{"id":17908,"date":"2024-06-04T00:57:08","date_gmt":"2024-06-04T00:57:08","guid":{"rendered":"https:\/\/visioncare.agency\/seniorcare\/?page_id=17908"},"modified":"2024-06-13T20:55:56","modified_gmt":"2024-06-13T20:55:56","slug":"client-registration","status":"publish","type":"page","link":"https:\/\/visioncare.agency\/seniorcare\/client-registration\/","title":{"rendered":"Client Registration"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p><!-- Google tag (gtag.js) --><br \/>\n<script async src=\"https:\/\/www.googletagmanager.com\/gtag\/js?id=AW-16608693470\"><\/script><\/p>\n<p><script>\n  window.dataLayer = window.dataLayer || [];\n  function gtag(){dataLayer.push(arguments);}\n  gtag('js', new Date());<\/p>\n<p>  gtag('config', 'AW-16608693470');\n<\/script><\/p>\n<p>[vc_row][vc_column][\/vc_column][vc_column][vc_row_inner][vc_column_inner width=&#8221;1\/3&#8243;]<div class='featured featured-large featured-has-content'><div class='featured-header'><img alt='Caring for a client' src='https:\/\/visioncare.agency\/seniorcare\/wp-content\/uploads\/sites\/2\/2024\/06\/assisted-living--722x368.png'\/><\/div><div class='featured-content'><h3 class='featured-title text-uppercase'>Caring for a client<\/h3><p class='featured-desc'>Assisting a client as a caregiver encompasses many responsibilities, depending on the client\u2019s needs and abilities.<\/p><\/div><\/div>[\/vc_column_inner][vc_column_inner width=&#8221;1\/3&#8243;]<div class='featured featured-large featured-has-content'><div class='featured-header'><img alt='Consultation' src='https:\/\/visioncare.agency\/seniorcare\/wp-content\/uploads\/sites\/2\/2023\/05\/consultancy-scaled-1.jpg'\/><\/div><div class='featured-content'><h3 class='featured-title text-uppercase'>Consultation<\/h3><p class='featured-desc'>Our Consultant acts as a trusted advisor, helping families navigate the complexities of elderly care and ensuring that their loved ones receive the best possible support and services.<\/p><\/div><\/div>[\/vc_column_inner][vc_column_inner width=&#8221;1\/3&#8243;]<div class='featured featured-large featured-has-content'><div class='featured-header'><img alt='Family Integration' src='https:\/\/visioncare.agency\/seniorcare\/wp-content\/uploads\/sites\/2\/2024\/06\/Family-Intigration-722x368.png'\/><\/div><div class='featured-content'><h3 class='featured-title text-uppercase'>Family Integration<\/h3><p class='featured-desc'>A family can create a supportive and welcoming environment for seniors, fostering a sense of belonging and enhancing their overall quality of life.<\/p><\/div><\/div>[\/vc_column_inner][\/vc_row_inner][\/vc_column][vc_column][vc_column_text]<div style=\"display:none\" class=\"fm-form-container fm-theme20\"><div id=\"fm-pages19\" class=\"fm-pages wdform_page_navigation \" show_title=\"false\" show_numbers=\"false\" type=\"none\"><\/div><form name=\"form19\" action=\"\/seniorcare\/wp-json\/wp\/v2\/pages\/17908\" method=\"post\" id=\"form19\" class=\"fm-form form19  \" enctype=\"multipart\/form-data\"><input type=\"hidden\" id=\"fm_page_id19\" value=\"17908\" name=\"fm_page_id19\" \/><input type=\"hidden\" id=\"fm_current_post_type19\" value=\"page\" name=\"fm_current_post_type19\" \/><input type=\"hidden\" id=\"counter19\" value=\"71\" name=\"counter19\" \/><input type=\"hidden\" id=\"Itemid19\" value=\"\" name=\"Itemid19\" \/><input type=\"hidden\" id=\"fm_shake19\" value=\"1\" name=\"fm_shake19\" \/><input type=\"text\" class=\"fm-hide\" id=\"fm_bot_validation19\" value=\"\" name=\"fm_bot_validation19\" \/><input type=\"text\" class=\"fm-hide\" id=\"fm_empty_field_validation19\" value=\"\" name=\"fm_empty_field_validation19\" data-value=\"bd736efb144d599cf463541431fbf5c4\" \/><input type=\"hidden\" id=\"fm_ajax_url19\" data-ajax_url=\"https:\/\/visioncare.agency\/seniorcare\/wp-admin\/admin-ajax.php?action=fm_submit_form&current_id=19&formType=embedded\" \/><input