www.cancersupportcommunity.org
Open in
urlscan Pro
35.167.236.162
Public Scan
URL:
https://www.cancersupportcommunity.org/bear-fund-application
Submission: On August 09 via manual from US — Scanned from DE
Submission: On August 09 via manual from US — Scanned from DE
Form analysis 3 forms found in the DOM
GET /search
<form action="/search" method="get" id="views-exposed-form-acquia-search-page" accept-charset="UTF-8" data-once="form-updated" data-drupal-form-fields="edit-search">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'views_exposed_form' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/views/views-exposed-form.html.twig' -->
<div class="form--inline clearfix">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-search form-item-search">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-search">Search</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__textfield' -->
<!-- FILE NAME SUGGESTIONS:
* input--textfield.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-search" type="text" id="edit-search" name="search" value="" size="30" maxlength="128" class="form-text">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'container' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<div data-drupal-selector="edit-actions" class="form-actions js-form-wrapper form-wrapper" id="edit-actions--2">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__submit' -->
<!-- FILE NAME SUGGESTIONS:
* input--submit.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-submit-acquia-search" type="submit" id="edit-submit-acquia-search" value="Search" class="button js-form-submit form-submit">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/views/views-exposed-form.html.twig' -->
</form>POST /bear-fund-application
<form
class="webform-submission-form webform-submission-add-form webform-submission-bear-fund-application-form webform-submission-bear-fund-application-add-form webform-submission-bear-fund-application-block_content-18061-form webform-submission-bear-fund-application-block_content-18061-add-form webform-submission-bear-fund-application-block-content-18061-add-form js-webform-details-toggle webform-details-toggle"
data-drupal-selector="webform-submission-bear-fund-application-block-content-18061-add-form" action="/bear-fund-application" method="post" id="webform-submission-bear-fund-application-block-content-18061-add-form" accept-charset="UTF-8"
data-once="form-updated"
data-drupal-form-fields="edit-if-no-please-stop-here-and-ask-your-health-care-team-to-apply-on-yes,edit-if-no-please-stop-here-and-ask-your-health-care-team-to-apply-on-no,edit-persons-in-household-maximum-income-2-person-household-and-income-up-to-86200-per-year,edit-persons-in-household-maximum-income-3-person-household-and-income-up-to-109800-per-year,edit-persons-in-household-maximum-income-4-person-household-and-income-up-to-132500-per-year,edit-persons-in-household-maximum-income-5-person-household-and-income-up-to-155200-per-year,edit-persons-in-household-maximum-income-6-person-household-and-income-up-to-177900-per-year,edit-persons-in-household-maximum-income-7-person-household-and-income-up-to-200600-per-year,edit-persons-in-household-maximum-income-8-person-household-and-income-up-to-223300-per-year,edit-do-you-meet-the-eligibility-requirements-in-the-chart-above-if-n-yes,edit-do-you-meet-the-eligibility-requirements-in-the-chart-above-if-n-no,edit-patient-s-first-name,edit-patient-s-last-name,edit-parent-guardian-first-name,edit-parent-guardian-last-name,edit-patient-s-date-of-birth,edit-family-is-spanish-speaking-writing-reading,edit-cancer-type,edit-date-of-cancer-diagnosis,edit-please-specify-if-the-patient-is-checkboxes-in-active-treatment-chemo-radiation-surgery-etc,edit-please-specify-if-the-patient-is-checkboxes-survivorship-follow-up,edit-please-specify-if-the-patient-is-checkboxes-palliative-or-hospice-care,edit-please-specify-if-the-patient-is-checkboxes-other-,edit-please-specify-if-the-patient-is-other,edit-gender,edit-ethnicity,edit-race,edit-mailing-address-for-fund-dstribution-address,edit-mailing-address-for-fund-dstribution-address-2,edit-mailing-address-for-fund-dstribution-city,edit-mailing-address-for-fund-dstribution-state-province,edit-mailing-address-for-fund-dstribution-postal-code,edit-phone-number,edit-email,edit-did-you-receive-consent-from-the-patient-s-parent-guardian-to-co-yes,edit-did-you-receive-consent-from-the-patient-s-parent-guardian-to-co-no,edit-does-the-patient-s-patient-guardian-consent-to-being-contacted-b-yes,edit-does-the-patient-s-patient-guardian-consent-to-being-contacted-b-no,edit-would-the-patient-s-patient-guardian-like-a-referral-to-the-csc-yes,edit-would-the-patient-s-patient-guardian-like-a-referral-to-the-csc-no,edit-indicate-if-family-has-already-been-referred-to-one-of-our-affil-cancer-support-community-greater-cincinnatinorthern-kentucky,edit-indicate-if-family-has-already-been-referred-to-one-of-our-affil-cancer-support-community-los-angeles-affiliate,edit-indicate-the-treatment-center-where-you-are-being-treated-cincinnati-childrens-hospital-,edit-indicate-the-treatment-center-where-you-are-being-treated-childrens-hospital-of-los-angeles,edit-name-and-relation-of-person-completing-the-application,edit-name-of-referring-professional,edit-specify-the-type-of-healthcare-professional-radios-social-worker,edit-specify-the-type-of-healthcare-professional-radios-nurse,edit-specify-the-type-of-healthcare-professional-radios-navigator,edit-specify-the-type-of-healthcare-professional-radios-physician,edit-specify-the-type-of-healthcare-professional-radios-affiliate-team-member,edit-specify-the-type-of-healthcare-professional-radios-other-,edit-specify-the-type-of-healthcare-professional-other,edit-phone,edit-email-referring-professional,edit-we-need-the-bear-fund-for-checkboxes-food,edit-we-need-the-bear-fund-for-checkboxes-transportation-gas-parking-airfare-rail,edit-we-need-the-bear-fund-for-checkboxes-temporary-lodging,edit-we-need-the-bear-fund-for-checkboxes-fertility-preservation,edit-we-need-the-bear-fund-for-checkboxes-rentmortgage-,edit-we-need-the-bear-fund-for-checkboxes-utility-bills,edit-we-need-the-bear-fund-for-checkboxes-childcare,edit-we-need-the-bear-fund-for-checkboxes-counseling-services,edit-we-need-the-bear-fund-for-checkboxes-medical-expenses-co-pays-prescriptions-deductibles-etc,edit-we-need-the-bear-fund-for-checkboxes-funeral-expenses,edit-we-need-the-bear-fund-for-checkboxes-other-,edit-we-need-the-bear-fund-for-other,edit-do-you-attest-i-attest,edit-do-you-attest-i-do-not-attest,edit-submit">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'webform_submission_form' -->
<!-- FILE NAME SUGGESTIONS:
* webform-submission-form--bear-fund-application.html.twig
x webform-submission-form.html.twig
-->
<!-- BEGIN OUTPUT from 'modules/contrib/webform/templates/webform-submission-form.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label class="section-label" data-drupal-selector="edit-household-financial-information" aria-describedby="edit-household-financial-information--description" for="edit-household-financial-information">Fund Eligibility</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-processed-text.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div id="edit-are-you-staff-member" class="js-form-item form-item js-form-type-processed-text form-type-processed-text js-form-item- form-item- form-no-label">
<p>Are you a staff member of Children's Hospital of Los Angeles, Cincinnati Children's Hospital Medical Center, or the Cancer Support Community Affiliate Network Program? </p>
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'fieldset' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<fieldset data-drupal-selector="edit-if-no-please-stop-here-and-ask-your-health-care-team-to-apply-on" id="edit-if-no-please-stop-here-and-ask-your-health-care-team-to-apply-on--wrapper"
class="radios--wrapper fieldgroup form-composite webform-composite-visible-title required js-webform-type-radios webform-type-radios js-form-item form-item js-form-wrapper form-wrapper" aria-required="true" role="radiogroup"
aria-labelledby="edit-if-no-please-stop-here-and-ask-your-health-care-team-to-apply-on--wrapper-legend">
<legend id="edit-if-no-please-stop-here-and-ask-your-health-care-team-to-apply-on--wrapper-legend">
<span class="fieldset-legend js-form-required form-required">If no, please stop here and ask your health care team to apply on your behalf. </span>
</legend>
<div class="fieldset-wrapper">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'radios' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/radios.html.twig' -->
<div id="edit-if-no-please-stop-here-and-ask-your-health-care-team-to-apply-on" class="js-webform-radios webform-options-display-one-column form-radios">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-if-no-please-stop-here-and-ask-your-health-care-team-to-apply-on form-item-if-no-please-stop-here-and-ask-your-health-care-team-to-apply-on">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-if-no-please-stop-here-and-ask-your-health-care-team-to-apply-on-yes" type="radio" id="edit-if-no-please-stop-here-and-ask-your-health-care-team-to-apply-on-yes"
name="if_no_please_stop_here_and_ask_your_health_care_team_to_apply_on" value="Yes" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-if-no-please-stop-here-and-ask-your-health-care-team-to-apply-on-yes" class="option">Yes</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-if-no-please-stop-here-and-ask-your-health-care-team-to-apply-on form-item-if-no-please-stop-here-and-ask-your-health-care-team-to-apply-on">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-if-no-please-stop-here-and-ask-your-health-care-team-to-apply-on-no" type="radio" id="edit-if-no-please-stop-here-and-ask-your-health-care-team-to-apply-on-no"
name="if_no_please_stop_here_and_ask_your_health_care_team_to_apply_on" value="No" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-if-no-please-stop-here-and-ask-your-health-care-team-to-apply-on-no" class="option">No</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/radios.html.twig' -->
</div>
</fieldset>
<!-- END OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-processed-text.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div id="edit-processed-text" class="js-form-item form-item js-form-type-processed-text form-type-processed-text js-form-item- form-item- form-no-label">
<p>Eligible applicants must meet specific annual income guidelines. Grant applicants cannot exceed 500% of U.S. Federal Poverty Guidelines.</p>
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'fieldset' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<fieldset data-drupal-selector="edit-persons-in-household-maximum-income" id="edit-persons-in-household-maximum-income--wrapper"
class="radios--wrapper fieldgroup form-composite webform-composite-visible-title required js-webform-type-radios webform-type-radios js-form-item form-item js-form-wrapper form-wrapper" aria-required="true" role="radiogroup"
aria-labelledby="edit-persons-in-household-maximum-income--wrapper-legend">
<legend id="edit-persons-in-household-maximum-income--wrapper-legend">
<span class="fieldset-legend js-form-required form-required">Please select the best description of your household:</span>
</legend>
<div class="fieldset-wrapper">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'radios' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/radios.html.twig' -->
<div id="edit-persons-in-household-maximum-income" class="js-webform-radios webform-options-display-one-column form-radios">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-persons-in-household-maximum-income form-item-persons-in-household-maximum-income">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-persons-in-household-maximum-income-2-person-household-and-income-up-to-86200-per-year" type="radio" id="edit-persons-in-household-maximum-income-2-person-household-and-income-up-to-86200-per-year"
name="persons_in_household_maximum_income" value="2 person household and income up to $86,200 per year" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-persons-in-household-maximum-income-2-person-household-and-income-up-to-86200-per-year" class="option">2 person household and income up to $86,200 per year</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-persons-in-household-maximum-income form-item-persons-in-household-maximum-income">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-persons-in-household-maximum-income-3-person-household-and-income-up-to-109800-per-year" type="radio" id="edit-persons-in-household-maximum-income-3-person-household-and-income-up-to-109800-per-year"
