( this )">
<label for="choice_1_22_6" id="label_1_22_6">90+</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_1_23" class="gfield field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_23">
<legend>
<legend class="gfield_label">Gender</legend>
</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_23">
<div class="gchoice gchoice_1_23_0">
<input class="gfield-choice-input" name="input_23" type="radio" value="gsurvey222f4d7a17" id="choice_1_23_0" onchange="gformToggleRadioOther( this )">
<label for="choice_1_23_0" id="label_1_23_0">Male</label>
</div>
<div class="gchoice gchoice_1_23_1">
<input class="gfield-choice-input" name="input_23" type="radio" value="gsurvey22abd12bbf" id="choice_1_23_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_23_1" id="label_1_23_1">Female</label>
</div>
<div class="gchoice gchoice_1_23_2">
<input class="gfield-choice-input" name="input_23" type="radio" value="gsurvey23a43ce617" id="choice_1_23_2" onchange="gformToggleRadioOther( this )">
<label for="choice_1_23_2" id="label_1_23_2">Other/Nonbinary</label>
</div>
<div class="gchoice gchoice_1_23_3">
<input class="gfield-choice-input" name="input_23" type="radio" value="gsurvey23e3266ee6" id="choice_1_23_3" onchange="gformToggleRadioOther( this )">
<label for="choice_1_23_3" id="label_1_23_3">Prefer not to specify</label>
</div>
</div>
</div>
</fieldset>
<div id="field_1_46" class="gfield field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_46" style="display: none;">
<legend><label class="gfield_label" for="input_1_46">Please specify:</label></legend>
<div class="ginput_container ginput_container_text"><input name="input_46" id="input_1_46" type="text" value="" class="medium" aria-invalid="false" disabled="disabled"> </div>
</div>
<fieldset id="field_1_24" class="gfield field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_24">
<legend>
<legend class="gfield_label">What is your marital status?</legend>
</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_24">
<div class="gchoice gchoice_1_24_0">
<input class="gfield-choice-input" name="input_24" type="radio" value="gsurvey222f4d7a17" id="choice_1_24_0" onchange="gformToggleRadioOther( this )">
<label for="choice_1_24_0" id="label_1_24_0">Married</label>
</div>
<div class="gchoice gchoice_1_24_1">
<input class="gfield-choice-input" name="input_24" type="radio" value="gsurvey22abd12bbf" id="choice_1_24_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_24_1" id="label_1_24_1">Single</label>
</div>
<div class="gchoice gchoice_1_24_2">
<input class="gfield-choice-input" name="input_24" type="radio" value="gsurvey246ad3b281" id="choice_1_24_2" onchange="gformToggleRadioOther( this )">
<label for="choice_1_24_2" id="label_1_24_2">Divorced</label>
</div>
<div class="gchoice gchoice_1_24_3">
<input class="gfield-choice-input" name="input_24" type="radio" value="gsurvey24630e2f83" id="choice_1_24_3" onchange="gformToggleRadioOther( this )">
<label for="choice_1_24_3" id="label_1_24_3">Widowed</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_1_25" class="gfield field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_25">
<legend>
<legend class="gfield_label">Which of the following best describes your family?</legend>
</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_25">
<div class="gchoice gchoice_1_25_0">
<input class="gfield-choice-input" name="input_25" type="radio" value="gsurvey222f4d7a17" id="choice_1_25_0" onchange="gformToggleRadioOther( this )">
<label for="choice_1_25_0" id="label_1_25_0">No children</label>
</div>
<div class="gchoice gchoice_1_25_1">
<input class="gfield-choice-input" name="input_25" type="radio" value="gsurvey22abd12bbf" id="choice_1_25_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_25_1" id="label_1_25_1">One child</label>
</div>
<div class="gchoice gchoice_1_25_2">
<input class="gfield-choice-input" name="input_25" type="radio" value="gsurvey246ad3b281" id="choice_1_25_2" onchange="gformToggleRadioOther( this )">
<label for="choice_1_25_2" id="label_1_25_2">Two or more children</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_1_26" class="gfield field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_26">
<legend>
<legend class="gfield_label">Please tell us the highest level of education you completed:</legend>
</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_26">
<div class="gchoice gchoice_1_26_0">
<input class="gfield-choice-input" name="input_26" type="radio" value="gsurvey222f4d7a17" id="choice_1_26_0" onchange="gformToggleRadioOther( this )">
<label for="choice_1_26_0" id="label_1_26_0">High school graduate or equivalent</label>
</div>
<div class="gchoice gchoice_1_26_1">