type=\"hidden\" id=\"fm_ajax_redirect_url19\" data-ajax_redirect_url=\"https:\/\/visioncare.agency\/seniorcare\/booking-page\/\" \/><input type=\"hidden\" id=\"fm_form_nonce19\" name=\"fm_form_nonce19\" value=\"9a18503d82\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/seniorcare\/wp-json\/wp\/v2\/pages\/17908\" \/><div class=\"wdform-page-and-images fm-form-builder\" style=\"border-width: 1px;\"><div id=\"19form_view1\" class=\"wdform_page\" page_title=\"Untitled page\" next_title=\"Next\" next_type=\"text\" next_class=\"wdform-page-button\" next_checkable=\"true\" previous_title=\"Previous\" previous_type=\"text\" previous_class=\"wdform-page-button\" previous_checkable=\"false\"><div class=\"wdform_section\"><div class=\"wdform_column\"><div wdid=\"49\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_own_select\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_own_select\" ><div class=\"wdform-label-section wd-width-100 wdform_select wd-flex-row\">    <label  for=\"wdform_49_element19\" class=\"wdform-label\">Registrant<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex wdform_select wd-flex-row wd-width-100\" ><select class=\"wd-width-100\" id=\"wdform_49_element19\" name=\"wdform_49_element19\" ><option value=\"\" >I am registering my love one or friend <\/option><option value=\"I am the registrant\" selected=\"selected\">I am the registrant<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"53\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_name\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_name\" ><div class=\"wdform-label-section wd-width-100  wd-flex-row\">    <label  for=\"wdform_53_element_first19\" class=\"wdform-label\">Name to person registering<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-width-100\" ><div class=\"wd-flex wd-flex-column wd-width-50\"><input type=\"text\" class=\"wd-width-100\" id=\"wdform_53_element_first19\" name=\"wdform_53_element_first19\" data-value=\"\" value=\"\" title=\"\" placeholder=\"\"  \/><label class=\"mini_label\" for=\"wdform_53_element_first19\">First<\/label><\/div><div class=\"wd-flex wd-flex-column wd-name-separator\"><\/div><div class=\"wd-flex wd-flex-column wd-width-50\"><input type=\"text\" class=\"wd-width-100\" id=\"wdform_53_element_last19\" name=\"wdform_53_element_last19\" data-value=\"\" value=\"\" title=\"\" placeholder=\"\"  \/><label class=\"mini_label\" for=\"wdform_53_element_last19\">Last<\/label><\/div><\/div><\/div><\/div><div wdid=\"54\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_name\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_name\" ><div class=\"wdform-label-section wd-width-100  wd-flex-row\">    <label  for=\"wdform_54_element_first19\" class=\"wdform-label\">Name of person to be registered<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-width-100\" ><div class=\"wd-flex wd-flex-column wd-width-50\"><input type=\"text\" class=\"wd-width-100\" id=\"wdform_54_element_first19\" name=\"wdform_54_element_first19\" data-value=\"\" value=\"\" title=\"\" placeholder=\"\"  \/><label class=\"mini_label\" for=\"wdform_54_element_first19\">First<\/label><\/div><div class=\"wd-flex wd-flex-column wd-name-separator\"><\/div><div class=\"wd-flex wd-flex-column wd-width-50\"><input type=\"text\" class=\"wd-width-100\" id=\"wdform_54_element_last19\" name=\"wdform_54_element_last19\" data-value=\"\" value=\"\" title=\"\" placeholder=\"\"  \/><label class=\"mini_label\" for=\"wdform_54_element_last19\">Last<\/label><\/div><\/div><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"64\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_file_upload\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_file_upload\" ><div class=\"wdform-label-section wd-width-100  wd-flex-column\">    <label  for=\"wdform_64_element19\" class=\"wdform-label\">Upload a photo of the person registering<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-column