name="persons_in_household_maximum_income" value="3 person household and income up to $109,800 per year" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-persons-in-household-maximum-income-3-person-household-and-income-up-to-109800-per-year" class="option">3 person household and income up to $109,800 per year</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-persons-in-household-maximum-income form-item-persons-in-household-maximum-income">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-persons-in-household-maximum-income-4-person-household-and-income-up-to-132500-per-year" type="radio" id="edit-persons-in-household-maximum-income-4-person-household-and-income-up-to-132500-per-year"
name="persons_in_household_maximum_income" value="4 person household and income up to $132,500 per year" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-persons-in-household-maximum-income-4-person-household-and-income-up-to-132500-per-year" class="option">4 person household and income up to $132,500 per year</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-persons-in-household-maximum-income form-item-persons-in-household-maximum-income">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-persons-in-household-maximum-income-5-person-household-and-income-up-to-155200-per-year" type="radio" id="edit-persons-in-household-maximum-income-5-person-household-and-income-up-to-155200-per-year"
name="persons_in_household_maximum_income" value="5 person household and income up to $155,200 per year" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-persons-in-household-maximum-income-5-person-household-and-income-up-to-155200-per-year" class="option">5 person household and income up to $155,200 per year</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-persons-in-household-maximum-income form-item-persons-in-household-maximum-income">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-persons-in-household-maximum-income-6-person-household-and-income-up-to-177900-per-year" type="radio" id="edit-persons-in-household-maximum-income-6-person-household-and-income-up-to-177900-per-year"
name="persons_in_household_maximum_income" value="6 person household and income up to $177,900 per year" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-persons-in-household-maximum-income-6-person-household-and-income-up-to-177900-per-year" class="option">6 person household and income up to $177,900 per year</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-persons-in-household-maximum-income form-item-persons-in-household-maximum-income">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-persons-in-household-maximum-income-7-person-household-and-income-up-to-200600-per-year" type="radio" id="edit-persons-in-household-maximum-income-7-person-household-and-income-up-to-200600-per-year"
name="persons_in_household_maximum_income" value="7 person household and income up to $200,600 per year" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-persons-in-household-maximum-income-7-person-household-and-income-up-to-200600-per-year" class="option">7 person household and income up to $200,600 per year</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-persons-in-household-maximum-income form-item-persons-in-household-maximum-income">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-persons-in-household-maximum-income-8-person-household-and-income-up-to-223300-per-year" type="radio" id="edit-persons-in-household-maximum-income-8-person-household-and-income-up-to-223300-per-year"
name="persons_in_household_maximum_income" value="8 person household and income up to $223,300 per year" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-persons-in-household-maximum-income-8-person-household-and-income-up-to-223300-per-year" class="option">8 person household and income up to $223,300 per year</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/radios.html.twig' -->
</div>
</fieldset>
<!-- END OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'fieldset' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<fieldset data-drupal-selector="edit-do-you-meet-the-eligibility-requirements-in-the-chart-above-if-n" id="edit-do-you-meet-the-eligibility-requirements-in-the-chart-above-if-n--wrapper"
class="radios--wrapper fieldgroup form-composite webform-composite-visible-title required js-webform-type-radios webform-type-radios js-form-item form-item js-form-wrapper form-wrapper" aria-required="true" role="radiogroup"
aria-labelledby="edit-do-you-meet-the-eligibility-requirements-in-the-chart-above-if-n--wrapper-legend">
<legend id="edit-do-you-meet-the-eligibility-requirements-in-the-chart-above-if-n--wrapper-legend">
<span class="fieldset-legend js-form-required form-required">Does your patient’s parent/guardian meet the eligibility requirements shown above? If no, please stop here. They are not eligible for a grant at this time.</span>
</legend>
<div class="fieldset-wrapper">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'radios' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/radios.html.twig' -->
<div id="edit-do-you-meet-the-eligibility-requirements-in-the-chart-above-if-n" class="js-webform-radios webform-options-display-one-column form-radios">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-do-you-meet-the-eligibility-requirements-in-the-chart-above-if-n form-item-do-you-meet-the-eligibility-requirements-in-the-chart-above-if-n">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-do-you-meet-the-eligibility-requirements-in-the-chart-above-if-n-yes" type="radio" id="edit-do-you-meet-the-eligibility-requirements-in-the-chart-above-if-n-yes"
name="do_you_meet_the_eligibility_requirements_in_the_chart_above_if_n" value="Yes" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-do-you-meet-the-eligibility-requirements-in-the-chart-above-if-n-yes" class="option">Yes</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-do-you-meet-the-eligibility-requirements-in-the-chart-above-if-n form-item-do-you-meet-the-eligibility-requirements-in-the-chart-above-if-n">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-do-you-meet-the-eligibility-requirements-in-the-chart-above-if-n-no" type="radio" id="edit-do-you-meet-the-eligibility-requirements-in-the-chart-above-if-n-no"
name="do_you_meet_the_eligibility_requirements_in_the_chart_above_if_n" value="No" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-do-you-meet-the-eligibility-requirements-in-the-chart-above-if-n-no" class="option">No</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/radios.html.twig' -->
</div>
</fieldset>
<!-- END OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label class="section-label" data-drupal-selector="edit-patient-information" for="edit-patient-information">Patient Information</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'container' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<div data-drupal-selector="edit-flexbox" class="webform-flexbox js-webform-flexbox js-form-wrapper form-wrapper" id="edit-flexbox">
<div class="webform-flex webform-flex--1">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-textfield.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-patient-s-first-name form-item-patient-s-first-name">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-patient-s-first-name" class="js-form-required form-required">Patient’s First Name</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__textfield' -->
<!-- FILE NAME SUGGESTIONS:
* input--textfield.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-patient-s-first-name" type="text" id="edit-patient-s-first-name" name="patient_s_first_name" value="" size="60" maxlength="255" class="form-text required" required="required" aria-required="true">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
<div class="webform-flex webform-flex--1">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-textfield.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-patient-s-last-name form-item-patient-s-last-name">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-patient-s-last-name" class="js-form-required form-required">Patient’s Last Name</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__textfield' -->
<!-- FILE NAME SUGGESTIONS:
* input--textfield.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-patient-s-last-name" type="text" id="edit-patient-s-last-name" name="patient_s_last_name" value="" size="60" maxlength="255" class="form-text required" required="required" aria-required="true">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'container' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<div data-drupal-selector="edit-flexbox-01" class="webform-flexbox js-webform-flexbox js-form-wrapper form-wrapper" id="edit-flexbox-01">
<div class="webform-flex webform-flex--1">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-textfield.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-parent-guardian-first-name form-item-parent-guardian-first-name">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-parent-guardian-first-name" class="js-form-required form-required">Parent/Guardian First Name</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__textfield' -->
<!-- FILE NAME SUGGESTIONS:
* input--textfield.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-parent-guardian-first-name" type="text" id="edit-parent-guardian-first-name" name="parent_guardian_first_name" value="" size="60" maxlength="255" class="form-text required" required="required"
aria-required="true">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
<div class="webform-flex webform-flex--1">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-textfield.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-parent-guardian-last-name form-item-parent-guardian-last-name">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-parent-guardian-last-name" class="js-form-required form-required">Parent/Guardian Last Name</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__textfield' -->
<!-- FILE NAME SUGGESTIONS:
* input--textfield.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-parent-guardian-last-name" type="text" id="edit-parent-guardian-last-name" name="parent_guardian_last_name" value="" size="60" maxlength="255" class="form-text required" required="required"
aria-required="true">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'container' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<div data-drupal-selector="edit-flexbox-02" class="webform-flexbox js-webform-flexbox js-form-wrapper form-wrapper" id="edit-flexbox-02">
<div class="webform-flex webform-flex--1">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-date.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-date form-type-date js-form-item-patient-s-date-of-birth form-item-patient-s-date-of-birth">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-patient-s-date-of-birth" class="js-form-required form-required">Patient’s Date of Birth</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__date' -->
<!-- FILE NAME SUGGESTIONS:
* input--date.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input type="date" data-drupal-selector="edit-patient-s-date-of-birth" data-drupal-date-format="Y-m-d" id="edit-patient-s-date-of-birth" name="patient_s_date_of_birth" value="" class="form-date required" required="required"
aria-required="true">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
<div class="webform-flex webform-flex--1">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-checkbox.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div style="margin-top: 35px;" class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-family-is-spanish-speaking-writing-reading form-item-family-is-spanish-speaking-writing-reading">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__checkbox' -->
<!-- FILE NAME SUGGESTIONS:
* input--checkbox.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-family-is-spanish-speaking-writing-reading" type="checkbox" id="edit-family-is-spanish-speaking-writing-reading" name="family_is_spanish_speaking_writing_reading" value="1" class="form-checkbox">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-family-is-spanish-speaking-writing-reading" class="option">Family is Spanish speaking/writing/reading</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'container' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<div data-drupal-selector="edit-flexbox-03" class="webform-flexbox js-webform-flexbox js-form-wrapper form-wrapper" id="edit-flexbox-03">
<div class="webform-flex webform-flex--1">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-select.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-select form-type-select js-form-item-cancer-type form-item-cancer-type">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-cancer-type" class="js-form-required form-required">Cancer Type</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'select' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/select.html.twig' -->
<select data-drupal-selector="edit-cancer-type" id="edit-cancer-type" name="cancer_type" class="form-select required" required="required" aria-required="true">
