{"id":87,"date":"2017-11-13T12:14:49","date_gmt":"2017-11-13T17:14:49","guid":{"rendered":"https:\/\/web.tusculum.edu\/trio\/ub-math-science\/?page_id=87"},"modified":"2018-02-06T14:31:30","modified_gmt":"2018-02-06T19:31:30","slug":"parentguardian-informationmedical-form","status":"publish","type":"page","link":"https:\/\/web.tusculum.edu\/trio\/ub-math-science\/parentguardian-informationmedical-form\/","title":{"rendered":"PARENT\/GUARDIAN INFORMATION\/MEDICAL FORM"},"content":{"rendered":"<p>Please complete the following form for your Upward Bound Math and Science Student. Forms are valid for a year and will be need to be resubmitted each year.\u00a0<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_9' >\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Parent\/Guardian Information\/Medical Form<\/h3>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_9'  action='\/trio\/ub-math-science\/wp-json\/wp\/v2\/pages\/87' data-formid='9' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_9_1\" class=\"gfield gfield--type-text 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' for='input_9_1'><span class='gform-field-label__text'>Name of Student<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_9_1' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_2\" class=\"gfield gfield--type-text 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' for='input_9_2'><span class='gform-field-label__text'>Today&#039;s Date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_9_2' type='text' value='' class='medium'    placeholder='99\/99\/9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/div><\/li><li id=\"field_9_3\" class=\"gfield gfield--type-text 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' for='input_9_3'><span class='gform-field-label__text'>Student&#039;s Date of Birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_9_3' type='text' value='' class='medium'    placeholder='99\/99\/9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"99\/99\/9999\"\/><\/div><\/li><li id=\"field_9_4\" class=\"gfield gfield--type-text 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' for='input_9_4'><span class='gform-field-label__text'>Student Age<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_9_4' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_5\" class=\"gfield gfield--type-text 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' for='input_9_5'><span class='gform-field-label__text'>Social Security Number<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_9_5' type='text' value='' class='medium'    placeholder='999-99-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"999-99-9999\"\/><\/div><\/li><li id=\"field_9_6\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_6'><span class='gform-field-label__text'>Student Cell Phone Number<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_9_6' type='text' value='' class='medium'  aria-describedby=\"gfield_description_9_6\"  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\"\/><\/div><div class='gfield_description' id='gfield_description_9_6'>If not applicable, please enter 0's (000-000-0000)<\/div><\/li><li id=\"field_9_7\" class=\"gfield gfield--type-text 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' for='input_9_7'><span class='gform-field-label__text'>Parent(s) or Guardian(s)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_9_7' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_8\" class=\"gfield gfield--type-text 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' for='input_9_8'><span class='gform-field-label__text'>Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_9_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_9\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_9'><span class='gform-field-label__text'>Home Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_9_9' type='text' value='' class='medium'  aria-describedby=\"gfield_description_9_9\"  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\"\/><\/div><div class='gfield_description' id='gfield_description_9_9'>If Not Applicable please enter 0's (000-000-0000)<\/div><\/li><li id=\"field_9_10\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_10'><span class='gform-field-label__text'>Parent Cell Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_9_10' type='text' value='' class='medium'  aria-describedby=\"gfield_description_9_10\"  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\"\/><\/div><div class='gfield_description' id='gfield_description_9_10'>If Not Applicable please enter 0's (000-000-0000)<\/div><\/li><li id=\"field_9_11\" class=\"gfield gfield--type-text 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' for='input_9_11'><span class='gform-field-label__text'>Father&#039;s Employer<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_9_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_12\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_12'><span class='gform-field-label__text'>Employer&#039;s Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_9_12' type='text' value='' class='medium'  aria-describedby=\"gfield_description_9_12\"  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\"\/><\/div><div class='gfield_description' id='gfield_description_9_12'>If Not Applicable please enter 0's (000-000-0000)<\/div><\/li><li id=\"field_9_13\" class=\"gfield gfield--type-text 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' for='input_9_13'><span class='gform-field-label__text'>Mother&#039;s Employer<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_9_13' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_14\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_14'><span class='gform-field-label__text'>Employer&#039;s Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_9_14' type='text' value='' class='medium'  aria-describedby=\"gfield_description_9_14\"  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\"\/><\/div><div class='gfield_description' id='gfield_description_9_14'>If Not Applicable please enter 0's (000-000-0000)<\/div><\/li><li id=\"field_9_15\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_15'><span class='gform-field-label__text'>Emergency Contact Name:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_9_15' type='text' value='' class='medium'  aria-describedby=\"gfield_description_9_15\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_9_15'>Someone we can contact other than the parent or guardian<\/div><\/li><li id=\"field_9_17\" class=\"gfield gfield--type-text 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' for='input_9_17'><span class='gform-field-label__text'>Emergency Contact Relationship to Student:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_9_17' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_16\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_16'><span class='gform-field-label__text'>Emergency Contact Phone Number<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_9_16' type='text' value='' class='medium'  aria-describedby=\"gfield_description_9_16\"  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\"\/><\/div><div class='gfield_description' id='gfield_description_9_16'>If Not Applicable please enter 0's (000-000-0000)<\/div><\/li><li id=\"field_9_18\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Does your child have any medical problems that the staff should be aware of?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_9_18'><li class='gchoice gchoice_9_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='Yes'  id='choice_9_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_18_1' id='label_9_18_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_9_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='No'  id='choice_9_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_18_2' id='label_9_18_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_20\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_20'><span class='gform-field-label__text'>If yes, please explain:<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_20' id='input_9_20' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_9_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Is your child taking any medications on a regular basis?