{"id":205,"date":"2020-09-29T16:28:29","date_gmt":"2020-09-29T16:28:29","guid":{"rendered":"http:\/\/round-plough.flywheelsites.com\/?page_id=205"},"modified":"2025-07-14T19:11:26","modified_gmt":"2025-07-14T19:11:26","slug":"crs","status":"publish","type":"page","link":"https:\/\/heartsofcleburne.com\/crs\/","title":{"rendered":"Cancer Relief Services"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"205\" class=\"elementor elementor-205\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-96acfa9 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"96acfa9\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-9233e78\" data-id=\"9233e78\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-8016e18 elementor-section-content-middle elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"8016e18\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-extended\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-aaebef9\" data-id=\"aaebef9\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-63f2901\" data-id=\"63f2901\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-a442961 elementor-widget elementor-widget-heading\" data-id=\"a442961\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">How it began<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-79e6b51 elementor-widget elementor-widget-text-editor\" data-id=\"79e6b51\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Because cancer does not discriminate among men, women and children, in an effort to fight cancer locally, the <b>HEARTS Cancer Relief Services (CRS)<\/b> program was established in April 2013 to provide local area assistance to individuals currently undergoing treatment for cancer.\u00a0 HEARTS CRS program serves a six county regions: Cleburne, Calhoun, Randolph in Alabama and Carroll, Haralson, and Heard in Georgia.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-832af18\" data-id=\"832af18\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-5c28071 elementor-section-content-middle elementor-reverse-tablet elementor-reverse-mobile elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"5c28071\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-extended\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-4dd14f5\" data-id=\"4dd14f5\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-eaf6b2f elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eaf6b2f\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;zoomIn&quot;}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"2560\" height=\"1707\" src=\"data:image\/gif;base64,R0lGODlhAQABAIAAAAAAAP\/\/\/yH5BAEAAAAALAAAAAABAAEAAAIBRAA7\" data-src=\"https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2024\/03\/vecteezy_purple-ribbon-for-world-cancer-day-photo-background_5255202-scaled.jpg\" class=\"attachment-full size-full wp-image-835 lazyload\" alt=\"\" data-srcset=\"https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2024\/03\/vecteezy_purple-ribbon-for-world-cancer-day-photo-background_5255202-scaled.jpg 2560w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2024\/03\/vecteezy_purple-ribbon-for-world-cancer-day-photo-background_5255202-300x200.jpg 300w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2024\/03\/vecteezy_purple-ribbon-for-world-cancer-day-photo-background_5255202-1024x683.jpg 1024w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2024\/03\/vecteezy_purple-ribbon-for-world-cancer-day-photo-background_5255202-768x512.jpg 768w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2024\/03\/vecteezy_purple-ribbon-for-world-cancer-day-photo-background_5255202-391x260.jpg 391w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2024\/03\/vecteezy_purple-ribbon-for-world-cancer-day-photo-background_5255202-1536x1024.jpg 1536w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2024\/03\/vecteezy_purple-ribbon-for-world-cancer-day-photo-background_5255202-2048x1365.jpg 2048w\" sizes=\"(max-width: 2560px) 100vw, 2560px\" \/><noscript><img decoding=\"async\" width=\"2560\" height=\"1707\" src=\"https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2024\/03\/vecteezy_purple-ribbon-for-world-cancer-day-photo-background_5255202-scaled.jpg\" class=\"attachment-full size-full wp-image-835 lazyload\" alt=\"\" srcset=\"https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2024\/03\/vecteezy_purple-ribbon-for-world-cancer-day-photo-background_5255202-scaled.jpg 2560w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2024\/03\/vecteezy_purple-ribbon-for-world-cancer-day-photo-background_5255202-300x200.jpg 300w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2024\/03\/vecteezy_purple-ribbon-for-world-cancer-day-photo-background_5255202-1024x683.jpg 1024w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2024\/03\/vecteezy_purple-ribbon-for-world-cancer-day-photo-background_5255202-768x512.jpg 768w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2024\/03\/vecteezy_purple-ribbon-for-world-cancer-day-photo-background_5255202-391x260.jpg 391w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2024\/03\/vecteezy_purple-ribbon-for-world-cancer-day-photo-background_5255202-1536x1024.jpg 1536w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2024\/03\/vecteezy_purple-ribbon-for-world-cancer-day-photo-background_5255202-2048x1365.jpg 2048w\" sizes=\"(max-width: 2560px) 100vw, 2560px\" \/><\/noscript>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-c2b6f7a\" data-id=\"c2b6f7a\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-5e46c15 elementor-widget elementor-widget-text-editor\" data-id=\"5e46c15\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><b>The 1st Annual Day of Hope <\/b>was held in April 2013 raising $13,000 helping to establish our ministry outreach.\u00a0 The Day of Hope\u00a0 fundraiser is a family oriented event focused on togetherness by fighting the disease as one supportive community.\u00a0<\/p><p>This event has grown tremendously every year with last year\u2019s efforts netting over $25,000. Grants from the <b>Community Foundation of West Georgia<\/b> and the <b>Community Foundation of Northeast Alabama\u00a0 <\/b>combined with donations from local community partners make it all possible.