<option value="" selected="selected">- Select -</option>
<option value="Acute Lymphoblastic Leukemia (ALL)">Acute Lymphoblastic Leukemia (ALL)</option>
<option value="Acute Myeloid Leukemia (AML)">Acute Myeloid Leukemia (AML)</option>
<option value="Adrenal Cancer">Adrenal Cancer</option>
<option value="Anal Cancer">Anal Cancer</option>
<option value="Bile Duct Cancer">Bile Duct Cancer</option>
<option value="Bladder Cancer">Bladder Cancer</option>
<option value="Bone Cancer">Bone Cancer</option>
<option value="Brain Tumor/Central Nervous System Cancer">Brain Tumor/Central Nervous System Cancer</option>
<option value="Breast Cancer, Metastatic">Breast Cancer, Metastatic</option>
<option value="Breast Cancer, Not Metastatic">Breast Cancer, Not Metastatic</option>
<option value="Carcinoid Tumor">Carcinoid Tumor</option>
<option value="Cervical Cancer">Cervical Cancer</option>
<option value="Chronic Lymphocytic Leukemia (CLL)">Chronic Lymphocytic Leukemia (CLL)</option>
<option value="Chronic Myeloid Leukemia (CML)">Chronic Myeloid Leukemia (CML)</option>
<option value="Colorectal Cancer">Colorectal Cancer</option>
<option value="Endometrial Cancer/Uterine Cancer">Endometrial Cancer/Uterine Cancer</option>
<option value="Esophageal Cancer">Esophageal Cancer</option>
<option value="Eye and Orbit Cancer">Eye and Orbit Cancer</option>
<option value="Gallbladder Cancer">Gallbladder Cancer</option>
<option value="Gastrointestinal Stromal Tumor (GIST)">Gastrointestinal Stromal Tumor (GIST)</option>
<option value="Head and Neck Cancers">Head and Neck Cancers</option>
<option value="Hodgkins Lymphoma">Hodgkins Lymphoma</option>
<option value="Kidney Cancer (Renal Cell Cancer)">Kidney Cancer (Renal Cell Cancer)</option>
<option value="Leukemia (other than ALL, AML, CLL, CML)">Leukemia (other than ALL, AML, CLL, CML)</option>
<option value="Lymphoma (other than Hodgkins or NHL)">Lymphoma (other than Hodgkins or NHL)</option>
<option value="Liver Cancer">Liver Cancer</option>
<option value="Lung Cancer">Lung Cancer</option>
<option value="Melanoma">Melanoma</option>
<option value="Mesothelioma">Mesothelioma</option>
<option value="Multiple Myeloma">Multiple Myeloma</option>
<option value="Myeloproliferative Neoplasms (MPN)">Myeloproliferative Neoplasms (MPN)</option>
<option value="Non-Hodgkins Lymphoma (NHL)">Non-Hodgkins Lymphoma (NHL)</option>
<option value="Ovarian Cancer">Ovarian Cancer</option>
<option value="Pancreatic Cancer">Pancreatic Cancer</option>
<option value="Penile Cancer">Penile Cancer</option>
<option value="Prostate Cancer">Prostate Cancer</option>
<option value="Sarcoma">Sarcoma</option>
<option value="Skin Cancer">Skin Cancer</option>
<option value="Small Intestine/Small Bowel Cancer">Small Intestine/Small Bowel Cancer</option>
<option value="Stomach Cancer">Stomach Cancer</option>
<option value="Testicular Cancer">Testicular Cancer</option>
<option value="Thymus Cancer">Thymus Cancer</option>
<option value="Thyroid Cancer">Thyroid Cancer</option>
<option value="Vaginal Cancer">Vaginal Cancer</option>
<option value="Vulvar Cancer">Vulvar Cancer</option>
<option value="Other Cancer">Other Cancer</option>
<option value="Unknown Type">Unknown Type</option>
</select>
<!-- END OUTPUT from 'core/themes/classy/templates/form/select.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
<div class="webform-flex webform-flex--1">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-date.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-date form-type-date js-form-item-date-of-cancer-diagnosis form-item-date-of-cancer-diagnosis">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-date-of-cancer-diagnosis" class="js-form-required form-required">Date of Cancer Diagnosis</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__date' -->
<!-- FILE NAME SUGGESTIONS:
* input--date.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input type="date" data-drupal-selector="edit-date-of-cancer-diagnosis" data-drupal-date-format="Y-m-d" id="edit-date-of-cancer-diagnosis" name="date_of_cancer_diagnosis" value="" class="form-date required" required="required"
aria-required="true">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'container' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<div data-drupal-selector="edit-flexbox-09" class="webform-flexbox js-webform-flexbox js-form-wrapper form-wrapper" id="edit-flexbox-09">
<div class="webform-flex webform-flex--1">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'fieldset' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<fieldset data-drupal-selector="edit-please-specify-if-the-patient-is-"
class="js-webform-checkboxes-other webform-checkboxes-other webform-checkboxes-other--wrapper fieldgroup form-composite webform-composite-visible-title js-webform-type-webform-checkboxes-other webform-type-webform-checkboxes-other js-form-item form-item js-form-wrapper form-wrapper"
id="edit-please-specify-if-the-patient-is-">
<legend>
<span class="fieldset-legend">Please specify if the patient is in:</span>
</legend>
<div class="fieldset-wrapper">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'checkboxes' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/checkboxes.html.twig' -->
<div id="edit-please-specify-if-the-patient-is-checkboxes" class="js-webform-checkboxes webform-options-display-one-column form-checkboxes">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div
class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-please-specify-if-the-patient-is--checkboxes-in-active-treatment-chemo-radiation-surgery-etc form-item-please-specify-if-the-patient-is--checkboxes-in-active-treatment-chemo-radiation-surgery-etc">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__checkbox' -->
<!-- FILE NAME SUGGESTIONS:
* input--checkbox.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-please-specify-if-the-patient-is-checkboxes-in-active-treatment-chemo-radiation-surgery-etc" type="checkbox"
id="edit-please-specify-if-the-patient-is-checkboxes-in-active-treatment-chemo-radiation-surgery-etc" name="please_specify_if_the_patient_is_[checkboxes][In Active Treatment (Chemo, Radiation, Surgery, etc)]"
value="In Active Treatment (Chemo, Radiation, Surgery, etc)" class="form-checkbox">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-please-specify-if-the-patient-is-checkboxes-in-active-treatment-chemo-radiation-surgery-etc" class="option">Active treatment (chemo, radiation, surgery, etc.)</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-please-specify-if-the-patient-is--checkboxes-survivorship-follow-up form-item-please-specify-if-the-patient-is--checkboxes-survivorship-follow-up">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__checkbox' -->
<!-- FILE NAME SUGGESTIONS:
* input--checkbox.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-please-specify-if-the-patient-is-checkboxes-survivorship-follow-up" type="checkbox" id="edit-please-specify-if-the-patient-is-checkboxes-survivorship-follow-up"
name="please_specify_if_the_patient_is_[checkboxes][Survivorship Follow-up]" value="Survivorship Follow-up" class="form-checkbox">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-please-specify-if-the-patient-is-checkboxes-survivorship-follow-up" class="option">Survivorship follow-up</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div
class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-please-specify-if-the-patient-is--checkboxes-palliative-or-hospice-care form-item-please-specify-if-the-patient-is--checkboxes-palliative-or-hospice-care">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__checkbox' -->
<!-- FILE NAME SUGGESTIONS:
* input--checkbox.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-please-specify-if-the-patient-is-checkboxes-palliative-or-hospice-care" type="checkbox" id="edit-please-specify-if-the-patient-is-checkboxes-palliative-or-hospice-care"
name="please_specify_if_the_patient_is_[checkboxes][Palliative or Hospice Care]" value="Palliative or Hospice Care" class="form-checkbox">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-please-specify-if-the-patient-is-checkboxes-palliative-or-hospice-care" class="option">Palliative or hospice care</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-please-specify-if-the-patient-is--checkboxes--other- form-item-please-specify-if-the-patient-is--checkboxes--other-">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__checkbox' -->
<!-- FILE NAME SUGGESTIONS:
* input--checkbox.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-please-specify-if-the-patient-is-checkboxes-other-" type="checkbox" id="edit-please-specify-if-the-patient-is-checkboxes-other-" name="please_specify_if_the_patient_is_[checkboxes][_other_]"
value="_other_" class="form-checkbox">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-please-specify-if-the-patient-is-checkboxes-other-" class="option">Other</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/checkboxes.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-textfield.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div
class="js-webform-checkboxes-other-input webform-checkboxes-other-input js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-please-specify-if-the-patient-is--other form-item-please-specify-if-the-patient-is--other form-no-label"
style="display: none;">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-please-specify-if-the-patient-is-other" class="visually-hidden">Enter other treatment status</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__textfield' -->
<!-- FILE NAME SUGGESTIONS:
* input--textfield.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-please-specify-if-the-patient-is-other" type="text" id="edit-please-specify-if-the-patient-is-other" name="please_specify_if_the_patient_is_[other]" value="" size="60" maxlength="255"
placeholder="Enter other treatment status" class="form-text">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</fieldset>
<!-- END OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
</div>
</div>
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'container' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<div data-drupal-selector="edit-flexbox-08" class="webform-flexbox js-webform-flexbox js-form-wrapper form-wrapper" id="edit-flexbox-08">
<div class="webform-flex webform-flex--1">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-select.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-select form-type-select js-form-item-gender form-item-gender">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-gender" class="js-form-required form-required">Gender</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'select' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/select.html.twig' -->
<select data-drupal-selector="edit-gender" id="edit-gender" name="gender" class="form-select required" required="required" aria-required="true">
<option value="" selected="selected">- Select -</option>
<option value="Man">Man</option>
<option value="Woman">Woman</option>
<option value="Trans man/transgender man/FTM">Trans man/transgender man/FTM</option>
<option value="Trans woman/transgender woman/MTF">Trans woman/transgender woman/MTF</option>
<option value="Genderqueer or Non-binary">Genderqueer or Non-binary</option>
</select>
<!-- END OUTPUT from 'core/themes/classy/templates/form/select.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
<div class="webform-flex webform-flex--1">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-select.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-select form-type-select js-form-item-ethnicity form-item-ethnicity">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-ethnicity" class="js-form-required form-required">Ethnicity</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'select' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/select.html.twig' -->
<select data-drupal-selector="edit-ethnicity" id="edit-ethnicity" name="ethnicity" class="form-select required" required="required" aria-required="true">
<option value="" selected="selected">- Select -</option>
<option value="Hispanic/Latino">Hispanic/Latino</option>
<option value="Non-Hispanic/Non-Latino">Non-Hispanic/Non-Latino</option>
</select>
<!-- END OUTPUT from 'core/themes/classy/templates/form/select.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
<div class="webform-flex webform-flex--1">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-select.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-select form-type-select js-form-item-race form-item-race">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-race" class="js-form-required form-required">Race</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'select' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/select.html.twig' -->
<select data-drupal-selector="edit-race" id="edit-race" name="race" class="form-select required" required="required" aria-required="true">