<input class="gfield-choice-input" name="input_26" type="radio" value="gsurvey22abd12bbf" id="choice_1_26_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_26_1" id="label_1_26_1">Some college</label>
</div>
<div class="gchoice gchoice_1_26_2">
<input class="gfield-choice-input" name="input_26" type="radio" value="gsurvey246ad3b281" id="choice_1_26_2" onchange="gformToggleRadioOther( this )">
<label for="choice_1_26_2" id="label_1_26_2">Associate's degree</label>
</div>
<div class="gchoice gchoice_1_26_3">
<input class="gfield-choice-input" name="input_26" type="radio" value="gsurvey268832f233" id="choice_1_26_3" onchange="gformToggleRadioOther( this )">
<label for="choice_1_26_3" id="label_1_26_3">Bachelor's degree</label>
</div>
<div class="gchoice gchoice_1_26_4">
<input class="gfield-choice-input" name="input_26" type="radio" value="gsurvey2601a312fb" id="choice_1_26_4" onchange="gformToggleRadioOther( this )">
<label for="choice_1_26_4" id="label_1_26_4">Advanced degree</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_1_27" class="gfield gf_list_2col field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_27">
<legend>
<legend class="gfield_label gfield_label_before_complex">Please select the option(s) that best describes your professional life.</legend>
</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_1_27">
<div class="gchoice gchoice_1_27_1">
<input class="gfield-choice-input" name="input_27.1" type="checkbox" value="gsurvey27e3c769c5" id="choice_1_27_1">
<label for="choice_1_27_1" id="label_1_27_1">Working full time</label>
</div>
<div class="gchoice gchoice_1_27_2">
<input class="gfield-choice-input" name="input_27.2" type="checkbox" value="gsurvey27073b4c55" id="choice_1_27_2">
<label for="choice_1_27_2" id="label_1_27_2">Working part time</label>
</div>
<div class="gchoice gchoice_1_27_3">
<input class="gfield-choice-input" name="input_27.3" type="checkbox" value="gsurvey278f982e51" id="choice_1_27_3">
<label for="choice_1_27_3" id="label_1_27_3">Retiring within 5 years</label>
</div>
<div class="gchoice gchoice_1_27_4">
<input class="gfield-choice-input" name="input_27.4" type="checkbox" value="gsurvey2720c76c57" id="choice_1_27_4">
<label for="choice_1_27_4" id="label_1_27_4">Retired</label>
</div>
<div class="gchoice gchoice_1_27_5">
<input class="gfield-choice-input" name="input_27.5" type="checkbox" value="gsurvey271e2eb9d1" id="choice_1_27_5">
<label for="choice_1_27_5" id="label_1_27_5">Volunteering</label>
</div>
<div class="gchoice gchoice_1_27_6">
<input class="gfield-choice-input" name="input_27.6" type="checkbox" value="gsurvey277c81735d" id="choice_1_27_6">
<label for="choice_1_27_6" id="label_1_27_6">Board member for a nonprofit</label>
</div>
<div class="gchoice gchoice_1_27_7">
<input class="gfield-choice-input" name="input_27.7" type="checkbox" value="gsurvey2741bb24ab" id="choice_1_27_7">
<label for="choice_1_27_7" id="label_1_27_7">Business owner or entrepreneur</label>
</div>
<div class="gchoice gchoice_1_27_8">
<input class="gfield-choice-input" name="input_27.8" type="checkbox" value="gsurvey2776fe4496" id="choice_1_27_8">
<label for="choice_1_27_8" id="label_1_27_8">Self-employed</label>
</div>
<div class="gchoice gchoice_1_27_9">
<input class="gfield-choice-input" name="input_27.9" type="checkbox" value="gsurvey27503124c1" id="choice_1_27_9">
<label for="choice_1_27_9" id="label_1_27_9">Other</label>
</div>
</div>
</div>
</fieldset>
<div id="field_1_28" class="gfield field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_28" style="display: none;">
<legend><label class="gfield_label" for="input_1_28">Profession:</label></legend>
<div class="ginput_container ginput_container_text"><input name="input_28" id="input_1_28" type="text" value="" class="large" aria-invalid="false" disabled="disabled"> </div>
</div>
<div id="field_1_67" class="gfield field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_67" style="display: none;">
<legend><label class="gfield_label" for="input_1_67">Where do you serve as a board member?</label></legend>
<div class="ginput_container ginput_container_text"><input name="input_67" id="input_1_67" type="text" value="" class="large" aria-invalid="false" disabled="disabled"> </div>
</div>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_1_4" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("10"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("10"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Previous Question"> <input type="button"
id="gform_next_button_1_4" class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("12"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("12"); jQuery("#gform_1").trigger("submit",[true]); } " aria-label="Next Question">
</div>
</div>
<div id="gform_page_1_12" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_1_12" class="gform_fields top_label form_sublabel_above description_below">