wd-width-100\" ><label class=\"file-upload\"><div class=\"file-picker\"><\/div><input type=\"file\" id=\"wdform_64_element19\" name=\"wdform_64_file19[]\"   \/><\/label><\/div><\/div><\/div><div wdid=\"65\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_file_upload\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_file_upload\" ><div class=\"wdform-label-section wd-width-100  wd-flex-column\">    <label  for=\"wdform_65_element19\" class=\"wdform-label\">Registrant Photo<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-column wd-width-100\" ><label class=\"file-upload\"><div class=\"file-picker\"><\/div><input type=\"file\" id=\"wdform_65_element19\" name=\"wdform_65_file19[]\"   \/><\/label><\/div><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"25\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_date_fields\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_date_fields\" ><div class=\"wdform-label-section wd-width-100 wdform_date_fields wd-flex-row\">    <label  for=\"wdform_25_day19\" class=\"wdform-label\">Date of Birth<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex wdform_date_fields wd-flex-row wd-width-100\" ><div class=\"wd-flex wd-flex-row wd-width-100 wd-align-items\"><div class=\"wd-flex wd-flex-column\"><select id=\"wdform_25_day19\" name=\"wdform_25_day19\" class=\"wdform_select_day\" style=\"width: 60px;\" ><option value=\"\"><\/option><option value=\"01\" >01<\/option><option value=\"02\" >02<\/option><option value=\"03\" >03<\/option><option value=\"04\" >04<\/option><option value=\"05\" >05<\/option><option value=\"06\" >06<\/option><option value=\"07\" >07<\/option><option value=\"08\" >08<\/option><option value=\"09\" >09<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><label for=\"wdform_25_day19\" class=\"mini_label\">day<\/label><\/div><span class=\"wdform_separator\">&nbsp;\/&nbsp;<\/span><div class=\"wd-flex wd-flex-column\"><select id=\"wdform_25_month19\" name=\"wdform_25_month19\" class=\"wdform_select_month\" style=\"width: 100px;\" ><option value=\"\"><\/option><option value=\"01\"   >January<\/option><option value=\"02\" >February<\/option><option value=\"03\" >March<\/option><option value=\"04\"  >April<\/option><option value=\"05\"  >May<\/option><option value=\"06\"  >June<\/option><option value=\"07\"  >July<\/option><option value=\"08\"  >August<\/option><option value=\"09\"  >September<\/option><option value=\"10\"  >October<\/option><option value=\"11\" >November<\/option><option value=\"12\"  >December<\/option><\/select><label for=\"wdform_25_month19\" class=\"mini_label\">month<\/label><\/div><span class=\"wdform_separator\">&nbsp;\/&nbsp;<\/span><div class=\"wd-flex wd-flex-column\"><select id=\"wdform_25_year19\" name=\"wdform_25_year19\"  from=\"1901\" to=\"2022\" class=\"wdform_select_year\" style=\"width: 80px;\" ><option value=\"\"><\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><option value=\"1919\" >1919<\/option><option value=\"1918\" >1918<\/option><option value=\"1917\" >1917<\/option><option value=\"1916\" >1916<\/option><option value=\"1915\" >1915<\/option><option value=\"1914\" >1914<\/option><option value=\"1913\" >1913<\/option><option value=\"1912\" >1912<\/option><option value=\"1911\" >1911<\/option><option value=\"1910\" >1910<\/option><option value=\"1909\" >1909<\/option><option value=\"1908\" >1908<\/option><option value=\"1907\" >1907<\/option><option value=\"1906\" >1906<\/option><option value=\"1905\" >1905<\/option><option value=\"1904\" >1904<\/option><option value=\"1903\" >1903<\/option><option value=\"1902\" >1902<\/option><option value=\"1901\" >1901<\/option><\/select><label for=\"wdform_25_year19\" class=\"mini_label\">year<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"26\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_text\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_text\" ><div