<option value="" selected="selected">- Select -</option>
<option value="Alaska Native">Alaska Native</option>
<option value="American Indian">American Indian</option>
<option value="Asian">Asian</option>
<option value="Black/African American">Black/African American</option>
<option value="Middle Eastern or North African">Middle Eastern or North African</option>
<option value="Native Hawaiian">Native Hawaiian</option>
<option value="Other Pacific Islander">Other Pacific Islander</option>
<option value="White">White</option>
</select>
<!-- END OUTPUT from 'core/themes/classy/templates/form/select.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'container' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<div data-drupal-selector="edit-flexbox-04" class="webform-flexbox js-webform-flexbox js-form-wrapper form-wrapper" id="edit-flexbox-04">
<div class="webform-flex webform-flex--1">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'fieldset' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<fieldset data-drupal-selector="edit-mailing-address-for-fund-dstribution-" id="edit-mailing-address-for-fund-dstribution---wrapper"
class="webform-address--wrapper fieldgroup form-composite webform-composite-visible-title required js-webform-type-webform-address webform-type-webform-address js-form-item form-item js-form-wrapper form-wrapper">
<legend>
<span class="fieldset-legend js-form-required form-required">Mailing Address for Fund Distribution </span>
</legend>
<div class="fieldset-wrapper">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'webform_composite_address' -->
<!-- BEGIN OUTPUT from 'modules/contrib/webform/templates/webform-composite-address.html.twig' -->
<div class="webform-address">
<div class="webform-flexbox webform-address__row-1">
<div class="webform-flex webform-flex--1 webform-address__address">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-textfield.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-mailing-address-for-fund-dstribution--address form-item-mailing-address-for-fund-dstribution--address">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-mailing-address-for-fund-dstribution-address">Address</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__textfield' -->
<!-- FILE NAME SUGGESTIONS:
* input--textfield.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-mailing-address-for-fund-dstribution-address" type="text" id="edit-mailing-address-for-fund-dstribution-address" name="mailing_address_for_fund_dstribution_[address]" value="" size="60"
maxlength="255" class="form-text">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
</div>
<div class="webform-flexbox webform-address__row-2">
<div class="webform-flex webform-flex--1 webform-address__address-2">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-textfield.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-mailing-address-for-fund-dstribution--address-2 form-item-mailing-address-for-fund-dstribution--address-2">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-mailing-address-for-fund-dstribution-address-2">Address 2</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__textfield' -->
<!-- FILE NAME SUGGESTIONS:
* input--textfield.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-mailing-address-for-fund-dstribution-address-2" type="text" id="edit-mailing-address-for-fund-dstribution-address-2" name="mailing_address_for_fund_dstribution_[address_2]" value="" size="60"
maxlength="255" class="form-text">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
</div>
<div class="webform-flexbox webform-address__row-3">
<div class="webform-flex webform-flex--1 webform-address__city">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-textfield.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-mailing-address-for-fund-dstribution--city form-item-mailing-address-for-fund-dstribution--city">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-mailing-address-for-fund-dstribution-city">City</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__textfield' -->
<!-- FILE NAME SUGGESTIONS:
* input--textfield.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-mailing-address-for-fund-dstribution-city" type="text" id="edit-mailing-address-for-fund-dstribution-city" name="mailing_address_for_fund_dstribution_[city]" value="" size="60" maxlength="255"
class="form-text">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
<div class="webform-flex webform-flex--1 webform-address__province">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-select.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-select form-type-select js-form-item-mailing-address-for-fund-dstribution--state-province form-item-mailing-address-for-fund-dstribution--state-province">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-mailing-address-for-fund-dstribution-state-province">State</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'select' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/select.html.twig' -->
<select data-drupal-selector="edit-mailing-address-for-fund-dstribution-state-province" id="edit-mailing-address-for-fund-dstribution-state-province" name="mailing_address_for_fund_dstribution_[state_province]"
class="form-select">
<option value="" selected="selected">- None -</option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="American Samoa">American Samoa</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="Armed Forces (Canada, Europe, Africa, or Middle East)">Armed Forces (Canada, Europe, Africa, or Middle East)</option>
<option value="Armed Forces Americas">Armed Forces Americas</option>
<option value="Armed Forces Pacific">Armed Forces Pacific</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Federated States of Micronesia">Federated States of Micronesia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Guam">Guam</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Palau">Palau</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="Vermont">Vermont</option>
<option value="Virgin Islands">Virgin Islands</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
<option value="Alberta">Alberta</option>
<option value="British Columbia">British Columbia</option>
<option value="Manitoba">Manitoba</option>
<option value="New Brunswick">New Brunswick</option>
<option value="Newfoundland and Labrador">Newfoundland and Labrador</option>
<option value="Nova Scotia">Nova Scotia</option>
<option value="Northwest Territories">Northwest Territories</option>
<option value="Nunavut">Nunavut</option>
<option value="Ontario">Ontario</option>
<option value="Prince Edward Island">Prince Edward Island</option>
<option value="Quebec">Quebec</option>
<option value="Saskatchewan">Saskatchewan</option>
<option value="Yukon">Yukon</option>
</select>
<!-- END OUTPUT from 'core/themes/classy/templates/form/select.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
<div class="webform-flex webform-flex--1 webform-address__postal-code">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-textfield.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-mailing-address-for-fund-dstribution--postal-code form-item-mailing-address-for-fund-dstribution--postal-code">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-mailing-address-for-fund-dstribution-postal-code">ZIP Code</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__textfield' -->
<!-- FILE NAME SUGGESTIONS:
* input--textfield.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-mailing-address-for-fund-dstribution-postal-code" type="text" id="edit-mailing-address-for-fund-dstribution-postal-code" name="mailing_address_for_fund_dstribution_[postal_code]" value=""
size="60" maxlength="255" class="form-text">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
</div>
</div>
<!-- END OUTPUT from 'modules/contrib/webform/templates/webform-composite-address.html.twig' -->
</div>
</fieldset>
<!-- END OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
</div>
</div>
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'container' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<div data-drupal-selector="edit-flexbox-05" class="webform-flexbox js-webform-flexbox js-form-wrapper form-wrapper" id="edit-flexbox-05">
<div class="webform-flex webform-flex--1">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-tel.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-tel form-type-tel js-form-item-phone-number form-item-phone-number">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-phone-number" class="js-form-required form-required">Phone Number</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__tel' -->
<!-- FILE NAME SUGGESTIONS:
* input--tel.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-phone-number" type="tel" id="edit-phone-number" name="phone_number" value="" size="30" maxlength="128" class="form-tel required" required="required" aria-required="true">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
<div class="webform-flex webform-flex--1">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-email.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-email form-type-email js-form-item-email form-item-email">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-email" class="js-form-required form-required">Email</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__email' -->
<!-- FILE NAME SUGGESTIONS:
* input--email.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-email" type="email" id="edit-email" name="email" value="" size="60" maxlength="254" class="form-email required" required="required" aria-required="true">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'fieldset' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<fieldset data-drupal-selector="edit-did-you-receive-consent-from-the-patient-s-parent-guardian-to-co" id="edit-did-you-receive-consent-from-the-patient-s-parent-guardian-to-co--wrapper"
class="radios--wrapper fieldgroup form-composite webform-composite-visible-title required js-webform-type-radios webform-type-radios js-form-item form-item js-form-wrapper form-wrapper" aria-required="true" role="radiogroup"
aria-labelledby="edit-did-you-receive-consent-from-the-patient-s-parent-guardian-to-co--wrapper-legend">
<legend id="edit-did-you-receive-consent-from-the-patient-s-parent-guardian-to-co--wrapper-legend">
<span class="fieldset-legend js-form-required form-required">Did you receive consent from the patient’s parent/guardian to complete this application on their behalf?</span>
</legend>
<div class="fieldset-wrapper">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'radios' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/radios.html.twig' -->
<div id="edit-did-you-receive-consent-from-the-patient-s-parent-guardian-to-co" class="js-webform-radios webform-options-display-one-column form-radios">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-did-you-receive-consent-from-the-patient-s-parent-guardian-to-co form-item-did-you-receive-consent-from-the-patient-s-parent-guardian-to-co">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-did-you-receive-consent-from-the-patient-s-parent-guardian-to-co-yes" type="radio" id="edit-did-you-receive-consent-from-the-patient-s-parent-guardian-to-co-yes"
name="did_you_receive_consent_from_the_patient_s_parent_guardian_to_co" value="Yes" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-did-you-receive-consent-from-the-patient-s-parent-guardian-to-co-yes" class="option">Yes</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-did-you-receive-consent-from-the-patient-s-parent-guardian-to-co form-item-did-you-receive-consent-from-the-patient-s-parent-guardian-to-co">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-did-you-receive-consent-from-the-patient-s-parent-guardian-to-co-no" type="radio" id="edit-did-you-receive-consent-from-the-patient-s-parent-guardian-to-co-no"
name="did_you_receive_consent_from_the_patient_s_parent_guardian_to_co" value="No" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-did-you-receive-consent-from-the-patient-s-parent-guardian-to-co-no" class="option">No</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/radios.html.twig' -->
</div>
</fieldset>
<!-- END OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'fieldset' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<fieldset data-drupal-selector="edit-does-the-patient-s-patient-guardian-consent-to-being-contacted-b" id="edit-does-the-patient-s-patient-guardian-consent-to-being-contacted-b--wrapper"
class="radios--wrapper fieldgroup form-composite webform-composite-visible-title required js-webform-type-radios webform-type-radios js-form-item form-item js-form-wrapper form-wrapper" aria-required="true" role="radiogroup"
aria-labelledby="edit-does-the-patient-s-patient-guardian-consent-to-being-contacted-b--wrapper-legend">
<legend id="edit-does-the-patient-s-patient-guardian-consent-to-being-contacted-b--wrapper-legend">
