horizonsfamily.org
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8.29.157.94
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URL:
https://horizonsfamily.org/
Submission: On August 30 via api from US — Scanned from US
Submission: On August 30 via api from US — Scanned from US
Form analysis 4 forms found in the DOM
POST
<form enctype="multipart/form-data" method="post" class="frm-show-form frm_ajax_submit frm_pro_form " id="form_volunteer-application">
<div class="frm_form_fields ">
<fieldset>
<legend class="frm_screen_reader">Meals on Wheels Delivery Volunteer Application</legend>
<div class="frm_fields_container">
<input type="hidden" name="frm_action" value="create">
<input type="hidden" name="form_id" value="16">
<input type="hidden" name="frm_hide_fields_16" id="frm_hide_fields_16" value="">
<input type="hidden" name="form_key" value="volunteer-application">
<input type="hidden" name="item_meta[0]" value="">
<input type="hidden" id="frm_submit_entry_16" name="frm_submit_entry_16" value="0d7a3a76be"><input type="hidden" name="_wp_http_referer" value="/">
<div id="frm_field_609_container" class="frm_form_field frm_first frm_half frm_html_container form-field">
<h2> Horizons Volunteer Application <p></p>
</h2>
<h2></h2>
</div>
<div id="frm_field_709_container" class="frm_form_field frm_first frm_half frm_html_container form-field">Thank you for your interest in volunteering with Horizons! We appreciate you taking the time to fill out this application. The
information you provide will assist us in placing you in an appropriate volunteer opportunity that will match your skills and interest.<p></p>
<p>The following application includes:<br> 1. Volunteer Application & Experience Forms<br> 2. Media Release, Etc. Form<br> 3. Criminal History Background Check<br> 4. Volunteer Waiver & Release Form<br> 5. State of Residence Other
Than Iowa<br> 6. Disclosure of Information Form</p>
<p>All volunteers must be 18 or older or accompanied by an adult.</p>
<p>
<b> We implement appropriate data collection, storage and processing practices and security measures to protect against unauthorized access, alteration, disclosure or destruction of your Personal Information and data stored on our Site. For example, we use security measures such as data encryption, SSL secure link usage and password protection where applicable. <b></b></b>
</p>
</div><b><b>
<div id="frm_field_610_container" class="frm_form_field frm_section_heading form-field ">
<h3 class="frm_pos_top frm_section_spacing frm_trigger" tabindex="0" role="button">Personal Information<i class="frm_icon_font frm_arrow_icon" aria-expanded="false" aria-label="Toggle fields"></i></h3>
<div class="frm_toggle_container frm_grid_container" style="display:none;">
<div id="frm_field_613_container" class="frm_form_field form-field frm_top_container frm_first frm_fourth">
<label for="field_s45ki" id="field_s45ki_label" class="frm_primary_label">Last Name
<span class="frm_required"></span>
</label>
<input type="text" id="field_s45ki" name="item_meta[613]" value="" data-sectionid="610" data-invmsg="Text is invalid" aria-invalid="false">
</div>
<div id="frm_field_706_container" class="frm_form_field form-field frm_top_container frm_fourth">
<label for="field_seini" id="field_seini_label" class="frm_primary_label">First Name
<span class="frm_required"></span>
</label>
<input type="text" id="field_seini" name="item_meta[706]" value="" data-sectionid="610" data-invmsg="Text is invalid" aria-invalid="false">
</div>
<div id="frm_field_614_container" class="frm_form_field form-field frm_top_container frm_first frm_two_thirds">
<div id="field_xeijt_label" class="frm_primary_label">Address
<span class="frm_required"></span>
</div>
<fieldset aria-labelledby="field_xeijt_label">
<legend class="frm_screen_reader frm_hidden">
Address</legend>
<div class="frm_combo_inputs_container">
<div id="frm_field_614-line1_container" class="frm_form_field form-field ">
<label for="field_xeijt_line1" class="frm_screen_reader frm_hidden">
Address </label>
<input type="text" id="field_xeijt_line1" value="" name="item_meta[614][line1]" data-sectionid="610" data-invmsg="Address is invalid" aria-invalid="false" autocomplete="address-line1">
</div>
<div id="frm_field_614-line2_container" class="frm_form_field form-field ">
<label for="field_xeijt_line2" class="frm_screen_reader frm_hidden">
Address </label>
<input type="text" id="field_xeijt_line2" value="" name="item_meta[614][line2]" data-sectionid="610" data-invmsg="Address is invalid" class="frm_optional" aria-invalid="false" autocomplete="address-line2">
</div>
<div id="frm_field_614-city_container" class="frm_form_field form-field frm_third frm_first">
<label for="field_xeijt_city" class="frm_screen_reader frm_hidden">
City </label>
<input type="text" id="field_xeijt_city" value="" name="item_meta[614][city]" data-sectionid="610" data-invmsg="Address is invalid" aria-invalid="false" autocomplete="address-level2">
<div class="frm_description">City</div></div>
<div id="frm_field_614-state_container" class="frm_form_field form-field frm_third">
<label for="field_xeijt_state" class="frm_screen_reader frm_hidden">
State/Province </label>
<input type="text" id="field_xeijt_state" value="" name="item_meta[614][state]" data-sectionid="610" data-invmsg="Address is invalid" aria-invalid="false" autocomplete="address-level1">
<div class="frm_description">State/Province</div></div>
<div id="frm_field_614-zip_container" class="frm_form_field form-field frm_third">
<label for="field_xeijt_zip" class="frm_screen_reader frm_hidden">
Zip/Postal </label>
<input type="text" id="field_xeijt_zip" value="" name="item_meta[614][zip]" data-sectionid="610" data-invmsg="Address is invalid" aria-invalid="false" autocomplete="postal-code">
<div class="frm_description">Zip/Postal</div></div>
</div>
</fieldset>
</div>
<div id="frm_field_707_container" class="frm_form_field form-field frm_top_container frm_first frm_fourth">
<label for="field_5bl0w" id="field_5bl0w_label" class="frm_primary_label">Date of Birth
<span class="frm_required"></span>
</label>
<input type="text" id="field_5bl0w" name="item_meta[707]" value="" data-sectionid="610" maxlength="10" data-invmsg="Date is invalid" class="frm_date" aria-invalid="false">
</div>
<div id="frm_field_615_container" class="frm_form_field form-field frm_top_container frm_first frm_fourth">
<label for="field_55v52" id="field_55v52_label" class="frm_primary_label">Home Phone
<span class="frm_required"></span>
</label>
<input type="tel" id="field_55v52" name="item_meta[615]" value="" data-sectionid="610" data-invmsg="Phone is invalid" aria-invalid="false" pattern="((\+\d{1,3}(-|.| )?\(?\d\)?(-| |.)?\d{1,5})|(\(?\d{2,6}\)?))(-|.| )?(\d{3,4})(-|.| )?(\d{4})(( x| ext)\d{1,5}){0,1}$">
</div>
<div id="frm_field_616_container" class="frm_form_field form-field frm_top_container frm_fourth">
<label for="field_1klhv" id="field_1klhv_label" class="frm_primary_label">Cell Phone
<span class="frm_required"></span>
</label>
<input type="tel" id="field_1klhv" name="item_meta[616]" value="" data-sectionid="610" data-invmsg="Phone is invalid" aria-invalid="false" pattern="((\+\d{1,3}(-|.| )?\(?\d\)?(-| |.)?\d{1,5})|(\(?\d{2,6}\)?))(-|.| )?(\d{3,4})(-|.| )?(\d{4})(( x| ext)\d{1,5}){0,1}$">
</div>
<div id="frm_field_617_container" class="frm_form_field form-field frm_top_container frm_first frm_sixth">
<label for="field_shvxt" id="field_shvxt_label" class="frm_primary_label">Best Time To Call
<span class="frm_required"></span>
</label>
<select name="item_meta[617]" id="field_shvxt" data-sectionid="610" data-invmsg="Best Time To Call is invalid" aria-invalid="false">
<option value="" selected="selected"> </option><option value="Morning">Morning</option><option value="Afternoon">Afternoon</option><option value="Evening">Evening</option> </select>
</div>
<div id="frm_field_618_container" class="frm_form_field form-field frm_top_container frm_sixth">
<label for="field_u6n1m" id="field_u6n1m_label" class="frm_primary_label">Can We Text You?
<span class="frm_required"></span>
</label>
<select name="item_meta[618]" id="field_u6n1m" data-sectionid="610" data-invmsg="Can We Text You? is invalid" aria-invalid="false">
<option value="" selected="selected"> </option><option value="Yes">Yes</option><option value="No">No</option> </select>
</div>
<div id="frm_field_619_container" class="frm_form_field form-field frm_top_container frm_first frm_fourth">
<label for="field_u165i" id="field_u165i_label" class="frm_primary_label">Email
<span class="frm_required"></span>
</label>
<input type="email" id="field_u165i" name="item_meta[619]" value="" data-sectionid="610" data-invmsg="Email is invalid" aria-invalid="false">
</div>
<div id="frm_field_620_container" class="frm_form_field form-field frm_top_container frm_fourth vertical_radio">
<div id="field_6zsdp_label" class="frm_primary_label">Would You Like To Receive Our Newsletter?
<span class="frm_required"></span>
</div>
<div class="frm_opt_container" aria-labelledby="field_6zsdp_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_620-610-0"><label for="field_6zsdp-0"><input type="checkbox" name="item_meta[620][]" id="field_6zsdp-0" value="Yes" data-sectionid="610" data-invmsg="Would You Like To Receive Our Newsletter? is invalid" aria-invalid="false"> Yes</label></div>
<div class="frm_checkbox" id="frm_checkbox_620-610-1"><label for="field_6zsdp-1"><input type="checkbox" name="item_meta[620][]" id="field_6zsdp-1" value="No" data-sectionid="610" data-invmsg="Would You Like To Receive Our Newsletter? is invalid" aria-invalid="false"> No</label></div>
</div>
</div>
<div id="frm_field_624_container" class="frm_form_field frm_html_container form-field"><b>Emergency Contact<b></b></b>
</div><b><b>
<div id="frm_field_621_container" class="frm_form_field form-field frm_top_container frm_first frm_fourth">
<label for="field_qzm6a" id="field_qzm6a_label" class="frm_primary_label">Name
<span class="frm_required"></span>
</label>
<input type="text" id="field_qzm6a" name="item_meta[621]" value="" data-sectionid="610" data-invmsg="Text is invalid" aria-invalid="false">
</div>
<div id="frm_field_622_container" class="frm_form_field form-field frm_top_container frm_fourth">
<label for="field_7ccna" id="field_7ccna_label" class="frm_primary_label">Phone
<span class="frm_required"></span>
</label>
<input type="tel" id="field_7ccna" name="item_meta[622]" value="" data-sectionid="610" data-invmsg="Phone is invalid" aria-invalid="false" pattern="((\+\d{1,3}(-|.| )?\(?\d\)?(-| |.)?\d{1,5})|(\(?\d{2,6}\)?))(-|.| )?(\d{3,4})(-|.| )?(\d{4})(( x| ext)\d{1,5}){0,1}$">
</div>
<div id="frm_field_623_container" class="frm_form_field form-field frm_top_container frm_fourth">
<label for="field_o4x45" id="field_o4x45_label" class="frm_primary_label">Relationship
<span class="frm_required"></span>
</label>
<input type="text" id="field_o4x45" name="item_meta[623]" value="" data-sectionid="610" data-invmsg="Text is invalid" aria-invalid="false">
</div>
<div id="frm_field_625_container" class="frm_form_field form-field frm_top_container frm_first frm_half">
<label for="field_1i304" id="field_1i304_label" class="frm_primary_label">For Office Use Only
<span class="frm_required"></span>
</label>
<input type="text" id="field_1i304" name="item_meta[625]" value="" readonly="readonly" data-sectionid="610" data-invmsg="Text is invalid" aria-invalid="false" aria-describedby="frm_desc_field_1i304">
<div class="frm_description" id="frm_desc_field_1i304">Referred By, Assignment, and Start Date Required</div>
</div>
</b></b>
</div><b><b>
</b></b></div><b><b>
<div id="frm_field_628_container" class="frm_form_field frm_section_heading form-field ">
<h3 class="frm_pos_top frm_section_spacing frm_trigger" tabindex="0" role="button">Volunteer Opportunities and Descriptions<i class="frm_icon_font frm_arrow_icon" aria-expanded="false" aria-label="Toggle fields"></i></h3>
<div class="frm_toggle_container frm_grid_container" style="display:none;">
<div id="frm_field_631_container" class="frm_form_field frm_first frm_two_thirds frm_html_container form-field"><picture decoding="async">
<source type="image/webp" srcset="https://horizonsfamily.org/wp-content/uploads/2020/09/Volunteer-Opportunities-and-Descriptions.png.webp">
<img decoding="async" src="https://horizonsfamily.org/wp-content/uploads/2020/09/Volunteer-Opportunities-and-Descriptions.png">
</picture>
</div>
<div id="frm_field_630_container" class="frm_form_field form-field frm_top_container vertical_radio">
<div id="field_6qeq0_label" class="frm_primary_label">Area of Volunteer Interest
<span class="frm_required"></span>
</div>
<div class="frm_opt_container" aria-labelledby="field_6qeq0_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_630-628-0"><label for="field_6qeq0-0"><input type="checkbox" name="item_meta[630][]" id="field_6qeq0-0" value="Financial Wellness" data-sectionid="628" data-invmsg="Area of Volunteer Interest is invalid" aria-invalid="false"> Financial Wellness</label></div>
<div class="frm_checkbox" id="frm_checkbox_630-628-1"><label for="field_6qeq0-1"><input type="checkbox" name="item_meta[630][]" id="field_6qeq0-1" value="Meals on Wheels" data-sectionid="628" data-invmsg="Area of Volunteer Interest is invalid" aria-invalid="false"> Meals on Wheels</label></div>
<div class="frm_checkbox" id="frm_checkbox_630-628-2"><label for="field_6qeq0-2"><input type="checkbox" name="item_meta[630][]" id="field_6qeq0-2" value="Administration Support" data-sectionid="628" data-invmsg="Area of Volunteer Interest is invalid" aria-invalid="false"> Administration Support</label></div>
<div class="frm_checkbox" id="frm_checkbox_630-628-3"><label for="field_6qeq0-3"><input type="checkbox" name="item_meta[630][]" id="field_6qeq0-3" value="Special Events" data-sectionid="628" data-invmsg="Area of Volunteer Interest is invalid" aria-invalid="false"> Special Events</label></div>
</div>
</div>
</div>
</div>
<div id="frm_field_632_container" class="frm_form_field frm_section_heading form-field ">
<h3 class="frm_pos_top frm_section_spacing frm_trigger" tabindex="0" role="button">Volunteer Experience<i class="frm_icon_font frm_arrow_icon" aria-expanded="false" aria-label="Toggle fields"></i></h3>
<div class="frm_toggle_container frm_grid_container" style="display:none;">
<div id="frm_field_634_container" class="frm_form_field form-field frm_top_container frm_first frm_two_thirds">
<label for="field_a59h8" id="field_a59h8_label" class="frm_primary_label">Summarize any special talents, skills, hobbies, and qualifications you have:
<span class="frm_required"></span>
</label>
<textarea name="item_meta[634]" id="field_a59h8" rows="5" data-sectionid="632" data-invmsg="Summarize any special talents, skills, hobbies, and qualifications you have: is invalid" aria-invalid="false"></textarea>
</div>
<div id="frm_field_635_container" class="frm_form_field form-field frm_top_container frm_first frm_two_thirds">
<label for="field_11z6j" id="field_11z6j_label" class="frm_primary_label">List organizations in your community that you are involved with, your responsibilities, and reason for leaving:
<span class="frm_required"></span>
</label>
<textarea name="item_meta[635]" id="field_11z6j" rows="5" data-sectionid="632" data-invmsg="List organizations in your community that you are involved with, your responsibilities, and reason for leaving: is invalid" aria-invalid="false" aria-describedby="frm_desc_field_11z6j"></textarea>
<div class="frm_description" id="frm_desc_field_11z6j">Organizations including, clubs, schools. professional associations, religious organizations, non-profit organizations, sporting organizations, etc.</div>
</div>
<div id="frm_field_636_container" class="frm_form_field form-field frm_top_container frm_first frm_fourth">
<label for="field_w8pz0" id="field_w8pz0_label" class="frm_primary_label">If presently employed, name employer
<span class="frm_required"></span>
</label>
<input type="text" id="field_w8pz0" name="item_meta[636]" value="" data-sectionid="632" data-invmsg="Text is invalid" aria-invalid="false">
</div>
<div id="frm_field_637_container" class="frm_form_field form-field frm_top_container frm_first frm_fourth">
<label for="field_mogow" id="field_mogow_label" class="frm_primary_label">Are you a student?
<span class="frm_required"></span>
</label>
<select name="item_meta[637]" id="field_mogow" data-sectionid="632" data-invmsg="Are you a student? is invalid" aria-invalid="false">
<option value="" selected="selected"> </option><option value="Yes">Yes</option><option value="No">No</option> </select>
</div>
<div id="frm_field_638_container" class="frm_form_field form-field frm_top_container frm_first frm_third">
<label for="field_idyvb" id="field_idyvb_label" class="frm_primary_label">Do you need hours for community service?
<span class="frm_required"></span>
</label>
<select name="item_meta[638]" id="field_idyvb" data-sectionid="632" data-invmsg="Do you need hours for community service? is invalid" aria-invalid="false">
<option value="" selected="selected"> </option><option value="Yes">Yes</option><option value="No">No</option> </select>
</div>
<div id="frm_field_640_container" class="frm_form_field form-field frm_top_container frm_fourth">
<label for="field_ozhyv" id="field_ozhyv_label" class="frm_primary_label">If yes, how many hours?
<span class="frm_required"></span>
</label>
<input type="number" id="field_ozhyv" name="item_meta[640]" value="" data-sectionid="632" data-invmsg="Text is invalid" aria-invalid="false" min="1" max="1000" step="1">
</div>
<div id="frm_field_641_container" class="frm_form_field form-field frm_top_container frm_first frm_fourth">
<label for="field_wzrt3" id="field_wzrt3_label" class="frm_primary_label">Is this for a legal matter?
<span class="frm_required"></span>
</label>
<select name="item_meta[641]" id="field_wzrt3" data-sectionid="632" data-invmsg="Is this for a legal matter? is invalid" aria-invalid="false">
<option value="" selected="selected"> </option><option value="Yes">Yes</option><option value="No">No</option> </select>
</div>
<div id="frm_field_642_container" class="frm_form_field form-field frm_top_container frm_first frm_half">
<label for="field_zvdt5" id="field_zvdt5_label" class="frm_primary_label">How many hours per week would you like to volunteer?