class=\"wdform-label-section wd-width-100  wd-flex-row wd-align-items-center\">    <label  for=\"wdform_26_element19\" class=\"wdform-label\">Height and Weight<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-align-items-center wd-width-100\" ><input type=\"text\"                           class=\"wd-width-100\"                           id=\"wdform_26_element19\"                           name=\"wdform_26_element19\"                           value=\"\"                           data-value=\"\"                           title=\"\"                           placeholder=\"\"                                                       \/><\/div><\/div><\/div><div wdid=\"50\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_own_select\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_own_select\" ><div class=\"wdform-label-section wd-width-100 wdform_select wd-flex-row\">    <label  for=\"wdform_50_element19\" class=\"wdform-label\">Sex<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex wdform_select wd-flex-row wd-width-100\" ><select class=\"wd-width-100\" id=\"wdform_50_element19\" name=\"wdform_50_element19\" ><option value=\"\" selected=\"selected\">Select value<\/option><option value=\"Male\" >Male<\/option><option value=\"Female\" >Female<\/option><option value=\"Transgender\" >Transgender<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"3\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_address\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_address\" ><div class=\"wdform-label-section wd-width-100 wdform_address wd-flex-column\">    <label  for=\"wdform_3_street119\" class=\"wdform-label\">Address<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex wdform_address wd-flex-column wd-width-100\" ><span class=\"wd-width-100 wd-address\" id=\"wdform_3_address_0\">                <input class=\"wd-width-100 wdform_3_address_0\" type=\"text\" id=\"wdform_3_street119\" name=\"wdform_3_street119\" value=\"\"  \/>                <label for=\"wdform_3_street119\" class=\"mini_label\">Street Address<\/label><\/span><span class=\"wd-width-100 wd-address\" id=\"wdform_3_address_1\">                <input class=\"wd-width-100 wdform_3_address_1\" type=\"text\" id=\"wdform_3_street219\" name=\"wdform_4_street219\" value=\"\"  \/>                <label for=\"wdform_3_street219\" class=\"mini_label\">Street Address Line 2<\/label><\/span><span class=\"wd-width-100 wd-flex wd-flex-row wd-flex-wrap wd-justify-content\"><span class=\"wd-width-49 wd-address\" id=\"wdform_3_address_2\">                <input class=\"wd-width-100 wdform_3_address_2\" type=\"text\" id=\"wdform_3_city19\" name=\"wdform_5_city19\" value=\"\"  \/>                <label for=\"wdform_3_city19\" class=\"mini_label\">City<\/label><\/span><span class=\"wd-width-49 wd-address\" id=\"wdform_3_address_3\">                <input class=\"wd-width-100 wdform_3_address_3\" type=\"text\" id=\"wdform_3_state19\" name=\"wdform_6_state19\" value=\"\"  \/>                <label for=\"wdform_3_state19\" class=\"mini_label\">State \/ Province \/ Region<\/label><\/span><span class=\"wd-width-49 wd-address\" id=\"wdform_3_address_4\">              <input class=\"wd-width-100 wdform_3_address_4\" type=\"text\" id=\"wdform_3_postal19\" name=\"wdform_7_postal19\" value=\"\"  \/>              <label for=\"wdform_3_postal19\" class=\"mini_label\">Postal \/ Zip Code<\/label><\/span><span class=\"wd-width-49 wd-address\" id=\"wdform_3_address_5\">              <select class=\"wd-width-100 wdform_3_address_5\"                      type=\"text\"                      id=\"wdform_3_country19\"                      name=\"wdform_8_country19\"                      onchange=\"wd_change_state_input('wdform_3', '19')\"                      ><option value=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" >Afghanistan<\/option><option value=\"Albania\" >Albania<\/option><option