\u00a0 People who have been diagnosed with cancer are more vulnerable than ever right now. They need support, people to talk with, resources to turn to, and reassurance that someone is looking out for them.\u00a0 HEARTS CRS program becomes their support system.\u00a0\u00a0<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-b596fcd elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"b596fcd\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-eeae6d7\" data-id=\"eeae6d7\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-69850ec elementor-widget elementor-widget-text-editor\" data-id=\"69850ec\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Clients served through this program need only complete a <a href=\"#online-application\"><b>HEARTS application<\/b><\/a>, provide proof of identity, and obtain a written diagnosis and treatment plan from the physician\/treatment center\/Hospice organization.\u00a0 Income varies among participants, and many of our clients are middle to low income, lack adequate insurance, or have little family support to care for the patient\u2019s needs.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-28fdf0e elementor-section-content-middle elementor-section-boxed elementor-section-height-default elementor-section-height-default elementor-invisible\" data-id=\"28fdf0e\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;animation&quot;:&quot;fadeInUp&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-extended\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-47d1095\" data-id=\"47d1095\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-f42eb83 elementor-widget elementor-widget-text-editor\" data-id=\"f42eb83\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><b>HEARTS is conveniently located in:<\/b><\/p>\n<p>&#8211; <strong>Ranburne, Al<\/strong> at 21517 Main Street, (256) 568-5003<\/p>\n<p>&#8211; <strong>Heflin, Al<\/strong> at 915 Ross Street, (256) 926-5544<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e91aa3e elementor-widget elementor-widget-text-editor\" data-id=\"e91aa3e\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>At this time, there are <b>30 actively enrolled cancer patients<\/b> receiving assistance through the <b>HEARTS<\/b> Cancer Relief Services (CRS) program.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-cb8c1b4\" data-id=\"cb8c1b4\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-48d774e elementor-widget elementor-widget-image\" data-id=\"48d774e\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"800\" height=\"534\" src=\"data:image\/gif;base64,R0lGODlhAQABAIAAAAAAAP\/\/\/yH5BAEAAAAALAAAAAABAAEAAAIBRAA7\" data-src=\"https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2020\/09\/img02-cancer_relief-1024x683.jpg\" class=\"attachment-large size-large wp-image-217 lazyload\" alt=\"\" data-srcset=\"https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2020\/09\/img02-cancer_relief-1024x683.jpg 1024w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2020\/09\/img02-cancer_relief-300x200.jpg 300w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2020\/09\/img02-cancer_relief-768x512.jpg 768w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2020\/09\/img02-cancer_relief-391x260.jpg 391w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2020\/09\/img02-cancer_relief.jpg 1200w\" sizes=\"(max-width: 800px) 100vw, 800px\" \/><noscript><img loading=\"lazy\" decoding=\"async\" width=\"800\" height=\"534\" src=\"https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2020\/09\/img02-cancer_relief-1024x683.jpg\" class=\"attachment-large size-large wp-image-217 lazyload\" alt=\"\" srcset=\"https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2020\/09\/img02-cancer_relief-1024x683.jpg 1024w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2020\/09\/img02-cancer_relief-300x200.jpg 300w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2020\/09\/img02-cancer_relief-768x512.jpg 768w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2020\/09\/img02-cancer_relief-391x260.jpg 391w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2020\/09\/img02-cancer_relief.jpg 1200w\" sizes=\"(max-width: 800px) 100vw, 800px\" \/><\/noscript>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-0215e30 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"0215e30\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-901939f\" data-id=\"901939f\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-685a235\" data-id=\"685a235\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-e5d6309 elementor-widget elementor-widget-image\" data-id=\"e5d6309\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"627\" height=\"570\" src=\"data:image\/gif;base64,R0lGODlhAQABAIAAAAAAAP\/\/\/yH5BAEAAAAALAAAAAABAAEAAAIBRAA7\" data-src=\"https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2020\/09\/img-logo-relay_for_life.png\" class=\"attachment-large size-large wp-image-218 lazyload\" alt=\"\" data-srcset=\"https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2020\/09\/img-logo-relay_for_life.png 627w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2020\/09\/img-logo-relay_for_life-300x273.png 300w\" sizes=\"(max-width: 627px) 100vw, 627px\" \/><noscript><img loading=\"lazy\" decoding=\"async\" width=\"627\" height=\"570\" src=\"https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2020\/09\/img-logo-relay_for_life.png\" class=\"attachment-large size-large wp-image-218 lazyload\" alt=\"\" srcset=\"https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2020\/09\/img-logo-relay_for_life.png 627w, https:\/\/heartsofcleburne.com\/wp-content\/uploads\/2020\/09\/img-logo-relay_for_life-300x273.png 300w\" sizes=\"(max-width: 627px) 100vw, 627px\" \/><\/noscript>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0610888 elementor-widget elementor-widget-text-editor\" data-id=\"0610888\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>The <b>HEARTS<\/b> Cancer Relief Services (CRS) program appreciates local efforts <b>for Relay for Life<\/b> that raises money for cancer research. Proceeds from <i>HEARTS Annual Day of Hope<\/i> fundraiser allows HEARTS to administer funds locally to help area clients with basic life necessities (food, clothing, shelter), emergency financial assistance for utilities, transportation vouchers during active treatment, Ensure or Boost nutritional supplement shakes, and incontinence products<br \/>(incontinence underwear and adult diapers). HEARTS of Cleburne\u2019s funding does not approve medications or medical supplies.