<span class="frm_required"></span>
</label>
<input type="number" id="field_zvdt5" name="item_meta[642]" value="" data-sectionid="632" data-invmsg="Text is invalid" aria-invalid="false" min="1" max="40" step="1">
</div>
<div id="frm_field_643_container" class="frm_form_field form-field frm_top_container frm_first frm_third vertical_radio">
<div id="field_dcp_label" class="frm_primary_label">Days Available to Volunteer
<span class="frm_required"></span>
</div>
<div class="frm_opt_container" aria-labelledby="field_dcp_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_643-632-0"><label for="field_dcp-0"><input type="checkbox" name="item_meta[643][]" id="field_dcp-0" value="Monday" data-sectionid="632" data-invmsg="Days Available to Volunteer is invalid" aria-invalid="false"> Monday</label></div>
<div class="frm_checkbox" id="frm_checkbox_643-632-1"><label for="field_dcp-1"><input type="checkbox" name="item_meta[643][]" id="field_dcp-1" value="Tuesday" data-sectionid="632" data-invmsg="Days Available to Volunteer is invalid" aria-invalid="false"> Tuesday</label></div>
<div class="frm_checkbox" id="frm_checkbox_643-632-2"><label for="field_dcp-2"><input type="checkbox" name="item_meta[643][]" id="field_dcp-2" value="Wednesday" data-sectionid="632" data-invmsg="Days Available to Volunteer is invalid" aria-invalid="false"> Wednesday</label></div>
<div class="frm_checkbox" id="frm_checkbox_643-632-3"><label for="field_dcp-3"><input type="checkbox" name="item_meta[643][]" id="field_dcp-3" value="Thursday" data-sectionid="632" data-invmsg="Days Available to Volunteer is invalid" aria-invalid="false"> Thursday</label></div>
<div class="frm_checkbox" id="frm_checkbox_643-632-4"><label for="field_dcp-4"><input type="checkbox" name="item_meta[643][]" id="field_dcp-4" value="Friday" data-sectionid="632" data-invmsg="Days Available to Volunteer is invalid" aria-invalid="false"> Friday</label></div>
<div class="frm_checkbox" id="frm_checkbox_643-632-5"><label for="field_dcp-5"><input type="checkbox" name="item_meta[643][]" id="field_dcp-5" value="Saturday" data-sectionid="632" data-invmsg="Days Available to Volunteer is invalid" aria-invalid="false"> Saturday</label></div>
<div class="frm_checkbox" id="frm_checkbox_643-632-6"><label for="field_dcp-6"><input type="checkbox" name="item_meta[643][]" id="field_dcp-6" value="Sunday" data-sectionid="632" data-invmsg="Days Available to Volunteer is invalid" aria-invalid="false"> Sunday</label></div>
</div>
</div>
</div>
</div>
<div id="frm_field_644_container" class="frm_form_field frm_section_heading form-field ">
<h3 class="frm_pos_top frm_section_spacing frm_trigger" tabindex="0" role="button">Media Release, Etc. Form<i class="frm_icon_font frm_arrow_icon" aria-expanded="false" aria-label="Toggle fields"></i></h3>
<div class="frm_toggle_container frm_grid_container" style="display:none;">
<div id="frm_field_646_container" class="frm_form_field frm_html_container form-field">Please check each box to confirm the statements below:</div>
<div id="frm_field_647_container" class="frm_form_field form-field frm_top_container frm_first frm_three_fourths vertical_radio">
<div id="field_z89q8_label" class="frm_primary_label">Media Release
<span class="frm_required"></span>
</div>
<div class="frm_opt_container" aria-labelledby="field_z89q8_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_647-644-0"><label for="field_z89q8-0"><input type="checkbox" name="item_meta[647][]" id="field_z89q8-0" value="I consent to Horizons or its assignee to be allowed to use my name or likenesses of me, including photographs, video, and/or quotations of my remarks for public distribution, including published articles and promotional pieces." data-sectionid="644" data-invmsg="Media Release is invalid" aria-invalid="false"> I consent to Horizons or its assignee to be allowed to use my name or likenesses of me, including photographs, video, and/or quotations of my remarks for public distribution, including published articles and promotional pieces.</label></div>
</div>
</div>
<div id="frm_field_648_container" class="frm_form_field form-field frm_top_container frm_first frm_three_fourths vertical_radio">
<div id="field_dpdsb_label" class="frm_primary_label">Confidentiality
<span class="frm_required"></span>
</div>
<div class="frm_opt_container" aria-labelledby="field_dpdsb_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_648-644-0"><label for="field_dpdsb-0"><input type="checkbox" name="item_meta[648][]" id="field_dpdsb-0" value="I understand that I may be in a position to view or overhear personal or medical information regarding some of the agency’s clients. In keeping with the professional standards and ethics of Horizons, I will consider all client information to be strictly confidential and, therefore, not to be shared with or discussed with any unauthorized person, either inside or outside the agency." data-sectionid="644" data-invmsg="Confidentiality is invalid" aria-invalid="false"> I understand that I may be in a position to view or overhear personal or medical information regarding some of the agency’s clients. In keeping with the professional standards and ethics of Horizons, I will consider all client information to be strictly confidential and, therefore, not to be shared with or discussed with any unauthorized person, either inside or outside the agency.</label></div>
</div>
</div>
<div id="frm_field_649_container" class="frm_form_field form-field frm_top_container frm_first frm_three_fourths vertical_radio">
<div id="field_sw8l0_label" class="frm_primary_label">Driver's License
<span class="frm_required"></span>
</div>
<div class="frm_opt_container" aria-labelledby="field_sw8l0_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_649-644-0"><label for="field_sw8l0-0"><input type="checkbox" name="item_meta[649][]" id="field_sw8l0-0" value="I declare that I have a valid Iowa Driver’s License and that I maintain liability insurance for operating a vehicle." data-sectionid="644" data-invmsg="Driver's License is invalid" aria-invalid="false"> I declare that I have a valid Iowa Driver’s License and that I maintain liability insurance for operating a vehicle.</label></div>
</div>
</div>
<div id="frm_field_650_container" class="frm_form_field form-field frm_top_container frm_first frm_three_fourths vertical_radio">
<div id="field_qfs8n_label" class="frm_primary_label">Non-Solicitation Policy
<span class="frm_required"></span>
</div>
<div class="frm_opt_container" aria-labelledby="field_qfs8n_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_650-644-0"><label for="field_qfs8n-0"><input type="checkbox" name="item_meta[650][]" id="field_qfs8n-0" value="The promotion of an individual person, their business/company or religion they represent is prohibited. The use of volunteering to directly or indirectly solicit or prospect for financial gain is strictly prohibited. This includes announcements of fee or free networking opportunities that ultimately lead to a solicitation. We do not allow solicitation of our clients at any time. You are fully responsible for your conduct and could be asked not to return to the agency." data-sectionid="644" data-invmsg="Non-Solicitation Policy is invalid" aria-invalid="false"> The promotion of an individual person, their business/company or religion they represent is prohibited. The use of volunteering to directly or indirectly solicit or prospect for financial gain is strictly prohibited. This includes announcements of fee or free networking opportunities that ultimately lead to a solicitation. We do not allow solicitation of our clients at any time. You are fully responsible for your conduct and could be asked not to return to the agency.</label></div>
</div>
</div>
<div id="frm_field_651_container" class="frm_form_field frm_first frm_three_fourths frm_html_container form-field"><b>Our Policies<b><br>
It is the policy of this organization to provide equal opportunity without regard to race, color, religion, national origin, gender, sexual preference, age, or disability. It is the policy of Horizons, A Family Service Alliance, to make every reasonable effort to provide a safe environment for our clients. Therefore, the agency requires a criminal background check be completed on all volunteers. Any criminal activity discovered may deem the applicant unable to volunteer for the agency. <p></p>
<p><b>Agreement and Signature<b><br>
By submitting this application, I affirm that the facts set forth in this application are true and complete to the best of my knowledge.</b></b></p></b></b></div><b><b><b>
<div id="frm_field_653_container" class="frm_form_field form-field frm_top_container frm_first frm_fourth">
<label for="field_z4602" id="field_z4602_label" class="frm_primary_label">Date
<span class="frm_required"></span>
</label>
<input type="text" id="field_z4602" name="item_meta[653]" value="08/29/2023" data-sectionid="644" maxlength="10" data-frmval="08/29/2023" data-invmsg="Date is invalid" class="frm_date" aria-invalid="false">
</div>
<div id="frm_field_652_container" class="frm_form_field form-field frm_top_container frm_first frm_half">
<label for="field_lg8ye" id="field_lg8ye_label" class="frm_primary_label">Signature
<span class="frm_required"></span>
</label>
<div class="sigPad" id="sigPad652" style="max-width:400px;">
<div class="sig sigWrapper" style="height:150px;border-color:#cccccc;--bg-color:#ffffff;--active:#008ec2;--inactive:#dddddd;--active-text:#ffffff;--inactive-text:#ffffff;--button-margin:22px;--button-size:20px;--button-padding:10px;--button-side-margin:22px;--icon:20px">
<ul class="sigNav">
<li class="drawIt"><a href="#" class="frm-active-sig-type" title="Draw It" aria-label="Draw It"><i class="frm_icon_font frm_signature_icon" aria-hidden=""></i></a></li>
<li class="typeIt"><a href="#" class="" title="Type It" aria-label="Type It"><i class="frm_icon_font frm_keyboard_icon" aria-hidden=""></i></a></li>
</ul>
<span class="frm-typed-drawline" style="height: 1px; background-color: rgb(204, 204, 204);"></span>
<div class="typed" style="visibility: hidden;">
<input type="text" name="item_meta[652][typed]" class="name" id="field_lg8ye" autocomplete="off" value="" data-sectionid="644" style="width:400px" maxlength="150" aria-invalid="false">
</div>
<canvas class="pad" data-fieldid="652" data-fieldname="item_meta[652]" width="396" height="150" style="touch-action: none; user-select: none; visibility: visible;"></canvas>
<div class="clearButton" style="visibility: visible;"><a href="#clear">Clear</a></div>
<input type="hidden" name="item_meta[652][output]" class="output" value="">
</div>
</div>
</div>
</b></b></b></div><b><b><b>
</b></b></b></div><b><b><b>
<div id="frm_field_654_container" class="frm_form_field frm_section_heading form-field ">
<h3 class="frm_pos_top frm_section_spacing frm_trigger" tabindex="0" role="button">Volunteer Waiver, Release, Hold Harmless and Indemnification Agreement<i class="frm_icon_font frm_arrow_icon" aria-expanded="false" aria-label="Toggle fields"></i></h3>
<div class="frm_toggle_container frm_grid_container" style="display:none;">
<div id="frm_field_656_container" class="frm_form_field frm_first frm_three_fourths frm_html_container form-field">I have agreed to serve as a volunteer for the Horizons, A Family Service Alliance, and I recognize that my volunteer participation is a privilege afforded to me by the Horizons, A Family Service Alliance. I fully understand, appreciate and assume all of the risks associated with my volunteer duties. In exchange for my participation, I hereby agree to the following: <p></p>
<p>1. I voluntarily waive, release and hold harmless the Horizons, A Family Service Alliance, its elected and appointed officials, officers, employees, agents and other volunteers from any and all claims, causes of action and damages for bodily injury or death that I may suffer as a result of, or in any manner connected with, directly or indirectly, my participation as a Horizons, A Family Service Alliance volunteer when such bodily injury or death is the result of my own negligent or intentional acts or omissions or those of another volunteer. I understand that this waiver and release precludes my right to recovery of damages in the event I am injured in the course of performing my volunteer duties.</p>
<p>2. I shall defend, hold harmless and indemnify the Horizons, A Family Service Alliance, its elected and appointed officials, officers, employees, agents and other volunteers, from and against all damages, claims, liabilities, causes of action, judgments, settlements, costs and expenses (including, but not limited to, reasonable expert witness and attorney fees) that may at any time arise or be claimed by any person as a result of bodily injury, death or property damage, or as a result of any other claim or cause of action of any nature whatsoever, arising from or in any manner connected with, directly or indirectly, my negligent or intentional acts or omissions in performing my volunteer duties.</p>
<p>I have read, fully understand and agree to the assumption of risk, waiver, release, hold harmless and indemnification terms set forth above.
</p></div>
<div id="frm_field_658_container" class="frm_form_field form-field frm_top_container frm_first frm_fourth">
<label for="field_ngecy" id="field_ngecy_label" class="frm_primary_label">Date
<span class="frm_required"></span>
</label>
<input type="text" id="field_ngecy" name="item_meta[658]" value="08/29/2023" data-sectionid="654" maxlength="10" data-frmval="08/29/2023" data-invmsg="Date is invalid" class="frm_date" aria-invalid="false">
</div>
<div id="frm_field_659_container" class="frm_form_field form-field frm_top_container frm_first frm_fourth">
<label for="field_shfdh" id="field_shfdh_label" class="frm_primary_label">Volunteer Name
<span class="frm_required"></span>
</label>
<input type="text" id="field_shfdh" name="item_meta[659]" value="" data-sectionid="654" data-invmsg="Text is invalid" aria-invalid="false">
</div>
<div id="frm_field_666_container" class="frm_form_field form-field frm_top_container frm_half">
<label for="field_c5si7" id="field_c5si7_label" class="frm_primary_label">Volunteer Signature
<span class="frm_required"></span>
</label>
<div class="sigPad" id="sigPad666" style="max-width:400px;">
<div class="sig sigWrapper" style="height:150px;border-color:#cccccc;--bg-color:#ffffff;--active:#008ec2;--inactive:#dddddd;--active-text:#ffffff;--inactive-text:#ffffff;--button-margin:22px;--button-size:20px;--button-padding:10px;--button-side-margin:22px;--icon:20px">
<ul class="sigNav">
<li class="drawIt"><a href="#" class="frm-active-sig-type" title="Draw It" aria-label="Draw It"><i class="frm_icon_font frm_signature_icon" aria-hidden=""></i></a></li>
<li class="typeIt"><a href="#" class="" title="Type It" aria-label="Type It"><i class="frm_icon_font frm_keyboard_icon" aria-hidden=""></i></a></li>
</ul>
<span class="frm-typed-drawline" style="height: 1px; background-color: rgb(204, 204, 204);"></span>
<div class="typed" style="visibility: hidden;">
<input type="text" name="item_meta[666][typed]" class="name" id="field_c5si7" autocomplete="off" value="" data-sectionid="654" style="width:400px" maxlength="150" aria-invalid="false">
</div>
<canvas class="pad" data-fieldid="666" data-fieldname="item_meta[666]" width="396" height="150" style="touch-action: none; user-select: none; visibility: visible;"></canvas>
<div class="clearButton" style="visibility: visible;"><a href="#clear">Clear</a></div>
<input type="hidden" name="item_meta[666][output]" class="output" value="">
</div>
</div>
</div>
<div id="frm_field_662_container" class="frm_form_field frm_html_container form-field">NOTE: If the volunteer is under 18 years of age, a parent or legal guardian must sign this agreement on behalf of the volunteer
</div>
<div id="frm_field_663_container" class="frm_form_field form-field frm_top_container frm_first frm_fourth">
<label for="field_c78oo" id="field_c78oo_label" class="frm_primary_label">Date
<span class="frm_required"></span>
</label>
<input type="text" id="field_c78oo" name="item_meta[663]" value="08/29/2023" data-sectionid="654" maxlength="10" data-frmval="08/29/2023" data-invmsg="Date is invalid" class="frm_date" aria-invalid="false">
</div>
<div id="frm_field_664_container" class="frm_form_field form-field frm_top_container frm_first frm_fourth">
<label for="field_dynzn" id="field_dynzn_label" class="frm_primary_label">Name of Parent or Legal Guardian
<span class="frm_required"></span>
</label>
<input type="text" id="field_dynzn" name="item_meta[664]" value="" data-sectionid="654" data-invmsg="Text is invalid" aria-invalid="false">
</div>
<div id="frm_field_665_container" class="frm_form_field form-field frm_top_container frm_half">
<label for="field_ygu9v" id="field_ygu9v_label" class="frm_primary_label">Signature
<span class="frm_required"></span>
</label>
<div class="sigPad" id="sigPad665" style="max-width:400px;">
<div class="sig sigWrapper" style="height:150px;border-color:#cccccc;--bg-color:#ffffff;--active:#008ec2;--inactive:#dddddd;--active-text:#ffffff;--inactive-text:#ffffff;--button-margin:22px;--button-size:20px;--button-padding:10px;--button-side-margin:22px;--icon:20px">
<ul class="sigNav">
<li class="drawIt"><a href="#" class="frm-active-sig-type" title="Draw It" aria-label="Draw It"><i class="frm_icon_font frm_signature_icon" aria-hidden=""></i></a></li>
<li class="typeIt"><a href="#" class="" title="Type It" aria-label="Type It"><i class="frm_icon_font frm_keyboard_icon" aria-hidden=""></i></a></li>
</ul>
<span class="frm-typed-drawline" style="height: 1px; background-color: rgb(204, 204, 204);"></span>
<div class="typed" style="visibility: hidden;">
<input type="text" name="item_meta[665][typed]" class="name" id="field_ygu9v" autocomplete="off" value="" data-sectionid="654" style="width:400px" maxlength="150" aria-invalid="false">
</div>
<canvas class="pad" data-fieldid="665" data-fieldname="item_meta[665]" width="396" height="150" style="touch-action: none; user-select: none; visibility: visible;"></canvas>
<div class="clearButton" style="visibility: visible;"><a href="#clear">Clear</a></div>
<input type="hidden" name="item_meta[665][output]" class="output" value="">
</div>
</div>
</div>
</div>
</div>
<div id="frm_field_667_container" class="frm_form_field frm_section_heading form-field ">
<h3 class="frm_pos_top frm_section_spacing frm_trigger" tabindex="0" role="button">Criminal History Background Check<i class="frm_icon_font frm_arrow_icon" aria-expanded="false" aria-label="Toggle fields"></i></h3>
<div class="frm_toggle_container frm_grid_container" style="display:none;">
<div id="frm_field_669_container" class="frm_form_field frm_first frm_three_fourths frm_html_container form-field">Relationship: Employer Screening as specified in Chapter 237 of the Iowa Code. Complete and return to Human Resources. Please allow minimum 24 hours to process. The results will be e-mailed to the employee requesting the background check. If further investigation is required by the D.C.I., allow 5-7 business days for the results.<p></p>
<p>If a criminal, dependent adult abuse, or child abuse conviction is reported by the D.C.I., additional investigation is required by the Department of Human Services. Allow 30 days for the results.</p>
<p>AN IOWA CRIMINAL HISTORY CHECK AND REGISTRY INFORMATION IS BEING REQUESTED ON:</p></div>
<div id="frm_field_670_container" class="frm_form_field form-field frm_top_container frm_first frm_fourth">