value=\"Algeria\" >Algeria<\/option><option value=\"Andorra\" >Andorra<\/option><option value=\"Angola\" >Angola<\/option><option value=\"Antigua and Barbuda\" >Antigua and Barbuda<\/option><option value=\"Argentina\" >Argentina<\/option><option value=\"Armenia\" >Armenia<\/option><option value=\"Australia\" >Australia<\/option><option value=\"Austria\" >Austria<\/option><option value=\"Azerbaijan\" >Azerbaijan<\/option><option value=\"Bahamas\" >Bahamas<\/option><option value=\"Bahrain\" >Bahrain<\/option><option value=\"Bangladesh\" >Bangladesh<\/option><option value=\"Barbados\" >Barbados<\/option><option value=\"Belarus\" >Belarus<\/option><option value=\"Belgium\" >Belgium<\/option><option value=\"Belize\" >Belize<\/option><option value=\"Benin\" >Benin<\/option><option value=\"Bhutan\" >Bhutan<\/option><option value=\"Bolivia\" >Bolivia<\/option><option value=\"Bosnia and Herzegovina\" >Bosnia and Herzegovina<\/option><option value=\"Botswana\" >Botswana<\/option><option value=\"Brazil\" >Brazil<\/option><option value=\"Brunei\" >Brunei<\/option><option value=\"Bulgaria\" >Bulgaria<\/option><option value=\"Burkina\" >Burkina Faso<\/option><option value=\"Burundi\" >Burundi<\/option><option value=\"Cambodia\" >Cambodia<\/option><option value=\"Cameroon\" >Cameroon<\/option><option value=\"Canada\" >Canada<\/option><option value=\"Cape Verde\" >Cape Verde<\/option><option value=\"Central African Republic\" >Central African Republic<\/option><option value=\"Chad\" >Chad<\/option><option value=\"Chile\" >Chile<\/option><option value=\"China\" >China<\/option><option value=\"Colombia\" >Colombia<\/option><option value=\"Comoros\" >Comoros<\/option><option value=\"Congo\" >Congo<\/option><option value=\"Congo (Brazzaville)\" >Congo (Brazzaville)<\/option><option value=\"Costa Rica\" >Costa Rica<\/option><option value=\"Cote d&#039;Ivoire\" >Cote d&#039;Ivoire<\/option><option value=\"Croatia\" >Croatia<\/option><option value=\"Cuba\" >Cuba<\/option><option value=\"Curacao\" >Curacao<\/option><option value=\"Cyprus\" >Cyprus<\/option><option value=\"Czech Republic\" >Czech Republic<\/option><option value=\"Denmark\" >Denmark<\/option><option value=\"Djibouti\" >Djibouti<\/option><option value=\"Dominica\" >Dominica<\/option><option value=\"Dominican Republic\" >Dominican Republic<\/option><option value=\"East Timor (Timor Timur\" >East Timor (Timor Timur)<\/option><option value=\"Ecuador\" >Ecuador<\/option><option value=\"Egypt\" >Egypt<\/option><option value=\"El Salvador\" >El Salvador<\/option><option value=\"Equatorial\" >Equatorial Guinea<\/option><option value=\"Eritrea\" >Eritrea<\/option><option value=\"Estonia\" >Estonia<\/option><option value=\"Eswatini\" >Eswatini<\/option><option value=\"Ethiopia\" >Ethiopia<\/option><option value=\"Fiji\" >Fiji<\/option><option value=\"Finland\" >Finland<\/option><option value=\"France\" >France<\/option><option value=\"Gabon\" >Gabon<\/option><option value=\"Gambia, The\" >Gambia, The<\/option><option value=\"Georgia\" >Georgia<\/option><option value=\"Germany\" >Germany<\/option><option value=\"Ghana\" >Ghana<\/option><option value=\"Greece\" >Greece<\/option><option value=\"Grenada\" >Grenada<\/option><option value=\"Guatemala\" >Guatemala<\/option><option value=\"Guinea\" >Guinea<\/option><option value=\"Guinea-Bissau\" >Guinea-Bissau<\/option><option value=\"Guyana\" >Guyana<\/option><option value=\"Haiti\" >Haiti<\/option><option value=\"Honduras\" >Honduras<\/option><option value=\"Hong Kong\" >Hong Kong<\/option><option value=\"Hungary\" >Hungary<\/option><option value=\"Iceland\" >Iceland<\/option><option value=\"India\" >India<\/option><option value=\"Indonesia\" >Indonesia<\/option><option value=\"Iran\" >Iran<\/option><option value=\"Iraq\" >Iraq<\/option><option value=\"Ireland\" >Ireland<\/option><option value=\"Israel\" >Israel<\/option><option value=\"Italy\" >Italy<\/option><option