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_9_21'><li class='gchoice gchoice_9_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Yes'  id='choice_9_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_21_1' id='label_9_21_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_9_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='No'  id='choice_9_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_21_2' id='label_9_21_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_22\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_22'><span class='gform-field-label__text'>If yes, please list medications and for what conditions:<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_9_22' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_9_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Is your child allergic to any medications?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_9_23'><li class='gchoice gchoice_9_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Yes'  id='choice_9_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_23_1' id='label_9_23_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_9_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='No'  id='choice_9_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_23_2' id='label_9_23_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_24\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_24'><span class='gform-field-label__text'>If yes, please list medications:<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_24' id='input_9_24' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_9_25\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Does your child have any food or environmental allergies (bee stings, seafood, etc.)?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_9_25'><li class='gchoice gchoice_9_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='Yes'  id='choice_9_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_25_1' id='label_9_25_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_9_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='No'  id='choice_9_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_25_2' id='label_9_25_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_26\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_26'><span class='gform-field-label__text'>If yes, please list:<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_26' id='input_9_26' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_9_27\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Are there any activities that your child should not be allowed to participate in due to medical or other reasons?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_9_27'><li class='gchoice gchoice_9_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='Yes'  id='choice_9_27_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_27_1' id='label_9_27_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_9_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='No'  id='choice_9_27_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_27_2' id='label_9_27_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_28\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_28'><span class='gform-field-label__text'>If yes, please list activities:<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_9_28' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_9_29\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Is there any other information about your child that we should be aware of?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_9_29'><li class='gchoice gchoice_9_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Yes'  id='choice_9_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_29_1' id='label_9_29_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_9_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='No'  id='choice_9_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_29_2' id='label_9_29_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_30\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_30'><span class='gform-field-label__text'>If yes, please explain:<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_30' id='input_9_30' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_9_31\" class=\"gfield gfield--type-text 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' for='input_9_31'><span class='gform-field-label__text'>Family Health Insurance Provider<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_9_31' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_32\" class=\"gfield gfield--type-text 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' for='input_9_32'><span class='gform-field-label__text'>Policy Holder<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_9_32' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_33\" class=\"gfield gfield--type-text 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' for='input_9_33'><span class='gform-field-label__text'>Policy Number<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_9_33' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_34\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_34'><span class='gform-field-label__text'>I certify that my child has permission to receive routine, preventative and\/or emergency medical and dental care during the period he\/she is attending Upward Bound Math and Science. In case of emergency, I understand that my child will be taken to a hospital or clinic and I will be notified. I hereby release the Director of Upward Bound Math and Science, his\/her staff and Tusculum University from responsibility for, or legal action as a result of, decisions made with regard to medical care and treatment for my child. I further certify that I understand that my child will be subject to all rules and regulations of the Upward Bound Math and Science program.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_9_34' type='text' value='' class='medium'  aria-describedby=\"gfield_description_9_34\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_9_34'>Type Name and Date (mm\/dd\/yyyy)<\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_9' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_9' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_9' id='gform_theme_9' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_9' id='gform_style_settings_9' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_9' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='9' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='V6NTceDWbQxSf+pgZwcd4lVOBzufIUK8jW3+ESaw2WS\/g7ld5rUQdylyKrkO2CXbCN6jFI0BpzkkJxS37KaV+3w9cvHqFty3\/QTt1jtv6zodWE4=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_9' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_9' id='gform_target_page_number_9' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_9' id='gform_source_page_number_9' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n","protected":false},"excerpt":{"rendered":"<p><p>Please complete the following form for your Upward Bound Math and Science Student. Forms are valid for a year and will be need to be resubmitted each year.\u00a0<\/p>\n<\/p>\n<p><a href=\"https:\/\/web.tusculum.edu\/trio\/ub-math-science\/parentguardian-informationmedical-form\/\"> Read the full article&#8230;<\/a><\/p>\n","protected":false},"author":9,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-87","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/web.tusculum.edu\/trio\/ub-math-science\/wp-json\/wp\/v2\/pages\/87","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/web.tusculum.edu\/trio\/ub-math-science\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/web.tusculum.edu\/trio\/ub-math-science\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/web.tusculum.edu\/trio\/ub-math-science\/wp-json\/wp\/v2\/users\/9"}],"replies":[{"embeddable":true,"href":"https:\/\/web.tusculum.edu\/trio\/ub-math-science\/wp-json\/wp\/v2\/comments?post=87"}],"version-history":[{"count":3,"href":"https:\/\/web.tusculum.edu\/trio\/ub-math-science\/wp-json\/wp\/v2\/pages\/87\/revisions"}],"predecessor-version":[{"id":155,"href":"https:\/\/web.tusculum.edu\/trio\/ub-math-science\/wp-json\/wp\/v2\/pages\/87\/revisions\/155"}],"wp:attachment":[{"href":"https:\/\/web.tusculum.edu\/trio\/ub-math-science\/wp-json\/wp\/v2\/media?parent=87"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}