<label for="field_974g1" id="field_974g1_label" class="frm_primary_label">Last Name
<span class="frm_required"></span>
</label>
<input type="text" id="field_974g1" name="item_meta[670]" value="" data-sectionid="667" data-invmsg="Text is invalid" aria-invalid="false">
</div>
<div id="frm_field_671_container" class="frm_form_field form-field frm_top_container frm_fourth">
<label for="field_w7182" id="field_w7182_label" class="frm_primary_label">First Name
<span class="frm_required"></span>
</label>
<input type="text" id="field_w7182" name="item_meta[671]" value="" data-sectionid="667" data-invmsg="Text is invalid" aria-invalid="false">
</div>
<div id="frm_field_672_container" class="frm_form_field form-field frm_top_container frm_sixth">
<label for="field_9bclw" id="field_9bclw_label" class="frm_primary_label">Middle Initial
<span class="frm_required"></span>
</label>
<input type="text" id="field_9bclw" name="item_meta[672]" value="" data-sectionid="667" data-invmsg="Text is invalid" aria-invalid="false">
</div>
<div id="frm_field_673_container" class="frm_form_field form-field frm_top_container frm_first frm_fourth">
<label for="field_l502" id="field_l502_label" class="frm_primary_label">Maiden Name
<span class="frm_required"></span>
</label>
<input type="text" id="field_l502" name="item_meta[673]" value="" data-sectionid="667" data-invmsg="Text is invalid" aria-invalid="false">
</div>
<div id="frm_field_674_container" class="frm_form_field form-field frm_top_container frm_third">
<label for="field_y2mli" id="field_y2mli_label" class="frm_primary_label">Alias or Previous Married Names
<span class="frm_required"></span>
</label>
<input type="text" id="field_y2mli" name="item_meta[674]" value="" data-sectionid="667" data-invmsg="Text is invalid" aria-invalid="false">
</div>
<div id="frm_field_676_container" class="frm_form_field form-field frm_top_container frm_first frm_fourth">
<label for="field_znkip" id="field_znkip_label" class="frm_primary_label">Social Security Number
<span class="frm_required"></span>
</label>
<input type="text" id="field_znkip" name="item_meta[676]" value="" data-sectionid="667" data-frmmask="999-99-9999" data-invmsg="Text is invalid" aria-invalid="false" pattern="\d\d\d-\d\d-\d\d\d\d$">
</div>
<div id="frm_field_677_container" class="frm_form_field form-field frm_top_container frm_fourth">
<label for="field_te8o7" id="field_te8o7_label" class="frm_primary_label">Date of Birth
<span class="frm_required"></span>
</label>
<input type="text" id="field_te8o7" name="item_meta[677]" value="" data-sectionid="667" maxlength="10" data-invmsg="Date is invalid" class="frm_date" aria-invalid="false">
</div>
<div id="frm_field_678_container" class="frm_form_field form-field frm_top_container frm_sixth frm_other_container">
<label for="field_s3k4f" id="field_s3k4f_label" class="frm_primary_label">Sex
<span class="frm_required"></span>
</label>
<select name="item_meta[678]" id="field_s3k4f" data-sectionid="667" data-invmsg="Sex is invalid" aria-invalid="false">
<option value="" selected="selected"> </option><option value="Male">Male</option><option value="Female">Female</option><option value="Other" class="frm_other_trigger">Other</option> </select>
<label for="field_s3k4f-otext" class="frm_screen_reader frm_hidden">Sex</label><input type="text" id="field_s3k4f-otext" class="frm_other_input frm_pos_none" name="item_meta[other][678]" value="">
</div>
<div id="frm_field_680_container" class="frm_form_field form-field frm_top_container frm_sixth vertical_radio">
<div id="field_oc7sb_label" class="frm_primary_label">
<span class="frm_required"></span>
</div>
<div class="frm_opt_container" aria-labelledby="field_oc7sb_label" role="radiogroup" tabindex="0"> <div class="frm_radio" id="frm_radio_680-0"><label for="field_oc7sb-0"> <input type="radio" name="item_meta[680]" id="field_oc7sb-0" value="Paid" data-invmsg=" is invalid" aria-invalid="false"> Paid</label></div>
<div class="frm_radio" id="frm_radio_680-1"><label for="field_oc7sb-1"> <input type="radio" name="item_meta[680]" id="field_oc7sb-1" value="Volunteer" data-invmsg=" is invalid" aria-invalid="false"> Volunteer</label></div>
</div>
</div>
<div id="frm_field_681_container" class="frm_form_field frm_first frm_three_fourths frm_html_container form-field">I hereby give permission for the above requesting organization to conduct an Iowa Criminal History, Dependent Adult and Child Abuse Registry check with the Division of Criminal Investigation. Any information maintained by the DCI may be released as allowed by law.</div>
<div id="frm_field_682_container" class="frm_form_field form-field frm_top_container frm_first frm_fourth">
<label for="field_rch87" id="field_rch87_label" class="frm_primary_label">Date
<span class="frm_required"></span>
</label>
<input type="text" id="field_rch87" name="item_meta[682]" value="08/29/2023" data-sectionid="667" maxlength="10" data-frmval="08/29/2023" data-invmsg="Date is invalid" class="frm_date" aria-invalid="false">
</div>
<div id="frm_field_683_container" class="frm_form_field form-field frm_top_container frm_first frm_half">
<label for="field_kcal4" id="field_kcal4_label" class="frm_primary_label">Signature
<span class="frm_required"></span>
</label>
<div class="sigPad" id="sigPad683" style="max-width:400px;">
<div class="sig sigWrapper" style="height:150px;border-color:#cccccc;--bg-color:#ffffff;--active:#008ec2;--inactive:#dddddd;--active-text:#ffffff;--inactive-text:#ffffff;--button-margin:22px;--button-size:20px;--button-padding:10px;--button-side-margin:22px;--icon:20px">
<ul class="sigNav">
<li class="drawIt"><a href="#" class="frm-active-sig-type" title="Draw It" aria-label="Draw It"><i class="frm_icon_font frm_signature_icon" aria-hidden=""></i></a></li>
<li class="typeIt"><a href="#" class="" title="Type It" aria-label="Type It"><i class="frm_icon_font frm_keyboard_icon" aria-hidden=""></i></a></li>
</ul>
<span class="frm-typed-drawline" style="height: 1px; background-color: rgb(204, 204, 204);"></span>
<div class="typed" style="visibility: hidden;">
<input type="text" name="item_meta[683][typed]" class="name" id="field_kcal4" autocomplete="off" value="" data-sectionid="667" style="width:400px" maxlength="150" aria-invalid="false">
</div>
<canvas class="pad" data-fieldid="683" data-fieldname="item_meta[683]" width="396" height="150" style="touch-action: none; user-select: none; visibility: visible;"></canvas>
<div class="clearButton" style="visibility: visible;"><a href="#clear">Clear</a></div>
<input type="hidden" name="item_meta[683][output]" class="output" value="">
</div>
</div>
</div>
<div id="frm_field_684_container" class="frm_form_field form-field frm_top_container frm_half">
<label for="field_iiku4" id="field_iiku4_label" class="frm_primary_label">TO BE COMPLETED BY HORIZONS EMPLOYEE
<span class="frm_required"></span>
</label>
<textarea name="item_meta[684]" id="field_iiku4" rows="5" readonly="readonly" data-sectionid="667" data-frmval="Employee & Dept Requesting Check:
Position/Job Duties of Above Person:
Date Requested:
Date Received by HR:" data-invmsg="TO BE COMPLETED BY HORIZONS EMPLOYEE is invalid" aria-invalid="false">Employee & Dept Requesting Check:
Position/Job Duties of Above Person:
Date Requested:
Date Received by HR:</textarea>
</div>
</div>
</div>
<div id="frm_field_685_container" class="frm_form_field frm_section_heading form-field ">
<h3 class="frm_pos_top frm_section_spacing frm_trigger" tabindex="0" role="button">States of Residence Other Than Iowa<i class="frm_icon_font frm_arrow_icon" aria-expanded="false" aria-label="Toggle fields"></i></h3>
<div class="frm_toggle_container frm_grid_container" style="display:none;">
<div id="frm_field_687_container" class="frm_form_field frm_first frm_three_fourths frm_html_container form-field">Horizons employment policy is to process criminal, dependent adult and child abuse background checks on all prospective employees. If a candidate has lived outside the state of Iowa in the past three years background checks will be requested in the states where the candidate has resided. <p></p>
<p>Please complete the following information from the time you turned 18.</p></div>
<div id="frm_field_688_container" class="frm_form_field form-field frm_top_container frm_first frm_third">
<label for="field_40i7u" id="field_40i7u_label" class="frm_primary_label">Last Name
<span class="frm_required"></span>
</label>
<input type="text" id="field_40i7u" name="item_meta[688]" value="" data-sectionid="685" data-invmsg="Text is invalid" aria-invalid="false">
</div>
<div id="frm_field_689_container" class="frm_form_field form-field frm_top_container frm_third">
<label for="field_7vkby" id="field_7vkby_label" class="frm_primary_label">First Name
<span class="frm_required"></span>
</label>
<input type="text" id="field_7vkby" name="item_meta[689]" value="" data-sectionid="685" data-invmsg="Text is invalid" aria-invalid="false">
</div>
<div id="frm_field_690_container" class="frm_form_field form-field frm_top_container frm_sixth">
<label for="field_b5wvb" id="field_b5wvb_label" class="frm_primary_label">Middle Initial
<span class="frm_required"></span>
</label>
<input type="text" id="field_b5wvb" name="item_meta[690]" value="" data-sectionid="685" data-invmsg="Text is invalid" aria-invalid="false">
</div>
<div id="frm_field_691_container" class="frm_form_field frm_first frm_three_fourths frm_html_container form-field">I hereby give permission for the above requesting organization to conduct a Criminal History, Child Abuse and Dependent Adult Abuse Registry check with the Division of Criminal Investigation for the residence states listed below. If this form is not acceptable by any/all of the states for authorization to process a background check, I agree to complete and return the required forms for that state(s). </div>
<div id="frm_field_692_container" class="frm_form_field form-field frm_top_container frm_first frm_fourth">
<label for="field_hc8hh" id="field_hc8hh_label" class="frm_primary_label">Date
<span class="frm_required"></span>
</label>
<input type="text" id="field_hc8hh" name="item_meta[692]" value="08/29/2023" data-sectionid="685" maxlength="10" data-frmval="08/29/2023" data-invmsg="Date is invalid" class="frm_date" aria-invalid="false">
</div>
<div id="frm_field_693_container" class="frm_form_field form-field frm_top_container frm_first frm_half">
<label for="field_srtjs" id="field_srtjs_label" class="frm_primary_label">Signature
<span class="frm_required"></span>
</label>
<div class="sigPad" id="sigPad693" style="max-width:400px;">
<div class="sig sigWrapper" style="height:150px;border-color:#cccccc;--bg-color:#ffffff;--active:#008ec2;--inactive:#dddddd;--active-text:#ffffff;--inactive-text:#ffffff;--button-margin:22px;--button-size:20px;--button-padding:10px;--button-side-margin:22px;--icon:20px">
<ul class="sigNav">
<li class="drawIt"><a href="#" class="frm-active-sig-type" title="Draw It" aria-label="Draw It"><i class="frm_icon_font frm_signature_icon" aria-hidden=""></i></a></li>
<li class="typeIt"><a href="#" class="" title="Type It" aria-label="Type It"><i class="frm_icon_font frm_keyboard_icon" aria-hidden=""></i></a></li>
</ul>
<span class="frm-typed-drawline" style="height: 1px; background-color: rgb(204, 204, 204);"></span>
<div class="typed" style="visibility: hidden;">
<input type="text" name="item_meta[693][typed]" class="name" id="field_srtjs" autocomplete="off" value="" data-sectionid="685" style="width:400px" maxlength="150" aria-invalid="false">
</div>
<canvas class="pad" data-fieldid="693" data-fieldname="item_meta[693]" width="396" height="150" style="touch-action: none; user-select: none; visibility: visible;"></canvas>
<div class="clearButton" style="visibility: visible;"><a href="#clear">Clear</a></div>
<input type="hidden" name="item_meta[693][output]" class="output" value="">
</div>
</div>
</div>
<div id="frm_field_694_container" class="frm_form_field form-field frm_top_container frm_first frm_fourth vertical_radio">
<div id="field_88596a_label" class="frm_primary_label">State(s) of Residence:
<span class="frm_required"></span>
</div>
<div class="frm_opt_container" aria-labelledby="field_88596a_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_694-0"><label for="field_88596a-0"><input type="checkbox" name="item_meta[694][]" id="field_88596a-0" value="Only Iowa" data-invmsg="State(s) of Residence: is invalid" aria-invalid="false"> Only Iowa</label></div>
<div class="frm_checkbox" id="frm_checkbox_694-1"><label for="field_88596a-1"><input type="checkbox" name="item_meta[694][]" id="field_88596a-1" value="Other" data-invmsg="State(s) of Residence: is invalid" aria-invalid="false"> Other</label></div>
</div>
</div>
<div id="frm_field_695_container" class="frm_form_field form-field frm_top_container frm_half">
<label for="field_ch3cq" id="field_ch3cq_label" class="frm_primary_label">If other, list state and dates of residence, and name used:
<span class="frm_required"></span>
</label>
<textarea name="item_meta[695]" id="field_ch3cq" rows="5" data-sectionid="685" data-invmsg="If other, list state and dates of residence, and name used: is invalid" aria-invalid="false"></textarea>
</div>
</div>
</div>
<div id="frm_field_696_container" class="frm_form_field frm_section_heading form-field ">
<h3 class="frm_pos_top frm_section_spacing frm_trigger" tabindex="0" role="button">Disclosure of Information<i class="frm_icon_font frm_arrow_icon" aria-expanded="false" aria-label="Toggle fields"></i></h3>
<div class="frm_toggle_container frm_grid_container" style="display:none;">
<div id="frm_field_698_container" class="frm_form_field frm_first frm_three_fourths frm_html_container form-field">It is the policy of Horizons, A Family Service Alliance to provide a safe, helping environment and service for our clients. Therefore, the Agency requires that criminal, child abuse and dependent adult abuse record checks and any other background information be completed on all who are considered for employment, internship, or volunteering at Horizons. Please complete the information below by checking the appropriate statement and adding additional information required. <p></p>
<p>Please note that charges that have been deferred will be visible in a criminal background history report as will non-convictions.</p></div>
<div id="frm_field_699_container" class="frm_form_field form-field frm_top_container frm_first frm_three_fourths vertical_radio">
<div id="field_7df9x_label" class="frm_primary_label">
<span class="frm_required"></span>
</div>
<div class="frm_opt_container" aria-labelledby="field_7df9x_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_699-696-0"><label for="field_7df9x-0"><input type="checkbox" name="item_meta[699][]" id="field_7df9x-0" value="I hereby state that I have NEVER been CHARGED and/or CONVICTED by any law, in any State, of commission of any criminal act, including but not limited to, operating a motor vehicle under the influence (OMVI/DWI), any lascivious act involving a child or dependent adult, child or dependent adult abuse, neglect, or endangerment." data-sectionid="696" data-invmsg=" is invalid" aria-invalid="false"> I hereby state that I have NEVER been CHARGED and/or CONVICTED by any law, in any State, of commission of any criminal act, including but not limited to, operating a motor vehicle under the influence (OMVI/DWI), any lascivious act involving a child or dependent adult, child or dependent adult abuse, neglect, or endangerment.</label></div>
<div class="frm_checkbox" id="frm_checkbox_699-696-1"><label for="field_7df9x-1"><input type="checkbox" name="item_meta[699][]" id="field_7df9x-1" value="I hereby state that I have been charged and/or convicted by the law(s) of the following State(s) of the action(s) described below." data-sectionid="696" data-invmsg=" is invalid" aria-invalid="false"> I hereby state that I have been charged and/or convicted by the law(s) of the following State(s) of the action(s) described below.</label></div>
</div>
</div>
<div id="frm_field_702_container" class="frm_form_field form-field frm_top_container frm_first frm_three_fourths">
<label for="field_k3x7e" id="field_k3x7e_label" class="frm_primary_label">
<span class="frm_required"></span>
</label>
<textarea name="item_meta[702]" id="field_k3x7e" rows="5" data-sectionid="696" data-invmsg=" is invalid" aria-invalid="false"></textarea>
</div>
<div id="frm_field_701_container" class="frm_form_field form-field frm_top_container frm_first frm_three_fourths vertical_radio">
<div id="field_90bh7_label" class="frm_primary_label">
<span class="frm_required"></span>
</div>
<div class="frm_opt_container" aria-labelledby="field_90bh7_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_701-696-0"><label for="field_90bh7-0"><input type="checkbox" name="item_meta[701][]" id="field_90bh7-0" value="I hereby state that I have charges pending involving a criminal act as described below." data-sectionid="696" data-invmsg=" is invalid" aria-invalid="false"> I hereby state that I have charges pending involving a criminal act as described below.</label></div>
</div>
</div>
<div id="frm_field_700_container" class="frm_form_field form-field frm_top_container frm_first frm_three_fourths">
<label for="field_lgkf2" id="field_lgkf2_label" class="frm_primary_label">
<span class="frm_required"></span>
</label>
<textarea name="item_meta[700]" id="field_lgkf2" rows="5" data-sectionid="696" data-invmsg=" is invalid" aria-invalid="false"></textarea>
</div>
<div id="frm_field_703_container" class="frm_form_field frm_first frm_three_fourths frm_html_container form-field">I understand that I am required to disclose this information. I further understand that falsification of this information is grounds for dismissal. If I begin working or volunteering at Horizons, A Family Service Alliance, I understand that I must advise the agency of additional convictions and complete appropriate paperwork. </div>
<div id="frm_field_705_container" class="frm_form_field form-field frm_top_container frm_first frm_fourth">
<label for="field_oxlwi" id="field_oxlwi_label" class="frm_primary_label">Date
<span class="frm_required"></span>
</label>
<input type="text" id="field_oxlwi" name="item_meta[705]" value="08/29/2023" data-sectionid="696" maxlength="10" data-frmval="08/29/2023" data-invmsg="Date is invalid" class="frm_date" aria-invalid="false">
</div>
<div id="frm_field_704_container" class="frm_form_field form-field frm_top_container frm_first frm_half">
<label for="field_jx8ck" id="field_jx8ck_label" class="frm_primary_label">Signature
<span class="frm_required"></span>
</label>
<div class="sigPad" id="sigPad704" style="max-width:400px;">
<div class="sig sigWrapper" style="height:150px;border-color:#cccccc;--bg-color:#ffffff;--active:#008ec2;--inactive:#dddddd;--active-text:#ffffff;--inactive-text:#ffffff;--button-margin:22px;--button-size:20px;--button-padding:10px;--button-side-margin:22px;--icon:20px">
<ul class="sigNav">
<li class="drawIt"><a href="#" class="frm-active-sig-type" title="Draw It" aria-label="Draw It"><i class="frm_icon_font frm_signature_icon" aria-hidden=""></i></a></li>
<li class="typeIt"><a href="#" class="" title="Type It" aria-label="Type It"><i class="frm_icon_font frm_keyboard_icon" aria-hidden=""></i></a></li>
</ul>
<span class="frm-typed-drawline" style="height: 1px; background-color: rgb(204, 204, 204);"></span>
<div class="typed" style="visibility: hidden;">