<span class="fieldset-legend js-form-required form-required">Does the patient’s parent/guardian consent to being contacted by CSC for any necessary clarification or follow up regarding the Bear Fund Grant?</span>
</legend>
<div class="fieldset-wrapper">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'radios' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/radios.html.twig' -->
<div id="edit-does-the-patient-s-patient-guardian-consent-to-being-contacted-b" class="js-webform-radios webform-options-display-one-column form-radios">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-does-the-patient-s-patient-guardian-consent-to-being-contacted-b form-item-does-the-patient-s-patient-guardian-consent-to-being-contacted-b">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-does-the-patient-s-patient-guardian-consent-to-being-contacted-b-yes" type="radio" id="edit-does-the-patient-s-patient-guardian-consent-to-being-contacted-b-yes"
name="does_the_patient_s_patient_guardian_consent_to_being_contacted_b" value="Yes" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-does-the-patient-s-patient-guardian-consent-to-being-contacted-b-yes" class="option">Yes</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-does-the-patient-s-patient-guardian-consent-to-being-contacted-b form-item-does-the-patient-s-patient-guardian-consent-to-being-contacted-b">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-does-the-patient-s-patient-guardian-consent-to-being-contacted-b-no" type="radio" id="edit-does-the-patient-s-patient-guardian-consent-to-being-contacted-b-no"
name="does_the_patient_s_patient_guardian_consent_to_being_contacted_b" value="No" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-does-the-patient-s-patient-guardian-consent-to-being-contacted-b-no" class="option">No</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/radios.html.twig' -->
</div>
</fieldset>
<!-- END OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'fieldset' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<fieldset data-drupal-selector="edit-would-the-patient-s-patient-guardian-like-a-referral-to-the-csc-" id="edit-would-the-patient-s-patient-guardian-like-a-referral-to-the-csc---wrapper"
class="radios--wrapper fieldgroup form-composite webform-composite-visible-title required js-webform-type-radios webform-type-radios js-form-item form-item js-form-wrapper form-wrapper" aria-required="true" role="radiogroup"
aria-labelledby="edit-would-the-patient-s-patient-guardian-like-a-referral-to-the-csc---wrapper-legend">
<legend id="edit-would-the-patient-s-patient-guardian-like-a-referral-to-the-csc---wrapper-legend">
<span class="fieldset-legend js-form-required form-required">Would the patient’s parent/guardian like a referral to the CSC Pediatric Oncology Navigation Services?</span>
</legend>
<div class="fieldset-wrapper">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'radios' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/radios.html.twig' -->
<div id="edit-would-the-patient-s-patient-guardian-like-a-referral-to-the-csc-" class="js-webform-radios webform-options-display-one-column form-radios">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-would-the-patient-s-patient-guardian-like-a-referral-to-the-csc- form-item-would-the-patient-s-patient-guardian-like-a-referral-to-the-csc-">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-would-the-patient-s-patient-guardian-like-a-referral-to-the-csc-yes" type="radio" id="edit-would-the-patient-s-patient-guardian-like-a-referral-to-the-csc-yes"
name="would_the_patient_s_patient_guardian_like_a_referral_to_the_csc_" value="Yes" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-would-the-patient-s-patient-guardian-like-a-referral-to-the-csc-yes" class="option">Yes</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-would-the-patient-s-patient-guardian-like-a-referral-to-the-csc- form-item-would-the-patient-s-patient-guardian-like-a-referral-to-the-csc-">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-would-the-patient-s-patient-guardian-like-a-referral-to-the-csc-no" type="radio" id="edit-would-the-patient-s-patient-guardian-like-a-referral-to-the-csc-no"
name="would_the_patient_s_patient_guardian_like_a_referral_to_the_csc_" value="No" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-would-the-patient-s-patient-guardian-like-a-referral-to-the-csc-no" class="option">No</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/radios.html.twig' -->
</div>
</fieldset>
<!-- END OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'fieldset' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<fieldset data-drupal-selector="edit-indicate-if-family-has-already-been-referred-to-one-of-our-affil" id="edit-indicate-if-family-has-already-been-referred-to-one-of-our-affil--wrapper"
class="radios--wrapper fieldgroup form-composite webform-composite-visible-title required js-webform-type-radios webform-type-radios js-form-item form-item js-form-wrapper form-wrapper" aria-required="true" role="radiogroup"
aria-labelledby="edit-indicate-if-family-has-already-been-referred-to-one-of-our-affil--wrapper-legend">
<legend id="edit-indicate-if-family-has-already-been-referred-to-one-of-our-affil--wrapper-legend">
<span class="fieldset-legend js-form-required form-required">Indicate if the family has already been referred to one of our affiliates. If so, select one of the choices below.</span>
</legend>
<div class="fieldset-wrapper">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'radios' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/radios.html.twig' -->
<div id="edit-indicate-if-family-has-already-been-referred-to-one-of-our-affil" class="js-webform-radios webform-options-display-one-column form-radios">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-indicate-if-family-has-already-been-referred-to-one-of-our-affil form-item-indicate-if-family-has-already-been-referred-to-one-of-our-affil">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-indicate-if-family-has-already-been-referred-to-one-of-our-affil-cancer-support-community-greater-cincinnatinorthern-kentucky" type="radio"
id="edit-indicate-if-family-has-already-been-referred-to-one-of-our-affil-cancer-support-community-greater-cincinnatinorthern-kentucky" name="indicate_if_family_has_already_been_referred_to_one_of_our_affil"
value="Cancer Support Community Greater Cincinnati/Northern Kentucky" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-indicate-if-family-has-already-been-referred-to-one-of-our-affil-cancer-support-community-greater-cincinnatinorthern-kentucky" class="option">Cancer Support Community Greater Cincinnati/Northern Kentucky</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-indicate-if-family-has-already-been-referred-to-one-of-our-affil form-item-indicate-if-family-has-already-been-referred-to-one-of-our-affil">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-indicate-if-family-has-already-been-referred-to-one-of-our-affil-cancer-support-community-los-angeles-affiliate" type="radio"
id="edit-indicate-if-family-has-already-been-referred-to-one-of-our-affil-cancer-support-community-los-angeles-affiliate" name="indicate_if_family_has_already_been_referred_to_one_of_our_affil"
value="Cancer Support Community Los Angeles Affiliate" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-indicate-if-family-has-already-been-referred-to-one-of-our-affil-cancer-support-community-los-angeles-affiliate" class="option">Cancer Support Community Los Angeles Affiliate</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/radios.html.twig' -->
</div>
</fieldset>
<!-- END OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'fieldset' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<fieldset data-drupal-selector="edit-indicate-the-treatment-center-where-you-are-being-treated" id="edit-indicate-the-treatment-center-where-you-are-being-treated--wrapper"
class="radios--wrapper fieldgroup form-composite webform-composite-visible-title required js-webform-type-radios webform-type-radios js-form-item form-item js-form-wrapper form-wrapper" aria-required="true" role="radiogroup"
aria-labelledby="edit-indicate-the-treatment-center-where-you-are-being-treated--wrapper-legend">
<legend id="edit-indicate-the-treatment-center-where-you-are-being-treated--wrapper-legend">
<span class="fieldset-legend js-form-required form-required">Indicate the treatment center where the patient is being treated</span>
</legend>
<div class="fieldset-wrapper">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'radios' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/radios.html.twig' -->
<div id="edit-indicate-the-treatment-center-where-you-are-being-treated" class="js-webform-radios webform-options-display-one-column form-radios">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-indicate-the-treatment-center-where-you-are-being-treated form-item-indicate-the-treatment-center-where-you-are-being-treated">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-indicate-the-treatment-center-where-you-are-being-treated-cincinnati-childrens-hospital-" type="radio" id="edit-indicate-the-treatment-center-where-you-are-being-treated-cincinnati-childrens-hospital-"
name="indicate_the_treatment_center_where_you_are_being_treated" value="Cincinnati Children’s Hospital " class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-indicate-the-treatment-center-where-you-are-being-treated-cincinnati-childrens-hospital-" class="option">Cincinnati Children’s Hospital </label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-indicate-the-treatment-center-where-you-are-being-treated form-item-indicate-the-treatment-center-where-you-are-being-treated">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-indicate-the-treatment-center-where-you-are-being-treated-childrens-hospital-of-los-angeles" type="radio"
id="edit-indicate-the-treatment-center-where-you-are-being-treated-childrens-hospital-of-los-angeles" name="indicate_the_treatment_center_where_you_are_being_treated" value="Children’s Hospital of Los Angeles" class="form-radio"
required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-indicate-the-treatment-center-where-you-are-being-treated-childrens-hospital-of-los-angeles" class="option">Children’s Hospital of Los Angeles</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/radios.html.twig' -->
</div>
</fieldset>
<!-- END OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'container' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<div data-drupal-selector="edit-flexbox-06" class="webform-flexbox js-webform-flexbox js-form-wrapper form-wrapper" id="edit-flexbox-06">
<div class="webform-flex webform-flex--1">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-textfield.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-name-and-relation-of-person-completing-the-application form-item-name-and-relation-of-person-completing-the-application">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-name-and-relation-of-person-completing-the-application" class="js-form-required form-required">Name and Relation of Person Completing the Application</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__textfield' -->
<!-- FILE NAME SUGGESTIONS:
* input--textfield.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-name-and-relation-of-person-completing-the-application" type="text" id="edit-name-and-relation-of-person-completing-the-application" name="name_and_relation_of_person_completing_the_application" value=""
size="60" maxlength="255" class="form-text required" required="required" aria-required="true">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-textfield.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="webform-element-help-container--title webform-element-help-container--title-after js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-name-of-referring-professional form-item-name-of-referring-professional">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-name-of-referring-professional" class="js-form-required form-required">Name of Referring Professional <!-- THEME DEBUG -->
<!-- THEME HOOK: 'webform_element_help' -->
<!-- BEGIN OUTPUT from 'modules/contrib/webform/templates/webform-element-help.html.twig' -->
<span class="webform-element-help js-webform-element-help" role="tooltip" tabindex="0" aria-label="Name of Referring Professional" data-webform-help="<div class="webform-element-help--title">Name of Referring Professional</div><div class="webform-element-help--content">
<span><span>(Doctor, medical social worker, nurse or affiliate team member)</span></span>
</div>" aria-expanded="false"><span aria-hidden="true">?</span></span>
<!-- END OUTPUT from 'modules/contrib/webform/templates/webform-element-help.html.twig' -->
</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__textfield' -->
<!-- FILE NAME SUGGESTIONS:
* input--textfield.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-name-of-referring-professional" type="text" id="edit-name-of-referring-professional" name="name_of_referring_professional" value="" size="60" maxlength="255" class="form-text required" required="required"
aria-required="true">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'fieldset' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<fieldset data-drupal-selector="edit-specify-the-type-of-healthcare-professional"
class="js-webform-radios-other webform-radios-other webform-radios-other--wrapper fieldgroup form-composite webform-composite-visible-title required js-webform-type-webform-radios-other webform-type-webform-radios-other js-form-item form-item js-form-wrapper form-wrapper"
id="edit-specify-the-type-of-healthcare-professional" aria-required="true" role="radiogroup" aria-labelledby="edit-specify-the-type-of-healthcare-professional-legend">
<legend id="edit-specify-the-type-of-healthcare-professional-legend">
<span class="fieldset-legend js-form-required form-required">Specify the type of health care professional</span>
</legend>
<div class="fieldset-wrapper">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'radios' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/radios.html.twig' -->
<div id="edit-specify-the-type-of-healthcare-professional-radios" class="js-webform-radios webform-options-display-one-column form-radios">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-specify-the-type-of-healthcare-professional-radios form-item-specify-the-type-of-healthcare-professional-radios">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-specify-the-type-of-healthcare-professional-radios-social-worker" type="radio" id="edit-specify-the-type-of-healthcare-professional-radios-social-worker"
name="specify_the_type_of_healthcare_professional[radios]" value="Social Worker" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-specify-the-type-of-healthcare-professional-radios-social-worker" class="option">Social Worker</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-specify-the-type-of-healthcare-professional-radios form-item-specify-the-type-of-healthcare-professional-radios">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-specify-the-type-of-healthcare-professional-radios-nurse" type="radio" id="edit-specify-the-type-of-healthcare-professional-radios-nurse" name="specify_the_type_of_healthcare_professional[radios]"
value="Nurse" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-specify-the-type-of-healthcare-professional-radios-nurse" class="option">Nurse</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-specify-the-type-of-healthcare-professional-radios form-item-specify-the-type-of-healthcare-professional-radios">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-specify-the-type-of-healthcare-professional-radios-navigator" type="radio" id="edit-specify-the-type-of-healthcare-professional-radios-navigator" name="specify_the_type_of_healthcare_professional[radios]"
value="Navigator" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-specify-the-type-of-healthcare-professional-radios-navigator" class="option">Navigator</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-specify-the-type-of-healthcare-professional-radios form-item-specify-the-type-of-healthcare-professional-radios">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-specify-the-type-of-healthcare-professional-radios-physician" type="radio" id="edit-specify-the-type-of-healthcare-professional-radios-physician" name="specify_the_type_of_healthcare_professional[radios]"
value="Physician" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-specify-the-type-of-healthcare-professional-radios-physician" class="option">Physician</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-specify-the-type-of-healthcare-professional-radios form-item-specify-the-type-of-healthcare-professional-radios">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-specify-the-type-of-healthcare-professional-radios-affiliate-team-member" type="radio" id="edit-specify-the-type-of-healthcare-professional-radios-affiliate-team-member"
name="specify_the_type_of_healthcare_professional[radios]" value="Affiliate Team Member" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-specify-the-type-of-healthcare-professional-radios-affiliate-team-member" class="option">Affiliate Team Member</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-specify-the-type-of-healthcare-professional-radios form-item-specify-the-type-of-healthcare-professional-radios">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-specify-the-type-of-healthcare-professional-radios-other-" type="radio" id="edit-specify-the-type-of-healthcare-professional-radios-other-" name="specify_the_type_of_healthcare_professional[radios]"
value="_other_" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-specify-the-type-of-healthcare-professional-radios-other-" class="option">Other (please specify)</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/radios.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-textfield.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div
class="js-webform-radios-other-input webform-radios-other-input js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-specify-the-type-of-healthcare-professional-other form-item-specify-the-type-of-healthcare-professional-other form-no-label"
style="display: none;">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-specify-the-type-of-healthcare-professional-other" class="visually-hidden">Enter other type of healthcare worker</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__textfield' -->
<!-- FILE NAME SUGGESTIONS:
* input--textfield.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-specify-the-type-of-healthcare-professional-other" type="text" id="edit-specify-the-type-of-healthcare-professional-other" name="specify_the_type_of_healthcare_professional[other]" value="" size="60"
maxlength="255" placeholder="Enter other type of healthcare worker" class="form-text">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</fieldset>
<!-- END OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label data-drupal-selector="edit-contact-information-for-referring-professional" for="edit-contact-information-for-referring-professional" class="js-form-required form-required">Contact Information for Referring Professional</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'container' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<div data-drupal-selector="edit-flexbox-07" class="webform-flexbox js-webform-flexbox js-form-wrapper form-wrapper" id="edit-flexbox-07">
<div class="webform-flex webform-flex--1">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-textfield.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-phone form-item-phone">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-phone" class="js-form-required form-required">Phone</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__textfield' -->
<!-- FILE NAME SUGGESTIONS:
* input--textfield.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-phone" type="text" id="edit-phone" name="phone" value="" size="60" maxlength="255" class="form-text required" required="required" aria-required="true">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
<div class="webform-flex webform-flex--1">
<div class="webform-flex--container">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-email.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-email form-type-email js-form-item-email-referring-professional form-item-email-referring-professional">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-email-referring-professional" class="js-form-required form-required">Email</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__email' -->
<!-- FILE NAME SUGGESTIONS:
* input--email.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-email-referring-professional" type="email" id="edit-email-referring-professional" name="email_referring_professional" value="" size="60" maxlength="254" class="form-email required" required="required"
aria-required="true">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</div>
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label class="section-label" data-drupal-selector="edit-financial-needs" for="edit-financial-needs">Financial Needs</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'fieldset' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<fieldset data-drupal-selector="edit-we-need-the-bear-fund-for"
class="js-webform-checkboxes-other webform-checkboxes-other webform-checkboxes-other--wrapper fieldgroup form-composite webform-composite-visible-title required js-webform-type-webform-checkboxes-other webform-type-webform-checkboxes-other js-form-item form-item js-form-wrapper form-wrapper"
id="edit-we-need-the-bear-fund-for">
<legend>
<span class="fieldset-legend js-form-required form-required">How can the Bear Fund help this family?</span>
</legend>
<div class="fieldset-wrapper">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'checkboxes' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/checkboxes.html.twig' -->
<div id="edit-we-need-the-bear-fund-for-checkboxes" class="js-webform-checkboxes webform-options-display-one-column form-checkboxes">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-we-need-the-bear-fund-for-checkboxes-food form-item-we-need-the-bear-fund-for-checkboxes-food">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__checkbox' -->
<!-- FILE NAME SUGGESTIONS:
* input--checkbox.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-we-need-the-bear-fund-for-checkboxes-food" type="checkbox" id="edit-we-need-the-bear-fund-for-checkboxes-food" name="we_need_the_bear_fund_for[checkboxes][Food]" value="Food" class="form-checkbox"
required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-we-need-the-bear-fund-for-checkboxes-food" class="option">Food</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div
class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-we-need-the-bear-fund-for-checkboxes-transportation-gas-parking-airfare-rail form-item-we-need-the-bear-fund-for-checkboxes-transportation-gas-parking-airfare-rail">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__checkbox' -->
<!-- FILE NAME SUGGESTIONS:
* input--checkbox.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-we-need-the-bear-fund-for-checkboxes-transportation-gas-parking-airfare-rail" type="checkbox" id="edit-we-need-the-bear-fund-for-checkboxes-transportation-gas-parking-airfare-rail"
name="we_need_the_bear_fund_for[checkboxes][Transportation (gas, parking, airfare, rail)]" value="Transportation (gas, parking, airfare, rail)" class="form-checkbox">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-we-need-the-bear-fund-for-checkboxes-transportation-gas-parking-airfare-rail" class="option">Transportation (gas, parking, airfare, rail)</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-we-need-the-bear-fund-for-checkboxes-temporary-lodging form-item-we-need-the-bear-fund-for-checkboxes-temporary-lodging">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__checkbox' -->
<!-- FILE NAME SUGGESTIONS:
* input--checkbox.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-we-need-the-bear-fund-for-checkboxes-temporary-lodging" type="checkbox" id="edit-we-need-the-bear-fund-for-checkboxes-temporary-lodging" name="we_need_the_bear_fund_for[checkboxes][Temporary Lodging]"
value="Temporary Lodging" class="form-checkbox">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-we-need-the-bear-fund-for-checkboxes-temporary-lodging" class="option">Temporary Lodging</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-we-need-the-bear-fund-for-checkboxes-fertility-preservation form-item-we-need-the-bear-fund-for-checkboxes-fertility-preservation">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__checkbox' -->
<!-- FILE NAME SUGGESTIONS:
* input--checkbox.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-we-need-the-bear-fund-for-checkboxes-fertility-preservation" type="checkbox" id="edit-we-need-the-bear-fund-for-checkboxes-fertility-preservation"
name="we_need_the_bear_fund_for[checkboxes][Fertility Preservation]" value="Fertility Preservation" class="form-checkbox">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-we-need-the-bear-fund-for-checkboxes-fertility-preservation" class="option">Fertility Preservation</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-we-need-the-bear-fund-for-checkboxes-rent-mortgage- form-item-we-need-the-bear-fund-for-checkboxes-rent-mortgage-">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__checkbox' -->
<!-- FILE NAME SUGGESTIONS:
* input--checkbox.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-we-need-the-bear-fund-for-checkboxes-rentmortgage-" type="checkbox" id="edit-we-need-the-bear-fund-for-checkboxes-rentmortgage-" name="we_need_the_bear_fund_for[checkboxes][Rent/Mortgage ]"