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-830d09a\" data-id=\"830d09a\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-69e8661 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"69e8661\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-b10c896\" data-id=\"b10c896\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-b99e192 elementor-widget elementor-widget-heading\" data-id=\"b99e192\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Online  Application  For  Assistance<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-47f7343 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"47f7343\" data-element_type=\"section\" data-e-type=\"section\" id=\"online-application\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-e1925e8\" data-id=\"e1925e8\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-795c508 elementor-button-align-stretch elementor-widget elementor-widget-global elementor-global-1395 elementor-widget-form\" data-id=\"795c508\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"CRS Questionnaire\" aria-label=\"CRS Questionnaire\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"205\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"795c508\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-name elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" placeholder=\"Date\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-email elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tReason for Visit:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-message elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-message\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[message]\" id=\"form-field-message\" rows=\"1\" placeholder=\"Last, First, Middle\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_d93ec6c elementor-col-40 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d93ec6c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_d93ec6c]\" id=\"form-field-field_d93ec6c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"(XXX) - XXX - XXXX\" required=\"required\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_6d0bf99 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6d0bf99\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_6d0bf99]\" id=\"form-field-field_6d0bf99\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Street, City, State, Zipcode, County\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_76f5ca1 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_76f5ca1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMarital Status:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_76f5ca1]\" id=\"form-field-field_76f5ca1\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"Married\">Married<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Single\">Single<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Separated\">Separated<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Divorced\">Divorced<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Widowed\">Widowed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Common Law\">Common Law<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Please Select The One That Applies To You\">Please Select The One That Applies To You<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_025e4fb elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_025e4fb\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHousing\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_025e4fb]\" id=\"form-field-field_025e4fb\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"Rent\">Rent<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Public Housing\">Public Housing<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Own\">Own<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Live w\/ others\">Live w\/ others<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Shelter\">Shelter<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Homeless\">Homeless<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Please Select The One That Applies To You\">Please Select The One That Applies To You<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_748e682 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_748e682\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMedical Coverage\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_748e682]\" id=\"form-field-field_748e682\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"Medicaid\">Medicaid<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Medicare\">Medicare<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"All Kids\">All Kids<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other (please specify in box below)\">Other (please specify in box below)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Please Select The One That Applies To You\">Please Select The One That Applies To You<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_2ac64ea elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_2ac64ea]\" id=\"form-field-field_2ac64ea\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Fill this box in if you chose &quot;Other&quot; on Medical Coverage\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_a366f0d elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a366f0d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo You Receive Food Stamps?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_a366f0d]\" id=\"form-field-field_a366f0d\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Please Select Yes or No\">Please Select Yes or No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_359442c elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_359442c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate You Applied for Food Stamps, If You Have\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_359442c]\" id=\"form-field-field_359442c\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" placeholder=\"Date\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ed5b8a9 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ed5b8a9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow Much Do You Receive in Food Stamps?