<input type="text" name="item_meta[704][typed]" class="name" id="field_jx8ck" autocomplete="off" value="" data-sectionid="696" style="width:400px" maxlength="150" aria-invalid="false">
</div>
<canvas class="pad" data-fieldid="704" data-fieldname="item_meta[704]" width="396" height="150" style="touch-action: none; user-select: none; visibility: visible;"></canvas>
<div class="clearButton" style="visibility: visible;"><a href="#clear">Clear</a></div>
<input type="hidden" name="item_meta[704][output]" class="output" value="">
</div>
</div>
</div>
</div>
</div>
<div id="frm_field_711_container" class="frm_form_field form-field frm_none_container">
<label for="g-recaptcha-response" id="field_r9pwn_label" class="frm_primary_label">reCAPTCHA
<span class="frm_required"></span>
</label>
<div id="field_r9pwn" class="frm-g-recaptcha" data-sitekey="6LfKgQAVAAAAAKB6TKU9pGYR5J_oQBxJ3xA4w-2q" data-size="invisible" data-theme="light" data-rid="0"><div class="grecaptcha-badge" data-style="bottomright" style="width: 256px; height: 60px; display: block; transition: right 0.3s ease 0s; position: fixed; bottom: 14px; right: -186px; box-shadow: gray 0px 0px 5px; border-radius: 2px; overflow: hidden;"><div class="grecaptcha-logo"><iframe title="reCAPTCHA" src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6LfKgQAVAAAAAKB6TKU9pGYR5J_oQBxJ3xA4w-2q&co=aHR0cHM6Ly9ob3Jpem9uc2ZhbWlseS5vcmc6NDQz&hl=en&v=0hCdE87LyjzAkFO5Ff-v7Hj1&theme=light&size=invisible&cb=knac68w1o2jt" width="256" height="60" role="presentation" name="a-8gnt8zqapck" frameborder="0" scrolling="no" sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox"></iframe></div><div class="grecaptcha-error"></div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response" style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea></div></div>
</div>
<input type="hidden" name="item_key" value="">
<input name="frm_state" type="hidden" value="0DJ+h6NHfjHltsVL/oBHv7DwEoYTcMiWI+UI4NM/CkY="><div class="frm_submit">
<button class="frm_button_submit frm_final_submit" type="submit" formnovalidate="formnovalidate">Submit</button>
</div></b></b></b></b></b></b></b></div><b><b><b>
</b></b></b></fieldset><b><b><b>
</b></b></b></div><b><b><b>
<p style="display: none !important;"><label>Δ<textarea name="ak_hp_textarea" cols="45" rows="8" maxlength="100"></textarea></label><input type="hidden" id="ak_js_1" name="ak_js" value="1693391835919"><script>document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() );</script></p>
</b></b></b>
</form>POST
<form enctype="multipart/form-data" method="post" class="frm-show-form frm_pro_form " id="form_financial-wellness-client-intake-form">
<div class="frm_form_fields ">
<fieldset>
<legend class="frm_screen_reader">Financial Wellness Client Intake Form</legend>
<h3 class="frm_form_title">Financial Wellness Client Intake Form</h3>
<div class="frm_fields_container"><input type="hidden" name="frm_action" value="create"><input type="hidden" name="form_id" value="11"><input type="hidden" name="frm_hide_fields_11" id="frm_hide_fields_11"
value="["frm_field_1333_container","frm_field_183_container","frm_field_228_container","frm_field_289_container","frm_field_314_container"]"><input type="hidden" name="form_key"
value="financial-wellness-client-intake-form"><input type="hidden" name="item_meta[0]" value=""><input type="hidden" id="frm_submit_entry_11" name="frm_submit_entry_11" value="0d7a3a76be"><input type="hidden" name="_wp_http_referer"
value="/">
<div id="frm_field_146_container" class="frm_form_field frm_section_heading form-field ">
<h3 class="frm_pos_top frm_section_spacing"></h3>
<div id="frm_field_136_container" class="frm_form_field form-field frm_top_container frm6 frm_first"><label for="field_mm1a8" id="field_mm1a8_label" class="frm_primary_label">How did you hear about us?<span
class="frm_required"></span></label><select name="item_meta[136]" id="field_mm1a8" data-sectionid="146" data-invmsg="How did you hear about us? is invalid" aria-invalid="false">
<option value="" selected="selected"> </option>
<option value="HUD Search">HUD Search</option>
<option value="Print/Radio AD">Print/Radio AD</option>
<option value="Bank/mortgage servicer">Bank/mortgage servicer</option>
<option value="Religious Org">Religious Org</option>
<option value="Internet Search">Internet Search</option>
<option value="Friend/Family">Friend/Family</option>
<option value="Other (specify)">Other (specify)</option>
</select></div>
<div id="frm_field_137_container" class="frm_form_field form-field frm_top_container frm6"><label for="field_6cczw" id="field_6cczw_label" class="frm_primary_label">Other<span class="frm_required"></span></label><input type="text"
id="field_6cczw" name="item_meta[137]" value="" data-sectionid="146" data-invmsg="Text is invalid" aria-invalid="false"></div>
<div id="frm_field_1332_container" class="frm_form_field form-field frm_required_field frm_top_container frm12 frm_first vertical_radio">
<div id="field_s45pz_label" class="frm_primary_label">Are you interested in:<span class="frm_required" aria-hidden="true">*</span></div>
<div class="frm_opt_container" aria-labelledby="field_s45pz_label" role="group" aria-required="true">
<div class="frm_checkbox" id="frm_checkbox_1332-146-0"><label for="field_s45pz-0"><input type="checkbox" name="item_meta[1332][]" id="field_s45pz-0" value="Student Loan Counseling" data-sectionid="146"
data-reqmsg="This field cannot be blank." data-invmsg="Are you interested in: is invalid" aria-invalid="false"> Student Loan Counseling</label></div>
<div class="frm_checkbox" id="frm_checkbox_1332-146-1"><label for="field_s45pz-1"><input type="checkbox" name="item_meta[1332][]" id="field_s45pz-1" value="Budget and Credit Counseling" data-sectionid="146"
data-reqmsg="This field cannot be blank." data-invmsg="Are you interested in: is invalid" aria-invalid="false"> Budget and Credit Counseling</label></div>
<div class="frm_checkbox" id="frm_checkbox_1332-146-2"><label for="field_s45pz-2"><input type="checkbox" name="item_meta[1332][]" id="field_s45pz-2" value="Housing Counseling" data-sectionid="146"
data-reqmsg="This field cannot be blank." data-invmsg="Are you interested in: is invalid" aria-invalid="false"> Housing Counseling</label></div>
</div>
</div>
</div>
<div id="frm_field_148_container" class="frm_form_field frm_section_heading form-field ">
<h3 class="frm_pos_top frm_section_spacing">Biographic & Demographic Info</h3>
<div id="frm_field_128_container" class="frm_form_field form-field frm_top_container frm4 frm_first"><label for="field_qh4icy2" id="field_qh4icy2_label" class="frm_primary_label">Head of Household Full Name<span
class="frm_required"></span></label><input type="text" id="field_qh4icy2" name="item_meta[128]" value="" data-sectionid="148" data-invmsg="Name is invalid" aria-invalid="false" aria-describedby="frm_desc_field_qh4icy2">
<div class="frm_description" id="frm_desc_field_qh4icy2">First</div>
</div>
<div id="frm_field_129_container" class="frm_form_field form-field frm_hidden_container frm4"><label for="field_ocfup12" id="field_ocfup12_label" class="frm_primary_label">Head of Household Full Name<span
class="frm_required"></span></label><input type="text" id="field_ocfup12" name="item_meta[129]" value="" data-sectionid="148" data-invmsg="Last is invalid" aria-invalid="false" aria-describedby="frm_desc_field_ocfup12">
<div class="frm_description" id="frm_desc_field_ocfup12">Last</div>
</div>
<div id="frm_field_1303_container" class="frm_form_field form-field frm_top_container frm6 frm4 frm4 frm4 frm4 frm4 frm4 frm4 frm4 frm4 frm4"><label for="field_ezl9q" id="field_ezl9q_label" class="frm_primary_label">Email<span
class="frm_required" aria-hidden="true"></span></label><input type="email" id="field_ezl9q" name="item_meta[1303]" value="" data-sectionid="148" data-invmsg="Email is invalid" aria-invalid="false"></div>
<div id="frm_field_140_container" class="frm_form_field form-field frm_top_container frm_third frm_first"><label for="field_ntpt3" id="field_ntpt3_label" class="frm_primary_label">Partner/Spouse Name (If Applicable)<span
class="frm_required"></span></label><input type="text" id="field_ntpt3" name="item_meta[140]" value="" data-sectionid="148" data-invmsg="Name is invalid" aria-invalid="false" aria-describedby="frm_desc_field_ntpt3">
<div class="frm_description" id="frm_desc_field_ntpt3">First</div>
</div>
<div id="frm_field_139_container" class="frm_form_field form-field frm_hidden_container frm_third"><label for="field_taofl" id="field_taofl_label" class="frm_primary_label">Partner/Spouse Name (If Applicable)<span
class="frm_required"></span></label><input type="text" id="field_taofl" name="item_meta[139]" value="" data-sectionid="148" data-invmsg="Last is invalid" aria-invalid="false" aria-describedby="frm_desc_field_taofl">
<div class="frm_description" id="frm_desc_field_taofl">Last</div>
</div>
<div id="frm_field_155_container" class="frm_form_field form-field frm_top_container frm_half frm_first">
<div id="field_9u9c6_label" class="frm_primary_label">Address<span class="frm_required"></span></div>
<fieldset aria-labelledby="field_9u9c6_label">
<legend class="frm_screen_reader frm_hidden">Address</legend>
<div class="frm_combo_inputs_container">
<div id="frm_field_155-line1_container" class="frm_form_field form-field "><label for="field_9u9c6_line1" class="frm_screen_reader frm_hidden">Street Address</label><input type="text" id="field_9u9c6_line1" value=""
name="item_meta[155][line1]" data-sectionid="148" data-invmsg="Address is invalid" aria-invalid="false" autocomplete="address-line1">
<div class="frm_description">Street Address</div>
</div>
<div id="frm_field_155-line2_container" class="frm_form_field form-field "><label for="field_9u9c6_line2" class="frm_screen_reader frm_hidden">Street Address Line 2</label><input type="text" id="field_9u9c6_line2" value=""
name="item_meta[155][line2]" data-sectionid="148" data-invmsg="Address is invalid" class="frm_optional" aria-invalid="false" autocomplete="address-line2">
<div class="frm_description">Street Address Line 2</div>
</div>
<div id="frm_field_155-city_container" class="frm_form_field form-field frm_third frm_first"><label for="field_9u9c6_city" class="frm_screen_reader frm_hidden">City</label><input type="text" id="field_9u9c6_city" value=""
name="item_meta[155][city]" data-sectionid="148" data-invmsg="Address is invalid" aria-invalid="false" autocomplete="address-level2">
<div class="frm_description">City</div>
</div>
<div id="frm_field_155-state_container" class="frm_form_field form-field frm_third"><label for="field_9u9c6_state" class="frm_screen_reader frm_hidden">State/Province</label><input type="text" id="field_9u9c6_state" value=""
name="item_meta[155][state]" data-sectionid="148" data-invmsg="Address is invalid" aria-invalid="false" autocomplete="address-level1">
<div class="frm_description">State/Province</div>
</div>
<div id="frm_field_155-zip_container" class="frm_form_field form-field frm_third"><label for="field_9u9c6_zip" class="frm_screen_reader frm_hidden">Zip/Postal</label><input type="text" id="field_9u9c6_zip" value=""
name="item_meta[155][zip]" data-sectionid="148" data-invmsg="Address is invalid" aria-invalid="false" autocomplete="postal-code">
<div class="frm_description">Zip/Postal</div>
</div>
</div>
</fieldset>
</div>
<div id="frm_field_269_container" class="frm_form_field form-field frm_top_container frm_third frm_first"><label for="field_7jv48" id="field_7jv48_label" class="frm_primary_label">County<span class="frm_required"></span></label><input
type="text" id="field_7jv48" name="item_meta[269]" value="" data-sectionid="148" data-invmsg="Text is invalid" aria-invalid="false"></div>
<div id="frm_field_154_container" class="frm_form_field form-field frm_top_container frm_third frm_first"><label for="field_j06as" id="field_j06as_label" class="frm_primary_label">Cell Phone Number<span
class="frm_required"></span></label><input type="tel" id="field_j06as" name="item_meta[154]" value="" data-sectionid="148" data-frmmask="(999)999-9999" maxlength="7" data-invmsg="Phone is invalid" aria-invalid="false"
pattern="\(\d\d\d\)\d\d\d-\d\d\d\d$"></div>
<div id="frm_field_157_container" class="frm_form_field form-field frm_top_container frm_third"><label for="field_s8rrt" id="field_s8rrt_label" class="frm_primary_label">Alternate Phone Number<span
class="frm_required"></span></label><input type="tel" id="field_s8rrt" name="item_meta[157]" value="" data-sectionid="148" data-frmmask="(999)999-9999" maxlength="7" data-invmsg="Phone is invalid" aria-invalid="false"
pattern="\(\d\d\d\)\d\d\d-\d\d\d\d$"></div>
<div id="frm_field_156_container" class="frm_form_field form-field frm_top_container vertical_radio">
<div id="field_4bcaq_label" class="frm_primary_label">Do we have permission to text message with appt. reminders or other information?<span class="frm_required"></span></div>
<div class="frm_opt_container" aria-labelledby="field_4bcaq_label" role="radiogroup" tabindex="0">
<div class="frm_radio" id="frm_radio_156-148-0"><label for="field_4bcaq-0"><input type="radio" name="item_meta[156]" id="field_4bcaq-0" value="Yes" data-sectionid="148"
data-invmsg="Do we have permission to text message with appt. reminders or other information? is invalid" aria-invalid="false"> Yes</label></div>
<div class="frm_radio" id="frm_radio_156-148-1"><label for="field_4bcaq-1"><input type="radio" name="item_meta[156]" id="field_4bcaq-1" value="No" data-sectionid="148"
data-invmsg="Do we have permission to text message with appt. reminders or other information? is invalid" aria-invalid="false"> No</label></div>
</div>
</div>
<div id="frm_field_158_container" class="frm_form_field form-field frm_top_container frm_third frm_first"><label for="field_yjmfq" id="field_yjmfq_label" class="frm_primary_label">Email<span class="frm_required"></span></label><input
type="email" id="field_yjmfq" name="item_meta[158]" value="" data-sectionid="148" data-invmsg="Email is invalid" aria-invalid="false"></div>
<div id="frm_field_361_container" class="frm_form_field form-field frm_top_container frm_sixth frm_first"><label for="field_y463t" id="field_y463t_label" class="frm_primary_label">Date of Birth<span
class="frm_required"></span></label><input type="text" id="field_y463t" name="item_meta[361]" value="" data-sectionid="148" maxlength="10" data-invmsg="Date is invalid" class="frm_date" aria-invalid="false"></div>
<div id="frm_field_159_container" class="frm_form_field form-field frm_top_container vertical_radio">
<div id="field_qfpbe_label" class="frm_primary_label">Preferred Contact Method:<span class="frm_required"></span></div>
<div class="frm_opt_container" aria-labelledby="field_qfpbe_label" role="group">
<div class="frm_checkbox" id="frm_checkbox_159-148-0"><label for="field_qfpbe-0"><input type="checkbox" name="item_meta[159][]" id="field_qfpbe-0" value="Cell Phone" data-sectionid="148"
data-invmsg="Preferred Contact Method: is invalid" aria-invalid="false"> Cell Phone</label></div>
<div class="frm_checkbox" id="frm_checkbox_159-148-1"><label for="field_qfpbe-1"><input type="checkbox" name="item_meta[159][]" id="field_qfpbe-1" value="Email" data-sectionid="148" data-invmsg="Preferred Contact Method: is invalid"
aria-invalid="false"> Email</label></div>
<div class="frm_checkbox" id="frm_checkbox_159-148-2"><label for="field_qfpbe-2"><input type="checkbox" name="item_meta[159][]" id="field_qfpbe-2" value="Alternate Phone" data-sectionid="148"
data-invmsg="Preferred Contact Method: is invalid" aria-invalid="false"> Alternate Phone</label></div>
</div>
</div>
<div id="frm_field_167_container" class="frm_form_field form-field frm_top_container vertical_radio">
<div id="field_7k68n_label" class="frm_primary_label">Marital Status<span class="frm_required"></span></div>
<div class="frm_opt_container" aria-labelledby="field_7k68n_label" role="radiogroup" tabindex="0">
<div class="frm_radio" id="frm_radio_167-148-0"><label for="field_7k68n-0"><input type="radio" name="item_meta[167]" id="field_7k68n-0" value="Single" data-sectionid="148" data-invmsg="Marital Status is invalid" aria-invalid="false">
Single</label></div>
<div class="frm_radio" id="frm_radio_167-148-1"><label for="field_7k68n-1"><input type="radio" name="item_meta[167]" id="field_7k68n-1" value="Married" data-sectionid="148" data-invmsg="Marital Status is invalid" aria-invalid="false">
Married</label></div>
<div class="frm_radio" id="frm_radio_167-148-2"><label for="field_7k68n-2"><input type="radio" name="item_meta[167]" id="field_7k68n-2" value="Divorced" data-sectionid="148" data-invmsg="Marital Status is invalid" aria-invalid="false">
Divorced</label></div>
<div class="frm_radio" id="frm_radio_167-148-3"><label for="field_7k68n-3"><input type="radio" name="item_meta[167]" id="field_7k68n-3" value="Separated" data-sectionid="148" data-invmsg="Marital Status is invalid" aria-invalid="false">
Separated</label></div>
<div class="frm_radio" id="frm_radio_167-148-4"><label for="field_7k68n-4"><input type="radio" name="item_meta[167]" id="field_7k68n-4" value="Widow" data-sectionid="148" data-invmsg="Marital Status is invalid" aria-invalid="false">
Widow</label></div>
</div>
</div>
<div id="frm_field_160_container" class="frm_form_field form-field frm_top_container frm_third frm_first vertical_radio frm_other_container">
<div id="field_yrwn2_label" class="frm_primary_label">Head of Household Race<span class="frm_required"></span></div>
<div class="frm_opt_container" aria-labelledby="field_yrwn2_label" role="radiogroup" tabindex="0">
<div class="frm_radio" id="frm_radio_160-148-0"><label for="field_yrwn2-0"><input type="radio" name="item_meta[160]" id="field_yrwn2-0" value="American Indian/Alaskan Native" data-sectionid="148"
data-invmsg="Head of Household Race is invalid" aria-invalid="false"> American Indian/Alaskan Native</label></div>
<div class="frm_radio" id="frm_radio_160-148-1"><label for="field_yrwn2-1"><input type="radio" name="item_meta[160]" id="field_yrwn2-1" value="Asian" data-sectionid="148" data-invmsg="Head of Household Race is invalid"
aria-invalid="false"> Asian</label></div>
<div class="frm_radio" id="frm_radio_160-148-2"><label for="field_yrwn2-2"><input type="radio" name="item_meta[160]" id="field_yrwn2-2" value="African-American" data-sectionid="148" data-invmsg="Head of Household Race is invalid"
aria-invalid="false"> African-American</label></div>
<div class="frm_radio" id="frm_radio_160-148-3"><label for="field_yrwn2-3"><input type="radio" name="item_meta[160]" id="field_yrwn2-3" value="Native Hawaiian/Pacific Islander" data-sectionid="148"
data-invmsg="Head of Household Race is invalid" aria-invalid="false"> Native Hawaiian/Pacific Islander</label></div>
<div class="frm_radio" id="frm_radio_160-148-4"><label for="field_yrwn2-4"><input type="radio" name="item_meta[160]" id="field_yrwn2-4" value="White" data-sectionid="148" data-invmsg="Head of Household Race is invalid"
aria-invalid="false"> White</label></div>
<div class="frm_radio" id="frm_radio_160-148-5"><label for="field_yrwn2-5"><input type="radio" name="item_meta[160]" id="field_yrwn2-5" value="Biracial/Multiracial" data-sectionid="148" data-invmsg="Head of Household Race is invalid"
aria-invalid="false"> Biracial/Multiracial</label></div>
<div class="frm_radio" id="frm_radio_160-148-6"><label for="field_yrwn2-6"><input type="radio" name="item_meta[160]" id="field_yrwn2-6" value="Prefer not to identify" data-sectionid="148" data-invmsg="Head of Household Race is invalid"
aria-invalid="false"> Prefer not to identify</label></div>