<fieldset id="field_1_5" class="gfield contact_updated field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_5" style="display: none;">
<legend>
<legend class="gfield_label gfield_label_before_complex">Please check the box below if you would like to update your contact information.</legend>
</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_1_5">
<div class="gchoice gchoice_1_5_1">
<input class="gfield-choice-input" name="input_5.1" type="checkbox" value="gsurvey5b055adf5" id="choice_1_5_1">
<label for="choice_1_5_1" id="label_1_5_1">I would like to update my contact information.</label>
</div>
</div>
</div>
</fieldset>
<div id="field_1_6" class="gfield gf_left_half disable gfield--width-half gfield_contains_required field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field"
data-js-reload="field_1_6">
<legend><label class="gfield_label" for="input_1_6">First name<span role="presentation" aria-hidden="true"><span class="gfield_required"><span role="presentation" aria-hidden="true"><span
class="gfield_required gfield_required_text">(Required)</span></span></span></span></label></legend>
<div class="ginput_container ginput_container_text"><input name="input_6" id="input_1_6" type="text" value="" class="medium" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_1_7" class="gfield gf_right_half disable gfield--width-half gfield_contains_required field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field"
data-js-reload="field_1_7">
<legend><label class="gfield_label" for="input_1_7">Last name<span role="presentation" aria-hidden="true"><span class="gfield_required"><span role="presentation" aria-hidden="true"><span
class="gfield_required gfield_required_text">(Required)</span></span></span></span></label></legend>
<div class="ginput_container ginput_container_text"><input name="input_7" id="input_1_7" type="text" value="" class="medium" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_1_8" class="gfield gf_left_half disable gfield--width-half field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_8">
<legend><label class="gfield_label" for="input_1_8">Address</label></legend>
<div class="ginput_container ginput_container_text"><input name="input_8" id="input_1_8" type="text" value="" class="medium" aria-invalid="false"> </div>
</div>
<div id="field_1_9" class="gfield gf_right_half disable gfield--width-half field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_9">
<legend><label class="gfield_label" for="input_1_9">Address 2</label></legend>
<div class="ginput_container ginput_container_text"><input name="input_9" id="input_1_9" type="text" value="" class="medium" aria-invalid="false"> </div>
</div>
<div id="field_1_10" class="gfield gf_left_half disable gfield--width-half field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_10">
<legend><label class="gfield_label" for="input_1_10">City</label></legend>
<div class="ginput_container ginput_container_text"><input name="input_10" id="input_1_10" type="text" value="" class="medium" aria-invalid="false"> </div>
</div>
<div id="field_1_11" class="gfield gf_right_half disable gfield--width-half field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_11">
<legend><label class="gfield_label" for="input_1_11">State</label></legend>
<div class="ginput_container ginput_container_select"><select name="input_11" id="input_1_11" class="medium gfield_select" aria-invalid="false">
<option value=""></option>
<option value="AL" aria-label="Alabama">AL</option>
<option value="AK" aria-label="Alaska">AK</option>
<option value="AR" aria-label="Arkansas">AR</option>
<option value="AZ" aria-label="Arizona">AZ</option>
<option value="CA" aria-label="California">CA</option>
<option value="CO" aria-label="Colorado">CO</option>
<option value="CT" aria-label="Connecticut">CT</option>
<option value="DE" aria-label="Delaware">DE</option>
<option value="FL" aria-label="Florida">FL</option>
<option value="GA" aria-label="Georgia">GA</option>
<option value="HI" aria-label="Hawaii">HI</option>
<option value="ID" aria-label="Idaho">ID</option>
<option value="IL" aria-label="Illinois">IL</option>
<option value="IN" aria-label="Indiana">IN</option>
<option value="IA" aria-label="Iowa">IA</option>
<option value="KS" aria-label="Kansas">KS</option>
<option value="KY" aria-label="Kentucky">KY</option>
<option value="LA" aria-label="Louisiana">LA</option>
<option value="ME" aria-label="Maine">ME</option>
<option value="MD" aria-label="Maryland">MD</option>
<option value="MA" aria-label="Massachusetts">MA</option>
<option value="MI" aria-label="Michigan">MI</option>
<option value="MN" aria-label="Minnesota">MN</option>
<option value="MS" aria-label="Mississippi">MS</option>