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ed5b8a9]\" id=\"form-field-field_ed5b8a9\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_f94aaf9 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f94aaf9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhen Did You Receive The Food Stamps?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_f94aaf9]\" id=\"form-field-field_f94aaf9\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_8a3c7b8 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8a3c7b8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo You Receive SS\/SSI\/FA or Unemployment?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_8a3c7b8]\" id=\"form-field-field_8a3c7b8\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Please Select Yes or No\">Please Select Yes or No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7394610 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7394610\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow Much do you Receive?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7394610]\" id=\"form-field-field_7394610\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"If you receive SS\/SSI\/FA or Unemployment\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_4042fa5 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4042fa5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate You Received?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_4042fa5]\" id=\"form-field-field_4042fa5\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" placeholder=\"If you receive SS\/SSI\/FA or Unemployment\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_535a018 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_535a018\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEducation Completed?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_535a018]\" id=\"form-field-field_535a018\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Please Select Yes or No\">Please Select Yes or No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_48d636c elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_48d636c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmployer?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_48d636c]\" id=\"form-field-field_48d636c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e2b6d70 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e2b6d70\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAnnual Household Income:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e2b6d70]\" id=\"form-field-field_e2b6d70\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"$\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_36dcfc3 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_36dcfc3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHousehold Income - List All People Living in Your Household\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_36dcfc3]\" id=\"form-field-field_36dcfc3\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Include: Name(First &amp; Last), Relationship, Sex, Race, Date of Birth, Age, and Social Security Number. (Include Yourself)\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_9eb27ac elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9eb27ac\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tYour Approximate Household Monthly Expenses:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_9eb27ac]\" id=\"form-field-field_9eb27ac\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Please Fill in the Boxes Below, All that apply to you:\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f6c42d3 elementor-col-25 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f6c42d3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMortgage:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f6c42d3]\" id=\"form-field-field_f6c42d3\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"$\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_06ba13b elementor-col-25 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_06ba13b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tElectric:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_06ba13b]\" id=\"form-field-field_06ba13b\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"$\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_937d397 elementor-col-25 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_937d397\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWater:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_937d397]\" id=\"form-field-field_937d397\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"$\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ac1af7d elementor-col-25 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ac1af7d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCar Payment:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ac1af7d]\" id=\"form-field-field_ac1af7d\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"$\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_12b9799 elementor-col-25 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_12b9799\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_12b9799]\" id=\"form-field-field_12b9799\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"$\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_be0317e elementor-col-25 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_be0317e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCable\/Satellite:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_be0317e]\" id=\"form-field-field_be0317e\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"$\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_222e8b6 elementor-col-25 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_222e8b6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCar Insurance:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_222e8b6]\" id=\"form-field-field_222e8b6\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"$\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_45cdfa5 elementor-col-25 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_45cdfa5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMedical Expenses:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_45cdfa5]\" id=\"form-field-field_45cdfa5\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"$\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_2c9e397 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2c9e397\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOther:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_2c9e397]\" id=\"form-field-field_2c9e397\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"List the Expenses and the amount they are each month.