<div class="frm_radio" id="frm_radio_160-148-other_7"><label for="field_yrwn2-other_7"><input type="radio" name="item_meta[160]" id="field_yrwn2-other_7" value="Other" data-sectionid="148" data-invmsg="Head of Household Race is invalid"
aria-invalid="false"> Other</label><label for="field_yrwn2-other_7-otext" class="frm_screen_reader frm_hidden">Other</label><input type="text" id="field_yrwn2-other_7-otext" class="frm_other_input frm_pos_none"
name="item_meta[other][160]" value=""></div>
</div>
</div>
<div id="frm_field_161_container" class="frm_form_field form-field frm_top_container frm_third vertical_radio frm_other_container">
<div id="field_9i3i8_label" class="frm_primary_label">Partner/Spouse Race (if applicable):<span class="frm_required"></span></div>
<div class="frm_opt_container" aria-labelledby="field_9i3i8_label" role="radiogroup" tabindex="0">
<div class="frm_radio" id="frm_radio_161-148-0"><label for="field_9i3i8-0"><input type="radio" name="item_meta[161]" id="field_9i3i8-0" value="American Indian/Alaskan Native" data-sectionid="148"
data-invmsg="Partner/Spouse Race (if applicable): is invalid" aria-invalid="false"> American Indian/Alaskan Native</label></div>
<div class="frm_radio" id="frm_radio_161-148-1"><label for="field_9i3i8-1"><input type="radio" name="item_meta[161]" id="field_9i3i8-1" value="Asian" data-sectionid="148" data-invmsg="Partner/Spouse Race (if applicable): is invalid"
aria-invalid="false"> Asian</label></div>
<div class="frm_radio" id="frm_radio_161-148-2"><label for="field_9i3i8-2"><input type="radio" name="item_meta[161]" id="field_9i3i8-2" value="African-American" data-sectionid="148"
data-invmsg="Partner/Spouse Race (if applicable): is invalid" aria-invalid="false"> African-American</label></div>
<div class="frm_radio" id="frm_radio_161-148-3"><label for="field_9i3i8-3"><input type="radio" name="item_meta[161]" id="field_9i3i8-3" value="Native Hawaiian/Pacific Islander" data-sectionid="148"
data-invmsg="Partner/Spouse Race (if applicable): is invalid" aria-invalid="false"> Native Hawaiian/Pacific Islander</label></div>
<div class="frm_radio" id="frm_radio_161-148-4"><label for="field_9i3i8-4"><input type="radio" name="item_meta[161]" id="field_9i3i8-4" value="White" data-sectionid="148" data-invmsg="Partner/Spouse Race (if applicable): is invalid"
aria-invalid="false"> White</label></div>
<div class="frm_radio" id="frm_radio_161-148-5"><label for="field_9i3i8-5"><input type="radio" name="item_meta[161]" id="field_9i3i8-5" value="Biracial/Multiracial" data-sectionid="148"
data-invmsg="Partner/Spouse Race (if applicable): is invalid" aria-invalid="false"> Biracial/Multiracial</label></div>
<div class="frm_radio" id="frm_radio_161-148-6"><label for="field_9i3i8-6"><input type="radio" name="item_meta[161]" id="field_9i3i8-6" value="Prefer not to identify" data-sectionid="148"
data-invmsg="Partner/Spouse Race (if applicable): is invalid" aria-invalid="false"> Prefer not to identify</label></div>
<div class="frm_radio" id="frm_radio_161-148-other_7"><label for="field_9i3i8-other_7"><input type="radio" name="item_meta[161]" id="field_9i3i8-other_7" value="Other" data-sectionid="148"
data-invmsg="Partner/Spouse Race (if applicable): is invalid" aria-invalid="false"> Other</label><label for="field_9i3i8-other_7-otext" class="frm_screen_reader frm_hidden">Other</label><input type="text"
id="field_9i3i8-other_7-otext" class="frm_other_input frm_pos_none" name="item_meta[other][161]" value=""></div>
</div>
</div>
<div id="frm_field_162_container" class="frm_form_field form-field frm_top_container frm_third frm_first vertical_radio">
<div id="field_rr2tl_label" class="frm_primary_label">Head of Household Ethnicity<span class="frm_required"></span></div>
<div class="frm_opt_container" aria-labelledby="field_rr2tl_label" role="radiogroup" tabindex="0">
<div class="frm_radio" id="frm_radio_162-148-0"><label for="field_rr2tl-0"><input type="radio" name="item_meta[162]" id="field_rr2tl-0" value="Hispanic" data-sectionid="148" data-invmsg="Head of Household Ethnicity is invalid"
aria-invalid="false"> Hispanic</label></div>
<div class="frm_radio" id="frm_radio_162-148-1"><label for="field_rr2tl-1"><input type="radio" name="item_meta[162]" id="field_rr2tl-1" value="Non-Hispanic" data-sectionid="148" data-invmsg="Head of Household Ethnicity is invalid"
aria-invalid="false"> Non-Hispanic</label></div>
<div class="frm_radio" id="frm_radio_162-148-2"><label for="field_rr2tl-2"><input type="radio" name="item_meta[162]" id="field_rr2tl-2" value="Prefer not to identify" data-sectionid="148"
data-invmsg="Head of Household Ethnicity is invalid" aria-invalid="false"> Prefer not to identify</label></div>
</div>
</div>
<div id="frm_field_163_container" class="frm_form_field form-field frm_top_container frm_third vertical_radio">
<div id="field_pl1vw_label" class="frm_primary_label">Partner/Spouse Ethnicity<span class="frm_required"></span></div>
<div class="frm_opt_container" aria-labelledby="field_pl1vw_label" role="radiogroup" tabindex="0">
<div class="frm_radio" id="frm_radio_163-148-0"><label for="field_pl1vw-0"><input type="radio" name="item_meta[163]" id="field_pl1vw-0" value="Hispanic" data-sectionid="148" data-invmsg="Partner/Spouse Ethnicity is invalid"
aria-invalid="false"> Hispanic</label></div>
<div class="frm_radio" id="frm_radio_163-148-1"><label for="field_pl1vw-1"><input type="radio" name="item_meta[163]" id="field_pl1vw-1" value="Non-Hispanic" data-sectionid="148" data-invmsg="Partner/Spouse Ethnicity is invalid"
aria-invalid="false"> Non-Hispanic</label></div>
<div class="frm_radio" id="frm_radio_163-148-2"><label for="field_pl1vw-2"><input type="radio" name="item_meta[163]" id="field_pl1vw-2" value="Prefer not to identify" data-sectionid="148"
data-invmsg="Partner/Spouse Ethnicity is invalid" aria-invalid="false"> Prefer not to identify</label></div>
</div>
</div>
<div id="frm_field_164_container" class="frm_form_field form-field frm_top_container frm_third frm_first"><label for="field_oezh6" id="field_oezh6_label" class="frm_primary_label">Are you a veteran?<span
class="frm_required"></span></label><select name="item_meta[164]" id="field_oezh6" data-sectionid="148" data-invmsg="Are you a veteran? is invalid" aria-invalid="false">
<option value="" selected="selected"> </option>
<option value="Yes">Yes</option>
<option value="No">No</option>
<option value="Prefer not to identify">Prefer not to identify</option>
</select></div>
<div id="frm_field_166_container" class="frm_form_field form-field frm_top_container frm_third frm_first"><label for="field_dgyyj" id="field_dgyyj_label" class="frm_primary_label">Are you disabled?<span
class="frm_required"></span></label><select name="item_meta[166]" id="field_dgyyj" data-sectionid="148" data-invmsg="Are you disabled? is invalid" aria-invalid="false">
<option value="" selected="selected"> </option>
<option value="Yes">Yes</option>
<option value="No">No</option>
<option value="Prefer not to identify">Prefer not to identify</option>
</select></div>
<div id="frm_field_165_container" class="frm_form_field form-field frm_top_container frm_third frm_first"><label for="field_gca7t" id="field_gca7t_label" class="frm_primary_label">What is your highest level of completed education?<span
class="frm_required"></span></label><select name="item_meta[165]" id="field_gca7t" data-sectionid="148" data-invmsg="What is your highest level of completed education? is invalid" aria-invalid="false">
<option value="" selected="selected"> </option>
<option value="Grade School">Grade School</option>
<option value="Middle">Middle</option>
<option value="High School">High School</option>
<option value="Two Year Degree">Two Year Degree</option>
<option value="Four Year Degree">Four Year Degree</option>
<option value="Advanced Degree">Advanced Degree</option>
</select></div>
<div id="frm_field_168_container" class="frm_form_field form-field frm_top_container frm_half frm_first frm_other_container"><label for="field_8c03r" id="field_8c03r_label" class="frm_primary_label">Household Type<span
class="frm_required"></span></label><select name="item_meta[168]" id="field_8c03r" data-sectionid="148" data-invmsg="Household Type is invalid" aria-invalid="false">
<option value="" selected="selected"> </option>
<option value="Single Adult">Single Adult</option>
<option value="Single male-headed household with dependents">Single male-headed household with dependents</option>
<option value="Single female-headed household with dependents">Single female-headed household with dependents</option>
<option value="Married adults without dependents">Married adults without dependents</option>
<option value="Married with dependents">Married with dependents</option>
<option value="Roommates/unrelated adults">Roommates/unrelated adults</option>
<option value="Living with non-spousal family members (parents, siblings, etc...)">Living with non-spousal family members (parents, siblings, etc...)</option>
<option value="Other" class="frm_other_trigger">Other</option>
</select><label for="field_8c03r-otext" class="frm_screen_reader frm_hidden">Household Type</label><input type="text" id="field_8c03r-otext" class="frm_other_input frm_pos_none" name="item_meta[other][168]" value=""></div>
<div id="frm_field_169_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_21iei" id="field_21iei_label" class="frm_primary_label">Total number of adults in your household<span
class="frm_required"></span></label><input type="number" id="field_21iei" name="item_meta[169]" value="1" data-sectionid="148" data-frmproduct="[]" data-frmval="1" data-invmsg="Quantity is invalid" aria-invalid="false" min="0"
max="9999999" step="1"></div>
<div id="frm_field_170_container" class="frm_form_field form-field frm_top_container frm_fourth frm_half"><label for="field_d267d" id="field_d267d_label" class="frm_primary_label">Total number of children in your household<span
class="frm_required"></span></label><input type="number" id="field_d267d" name="item_meta[170]" value="1" data-sectionid="148" data-frmproduct="[]" data-frmval="1" data-invmsg="Quantity is invalid" aria-invalid="false" min="0"
max="9999999" step="1"></div>
<div id="frm_field_171_container" class="frm_form_field form-field frm_top_container frm_third frm_first"><label for="field_cv1s6" id="field_cv1s6_label" class="frm_primary_label">Please list your household's primary languages.<span
class="frm_required"></span></label><input type="text" id="field_cv1s6" name="item_meta[171]" value="" data-sectionid="148" data-invmsg="Text is invalid" aria-invalid="false"></div>
<div id="frm_field_172_container" class="frm_form_field form-field frm_top_container frm_half vertical_radio">
<div id="field_ros0m_label" class="frm_primary_label">Do you want an interpreter for services?<span class="frm_required"></span></div>
<div class="frm_opt_container" aria-labelledby="field_ros0m_label" role="radiogroup" tabindex="0">
<div class="frm_radio" id="frm_radio_172-148-0"><label for="field_ros0m-0"><input type="radio" name="item_meta[172]" id="field_ros0m-0" value="Yes" data-sectionid="148" data-invmsg="Do you want an interpreter for services? is invalid"
aria-invalid="false"> Yes</label></div>
<div class="frm_radio" id="frm_radio_172-148-1"><label for="field_ros0m-1"><input type="radio" name="item_meta[172]" id="field_ros0m-1" value="No" data-sectionid="148" data-invmsg="Do you want an interpreter for services? is invalid"
aria-invalid="false"> No</label></div>
</div>
</div>
<div id="frm_field_173_container" class="frm_form_field form-field frm_top_container frm_third"><label for="field_svzh8" id="field_svzh8_label" class="frm_primary_label">If an interpreter is desired, what kind of interpretation do you
need?<span class="frm_required"></span></label><input type="text" id="field_svzh8" name="item_meta[173]" value="" data-sectionid="148" data-invmsg="Text is invalid" aria-invalid="false"></div>
</div>
<div id="frm_field_174_container" class="frm_form_field frm_section_heading form-field ">
<h3 class="frm_pos_top frm_section_spacing">Employment Information</h3>
<div id="frm_field_176_container" class="frm_form_field form-field frm_top_container frm_third frm_first frm_other_container"><label for="field_f8juq" id="field_f8juq_label" class="frm_primary_label">Employment Status<span
class="frm_required"></span></label><select name="item_meta[176]" id="field_f8juq" data-sectionid="174" data-invmsg="Employment Status is invalid" aria-invalid="false">
<option value="" selected="selected"> </option>
<option value="Employed full-time">Employed full-time</option>
<option value="Employed part-time">Employed part-time</option>
<option value="Employed seasonally">Employed seasonally</option>
<option value="Unemployed, receiving benefits">Unemployed, receiving benefits</option>
<option value="Unemployed, receiving no benefits">Unemployed, receiving no benefits</option>
<option value="Self-employed">Self-employed</option>
<option value="Disabled, receiving benefits">Disabled, receiving benefits</option>
<option value="Retired">Retired</option>
<option value="Other (specify)" class="frm_other_trigger">Other (specify)</option>
</select><label for="field_f8juq-otext" class="frm_screen_reader frm_hidden">Employment Status</label><input type="text" id="field_f8juq-otext" class="frm_other_input frm_pos_none" name="item_meta[other][176]" value=""></div>
<div id="frm_field_177_container" class="frm_form_field form-field frm_top_container frm_third"><label for="field_d9qbs" id="field_d9qbs_label" class="frm_primary_label">Name of Employer<span class="frm_required"></span></label><input
type="text" id="field_d9qbs" name="item_meta[177]" value="" data-sectionid="174" data-invmsg="Text is invalid" aria-invalid="false"></div>
<div id="frm_field_178_container" class="frm_form_field form-field frm_top_container frm_third frm_first"><label for="field_cym7i" id="field_cym7i_label" class="frm_primary_label">How long have you been employed here?<span
class="frm_required"></span></label><input type="text" id="field_cym7i" name="item_meta[178]" value="" data-sectionid="174" data-invmsg="Text is invalid" aria-invalid="false"></div>
<div id="frm_field_179_container" class="frm_form_field form-field frm_top_container frm_third frm_first"><label for="field_we1it" id="field_we1it_label" class="frm_primary_label">Do you have secondary employement?<span
class="frm_required"></span></label><select name="item_meta[179]" id="field_we1it" data-sectionid="174" data-invmsg="Do you have secondary employement? is invalid" aria-invalid="false">
<option value="" selected="selected"> </option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select></div>
<div id="frm_field_180_container" class="frm_form_field form-field frm_top_container frm_third"><label for="field_8fwlr" id="field_8fwlr_label" class="frm_primary_label">If yes, who is your secondary employer?<span
class="frm_required"></span></label><input type="text" id="field_8fwlr" name="item_meta[180]" value="" data-sectionid="174" data-invmsg="Text is invalid" aria-invalid="false"></div>
<div id="frm_field_181_container" class="frm_form_field form-field frm_top_container frm_third frm_first frm_other_container"><label for="field_fdc07" id="field_fdc07_label" class="frm_primary_label">Partner/Spouse Employment Status<span
class="frm_required"></span></label><select name="item_meta[181]" id="field_fdc07" data-sectionid="174" data-invmsg="Partner/Spouse Employment Status is invalid" aria-invalid="false">
<option value="" selected="selected"> </option>
<option value="Employed full-time">Employed full-time</option>
<option value="Employed part-time">Employed part-time</option>
<option value="Employed seasonally">Employed seasonally</option>
<option value="Unemployed, receiving benefits">Unemployed, receiving benefits</option>
<option value="Unemployed, receiving no benefits">Unemployed, receiving no benefits</option>
<option value="Self employed">Self employed</option>
<option value="Disabled, receiving benefits">Disabled, receiving benefits</option>
<option value="Retired">Retired</option>
<option value="Other" class="frm_other_trigger">Other</option>
</select><label for="field_fdc07-otext" class="frm_screen_reader frm_hidden">Partner/Spouse Employment Status</label><input type="text" id="field_fdc07-otext" class="frm_other_input frm_pos_none" name="item_meta[other][181]" value="">
</div>
<div id="frm_field_182_container" class="frm_form_field form-field frm_top_container frm_third"><label for="field_rsf30" id="field_rsf30_label" class="frm_primary_label">Name of Partner/Spouse Employer<span
class="frm_required"></span></label><input type="text" id="field_rsf30" name="item_meta[182]" value="" data-sectionid="174" data-invmsg="Text is invalid" aria-invalid="false"></div>
</div>
<div id="frm_field_1333_container" class="frm_form_field frm_section_heading form-field " style="display: none;">
<h3 class="frm_pos_top frm_section_spacing">Student Loan Interests</h3>
<div id="frm_field_1335_container" class="frm_form_field form-field frm_top_container vertical_radio frm_other_container">
<div id="field_sdtb3_label" class="frm_primary_label">I'm interested in (check all that apply):<span class="frm_required" aria-hidden="true"></span></div>
<div class="frm_opt_container" aria-labelledby="field_sdtb3_label" role="group">
<div class="frm_checkbox" id="frm_checkbox_1335-1333-0"><label for="field_sdtb3-0"><input type="checkbox" name="item_meta[1335][]" id="field_sdtb3-0" value="Choosing a repayment plan" data-sectionid="1333"
data-invmsg="I'm interested in (check all that apply): is invalid" aria-invalid="false" aria-required="false"> Choosing a repayment plan</label></div>
<div class="frm_checkbox" id="frm_checkbox_1335-1333-1"><label for="field_sdtb3-1"><input type="checkbox" name="item_meta[1335][]" id="field_sdtb3-1" value="Establishing affordably monthly payments" data-sectionid="1333"
data-invmsg="I'm interested in (check all that apply): is invalid" aria-invalid="false" aria-required="false"> Establishing affordably monthly payments</label></div>
<div class="frm_checkbox" id="frm_checkbox_1335-1333-2"><label for="field_sdtb3-2"><input type="checkbox" name="item_meta[1335][]" id="field_sdtb3-2" value="Loan forgiveness programs" data-sectionid="1333"
data-invmsg="I'm interested in (check all that apply): is invalid" aria-invalid="false" aria-required="false"> Loan forgiveness programs</label></div>
<div class="frm_checkbox" id="frm_checkbox_1335-1333-3"><label for="field_sdtb3-3"><input type="checkbox" name="item_meta[1335][]" id="field_sdtb3-3" value="Payment options for disability or financial hardship" data-sectionid="1333"
data-invmsg="I'm interested in (check all that apply): is invalid" aria-invalid="false" aria-required="false"> Payment options for disability or financial hardship</label></div>
<div class="frm_checkbox" id="frm_checkbox_1335-1333-4"><label for="field_sdtb3-4"><input type="checkbox" name="item_meta[1335][]" id="field_sdtb3-4" value="Dealing with delinquent or defaulted student loans" data-sectionid="1333"
data-invmsg="I'm interested in (check all that apply): is invalid" aria-invalid="false" aria-required="false"> Dealing with delinquent or defaulted student loans</label></div>
<div class="frm_checkbox" id="frm_checkbox_1335-1333-5"><label for="field_sdtb3-5"><input type="checkbox" name="item_meta[1335][]" id="field_sdtb3-5" value="Improving my credit score" data-sectionid="1333"
data-invmsg="I'm interested in (check all that apply): is invalid" aria-invalid="false" aria-required="false"> Improving my credit score</label></div>