value="Rent/Mortgage " class="form-checkbox">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-we-need-the-bear-fund-for-checkboxes-rentmortgage-" class="option">Rent/Mortgage </label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-we-need-the-bear-fund-for-checkboxes-utility-bills form-item-we-need-the-bear-fund-for-checkboxes-utility-bills">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__checkbox' -->
<!-- FILE NAME SUGGESTIONS:
* input--checkbox.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-we-need-the-bear-fund-for-checkboxes-utility-bills" type="checkbox" id="edit-we-need-the-bear-fund-for-checkboxes-utility-bills" name="we_need_the_bear_fund_for[checkboxes][Utility Bills]"
value="Utility Bills" class="form-checkbox">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-we-need-the-bear-fund-for-checkboxes-utility-bills" class="option">Utility Bills</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-we-need-the-bear-fund-for-checkboxes-childcare form-item-we-need-the-bear-fund-for-checkboxes-childcare">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__checkbox' -->
<!-- FILE NAME SUGGESTIONS:
* input--checkbox.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-we-need-the-bear-fund-for-checkboxes-childcare" type="checkbox" id="edit-we-need-the-bear-fund-for-checkboxes-childcare" name="we_need_the_bear_fund_for[checkboxes][Childcare]" value="Childcare"
class="form-checkbox">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-we-need-the-bear-fund-for-checkboxes-childcare" class="option">Childcare</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-we-need-the-bear-fund-for-checkboxes-counseling-services form-item-we-need-the-bear-fund-for-checkboxes-counseling-services">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__checkbox' -->
<!-- FILE NAME SUGGESTIONS:
* input--checkbox.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-we-need-the-bear-fund-for-checkboxes-counseling-services" type="checkbox" id="edit-we-need-the-bear-fund-for-checkboxes-counseling-services" name="we_need_the_bear_fund_for[checkboxes][Counseling Services]"
value="Counseling Services" class="form-checkbox">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-we-need-the-bear-fund-for-checkboxes-counseling-services" class="option">Counseling Services</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div
class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-we-need-the-bear-fund-for-checkboxes-medical-expenses-co-pays-prescriptions-deductibles-etc form-item-we-need-the-bear-fund-for-checkboxes-medical-expenses-co-pays-prescriptions-deductibles-etc">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__checkbox' -->
<!-- FILE NAME SUGGESTIONS:
* input--checkbox.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-we-need-the-bear-fund-for-checkboxes-medical-expenses-co-pays-prescriptions-deductibles-etc" type="checkbox"
id="edit-we-need-the-bear-fund-for-checkboxes-medical-expenses-co-pays-prescriptions-deductibles-etc" name="we_need_the_bear_fund_for[checkboxes][Medical expenses (co-pays, prescriptions, deductibles, etc)]"
value="Medical expenses (co-pays, prescriptions, deductibles, etc)" class="form-checkbox">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-we-need-the-bear-fund-for-checkboxes-medical-expenses-co-pays-prescriptions-deductibles-etc" class="option">Medical expenses (co-pays, prescriptions, deductibles, etc)</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-we-need-the-bear-fund-for-checkboxes-funeral-expenses form-item-we-need-the-bear-fund-for-checkboxes-funeral-expenses">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__checkbox' -->
<!-- FILE NAME SUGGESTIONS:
* input--checkbox.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-we-need-the-bear-fund-for-checkboxes-funeral-expenses" type="checkbox" id="edit-we-need-the-bear-fund-for-checkboxes-funeral-expenses" name="we_need_the_bear_fund_for[checkboxes][Funeral expenses]"
value="Funeral expenses" class="form-checkbox">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-we-need-the-bear-fund-for-checkboxes-funeral-expenses" class="option">Funeral expenses</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-we-need-the-bear-fund-for-checkboxes--other- form-item-we-need-the-bear-fund-for-checkboxes--other-">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__checkbox' -->
<!-- FILE NAME SUGGESTIONS:
* input--checkbox.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-we-need-the-bear-fund-for-checkboxes-other-" type="checkbox" id="edit-we-need-the-bear-fund-for-checkboxes-other-" name="we_need_the_bear_fund_for[checkboxes][_other_]" value="_other_"
class="form-checkbox">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-we-need-the-bear-fund-for-checkboxes-other-" class="option">Other (please specify)</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/checkboxes.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- FILE NAME SUGGESTIONS:
* form-element--webform-textfield.html.twig
x form-element.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-webform-checkboxes-other-input webform-checkboxes-other-input js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-we-need-the-bear-fund-for-other form-item-we-need-the-bear-fund-for-other form-no-label"
style="display: none;">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-we-need-the-bear-fund-for-other" class="visually-hidden">Enter other…</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__textfield' -->
<!-- FILE NAME SUGGESTIONS:
* input--textfield.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-we-need-the-bear-fund-for-other" type="text" id="edit-we-need-the-bear-fund-for-other" name="we_need_the_bear_fund_for[other]" value="" size="60" maxlength="255" placeholder="Enter other…" class="form-text">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
</fieldset>
<!-- END OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label class="section-label" data-drupal-selector="edit-applicant-agreement" for="edit-applicant-agreement">Applicant Agreement</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'fieldset' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<fieldset data-drupal-selector="edit-do-you-attest-" id="edit-do-you-attest---wrapper"
class="radios--wrapper fieldgroup form-composite webform-composite-visible-title required js-webform-type-radios webform-type-radios js-form-item form-item js-form-wrapper form-wrapper" aria-required="true" role="radiogroup"
aria-labelledby="edit-do-you-attest---wrapper-legend">
<legend id="edit-do-you-attest---wrapper-legend">
<span class="fieldset-legend js-form-required form-required">Do you attest that the information you've provided on this form is accurate?</span>
</legend>
<div class="fieldset-wrapper">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'radios' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/radios.html.twig' -->
<div id="edit-do-you-attest-" class="js-webform-radios webform-options-display-one-column form-radios">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-do-you-attest- form-item-do-you-attest-">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-do-you-attest-i-attest" type="radio" id="edit-do-you-attest-i-attest" name="do_you_attest_" value="I attest" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-do-you-attest-i-attest" class="option">I attest</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-do-you-attest- form-item-do-you-attest-">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__radio' -->
<!-- FILE NAME SUGGESTIONS:
* input--radio.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-do-you-attest-i-do-not-attest" type="radio" id="edit-do-you-attest-i-do-not-attest" name="do_you_attest_" value="I do not attest" class="form-radio" required="required">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-do-you-attest-i-do-not-attest" class="option">I do not attest</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/radios.html.twig' -->
</div>
</fieldset>
<!-- END OUTPUT from 'core/themes/classy/templates/form/fieldset.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__hidden' -->
<!-- FILE NAME SUGGESTIONS:
* input--hidden.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input autocomplete="off" data-drupal-selector="form-hunrm3hphmniocrnxmzphqegr5ouwo-c6trgpbe036e" type="hidden" name="form_build_id" value="form-HUNRM3HPHmniocrNXmZpHQEgr5ouWo_C6trgpBe036E">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__hidden' -->
<!-- FILE NAME SUGGESTIONS:
* input--hidden.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-webform-submission-bear-fund-application-block-content-18061-add-form" type="hidden" name="form_id" value="webform_submission_bear_fund_application_block_content_18061_add_form">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'container' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<div data-drupal-selector="edit-actions" class="form-actions js-form-wrapper form-wrapper" id="edit-actions">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'webform_actions' -->
<!-- BEGIN OUTPUT from 'modules/contrib/webform/templates/webform-actions.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__submit' -->
<!-- FILE NAME SUGGESTIONS:
* input--submit.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input class="webform-button--submit button button--primary js-form-submit form-submit" data-drupal-selector="edit-submit" type="submit" id="edit-submit" name="op" value="Submit">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- END OUTPUT from 'modules/contrib/webform/templates/webform-actions.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<!-- END OUTPUT from 'modules/contrib/webform/templates/webform-submission-form.html.twig' -->
</form>POST /
<form action="/" method="post" id="email-footer-subscription-form" accept-charset="UTF-8" data-once="form-updated" data-drupal-form-fields="edit-email,edit-zip">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-email form-type-email js-form-item-email form-item-email form-no-label">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-email" class="visually-hidden js-form-required form-required">Email Address</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__email' -->
<!-- FILE NAME SUGGESTIONS:
* input--email.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input title="Enter the email address." data-drupal-selector="edit-email" type="email" id="edit-email" name="email" value="" size="15" maxlength="254" placeholder="name@email.com" class="form-email required" required="required"
aria-required="true">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<div class="js-form-item form-item js-form-type-tel form-type-tel js-form-item-zip form-item-zip form-no-label">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'form_element_label' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<label for="edit-zip" class="visually-hidden js-form-required form-required">ZIP Code</label>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element-label.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__tel' -->
<!-- FILE NAME SUGGESTIONS:
* input--tel.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input title="Enter a ZIP Code." data-drupal-selector="edit-zip" type="tel" id="edit-zip" name="zip" value="" size="15" maxlength="128" placeholder="ZIP Code" class="form-tel required" required="required" aria-required="true">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/form-element.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__hidden' -->
<!-- FILE NAME SUGGESTIONS:
* input--hidden.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input autocomplete="off" data-drupal-selector="form-mfondccpyhp-litag5dfmg-pimibls6y115vjvudhoc" type="hidden" name="form_build_id" value="form-mfoNdCCpYHP-lITag5dfMG_PImiBLS6Y115VjVUDHoc">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__hidden' -->
<!-- FILE NAME SUGGESTIONS:
* input--hidden.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-email-footer-subscription-form" type="hidden" name="form_id" value="email_footer_subscription_form">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'container' -->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
<div data-drupal-selector="edit-actions" class="form-actions js-form-wrapper form-wrapper" id="edit-actions--2">
<!-- THEME DEBUG -->
<!-- THEME HOOK: 'input__submit' -->
<!-- FILE NAME SUGGESTIONS:
* input--submit.html.twig
x input.html.twig
-->
<!-- BEGIN OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
<input data-drupal-selector="edit-submit" type="submit" id="edit-submit" value="Subscribe" class="button js-form-submit form-submit">
<!-- END OUTPUT from 'core/themes/classy/templates/form/input.html.twig' -->
</div>
<!-- END OUTPUT from 'core/themes/classy/templates/form/container.html.twig' -->
</form>Text Content
Skip to main content
UTILITY
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RTI conducts novel psychosocial, behavioral, and survivorship research to
support CSC's mission.