\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a0ae748 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a0ae748\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease give a brief explanation of your current need and briefly explain what circumstances have created this need. \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a0ae748]\" id=\"form-field-field_a0ae748\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7c1fea6 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7c1fea6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tI do hereby state, to the best of my knowledge, that the information I have given is correct and that HEARTS has my permission to obtain and release any of the information as deemed necessary, and I understand that the HEARTS Family Service Center is under no obligation to provide this assistance. \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7c1fea6]\" id=\"form-field-field_7c1fea6\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Signature: Please Type your full name here\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e250930 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e250930\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCRS Client as of\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e250930]\" id=\"form-field-field_e250930\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Application date\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_4ff033a elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4ff033a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tReferred by\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_4ff033a]\" id=\"form-field-field_4ff033a\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3c96b0b elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3c96b0b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tClient name:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3c96b0b]\" id=\"form-field-field_3c96b0b\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Last, First, Middle\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d0a545f elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d0a545f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tClient Date of Birth:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d0a545f]\" id=\"form-field-field_d0a545f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"mm\/dd\/yyyy\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_81f06ce elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_81f06ce\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSpouse Name:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_81f06ce]\" id=\"form-field-field_81f06ce\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5e50ddc elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5e50ddc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5e50ddc]\" id=\"form-field-field_5e50ddc\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Street, City\/State, Zip Code, County\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b3da851 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b3da851\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b3da851]\" id=\"form-field-field_b3da851\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_14f200e elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_14f200e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAge:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_14f200e]\" id=\"form-field-field_14f200e\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_9205ac6 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9205ac6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNeeds\/Assistance:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Medication\" id=\"form-field-field_9205ac6-0\" name=\"form_fields[field_9205ac6][]\"> <label for=\"form-field-field_9205ac6-0\">Medication<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Utilities\" id=\"form-field-field_9205ac6-1\" name=\"form_fields[field_9205ac6][]\"> <label for=\"form-field-field_9205ac6-1\">Utilities<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Gas\/transportation\" id=\"form-field-field_9205ac6-2\" name=\"form_fields[field_9205ac6][]\"> <label for=\"form-field-field_9205ac6-2\">Gas\/transportation<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Supplements\" id=\"form-field-field_9205ac6-3\" name=\"form_fields[field_9205ac6][]\"> <label for=\"form-field-field_9205ac6-3\">Supplements<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f7d7109 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f7d7109\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNotes:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f7d7109]\" id=\"form-field-field_f7d7109\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Optional additional notes\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d17317b elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d17317b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tType of Cancer:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d17317b]\" id=\"form-field-field_d17317b\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_0a36196 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0a36196\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of original diagnosis:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_0a36196]\" id=\"form-field-field_0a36196\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_71199ef elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_71199ef\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPaperwork received from DR:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_71199ef]\" id=\"form-field-field_71199ef\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"yes\/no\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_8699553 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8699553\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCurrent form of treatment:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_8699553]\" id=\"form-field-field_8699553\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_c05bd47 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c05bd47\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\thow often?