<option value="MO" aria-label="Missouri">MO</option>
<option value="MT" aria-label="Montana">MT</option>
<option value="NE" aria-label="Nebraska">NE</option>
<option value="NH" aria-label="New Hampshire">NH</option>
<option value="NV" aria-label="Nevada">NV</option>
<option value="NJ" aria-label="New Jersey">NJ</option>
<option value="NM" aria-label="New Mexico">NM</option>
<option value="NY" aria-label="New York">NY</option>
<option value="NC" aria-label="North Carolina">NC</option>
<option value="ND" aria-label="North Dakota">ND</option>
<option value="OH" aria-label="Ohio">OH</option>
<option value="OK" aria-label="Oklahoma">OK</option>
<option value="OR" aria-label="Oregon">OR</option>
<option value="PA" aria-label="Pennsylvania">PA</option>
<option value="RI" aria-label="Rhode Island">RI</option>
<option value="SC" aria-label="South Carolina">SC</option>
<option value="SD" aria-label="South Dakota">SD</option>
<option value="TN" aria-label="Tennessee">TN</option>
<option value="TX" aria-label="Texas">TX</option>
<option value="UT" aria-label="Utah">UT</option>
<option value="VT" aria-label="Vermont">VT</option>
<option value="VA" aria-label="Virginia">VA</option>
<option value="DC" aria-label="District of Columbia">DC</option>
<option value="WA" aria-label="Washington">WA</option>
<option value="WV" aria-label="West Virginia">WV</option>
<option value="WI" aria-label="Wisconsin">WI</option>
<option value="WY" aria-label="Wyoming">WY</option>
</select></div>
</div>
<div id="field_1_12" class="gfield gf_left_half disable gfield--width-half field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_12">
<legend><label class="gfield_label" for="input_1_12">ZIP</label></legend>
<div class="ginput_container ginput_container_text"><input name="input_12" id="input_1_12" type="text" value="" class="medium" aria-invalid="false"> </div>
</div>
<div id="field_1_13" class="gfield gf_right_half disable gfield--width-half field_sublabel_above field_description_below gfield_visibility_visible gsurvey-survey-field " data-field-class="gsurvey-survey-field" data-js-reload="field_1_13">
<legend><label class="gfield_label" for="input_1_13">Country</label></legend>
<div class="ginput_container ginput_container_select"><select name="input_13" id="input_1_13" class="medium gfield_select" aria-invalid="false">
<option value=""></option>
<option value="United States">United States</option>
<option value="Afghanistan">Afghanistan</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivia">Bolivia</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Brazil">Brazil</option>
<option value="Brunei">Brunei</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cape Verde">Cape Verde</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option>
<option value="Congo, Republic of the">Congo, Republic of the</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Côte d'Ivoire">Côte d'Ivoire</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Curaçao">Curaçao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="East Timor">East Timor</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="France">France</option>
<option value="French Polynesia">French Polynesia</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iran">Iran</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="North Korea">North Korea</option>
<option value="South Korea">South Korea</option>
<option value="Kosovo">Kosovo</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Laos">Laos</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macedonia">Macedonia</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mexico">Mexico</option>
<option value="Micronesia">Micronesia</option>
<option value="Moldova">Moldova</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montenegro">Montenegro</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="New Zealand">New Zealand</option>
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<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Vatican City">Vatican City</option>
<option value="Venezuela">Venezuela</option>
<option value="Vietnam">Vietnam</option>
<option value="Virgin Islands, British">Virgin Islands, British</option>
<option value="Virgin Islands, U.S.">Virgin Islands, U.S.</option>
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<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