<div class="frm_checkbox" id="frm_checkbox_1335-1333-6"><label for="field_sdtb3-6"><input type="checkbox" name="item_meta[1335][]" id="field_sdtb3-6" value="Restoring eligibility for federal student aid" data-sectionid="1333"
data-invmsg="I'm interested in (check all that apply): is invalid" aria-invalid="false" aria-required="false"> Restoring eligibility for federal student aid</label></div>
<div class="frm_checkbox" id="frm_checkbox_1335-1333-7"><label for="field_sdtb3-7"><input type="checkbox" name="item_meta[1335][]" id="field_sdtb3-7" value="Minimizing the total cost of debt over time" data-sectionid="1333"
data-invmsg="I'm interested in (check all that apply): is invalid" aria-invalid="false" aria-required="false"> Minimizing the total cost of debt over time</label></div>
<div class="frm_checkbox" id="frm_checkbox_1335-1333-other_8"><label for="field_sdtb3-other_8"><input type="checkbox" name="item_meta[1335][other_8]" id="field_sdtb3-other_8" value="Other" data-sectionid="1333"
data-invmsg="I'm interested in (check all that apply): is invalid" aria-invalid="false" aria-required="false"> Other</label><label for="field_sdtb3-other_8-otext" class="frm_screen_reader frm_hidden">Other</label><input
type="text" id="field_sdtb3-other_8-otext" class="frm_other_input frm_pos_none" name="item_meta[other][1335][other_8]" value="" aria-required="false"></div>
</div>
</div>
</div>
<div id="frm_field_183_container" class="frm_form_field frm_section_heading form-field frm12 frm_first" style="display: none;">
<h3 class="frm_pos_top frm_section_spacing">Housing Status and Housing Goals</h3>
<div id="frm_field_185_container" class="frm_form_field form-field frm_top_container frm_third frm_first"><label for="field_fj0bz" id="field_fj0bz_label" class="frm_primary_label">Current housing status<span
class="frm_required"></span></label><select name="item_meta[185]" id="field_fj0bz" data-sectionid="183" data-invmsg="Current housing status is invalid" aria-invalid="false" aria-required="false">
<option value="" selected="selected"> </option>
<option value="Renting/leasing">Renting/leasing</option>
<option value="Homeowner with mortgage(s)">Homeowner with mortgage(s)</option>
<option value="Homeowner (no mortgage debt)">Homeowner (no mortgage debt)</option>
<option value="Homeless">Homeless</option>
<option value="Living with family/friends">Living with family/friends</option>
</select></div>
<div id="frm_field_186_container" class="frm_form_field form-field frm_top_container vertical_radio">
<div id="field_sv66i_label" class="frm_primary_label">If you are currently renting, please identify your rental status (check all that apply)<span class="frm_required"></span></div>
<div class="frm_opt_container" aria-labelledby="field_sv66i_label" role="group">
<div class="frm_checkbox" id="frm_checkbox_186-183-0"><label for="field_sv66i-0"><input type="checkbox" name="item_meta[186][]" id="field_sv66i-0" value="I pay full rent" data-sectionid="183"
data-invmsg="If you are currently renting, please identify your rental status (check all that apply) is invalid" aria-invalid="false" aria-required="false"> I pay full rent</label></div>
<div class="frm_checkbox" id="frm_checkbox_186-183-1"><label for="field_sv66i-1"><input type="checkbox" name="item_meta[186][]" id="field_sv66i-1" value="I receive a rent subsidy and/or live in public housing" data-sectionid="183"
data-invmsg="If you are currently renting, please identify your rental status (check all that apply) is invalid" aria-invalid="false" aria-required="false"> I receive a rent subsidy and/or live in public housing</label></div>
<div class="frm_checkbox" id="frm_checkbox_186-183-2"><label for="field_sv66i-2"><input type="checkbox" name="item_meta[186][]" id="field_sv66i-2" value="I am a Section 8 recipient" data-sectionid="183"
data-invmsg="If you are currently renting, please identify your rental status (check all that apply) is invalid" aria-invalid="false" aria-required="false"> I am a Section 8 recipient</label></div>
<div class="frm_checkbox" id="frm_checkbox_186-183-3"><label for="field_sv66i-3"><input type="checkbox" name="item_meta[186][]" id="field_sv66i-3" value="I am facing eviction" data-sectionid="183"
data-invmsg="If you are currently renting, please identify your rental status (check all that apply) is invalid" aria-invalid="false" aria-required="false"> I am facing eviction</label></div>
<div class="frm_checkbox" id="frm_checkbox_186-183-4"><label for="field_sv66i-4"><input type="checkbox" name="item_meta[186][]" id="field_sv66i-4" value="I am delinquent with my rent and need assistance" data-sectionid="183"
data-invmsg="If you are currently renting, please identify your rental status (check all that apply) is invalid" aria-invalid="false" aria-required="false"> I am delinquent with my rent and need assistance</label></div>
<div class="frm_checkbox" id="frm_checkbox_186-183-5"><label for="field_sv66i-5"><input type="checkbox" name="item_meta[186][]" id="field_sv66i-5" value="I am delinquent with utilities and need assistance" data-sectionid="183"
data-invmsg="If you are currently renting, please identify your rental status (check all that apply) is invalid" aria-invalid="false" aria-required="false"> I am delinquent with utilities and need assistance</label></div>
</div>
</div>
<div id="frm_field_187_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_nrh0i" id="field_nrh0i_label" class="frm_primary_label">If you are currently renting, how long have you been
renting? (Total months)<span class="frm_required"></span></label><input type="number" id="field_nrh0i" name="item_meta[187]" value="1" data-sectionid="183" data-frmproduct="[]" data-frmval="1" data-invmsg="Quantity is invalid"
aria-invalid="false" min="0" max="9999999" step="1" aria-required="false"></div>
<div id="frm_field_188_container" class="frm_form_field form-field frm_top_container frm_third frm_first vertical_radio">
<div id="field_fv3hp_label" class="frm_primary_label">If you own your property, do you have a mortgage?<span class="frm_required"></span></div>
<div class="frm_opt_container" aria-labelledby="field_fv3hp_label" role="radiogroup" tabindex="0">
<div class="frm_radio" id="frm_radio_188-183-0"><label for="field_fv3hp-0"><input type="radio" name="item_meta[188]" id="field_fv3hp-0" value="Yes" data-sectionid="183"
data-invmsg="If you own your property, do you have a mortgage? is invalid" aria-invalid="false" aria-required="false"> Yes</label></div>
<div class="frm_radio" id="frm_radio_188-183-1"><label for="field_fv3hp-1"><input type="radio" name="item_meta[188]" id="field_fv3hp-1" value="No" data-sectionid="183"
data-invmsg="If you own your property, do you have a mortgage? is invalid" aria-invalid="false" aria-required="false"> No</label></div>
</div>
</div>
<div id="frm_field_189_container" class="frm_form_field form-field frm_top_container frm_third vertical_radio">
<div id="field_dbhxq_label" class="frm_primary_label">Is your mortgage current or delinquent?<span class="frm_required"></span></div>
<div class="frm_opt_container" aria-labelledby="field_dbhxq_label" role="radiogroup" tabindex="0">
<div class="frm_radio" id="frm_radio_189-183-0"><label for="field_dbhxq-0"><input type="radio" name="item_meta[189]" id="field_dbhxq-0" value="Current" data-sectionid="183"
data-invmsg="Is your mortgage current or delinquent? is invalid" aria-invalid="false" aria-required="false"> Current</label></div>
<div class="frm_radio" id="frm_radio_189-183-1"><label for="field_dbhxq-1"><input type="radio" name="item_meta[189]" id="field_dbhxq-1" value="Delinquent" data-sectionid="183"
data-invmsg="Is your mortgage current or delinquent? is invalid" aria-invalid="false" aria-required="false"> Delinquent</label></div>
</div>
</div>
<div id="frm_field_190_container" class="frm_form_field form-field frm_top_container frm_third frm_first"><label for="field_n83q2" id="field_n83q2_label" class="frm_primary_label">Do you receive housing assistance subsidies?<span
class="frm_required"></span></label><select name="item_meta[190]" id="field_n83q2" data-sectionid="183" data-frmval="Yes" data-invmsg="Do you receive housing assistance subsidies? is invalid" aria-invalid="false"
aria-required="false">
<option value="Yes" selected="selected">Yes</option>
<option value="No">No</option>
</select></div>
<div id="frm_field_191_container" class="frm_form_field form-field frm_top_container frm_third"><label for="field_3ihrl" id="field_3ihrl_label" class="frm_primary_label">If yes, please specify type of subsidy:<span
class="frm_required"></span></label><input type="text" id="field_3ihrl" name="item_meta[191]" value="" data-sectionid="183" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_192_container" class="frm_form_field form-field frm_top_container vertical_radio frm_other_container">
<div id="field_3bplg_label" class="frm_primary_label">I am seeking assistance to (check all that apply):<span class="frm_required"></span></div>
<div class="frm_opt_container" aria-labelledby="field_3bplg_label" role="group">
<div class="frm_checkbox" id="frm_checkbox_192-183-0"><label for="field_3bplg-0"><input type="checkbox" name="item_meta[192][]" id="field_3bplg-0" value="Buy a home" data-sectionid="183"
data-invmsg="I am seeking assistance to (check all that apply): is invalid" aria-invalid="false" aria-required="false"> Buy a home</label></div>
<div class="frm_checkbox" id="frm_checkbox_192-183-1"><label for="field_3bplg-1"><input type="checkbox" name="item_meta[192][]" id="field_3bplg-1" value="Prevent foreclosure" data-sectionid="183"
data-invmsg="I am seeking assistance to (check all that apply): is invalid" aria-invalid="false" aria-required="false"> Prevent foreclosure</label></div>
<div class="frm_checkbox" id="frm_checkbox_192-183-2"><label for="field_3bplg-2"><input type="checkbox" name="item_meta[192][]" id="field_3bplg-2" value="Obtain rental housing" data-sectionid="183"
data-invmsg="I am seeking assistance to (check all that apply): is invalid" aria-invalid="false" aria-required="false"> Obtain rental housing</label></div>
<div class="frm_checkbox" id="frm_checkbox_192-183-3"><label for="field_3bplg-3"><input type="checkbox" name="item_meta[192][]" id="field_3bplg-3" value="Increase housing affordability" data-sectionid="183"
data-invmsg="I am seeking assistance to (check all that apply): is invalid" aria-invalid="false" aria-required="false"> Increase housing affordability</label></div>
<div class="frm_checkbox" id="frm_checkbox_192-183-4"><label for="field_3bplg-4"><input type="checkbox" name="item_meta[192][]" id="field_3bplg-4" value="Get credit and budget counseling" data-sectionid="183"
data-invmsg="I am seeking assistance to (check all that apply): is invalid" aria-invalid="false" aria-required="false"> Get credit and budget counseling</label></div>
<div class="frm_checkbox" id="frm_checkbox_192-183-5"><label for="field_3bplg-5"><input type="checkbox" name="item_meta[192][]" id="field_3bplg-5" value="Transition from homelessness" data-sectionid="183"
data-invmsg="I am seeking assistance to (check all that apply): is invalid" aria-invalid="false" aria-required="false"> Transition from homelessness</label></div>
<div class="frm_checkbox" id="frm_checkbox_192-183-other_7"><label for="field_3bplg-other_7"><input type="checkbox" name="item_meta[192][other_7]" id="field_3bplg-other_7" value="Other" data-sectionid="183"
data-invmsg="I am seeking assistance to (check all that apply): is invalid" aria-invalid="false" aria-required="false"> Other</label><label for="field_3bplg-other_7-otext" class="frm_screen_reader frm_hidden">Other</label><input
type="text" id="field_3bplg-other_7-otext" class="frm_other_input frm_pos_none" name="item_meta[other][192][other_7]" value="" aria-required="false"></div>
</div>
</div>
</div>
<div id="frm_field_228_container" class="frm_form_field frm_section_heading form-field frm12 frm_first" style="display: none;">
<h3 class="frm_pos_top frm_section_spacing">Income and Average Monthly Expenses</h3>
<div id="frm_field_233_container" class="frm_form_field frm6 frm12 frm_first frm_html_container form-field">Please list all applicable income.</div>
<div id="frm_field_362_container" class="frm_form_field form-field frm_top_container frm12 frm_first frm_other_container"><label for="field_duci0" id="field_duci0_label" class="frm_primary_label">How often do you receive income?<span
class="frm_required"></span></label><select name="item_meta[362]" id="field_duci0" data-sectionid="228" data-invmsg="How often do you receive income? is invalid" aria-invalid="false" aria-required="false">
<option value="" selected="selected"> </option>
<option value="Temporary/seasonal">Temporary/seasonal</option>
<option value="Weekly" class="frm_other_trigger">Weekly</option>
<option value="Bi-Weekly">Bi-Weekly</option>
<option value="Monthly">Monthly</option>
<option value="Bi-Monthly">Bi-Monthly</option>
<option value="Annually">Annually</option>
</select><label for="field_duci0-otext" class="frm_screen_reader frm_hidden">How often do you receive income?</label><input type="text" id="field_duci0-otext" class="frm_other_input frm_pos_none" name="item_meta[other][362]" value=""
aria-required="false"></div>
<div id="frm_field_230_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_vrj12" id="field_vrj12_label" class="frm_primary_label">Salary/Wage Earnings<span
class="frm_required"></span></label><input type="text" id="field_vrj12" name="item_meta[230]" value="" data-sectionid="228" placeholder="Gross (Before taxes)" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false">
</div>
<div id="frm_field_231_container" class="frm_form_field form-field frm_hidden_container frm_fourth"><label for="field_6gzqn" id="field_6gzqn_label" class="frm_primary_label">Salary/Wage Earnings<span
class="frm_required"></span></label><input type="text" id="field_6gzqn" name="item_meta[231]" value="" data-sectionid="228" placeholder="Net (After taxes)" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false">
</div>
<div id="frm_field_271_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_x86nd" id="field_x86nd_label" class="frm_primary_label">Rental Income<span
class="frm_required"></span></label><input type="text" id="field_x86nd" name="item_meta[271]" value="" data-sectionid="228" placeholder="Gross (Before taxes)" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false">
</div>
<div id="frm_field_234_container" class="frm_form_field form-field frm_hidden_container frm_fourth"><label for="field_wfb0s" id="field_wfb0s_label" class="frm_primary_label">Rental Income<span class="frm_required"></span></label><input
type="text" id="field_wfb0s" name="item_meta[234]" value="" data-sectionid="228" placeholder="Net (After taxes)" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_272_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_lizhw" id="field_lizhw_label" class="frm_primary_label">Child support/Alimony<span
class="frm_required"></span></label><input type="text" id="field_lizhw" name="item_meta[272]" value="" data-sectionid="228" placeholder="Gross (Before taxes)" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false">
</div>
<div id="frm_field_273_container" class="frm_form_field form-field frm_hidden_container frm_fourth"><label for="field_pahmp" id="field_pahmp_label" class="frm_primary_label">Child support/Alimony<span
class="frm_required"></span></label><input type="text" id="field_pahmp" name="item_meta[273]" value="" data-sectionid="228" placeholder="Net (After taxes)" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false">
</div>
<div id="frm_field_274_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_re3zw" id="field_re3zw_label" class="frm_primary_label">Social Security<span
class="frm_required"></span></label><input type="text" id="field_re3zw" name="item_meta[274]" value="" data-sectionid="228" placeholder="Gross (Before taxes)" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false">
</div>
<div id="frm_field_275_container" class="frm_form_field form-field frm_hidden_container frm_fourth"><label for="field_5sowi" id="field_5sowi_label" class="frm_primary_label">Social Security<span class="frm_required"></span></label><input
type="text" id="field_5sowi" name="item_meta[275]" value="" data-sectionid="228" placeholder="Net (After taxes)" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_276_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_6ubn7" id="field_6ubn7_label" class="frm_primary_label">Pension<span class="frm_required"></span></label><input
type="text" id="field_6ubn7" name="item_meta[276]" value="" data-sectionid="228" placeholder="Gross (Before taxes)" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_277_container" class="frm_form_field form-field frm_hidden_container frm_fourth"><label for="field_wq58g" id="field_wq58g_label" class="frm_primary_label">Pension<span class="frm_required"></span></label><input
type="text" id="field_wq58g" name="item_meta[277]" value="" data-sectionid="228" placeholder="Net (After taxes)" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_278_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_qbcu4" id="field_qbcu4_label" class="frm_primary_label">Dependent SSI Income<span
class="frm_required"></span></label><input type="text" id="field_qbcu4" name="item_meta[278]" value="" data-sectionid="228" placeholder="Gross (Before taxes)" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false">
</div>
<div id="frm_field_279_container" class="frm_form_field form-field frm_hidden_container frm_fourth"><label for="field_9mj8j" id="field_9mj8j_label" class="frm_primary_label">Dependent SSI Income<span
class="frm_required"></span></label><input type="text" id="field_9mj8j" name="item_meta[279]" value="" data-sectionid="228" placeholder="Net (After taxes)" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false">
</div>
<div id="frm_field_280_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_v6jz5" id="field_v6jz5_label" class="frm_primary_label">Disability Income<span
class="frm_required"></span></label><input type="text" id="field_v6jz5" name="item_meta[280]" value="" data-sectionid="228" placeholder="Gross (Before taxes)" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false">
</div>
<div id="frm_field_281_container" class="frm_form_field form-field frm_hidden_container frm_fourth"><label for="field_a4lyi" id="field_a4lyi_label" class="frm_primary_label">Disability Income<span class="frm_required"></span></label><input
type="text" id="field_a4lyi" name="item_meta[281]" value="" data-sectionid="228" placeholder="Net (After taxes)" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_284_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_mmu7l" id="field_mmu7l_label" class="frm_primary_label">Unemployment Income<span
class="frm_required"></span></label><input type="text" id="field_mmu7l" name="item_meta[284]" value="" data-sectionid="228" placeholder="Gross (Before taxes)" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false">
</div>
<div id="frm_field_283_container" class="frm_form_field form-field frm_hidden_container frm_fourth"><label for="field_iiw61" id="field_iiw61_label" class="frm_primary_label">Unemployment Income<span
class="frm_required"></span></label><input type="text" id="field_iiw61" name="item_meta[283]" value="" data-sectionid="228" placeholder="Net (After taxes)" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false">
</div>
<div id="frm_field_285_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_apq7s" id="field_apq7s_label" class="frm_primary_label">Public Assistance Income<span