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_c05bd47]\" id=\"form-field-field_c05bd47\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_50d2817 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_50d2817\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName of Treatment Center:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_50d2817]\" id=\"form-field-field_50d2817\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e9f53d1 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e9f53d1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress of Center:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e9f53d1]\" id=\"form-field-field_e9f53d1\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_c32b6c9 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c32b6c9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInsurance:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Medicaid\" id=\"form-field-field_c32b6c9-0\" name=\"form_fields[field_c32b6c9][]\"> <label for=\"form-field-field_c32b6c9-0\">Medicaid<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Medicare\" id=\"form-field-field_c32b6c9-1\" name=\"form_fields[field_c32b6c9][]\"> <label for=\"form-field-field_c32b6c9-1\">Medicare<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Other\" id=\"form-field-field_c32b6c9-2\" name=\"form_fields[field_c32b6c9][]\"> <label for=\"form-field-field_c32b6c9-2\">Other<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"None\" id=\"form-field-field_c32b6c9-3\" name=\"form_fields[field_c32b6c9][]\"> <label for=\"form-field-field_c32b6c9-3\">None<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_c3e8a0a elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c3e8a0a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf Other:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_c3e8a0a]\" id=\"form-field-field_c3e8a0a\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Fill this box if you checked &quot;other&quot; for Insurance\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d1667b7 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d1667b7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tVehicle type:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d1667b7]\" id=\"form-field-field_d1667b7\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"What kind of car do you drive?\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_522b5bc elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_522b5bc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSpecific needs at this time:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_522b5bc]\" id=\"form-field-field_522b5bc\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Your specific needs at this time\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_d0b1b38 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d0b1b38\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNutritional supplements:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Ensure\" id=\"form-field-field_d0b1b38-0\" name=\"form_fields[field_d0b1b38][]\"> <label for=\"form-field-field_d0b1b38-0\">Ensure<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Boost\" id=\"form-field-field_d0b1b38-1\" name=\"form_fields[field_d0b1b38][]\"> <label for=\"form-field-field_d0b1b38-1\">Boost<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Carnation\" id=\"form-field-field_d0b1b38-2\" name=\"form_fields[field_d0b1b38][]\"> <label for=\"form-field-field_d0b1b38-2\">Carnation<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Other\" id=\"form-field-field_d0b1b38-3\" name=\"form_fields[field_d0b1b38][]\"> <label for=\"form-field-field_d0b1b38-3\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_c5eb610 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c5eb610\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tContinence Supplies needed:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_c5eb610]\" id=\"form-field-field_c5eb610\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Depends\/other, and Size - please detail here\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-field_69a6d0f elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_69a6d0f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease provide us with photo ID, Social Security numbers for every household member, proof of income (if monetary assistance is being requested). A cancer diagnosis and treatment plan from your doctor is required within two weeks of application date to receive further assistance. Return requested information to HEARTS of Cleburne, P.O. Box 377, Ranburne, AL 36273, Attention: Robi Mobley. For questions, please email kelly.cobb@heartsofcleburne.com\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[field_69a6d0f]\" id=\"form-field-field_69a6d0f\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_69a6d0f\">Okay<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-field_d374b51 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d374b51\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tI agree that all non-medical information I provide in this application will be shared with nonprofit partners who provide assistance.