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Skip to content Contact Information Call us: (833) 752-1573 Email us How is this information used? HOW YOUR SURVEY INFORMATION IS USED At Providence, we are so appreciative of the support we receive from donors, volunteers, advocates, partners, and others like you. That is why we are committed to protecting your privacy and take steps to keep any personal information you provide confidential. You were invited to take this survey because we value your trust and confidence and sincerely would like to understand your preferences, interests, and wishes so we can be more sensitive to them. By answering these survey questions, you will help us: * Reduce the amount of communications we send you; * Lessen our environmental impact together; * Improve the relevance of the information we send you. As a whole, your answers will help us become better stewards of donation dollars as a result of time savings and reduction of printing, mailing, and postage costs. Going forward, we will make our best attempts to use the information you provide in this survey to adjust the content of the communications we send you and the frequency with which you receive them. Please remember, you can always review our complete privacy policy and you may opt-out of receiving communications from us at any time. Thank you so much for your time, interest, and commitment to . You can read more about our privacy policy here. Close SURVEY WE VALUE YOUR FEEDBACK. Because of supporters like you, Providence is providing lifesaving treatment, investing in our communities and helping those who need us most. We couldn’t do it without you, and that’s why we need your input. Please complete our brief survey to help us understand what matters to you. Step 1 of 12 - Q1 8% 1) Which of the following Providence medical centers do you feel most connected to? Providence Holy Cross Medical Center Providence Little Company of Mary Medical Center San Pedro Providence Little Company of Mary Medical Center Torrance Providence Mission Hospital Providence St. Joseph Hospital Orange Providence St. Jude Medical Center Providence St. Mary Medical Center Providence Cedars-Sinai Tarzana Medical Center Providence Saint Joseph Medical Center Burbank Other Please specify: 2) In what ways have you engaged with Providence medical centers? Please select all that apply. I was treated at a Providence medical center. A friend or family member was treated at a Providence medical center. I am a current or former volunteer at a Providence medical center. I am a current or former employee of Providence. I am a current/former Board Member at a Providence medical center. I donate. I have attended events. I follow on social media. I have visited the website. Other 2a) Other - Please specify: Please specify: 2b) How frequently do you engage with Providence medical centers? How frequently do you engage with Providence medical centers? Weekly Monthly Every few months Yearly Rarely or never Other 2b-i) Other - Please specify: Please specify: 3) We like to send friends like you occasional emails with updates including videos, stories and information about how we are making an impact on your behalf. Would you like to receive these updates? (You can opt-out at any time). Yes, I want to receive occasional emails with updates. Not at this time. 4) Which of the following medical center community initiatives is most meaningful to you? Behavioral Health Cancer COVID-19 Community Benefit/Health Equity Emergency/Trauma Heart & Vascular Homeless Neuroscience Nursing Orthopedics Women & Children Other Please specify: 5) Was there an influential person in your life who inspired your appreciation of the medical center you identified at the beginning of this survey? Yes No 5a) If yes, please indicate their relationship to you. If yes, please indicate their relationship to you. Parent/grandparent Spouse/partner/significant other Child/children Other family member Friend Doctor, nurse or other health care provider Teacher or professor Other 5a-i) Other - Please specify: Please specify: If you feel comfortable, please tell us more about this person. 6) When thinking about future generations, how important is it to you that your preferred Providence medical center remains steadfast in serving all, especially those who are poor and vulnerable? Of utmost importance Very important Somewhat important Not very important Not important at all 7) Supporters often recognize the need to help Providence medical centers continue their important work in our community. Would you consider supporting our shared mission in any of the following ways? I already have I am likely I am somewhat likely I am not likely Talking with a gift officer to learn more about different ways to give I already have I am likely I am somewhat likely I am not likely Donating from a Donor-Advised Fund or Family Foundation I already have I am likely I am somewhat likely I am not likely Giving appreciated assets (such as personal or business stocks or bonds, land or rental real estate, etc.) I already have I am likely I am somewhat likely I am not likely Donating a portion of my Individual