class="frm_required"></span></label><input type="text" id="field_apq7s" name="item_meta[285]" value="" data-sectionid="228" placeholder="Gross (Before taxes)" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false">
</div>
<div id="frm_field_286_container" class="frm_form_field form-field frm_hidden_container frm_fourth"><label for="field_m08v1" id="field_m08v1_label" class="frm_primary_label">Public Assistance Income<span
class="frm_required"></span></label><input type="text" id="field_m08v1" name="item_meta[286]" value="" data-sectionid="228" placeholder="Net (After taxes)" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false">
</div>
<div id="frm_field_287_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_yvmbe" id="field_yvmbe_label" class="frm_primary_label">Other<span class="frm_required"></span></label><input
type="text" id="field_yvmbe" name="item_meta[287]" value="" data-sectionid="228" placeholder="Gross (Before taxes)" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_288_container" class="frm_form_field form-field frm_hidden_container frm_fourth"><label for="field_2uei3" id="field_2uei3_label" class="frm_primary_label">Other<span class="frm_required"></span></label><input type="text"
id="field_2uei3" name="item_meta[288]" value="" data-sectionid="228" placeholder="Net (After taxes)" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
</div>
<div id="frm_field_289_container" class="frm_form_field frm_section_heading form-field " style="display: none;">
<h3 class="frm_pos_top frm_section_spacing">Monthly Expenses (Please List All Applicable Expenses)</h3>
<div id="frm_field_295_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_xuxbo" id="field_xuxbo_label" class="frm_primary_label">Rent/Mortgage<span
class="frm_required"></span></label><input type="text" id="field_xuxbo" name="item_meta[295]" value="" data-sectionid="289" placeholder="Monthly Payment" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_296_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_o5d8a" id="field_o5d8a_label" class="frm_primary_label">Car Payment<span
class="frm_required"></span></label><input type="text" id="field_o5d8a" name="item_meta[296]" value="" data-sectionid="289" placeholder="Monthly Payment" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_297_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_4assa" id="field_4assa_label" class="frm_primary_label">Car Insurance<span
class="frm_required"></span></label><input type="text" id="field_4assa" name="item_meta[297]" value="" data-sectionid="289" placeholder="Monthly Payment" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_298_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_8rwi3" id="field_8rwi3_label" class="frm_primary_label">Credit Cards<span
class="frm_required"></span></label><input type="text" id="field_8rwi3" name="item_meta[298]" value="" data-sectionid="289" placeholder="Monthly Payment" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_299_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_3bvsv" id="field_3bvsv_label" class="frm_primary_label">Child Care<span class="frm_required"></span></label><input
type="text" id="field_3bvsv" name="item_meta[299]" value="" data-sectionid="289" placeholder="Monthly Payment" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_300_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_ds7s1" id="field_ds7s1_label" class="frm_primary_label">Alimony/Child Support<span
class="frm_required"></span></label><input type="text" id="field_ds7s1" name="item_meta[300]" value="" data-sectionid="289" placeholder="Monthly Payment" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_301_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_4uni4" id="field_4uni4_label" class="frm_primary_label">School Tuition<span
class="frm_required"></span></label><input type="text" id="field_4uni4" name="item_meta[301]" value="" data-sectionid="289" placeholder="Monthly Payment" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_302_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_qtdx6" id="field_qtdx6_label" class="frm_primary_label">Medical Payments<span
class="frm_required"></span></label><input type="text" id="field_qtdx6" name="item_meta[302]" value="" data-sectionid="289" placeholder="Monthly Payment" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_303_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_52ww6" id="field_52ww6_label" class="frm_primary_label">Transportation (i.e. gas, bus, ride-share)<span
class="frm_required"></span></label><input type="text" id="field_52ww6" name="item_meta[303]" value="" data-sectionid="289" placeholder="Monthly Payment" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_304_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_sm1c3" id="field_sm1c3_label" class="frm_primary_label">Water<span class="frm_required"></span></label><input
type="text" id="field_sm1c3" name="item_meta[304]" value="" data-sectionid="289" placeholder="Monthly Payment" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_305_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_o3vvb" id="field_o3vvb_label" class="frm_primary_label">Electricity<span
class="frm_required"></span></label><input type="text" id="field_o3vvb" name="item_meta[305]" value="" data-sectionid="289" placeholder="Monthly Payment" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_306_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_as3sv" id="field_as3sv_label" class="frm_primary_label">Gas (Utilities)<span
class="frm_required"></span></label><input type="text" id="field_as3sv" name="item_meta[306]" value="" data-sectionid="289" placeholder="Monthly Payment" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_307_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_sfi76" id="field_sfi76_label" class="frm_primary_label">Cable/Streaming Service<span
class="frm_required"></span></label><input type="text" id="field_sfi76" name="item_meta[307]" value="" data-sectionid="289" placeholder="Monthly Payment" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_308_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_jni9i" id="field_jni9i_label" class="frm_primary_label">Cell Phone<span class="frm_required"></span></label><input
type="text" id="field_jni9i" name="item_meta[308]" value="" data-sectionid="289" placeholder="Monthly Payment" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_309_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_bsh31" id="field_bsh31_label" class="frm_primary_label">Food-groceries<span
class="frm_required"></span></label><input type="text" id="field_bsh31" name="item_meta[309]" value="" data-sectionid="289" placeholder="Monthly Payment" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_310_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_diy8j" id="field_diy8j_label" class="frm_primary_label">Food-dining out<span
class="frm_required"></span></label><input type="text" id="field_diy8j" name="item_meta[310]" value="" data-sectionid="289" placeholder="Monthly Payment" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_311_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_th3m4" id="field_th3m4_label" class="frm_primary_label">Student Loan Payments<span
class="frm_required"></span></label><input type="text" id="field_th3m4" name="item_meta[311]" value="" data-sectionid="289" placeholder="Monthly Payment" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_312_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_43jr8" id="field_43jr8_label" class="frm_primary_label">Tithing/Charitable Donations<span
class="frm_required"></span></label><input type="text" id="field_43jr8" name="item_meta[312]" value="" data-sectionid="289" placeholder="Monthly Payment" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_313_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_xvvla" id="field_xvvla_label" class="frm_primary_label">Other<span class="frm_required"></span></label><input
type="text" id="field_xvvla" name="item_meta[313]" value="" data-sectionid="289" placeholder="Monthly Payment" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
</div>
<div id="frm_field_314_container" class="frm_form_field frm_section_heading form-field " style="display: none;">
<h3 class="frm_pos_top frm_section_spacing">Assets (Please List All Applicable Assets)</h3>
<div id="frm_field_316_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_w8dp2" id="field_w8dp2_label" class="frm_primary_label">Home<span class="frm_required"></span></label><input
type="text" id="field_w8dp2" name="item_meta[316]" value="" data-sectionid="314" placeholder="Value" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_317_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_ogbfg" id="field_ogbfg_label" class="frm_primary_label">Vehicle<span class="frm_required"></span></label><input
type="text" id="field_ogbfg" name="item_meta[317]" value="" data-sectionid="314" placeholder="Value" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_318_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_rndpe" id="field_rndpe_label" class="frm_primary_label">401k/Retirement<span
class="frm_required"></span></label><input type="text" id="field_rndpe" name="item_meta[318]" value="" data-sectionid="314" placeholder="Value" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_319_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_p0l8m" id="field_p0l8m_label" class="frm_primary_label">Recreational Vehicles<span
class="frm_required"></span></label><input type="text" id="field_p0l8m" name="item_meta[319]" value="" data-sectionid="314" placeholder="Value" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_320_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_dlcmm" id="field_dlcmm_label" class="frm_primary_label">Checking Account(s)<span
class="frm_required"></span></label><input type="text" id="field_dlcmm" name="item_meta[320]" value="" data-sectionid="314" placeholder="Value" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_321_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_924t" id="field_924t_label" class="frm_primary_label">Savings Account(s)<span
class="frm_required"></span></label><input type="text" id="field_924t" name="item_meta[321]" value="" data-sectionid="314" placeholder="Value" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_322_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_5hfxt" id="field_5hfxt_label" class="frm_primary_label">Rental Property(s)<span
class="frm_required"></span></label><input type="text" id="field_5hfxt" name="item_meta[322]" value="" data-sectionid="314" placeholder="Value" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
<div id="frm_field_323_container" class="frm_form_field form-field frm_top_container frm_fourth frm_first"><label for="field_1nump" id="field_1nump_label" class="frm_primary_label">Other<span class="frm_required"></span></label><input
type="text" id="field_1nump" name="item_meta[323]" value="" data-sectionid="314" placeholder="Value" data-invmsg="Text is invalid" aria-invalid="false" aria-required="false"></div>
</div>
<div id="frm_field_324_container" class="frm_form_field form-field frm_top_container"><label for="field_ub3qs" id="field_ub3qs_label" class="frm_primary_label">Is there anything else you want to share about your financial situation?<span
class="frm_required"></span></label><input type="text" id="field_ub3qs" name="item_meta[324]" value="" data-invmsg="Text is invalid" aria-invalid="false"></div>
<div id="frm_field_348_container" class="frm_form_field frm_html_container form-field">
<h2>Horizons' Statement of Counseling Services, Privacy Policy, and Fee Schedule</h2>
</div>
<div id="frm_field_340_container" class="frm_form_field frm_section_heading form-field ">
<h3 class="frm_pos_top frm_section_spacing">Statement of Counseling</h3>
<div id="frm_field_342_container" class="frm_form_field frm_scroll_box frm_html_container form-field"><img decoding="async" src="https://horizonsfamily.org/wp-content/uploads/2020/07/Statement-of-Counseling_Page_1-e1595523607568.jpg"
alt="Statement_of_Counseling_Page_1"> <img decoding="async" src="https://horizonsfamily.org/wp-content/uploads/2020/07/Statement-of-Counseling_Page_2-e1595523593919.jpg" alt="Statement_of_Counseling_Page_2"></div>
</div>
<div id="frm_field_357_container" class="frm_form_field frm_section_heading form-field ">
<h3 class="frm_pos_top frm_section_spacing">Privacy Policy</h3>
<div id="frm_field_343_container" class="frm_form_field frm_scroll_box frm_html_container form-field"><img decoding="async" src="https://horizonsfamily.org/wp-content/uploads/2020/07/Horizons-Privacy-Policy-002-e1595523373741.jpg"
alt="Privacy_Policy"> </div>
</div>
<div id="frm_field_359_container" class="frm_form_field frm_section_heading form-field ">
<h3 class="frm_pos_top frm_section_spacing">Fee Schedule</h3>
<div id="frm_field_344_container" class="frm_form_field frm_scroll_box frm_html_container form-field"><img decoding="async" src="https://horizonsfamily.org/wp-content/uploads/2020/07/Fee-Schedule-e1595531409899.jpg" alt="Fee_Schedule">
</div>
</div>
<div id="frm_field_328_container" class="frm_form_field frm_section_heading form-field ">
<h3 class="frm_pos_top frm_section_spacing">By signing and dating below, I confirm that I have received a copy of Horizons' Statement of Counseling Services, Privacy Policy, and Fee Schedule.</h3>
<div id="frm_field_326_container" class="frm_form_field form-field frm_top_container frm_first frm_sixth"><label for="field_cdzp6" id="field_cdzp6_label" class="frm_primary_label">Date<span class="frm_required"></span></label><input
type="text" id="field_cdzp6" name="item_meta[326]" value="08/29/2023" data-sectionid="328" maxlength="10" data-frmval="08/29/2023" data-invmsg="Date is invalid" class="frm_date" aria-invalid="false"></div>
<div id="frm_field_236_container" class="frm_form_field form-field frm_top_container frm_half frm_first"><label for="field_812xa" id="field_812xa_label" class="frm_primary_label">Signature<span class="frm_required"></span></label>
<div class="sigPad" id="sigPad236" style="max-width:400px;">
<div class="sig sigWrapper"
style="height:150px;border-color:#cccccc;--bg-color:#ffffff;--active:#008ec2;--inactive:#dddddd;--active-text:#ffffff;--inactive-text:#ffffff;--button-margin:22px;--button-size:20px;--button-padding:10px;--button-side-margin:22px;--icon:20px">
<ul class="sigNav">
<li class="drawIt"><a href="#" class="frm-active-sig-type" title="Draw It" aria-label="Draw It"><i class="frm_icon_font frm_signature_icon" aria-hidden=""></i></a></li>
<li class="typeIt"><a href="#" class="" title="Type It" aria-label="Type It"><i class="frm_icon_font frm_keyboard_icon" aria-hidden=""></i></a></li>
</ul><span class="frm-typed-drawline" style="height: 1px; background-color: rgb(204, 204, 204);"></span>
<div class="typed" style="visibility: hidden;"><input type="text" name="item_meta[236][typed]" class="name" id="field_812xa" autocomplete="off" value="" data-sectionid="328" style="width:400px" maxlength="150" aria-invalid="false">
</div><canvas class="pad" data-fieldid="236" data-fieldname="item_meta[236]" width="396" height="150" style="touch-action: none; user-select: none; visibility: visible;"></canvas>
<div class="clearButton" style="visibility: visible;"><a href="#clear">Clear</a></div><input type="hidden" name="item_meta[236][output]" class="output" value="">
</div>
</div>
</div>
</div>
<div id="frm_field_1127_container" class="frm_form_field frm_html_container form-field">
<script>
console.log("wut");
jQuery(document).ready(function() {
jQuery(window).keydown(function(event) {
if (event.keyCode == 13) {
event.preventDefault();
return false;
}
});
});
</script>
</div>
<div id="frm_field_710_container" class="frm_form_field form-field frm_none_container"><label for="g-recaptcha-response" id="field_psie9_label" class="frm_primary_label">reCAPTCHA<span class="frm_required"></span></label>
<div id="field_psie9" class="frm-g-recaptcha" data-sitekey="6LfKgQAVAAAAAKB6TKU9pGYR5J_oQBxJ3xA4w-2q" data-size="invisible" data-theme="light" data-rid="1">
<div class="grecaptcha-badge" data-style="none" style="width: 256px; height: 60px; position: fixed; visibility: hidden;">
<div class="grecaptcha-logo"><iframe title="reCAPTCHA"
src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6LfKgQAVAAAAAKB6TKU9pGYR5J_oQBxJ3xA4w-2q&co=aHR0cHM6Ly9ob3Jpem9uc2ZhbWlseS5vcmc6NDQz&hl=en&v=0hCdE87LyjzAkFO5Ff-v7Hj1&theme=light&size=invisible&cb=gp8yvkgohzm"
width="256" height="60" role="presentation" name="a-mt7s4oqqk4jj" frameborder="0" scrolling="no"
sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox"></iframe></div>
<div class="grecaptcha-error"></div><textarea id="g-recaptcha-response-1" name="g-recaptcha-response" class="g-recaptcha-response"
style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div>
</div>
</div><input type="hidden" name="item_key" value="">
<div class="frm_verify" aria-hidden="true"><label for="frm_email_11">If you are human, leave this field blank.</label><input type="text" class="frm_verify" id="frm_email_11" name="frm_verify" value=""></div><input name="frm_state"
type="hidden" value="CPuP505u6p4gkSC7/wk4qe4mFxn1vBs4AYcM0XZxBv4=">
<div class="frm_submit"><button class="frm_button_submit frm_final_submit" type="submit" formnovalidate="formnovalidate">Submit</button></div>
</div>
</fieldset>
</div>
<p style="display: none !important;"><label>Δ<textarea name="ak_hp_textarea" cols="45" rows="8" maxlength="100"></textarea></label><input type="hidden" id="ak_js_2" name="ak_js" value="1693391835991">
<script>
document.getElementById("ak_js_2").setAttribute("value", (new Date()).getTime());
</script>
</p>
</form>POST
<form enctype="multipart/form-data" method="post" class="frm-show-form frm_pro_form " id="form_moneyinmotion">
<div class="frm_form_fields ">
<fieldset>
<legend class="frm_screen_reader">money in motion popup</legend>
<div class="frm_fields_container">
<input type="hidden" name="frm_action" value="create">
<input type="hidden" name="form_id" value="9">
<input type="hidden" name="frm_hide_fields_9" id="frm_hide_fields_9" value="["frm_field_107_container"]">
<input type="hidden" name="form_key" value="moneyinmotion">
<input type="hidden" name="item_meta[0]" value="">
<input type="hidden" id="frm_submit_entry_9" name="frm_submit_entry_9" value="0d7a3a76be"><input type="hidden" name="_wp_http_referer" value="/">
<div id="frm_field_1174_container" class="frm_form_field frm_html_container form-field">Click <a href="https://horizonsfamily.org/wp-content/uploads/2021/06/Predischarge-Document-Download.pdf" target="_blank">Here</a> to download the above
disclosures.</div>
<div id="frm_field_105_container" class="frm_form_field frm_section_heading form-field ">
<h3 class="frm_pos_top frm_section_spacing">Bankruptcy Education Disclosure</h3>
<div id="frm_field_101_container" class="frm_form_field frm_html_container form-field">
<div class="popup-disclosure"><img decoding="async" src="/wp-content/uploads/2021/06/BANKRUPTCY-DEBTOR-EDUCATION-DISCLOSURE.jpg"></div>
</div>
<div id="frm_field_102_container" class="frm_form_field form-field frm_top_container vertical_radio">
<div id="field_m7p4e2_label" class="frm_primary_label">
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A FAMILY SERVICE ALLIANCE
HORIZONS’ MISSION IS TO INSTILL HOPE, STRENGTHEN COMMUNITIES, AND BRIGHTEN
FUTURES BY PROVIDING LIFE CHANGING SERVICES TO UNDER SERVED POPULATIONS.