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[field_d374b51]\" id=\"form-field-field_d374b51\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_d374b51\">I agree<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Send<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-6d4897e elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"6d4897e\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-bf9adfd\" data-id=\"bf9adfd\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-dadcdc1 elementor-widget elementor-widget-heading\" data-id=\"dadcdc1\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Printable  Application  for  Cancer Relief<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-7b9a805 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"7b9a805\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-61c7d1c\" data-id=\"61c7d1c\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-ad45276 elementor-align-justify elementor-widget elementor-widget-button\" data-id=\"ad45276\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-md\" href=\"https:\/\/drive.google.com\/file\/d\/1jKfJAll6ICv73UlyqaLla47Axu_SwGTJ\/view?ts=68505fd6\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Click here for the Printable PDF<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-ca60f03 elementor-section-full_width elementor-section-content-bottom elementor-section-height-default elementor-section-height-default\" data-id=\"ca60f03\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-4029663\" data-id=\"4029663\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-a2c4725 elementor-invisible\" data-id=\"a2c4725\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;animation&quot;:&quot;zoomIn&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-e1cd5a0 title-join-us elementor-widget elementor-widget-heading\" data-id=\"e1cd5a0\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Join Us Now!<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-4d5a461 content-join-us elementor-widget elementor-widget-text-editor\" data-id=\"4d5a461\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Here at HEARTS of Cleburne, we are driven by a single goal; to do our part in making the world a better place for all.<\/p><p>HEARTS is a faith-based, charitable organization working in cooperation with area churches, volunteers, and businesses willing to give of their expertise, skills, and resources to help people with short term needs reach long term success.<\/p><p>We strive to build productive relationships and make a positive impact with all of our pursuits.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-cf7d22c elementor-section-content-middle elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"cf7d22c\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-extended\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-8d5f181\" data-id=\"8d5f181\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-e9a6575 elementor-align-left elementor-tablet-align-left elementor-mobile-align-center elementor-widget elementor-widget-button\" data-id=\"e9a6575\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm elementor-animation-float\" href=\"https:\/\/heartsofcleburne.com\/give\/\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">GIVE<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-df3cc57\" data-id=\"df3cc57\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-ef81f3b elementor-align-left elementor-tablet-align-left elementor-mobile-align-center elementor-widget elementor-widget-button\" data-id=\"ef81f3b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm elementor-animation-float\" href=\"https:\/\/heartsofcleburne.com\/volunteer\/\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">VOLUNTEER<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-0ae33a7\" data-id=\"0ae33a7\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap 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class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-7c8cd35 elementor-invisible\" data-id=\"7c8cd35\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;animation&quot;:&quot;fadeInUp&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-595a0ca elementor-widget elementor-widget-heading\" data-id=\"595a0ca\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Sign Up<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-631f068 elementor-widget elementor-widget-text-editor\" data-id=\"631f068\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Here at HEARTS of Cleburne, we are driven by a single goal; to do our part in making the world a better place for all.<\/p><p>We strive to build productive relationships and make a positive impact with all of our pursuits.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-afb2c32 eael-gravity-form-button-custom elementor-widget elementor-widget-eael-gravity-form\" data-id=\"afb2c32\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"eael-gravity-form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t<div class=\"eael-contact-form eael-gravity-form labels-hide eael-contact-form-align-center\">\n\t\t        <script>\nvar 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gform_body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_4\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_4'>\n                            \n                            <span id='input_1_4_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_4.3' 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Please edit the form settings and turn off Legacy Markup.\",\"fieldCanBeAddedImageChoice\":\"You cannot add an Image Choice field to a form that uses legacy markup. Please edit the form settings and turn off Legacy Markup.\",\"FieldAjaxonErrorTitle\":\"Error\",\"StartAddFieldAjaxonError\":\"Ajax error while adding field. Please refresh the page and try again.\",\"StartChangeInputTypeAjaxonError\":\"Ajax error while changing input type. Please refresh the page and try again.\",\"MissingNameCustomChoicesTitle\":\"Missing Name\",\"MissingNameCustomChoices\":\"Please give this custom choice a name.\",\"DuplicateNameCustomChoicesTitle\":\"Duplicate Name\",\"DuplicateNameCustomChoices\":\"This custom choice name is already in use. Please enter another name.\",\"DuplicateTitleMessageTitle\":\"Duplicate Title\",\"DuplicateTitleMessage\":\"The form title you have entered is already taken. 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