Retirement Account or Required Minimum Distribution I already have I am likely I am somewhat likely I am not likely Making a charitable gift that provides a lifetime income to me or my loved ones I already have I am likely I am somewhat likely I am not likely 8) Many people like to include a gift to charity in their will, trust or other estate plans to support causes that are important in their life. Would you consider creating a legacy at the medical center? I have included a gift in my will, trust, or by beneficiary designation. I am interested in making this type of gift. Not now, but in the future I would definitely be interested in making this type of gift. Not now, but in the future I might possibly be interested in making this type of gift. I am not interested in this type of gift. 8a) If you feel comfortable sharing, which of the following organizations are a beneficiary of your intended gift? If you feel comfortable sharing, which of the following organizations are a beneficiary of your intended gift? Providence Holy Cross Foundation Providence Little Company of Mary Foundation Providence Mission Hospital Foundation Providence St. Joseph Hospital Foundation Orange Providence St. Jude Memorial Foundation Providence St. Mary Medical Center Foundation Providence Tarzana Foundation Providence Saint Joseph Foundation Burbank 8a-i) Please tell us about your gift: Please tell us about your gift: I made this gift to honor or in memory of someone. I made this gift for a specific purpose. The organization may use my gift where it will do the most good. 8a-ii) Please provide the name of and/or association with this person: Please provide the name of and/or association with this person: 8a-iii) Please describe the intended purpose: Please describe the intended purpose: 8b) If you feel comfortable sharing, are you considering such a gift to any of the following organizations? If you feel comfortable sharing, are you considering such a gift to any of the following organizations? Providence Holy Cross Foundation Providence Little Company of Mary Foundation Providence Mission Hospital Foundation Providence St. Joseph Hospital Foundation Orange Providence St. Jude Memorial Foundation Providence St. Mary Medical Center Foundation Providence Tarzana Foundation Providence Saint Joseph Foundation Burbank Guides Please send me more information to help with my decision. 9) How does the Providence medical center you identified at the beginning of this survey rank in comparison to other charitable causes? My top choice Near the top of my list Middle of my list Bottom of my list Not on my list 9a) Do you have any friends/colleagues/family members with similar interests who would consider supporting the mission and vision of Providence? Do you have any friends/colleagues/family members with similar interests who would consider supporting the mission and vision of Providence? Yes No 9a-i) Please let us know the most convenient way to connect: Please let us know the most convenient way to connect: I would like to introduce the person(s) to Providence on my own. I would like Providence to provide me with resources to share with the person(s). 10) We would love to hear your story. If you would like, please share a memory or experience from your involvement with the Providence medical center you identified at the beginning of this survey. 0 of 16000 max characters I prefer to tell you my story directly. 11) About You (optional) Age Under 40 40 - 49 50 - 59 60 - 69 70 - 79 80 - 89 90+ Gender Male Female Other/Nonbinary Prefer not to specify Please specify: What is your marital status? Married Single Divorced Widowed Which of the following best describes your family? No children One child Two or more children Please tell us the highest level of education you completed: High school graduate or equivalent Some college Associate's degree Bachelor's degree Advanced degree Please select the option(s) that best describes your professional life. Working full time Working part time Retiring within 5 years Retired Volunteering Board member for a nonprofit Business owner or entrepreneur Self-employed Other Profession: Where do you serve as a board member? Please check the box below if you would like to update your contact information. I would like to update my contact information. First name(Required) Last name(Required) Address Address 2 City State ALAKARAZCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENHNVNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVADCWAWVWIWY ZIP Country United StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Phone Email(Required) Hidden segment Name This field is for validation purposes and should be left unchanged. 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