#BETTERTOGETHER
Go to our News & Events page to register, donate, and participate in program
events!
Visit these local businesses donating proceeds from their sales to Horizons.
Current Volunteer Vicnet Portal
If you are looking for volunteer opportunities at Horizons please complete this
Volunteer Application and consider the following:
* Hot Meal Drivers: We’ve returned to a daily hot meal Monday through Friday
from 10:45-11:45 a.m. and need your help delivering a regular route weekly or
bi-weekly.
* Substitute Drivers: Can’t commit to a regular volunteer schedule? No problem,
opt in to our sub list!
* Breakfast Bag Drivers: Help deliver a week’s worth of breakfast foods to food
insecure seniors! Pickup times are between 8:00 – 10:00 a.m. and may require
a larger vehicle.
* Iowa City Commuters: Help us transport food Monday – Friday between 9:00 –
10:30 a.m. between our Cedar Rapids kitchen and our Coralville office!
TRANSPORTATION
Transportation should not be a barrier to employment
NTS Rules
Frequently Asked Questions
Via Ride Service
01.
TRANSPORTATION
Transportation should not be a barrier to employment.
NTS Rules
Frequently Asked Questions
Via Ride Service
FINANCIAL HEALTH & WELLNESS
Improving the financial capability of those seeking services, as well as raise
the level of financial stability in the community.
* Budget & Credit Counseling Programs
* Online Financial Education
* Home Buyer Education
02.
FINANCIAL HEALTH & WELLNESS
Improving the financial capability of those seeking services, as well as raise
the level of financial stability in the community.
* Student Loan Counseling
* Budget & Credit Counseling Programs
* Online Financial Education
* Home Buyer Education
MEALS ON WHEELS
Food is essential to well-being and it is important that everyone has access to
food that is fresh and nutritious. Horizons strives to meet this goal through
our Community Health & Nutrition Programs. One key program is Meals on Wheels,
helping older adults and persons with disabilities meet their daily nutritional
needs.
Referral Form
Volunteer
03.
MEALS ON WHEELS
Food is essential to well-being and it is important that everyone has access to
food that is fresh and nutritious. Horizons strives to meet this goal through
our Community Health & Nutrition Programs. One key program is Meals on Wheels,
helping older adults and persons with disabilities meet their daily nutritional
needs.
Lunchbox Fundraiser
Referral Form
Volunteer or Donate
CONTACT US
Horizons Family Services
819 5th St SE
PO Box 667
Cedar Rapids, IA 52406-0667
Phone: 319-398-3943 | 877-653-3123
Fax: 319-398-3577 | 877-453-2775
*
*
*
PROGRAMS
Transportation
Financial Health & Wellness
Meals on Wheels
Meals on Wheels of Johnson County
GET INVOLVED
Donate
Volunteer
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Meals on Wheels Delivery Volunteer Application
HORIZONS VOLUNTEER APPLICATION
Thank you for your interest in volunteering with Horizons! We appreciate you
taking the time to fill out this application. The information you provide will
assist us in placing you in an appropriate volunteer opportunity that will match
your skills and interest.
The following application includes:
1. Volunteer Application & Experience Forms
2. Media Release, Etc. Form
3. Criminal History Background Check
4. Volunteer Waiver & Release Form
5. State of Residence Other Than Iowa
6. Disclosure of Information Form
All volunteers must be 18 or older or accompanied by an adult.
We implement appropriate data collection, storage and processing practices and
security measures to protect against unauthorized access, alteration, disclosure
or destruction of your Personal Information and data stored on our Site. For
example, we use security measures such as data encryption, SSL secure link usage
and password protection where applicable.
PERSONAL INFORMATION
Last Name
First Name
Address
Address
Address
Address
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Date of Birth
Home Phone
Cell Phone
Best Time To Call MorningAfternoonEvening
Can We Text You? YesNo
Email
Would You Like To Receive Our Newsletter?
Yes
No
Emergency Contact
Name
Phone
Relationship
For Office Use Only
Referred By, Assignment, and Start Date Required
VOLUNTEER OPPORTUNITIES AND DESCRIPTIONS
Area of Volunteer Interest
Financial Wellness
Meals on Wheels
Administration Support
Special Events
VOLUNTEER EXPERIENCE
Summarize any special talents, skills, hobbies, and qualifications you have:
List organizations in your community that you are involved with, your
responsibilities, and reason for leaving:
Organizations including, clubs, schools. professional associations, religious
organizations, non-profit organizations, sporting organizations, etc.
If presently employed, name employer
Are you a student? YesNo
Do you need hours for community service? YesNo
If yes, how many hours?
Is this for a legal matter? YesNo
How many hours per week would you like to volunteer?
Days Available to Volunteer
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
MEDIA RELEASE, ETC. FORM
Please check each box to confirm the statements below:
Media Release
I consent to Horizons or its assignee to be allowed to use my name or likenesses
of me, including photographs, video, and/or quotations of my remarks for public
distribution, including published articles and promotional pieces.
Confidentiality
I understand that I may be in a position to view or overhear personal or medical
information regarding some of the agency’s clients. In keeping with the
professional standards and ethics of Horizons, I will consider all client
information to be strictly confidential and, therefore, not to be shared with or
discussed with any unauthorized person, either inside or outside the agency.
Driver's License
I declare that I have a valid Iowa Driver’s License and that I maintain
liability insurance for operating a vehicle.
Non-Solicitation Policy
The promotion of an individual person, their business/company or religion they
represent is prohibited. The use of volunteering to directly or indirectly
solicit or prospect for financial gain is strictly prohibited. This includes
announcements of fee or free networking opportunities that ultimately lead to a
solicitation. We do not allow solicitation of our clients at any time. You are
fully responsible for your conduct and could be asked not to return to the
agency.
Our Policies
It is the policy of this organization to provide equal opportunity without
regard to race, color, religion, national origin, gender, sexual preference,
age, or disability. It is the policy of Horizons, A Family Service Alliance, to
make every reasonable effort to provide a safe environment for our clients.
Therefore, the agency requires a criminal background check be completed on all
volunteers. Any criminal activity discovered may deem the applicant unable to
volunteer for the agency.
Agreement and Signature
By submitting this application, I affirm that the facts set forth in this
application are true and complete to the best of my knowledge.
Date
Signature
*
*
Clear
VOLUNTEER WAIVER, RELEASE, HOLD HARMLESS AND INDEMNIFICATION AGREEMENT
I have agreed to serve as a volunteer for the Horizons, A Family Service
Alliance, and I recognize that my volunteer participation is a privilege
afforded to me by the Horizons, A Family Service Alliance. I fully understand,
appreciate and assume all of the risks associated with my volunteer duties. In
exchange for my participation, I hereby agree to the following:
1. I voluntarily waive, release and hold harmless the Horizons, A Family Service
Alliance, its elected and appointed officials, officers, employees, agents and
other volunteers from any and all claims, causes of action and damages for
bodily injury or death that I may suffer as a result of, or in any manner
connected with, directly or indirectly, my participation as a Horizons, A Family
Service Alliance volunteer when such bodily injury or death is the result of my
own negligent or intentional acts or omissions or those of another volunteer. I
understand that this waiver and release precludes my right to recovery of
damages in the event I am injured in the course of performing my volunteer
duties.
2. I shall defend, hold harmless and indemnify the Horizons, A Family Service
Alliance, its elected and appointed officials, officers, employees, agents and
other volunteers, from and against all damages, claims, liabilities, causes of
action, judgments, settlements, costs and expenses (including, but not limited
to, reasonable expert witness and attorney fees) that may at any time arise or
be claimed by any person as a result of bodily injury, death or property damage,
or as a result of any other claim or cause of action of any nature whatsoever,
arising from or in any manner connected with, directly or indirectly, my
negligent or intentional acts or omissions in performing my volunteer duties.
I have read, fully understand and agree to the assumption of risk, waiver,
release, hold harmless and indemnification terms set forth above.
Date
Volunteer Name
Volunteer Signature
*
*
Clear
NOTE: If the volunteer is under 18 years of age, a parent or legal guardian must
sign this agreement on behalf of the volunteer
Date
Name of Parent or Legal Guardian
Signature
*
*
Clear
CRIMINAL HISTORY BACKGROUND CHECK
Relationship: Employer Screening as specified in Chapter 237 of the Iowa Code.
Complete and return to Human Resources. Please allow minimum 24 hours to
process. The results will be e-mailed to the employee requesting the background
check. If further investigation is required by the D.C.I., allow 5-7 business
days for the results.
If a criminal, dependent adult abuse, or child abuse conviction is reported by
the D.C.I., additional investigation is required by the Department of Human
Services. Allow 30 days for the results.
AN IOWA CRIMINAL HISTORY CHECK AND REGISTRY INFORMATION IS BEING REQUESTED ON:
Last Name
First Name
Middle Initial
Maiden Name
Alias or Previous Married Names
Social Security Number
Date of Birth
Sex MaleFemaleOther Sex
Paid
Volunteer
I hereby give permission for the above requesting organization to conduct an
Iowa Criminal History, Dependent Adult and Child Abuse Registry check with the
Division of Criminal Investigation. Any information maintained by the DCI may be
released as allowed by law.
Date
Signature
*
*
Clear
TO BE COMPLETED BY HORIZONS EMPLOYEE Employee & Dept Requesting Check:
Position/Job Duties of Above Person: Date Requested: Date Received by HR:
STATES OF RESIDENCE OTHER THAN IOWA
Horizons employment policy is to process criminal, dependent adult and child
abuse background checks on all prospective employees. If a candidate has lived
outside the state of Iowa in the past three years background checks will be
requested in the states where the candidate has resided.
Please complete the following information from the time you turned 18.
Last Name
First Name
Middle Initial
I hereby give permission for the above requesting organization to conduct a
Criminal History, Child Abuse and Dependent Adult Abuse Registry check with the
Division of Criminal Investigation for the residence states listed below. If
this form is not acceptable by any/all of the states for authorization to
process a background check, I agree to complete and return the required forms
for that state(s).
Date
Signature
*
*
Clear
State(s) of Residence:
Only Iowa
Other
If other, list state and dates of residence, and name used:
DISCLOSURE OF INFORMATION
It is the policy of Horizons, A Family Service Alliance to provide a safe,
helping environment and service for our clients. Therefore, the Agency requires
that criminal, child abuse and dependent adult abuse record checks and any other
background information be completed on all who are considered for employment,
internship, or volunteering at Horizons. Please complete the information below
by checking the appropriate statement and adding additional information
required.
Please note that charges that have been deferred will be visible in a criminal
background history report as will non-convictions.
I hereby state that I have NEVER been CHARGED and/or CONVICTED by any law, in
any State, of commission of any criminal act, including but not limited to,
operating a motor vehicle under the influence (OMVI/DWI), any lascivious act
involving a child or dependent adult, child or dependent adult abuse, neglect,
or endangerment.
I hereby state that I have been charged and/or convicted by the law(s) of the
following State(s) of the action(s) described below.
I hereby state that I have charges pending involving a criminal act as described
below.
I understand that I am required to disclose this information. I further
understand that falsification of this information is grounds for dismissal. If I
begin working or volunteering at Horizons, A Family Service Alliance, I
understand that I must advise the agency of additional convictions and complete
appropriate paperwork.
Date
Signature
*
*
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Financial Wellness Client Intake Form
FINANCIAL WELLNESS CLIENT INTAKE FORM
How did you hear about us? HUD SearchPrint/Radio ADBank/mortgage
servicerReligious OrgInternet SearchFriend/FamilyOther (specify)
Other
Are you interested in:*
Student Loan Counseling
Budget and Credit Counseling
Housing Counseling
BIOGRAPHIC & DEMOGRAPHIC INFO
Head of Household Full Name
First
Head of Household Full Name
Last
Email
Partner/Spouse Name (If Applicable)
First
Partner/Spouse Name (If Applicable)
Last
Address
Address
Street Address
Street Address
Street Address Line 2
Street Address Line 2
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
County
Cell Phone Number
Alternate Phone Number
Do we have permission to text message with appt. reminders or other information?
Yes
No
Email
Date of Birth
Preferred Contact Method:
Cell Phone
Email
Alternate Phone
Marital Status
Single
Married
Divorced
Separated
Widow
Head of Household Race
American Indian/Alaskan Native
Asian
African-American
Native Hawaiian/Pacific Islander
White
Biracial/Multiracial
Prefer not to identify
OtherOther
Partner/Spouse Race (if applicable):
American Indian/Alaskan Native
Asian
African-American
Native Hawaiian/Pacific Islander
White
Biracial/Multiracial
Prefer not to identify
OtherOther
Head of Household Ethnicity
Hispanic
Non-Hispanic
Prefer not to identify
Partner/Spouse Ethnicity
Hispanic
Non-Hispanic
Prefer not to identify
Are you a veteran? YesNoPrefer not to identify
Are you disabled? YesNoPrefer not to identify
What is your highest level of completed education? Grade SchoolMiddleHigh
SchoolTwo Year DegreeFour Year DegreeAdvanced Degree
Household Type Single AdultSingle male-headed household with dependentsSingle
female-headed household with dependentsMarried adults without dependentsMarried
with dependentsRoommates/unrelated adultsLiving with non-spousal family members
(parents, siblings, etc...)OtherHousehold Type
Total number of adults in your household
Total number of children in your household
Please list your household's primary languages.
Do you want an interpreter for services?
Yes
No
If an interpreter is desired, what kind of interpretation do you need?
EMPLOYMENT INFORMATION
Employment Status Employed full-timeEmployed part-timeEmployed
seasonallyUnemployed, receiving benefitsUnemployed, receiving no
benefitsSelf-employedDisabled, receiving benefitsRetiredOther
(specify)Employment Status
Name of Employer
How long have you been employed here?
Do you have secondary employement? YesNo
If yes, who is your secondary employer?
Partner/Spouse Employment Status Employed full-timeEmployed part-timeEmployed
seasonallyUnemployed, receiving benefitsUnemployed, receiving no benefitsSelf
employedDisabled, receiving benefitsRetiredOtherPartner/Spouse Employment Status
Name of Partner/Spouse Employer
STUDENT LOAN INTERESTS
I'm interested in (check all that apply):
Choosing a repayment plan
Establishing affordably monthly payments
Loan forgiveness programs
Payment options for disability or financial hardship
Dealing with delinquent or defaulted student loans
Improving my credit score
Restoring eligibility for federal student aid
Minimizing the total cost of debt over time
OtherOther
HOUSING STATUS AND HOUSING GOALS
Current housing status Renting/leasingHomeowner with mortgage(s)Homeowner (no
mortgage debt)HomelessLiving with family/friends
If you are currently renting, please identify your rental status (check all that
apply)
I pay full rent
I receive a rent subsidy and/or live in public housing
I am a Section 8 recipient
I am facing eviction
I am delinquent with my rent and need assistance
I am delinquent with utilities and need assistance
If you are currently renting, how long have you been renting? (Total months)
If you own your property, do you have a mortgage?
Yes
No
Is your mortgage current or delinquent?
Current
Delinquent
Do you receive housing assistance subsidies?YesNo
If yes, please specify type of subsidy:
I am seeking assistance to (check all that apply):
Buy a home
Prevent foreclosure
Obtain rental housing
Increase housing affordability
Get credit and budget counseling
Transition from homelessness
OtherOther
INCOME AND AVERAGE MONTHLY EXPENSES
Please list all applicable income.
How often do you receive income?
Temporary/seasonalWeeklyBi-WeeklyMonthlyBi-MonthlyAnnuallyHow often do you
receive income?
Salary/Wage Earnings
Salary/Wage Earnings
Rental Income
Rental Income
Child support/Alimony
Child support/Alimony
Social Security
Social Security
Pension
Pension
Dependent SSI Income
Dependent SSI Income
Disability Income
Disability Income
Unemployment Income
Unemployment Income
Public Assistance Income
Public Assistance Income
Other
Other
MONTHLY EXPENSES (PLEASE LIST ALL APPLICABLE EXPENSES)
Rent/Mortgage
Car Payment
Car Insurance
Credit Cards
Child Care
Alimony/Child Support
School Tuition
Medical Payments
Transportation (i.e. gas, bus, ride-share)
Water
Electricity
Gas (Utilities)
Cable/Streaming Service
Cell Phone
Food-groceries
Food-dining out
Student Loan Payments
Tithing/Charitable Donations
Other
ASSETS (PLEASE LIST ALL APPLICABLE ASSETS)
Home
Vehicle
401k/Retirement
Recreational Vehicles
Checking Account(s)
Savings Account(s)
Rental Property(s)
Other
Is there anything else you want to share about your financial situation?
HORIZONS' STATEMENT OF COUNSELING SERVICES, PRIVACY POLICY, AND FEE SCHEDULE
STATEMENT OF COUNSELING
PRIVACY POLICY
FEE SCHEDULE
BY SIGNING AND DATING BELOW, I CONFIRM THAT I HAVE RECEIVED A COPY OF HORIZONS'
STATEMENT OF COUNSELING SERVICES, PRIVACY POLICY, AND FEE SCHEDULE.
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BANKRUPTCY EDUCATION DISCLOSURE
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BANKRUPTCY SERVICES FEE POLICY
I acknowledge that I have received the Bankruptcy Services Fee Policy provided
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BANKRUPTCY COUNSELING DISCLOSURE
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BANKRUPTCY SERVICES FEE POLICY
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I would prefer my counseling to be conducted:
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