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MAIN NAVIGATION
* 888-793-9355
* Start Here
* For Patients & Caregivers
* Newly Diagnosed
* In Treatment
* Beyond Treatment
* Caregivers
* For Partners
* Oncology Professionals
* Policy Partners & Advocates
* Researchers
* Get Support
* Talk with Someone
* Cancer Support Helpline
Mon – Fri 9 a.m. – 8 p.m. ET
Sat 9 a.m. – 5 p.m. ET
(888) 793-9355
Cancer Support Community is a 501(c)3 charitable organization
* Find Your Location
Become a part of our caring and supportive community today.
* Connect Digitally
* Connect to Your Online Community
Easily connect with your caregivers, friends, family, and others
(English/ Español).
* Join the Cancer Experience Registry
Share your experiences to help identify the topics that are important to
the cancer community.
* Additional Support
* COVID-19 Information
What cancer patients, survivors, and caregivers need to know
* Find a Clinical Trial
Help to find a clinical trial that is right for you
* Other Resources
A list of organizations that may provide support, information and
financial resources
* Your Cancer Road Map
A comprehensive guidebook for cancer patients, their families, and
caregivers
* Get Educated & Inspired
* Column
* Get Educated & Inspired
Discover articles, videos, podcasts and more to help you learn about
cancer and find inspiration.
* Ideas & Advice
* Coping With Cancer
* Explore Cancer Types
* Navigating Cancer
* Treatment Decisions
* Clinical Trials
* Voices of Our Community
* Tools
* Blog
* Cancer Insurance Checklist
* Healthy Recipe Gallery
* Order Education Materials
* Podcasts/ Radio Shows
* Virtual Programs
* Get Involved
* Column
* Get Involved with Our Community
There are many ways that you can be involved in helping yourself &
others.
* Ways to Give
* Donate
* Donate Monthly
* Circle of Strength Giving Club
* Legacy & Planned Giving
* Workplace Giving
* The Bear Fund
* Navajo Nation Cancer Program
* CSC Washington, D.C.
* View All
* Ways to Get Involved
* Become an Advocate
Make your voice heard at local and national levels to policymakers.
* Attend Events
Join us for CSC events.
* Participate in Research Opportunities
Share your cancer journey to enhance the lives of others.
* Our Institutes
* Column
* Learn About Our Institutes
Our three institutes help us improve medical outcomes and create better
patient experiences.
* Our Institutes
* Cancer Policy Institute
CPI brings together patient advocates and policy experts to effect
policymaking.
* Institute for Excellence in Psychosocial Care
IEPC represents a key component of the direct service arm of CSC.
* Research & Training Institute
RTI conducts novel psychosocial, behavioral, and survivorship research to
support CSC's mission.
* About Us
* Column
* Learn about Us
We are dedicated to ensuring that all people impacted by cancer are
empowered by knowledge, strengthened by action, and sustained by
community.
* About Us
* Our Staff
* Our Board
* Health Equity in Action
* Financials
* News & Media
* Partners & Funders
* Careers
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BREADCRUMB
1. HOME
2. MAKE A DIFFERENCE
3. THE BEAR FUND
THE BEAR FUND APPLICATION
This grant will provide assistance in the form of a $250 grant debit card for
eligible families who are coping with pediatric cancer in active treatment. This
assistance is for medical and non-medical expenses. Please be aware that our
funds are limited and we are working to assist as many pediatric patients as
possible. The financial assistance will be provided as a limited credit card to
be used for food, transportation, housing, utilities, childcare, or other
medical and non-medical expenses.
*Note that the funds will only be awarded to families who are being treated at
the Cincinnati Children’s Hospital Medical Center and Children’s Hospital of Los
Angeles. (However, if you'd like to speak with our pediatric navigators please
visit this Resource Page.) We cannot accept applications from parents or
guardians of the pediatric oncology patient. Applications must be completed and
submitted by one of the following:
* Children's Hospital of Los Angeles or Cincinnati Children's Hospital Medical
Center health care team (e.g., oncologist, nurse, social worker, navigator)
* Cancer Support Community affiliate network program staff
The Cancer Support Community will review this application and contact the person
who is requesting funds if more information is required. It will take
approximately 48-72 hours to process your completed application. All information
is strictly confidential and is for Cancer Support Community use only.
This fund is made possible with support from the Bear Fund.
Fund Eligibility
Are you a staff member of Children's Hospital of Los Angeles, Cincinnati
Children's Hospital Medical Center, or the Cancer Support Community Affiliate
Network Program?
If no, please stop here and ask your health care team to apply on your behalf.
Yes
No
Eligible applicants must meet specific annual income guidelines. Grant
applicants cannot exceed 500% of U.S. Federal Poverty Guidelines.
Please select the best description of your household:
2 person household and income up to $86,200 per year
3 person household and income up to $109,800 per year
4 person household and income up to $132,500 per year
5 person household and income up to $155,200 per year
6 person household and income up to $177,900 per year
7 person household and income up to $200,600 per year
8 person household and income up to $223,300 per year
Does your patient’s parent/guardian meet the eligibility requirements shown
above? If no, please stop here. They are not eligible for a grant at this time.
Yes
No
Patient Information
Patient’s First Name
Patient’s Last Name
Parent/Guardian First Name
Parent/Guardian Last Name
Patient’s Date of Birth
Family is Spanish speaking/writing/reading
Cancer Type - Select -Acute Lymphoblastic Leukemia (ALL)Acute Myeloid Leukemia
(AML)Adrenal CancerAnal CancerBile Duct CancerBladder CancerBone CancerBrain
Tumor/Central Nervous System CancerBreast Cancer, MetastaticBreast Cancer, Not
MetastaticCarcinoid TumorCervical CancerChronic Lymphocytic Leukemia
(CLL)Chronic Myeloid Leukemia (CML)Colorectal CancerEndometrial Cancer/Uterine
CancerEsophageal CancerEye and Orbit CancerGallbladder CancerGastrointestinal
Stromal Tumor (GIST)Head and Neck CancersHodgkins LymphomaKidney Cancer (Renal
Cell Cancer)Leukemia (other than ALL, AML, CLL, CML)Lymphoma (other than
Hodgkins or NHL)Liver CancerLung CancerMelanomaMesotheliomaMultiple
MyelomaMyeloproliferative Neoplasms (MPN)Non-Hodgkins Lymphoma (NHL)Ovarian
CancerPancreatic CancerPenile CancerProstate CancerSarcomaSkin CancerSmall
Intestine/Small Bowel CancerStomach CancerTesticular CancerThymus CancerThyroid
CancerVaginal CancerVulvar CancerOther CancerUnknown Type
Date of Cancer Diagnosis
Please specify if the patient is in:
Active treatment (chemo, radiation, surgery, etc.)
Survivorship follow-up
Palliative or hospice care
Other
Enter other treatment status
Gender - Select -ManWomanTrans man/transgender man/FTMTrans woman/transgender
woman/MTFGenderqueer or Non-binary
Ethnicity - Select -Hispanic/LatinoNon-Hispanic/Non-Latino
Race - Select -Alaska NativeAmerican IndianAsianBlack/African AmericanMiddle
Eastern or North AfricanNative HawaiianOther Pacific IslanderWhite
Mailing Address for Fund Distribution
Address
Address 2
City
State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada,
Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces
PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States
of
MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall
IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew
HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana
IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth
CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin
IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish
ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest
TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon
ZIP Code
Phone Number
Email
Did you receive consent from the patient’s parent/guardian to complete this
application on their behalf?
Yes
No
Does the patient’s parent/guardian consent to being contacted by CSC for any
necessary clarification or follow up regarding the Bear Fund Grant?
Yes
No
Would the patient’s parent/guardian like a referral to the CSC Pediatric
Oncology Navigation Services?
Yes
No
Indicate if the family has already been referred to one of our affiliates. If
so, select one of the choices below.
Cancer Support Community Greater Cincinnati/Northern Kentucky
Cancer Support Community Los Angeles Affiliate
Indicate the treatment center where the patient is being treated
Cincinnati Children’s Hospital
Children’s Hospital of Los Angeles
Name and Relation of Person Completing the Application
Name of Referring Professional ?
Specify the type of health care professional
Social Worker
Nurse
Navigator
Physician
Affiliate Team Member
Other (please specify)
Enter other type of healthcare worker
Contact Information for Referring Professional
Phone
Email
Financial Needs How can the Bear Fund help this family?
Food
Transportation (gas, parking, airfare, rail)
Temporary Lodging
Fertility Preservation
Rent/Mortgage
Utility Bills
Childcare
Counseling Services
Medical expenses (co-pays, prescriptions, deductibles, etc)
Funeral expenses
Other (please specify)
Enter other…
Applicant Agreement Do you attest that the information you've provided on this
form is accurate?
I attest
I do not attest
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