value=\"Jamaica\" >Jamaica<\/option><option value=\"Japan\" >Japan<\/option><option value=\"Jordan\" >Jordan<\/option><option value=\"Kazakhstan\" >Kazakhstan<\/option><option value=\"Kenya\" >Kenya<\/option><option value=\"Kiribati\" >Kiribati<\/option><option value=\"Korea, North\" >Korea, North<\/option><option value=\"Korea, South\" >Korea, South<\/option><option value=\"Kuwait\" >Kuwait<\/option><option value=\"Kyrgyzstan\" >Kyrgyzstan<\/option><option value=\"Laos\" >Laos<\/option><option value=\"Latvia\" >Latvia<\/option><option value=\"Lebanon\" >Lebanon<\/option><option value=\"Lesotho\" >Lesotho<\/option><option value=\"Liberia\" >Liberia<\/option><option value=\"Libya\" >Libya<\/option><option value=\"Liechtenstein\" >Liechtenstein<\/option><option value=\"Lithuania\" >Lithuania<\/option><option value=\"Luxembourg\" >Luxembourg<\/option><option value=\"Madagascar\" >Madagascar<\/option><option value=\"Malawi\" >Malawi<\/option><option value=\"Malaysia\" >Malaysia<\/option><option value=\"Maldives\" >Maldives<\/option><option value=\"Mali\" >Mali<\/option><option value=\"Malta\" >Malta<\/option><option value=\"Marshall Islands\" >Marshall Islands<\/option><option value=\"Mauritania\" >Mauritania<\/option><option value=\"Mauritius\" >Mauritius<\/option><option value=\"Mexico\" >Mexico<\/option><option value=\"Micronesia\" >Micronesia<\/option><option value=\"Moldova\" >Moldova<\/option><option value=\"Monaco\" >Monaco<\/option><option value=\"Mongolia\" >Mongolia<\/option><option value=\"Montenegro\" >Montenegro<\/option><option value=\"Morocco\" >Morocco<\/option><option value=\"Mozambique\" >Mozambique<\/option><option value=\"Myanmar\" >Myanmar<\/option><option value=\"Namibia\" >Namibia<\/option><option value=\"Nauru\" >Nauru<\/option><option value=\"Nepal\" >Nepal<\/option><option value=\"Netherlands\" >Netherlands<\/option><option value=\"New Zealand\" >New Zealand<\/option><option value=\"Nicaragua\" >Nicaragua<\/option><option value=\"Niger\" >Niger<\/option><option value=\"Nigeria\" >Nigeria<\/option><option value=\"North Macedonia\" >North Macedonia<\/option><option value=\"Norway\" >Norway<\/option><option value=\"Oman\" >Oman<\/option><option value=\"Pakistan\" >Pakistan<\/option><option value=\"Palau\" >Palau<\/option><option value=\"Palestine\" >Palestine<\/option><option value=\"Panama\" >Panama<\/option><option value=\"Papua New Guinea\" >Papua New Guinea<\/option><option value=\"Paraguay\" >Paraguay<\/option><option value=\"Peru\" >Peru<\/option><option value=\"Philippines\" >Philippines<\/option><option value=\"Poland\" >Poland<\/option><option value=\"Portugal\" >Portugal<\/option><option value=\"Puerto Rico\" >Puerto Rico<\/option><option value=\"Qatar\" >Qatar<\/option><option value=\"Romania\" >Romania<\/option><option value=\"Russia\" >Russia<\/option><option value=\"Rwanda\" >Rwanda<\/option><option value=\"Saint Kitts and Nevis\" >Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\" >Saint Lucia<\/option><option value=\"Saint Vincent\" >Saint Vincent<\/option><option value=\"Samoa\" >Samoa<\/option><option value=\"San Marino\" >San Marino<\/option><option value=\"Sao Tome and Principe\" >Sao Tome and Principe<\/option><option value=\"Saudi Arabia\" >Saudi Arabia<\/option><option value=\"Senegal\" >Senegal<\/option><option value=\"Serbia\" >Serbia<\/option><option value=\"Seychelles\" >Seychelles<\/option><option value=\"Sierra Leone\" >Sierra Leone<\/option><option value=\"Singapore\" >Singapore<\/option><option value=\"Slovakia\" >Slovakia<\/option><option value=\"Slovenia\" >Slovenia<\/option><option value=\"Solomon Islands\" >Solomon Islands<\/option><option value=\"Somalia\" >Somalia<\/option><option value=\"South Africa\" >South Africa<\/option><option value=\"South Sudan\" >South Sudan<\/option><option value=\"Spain\" >Spain<\/option><option value=\"Sri Lanka\" >Sri Lanka<\/option><option value=\"Sudan\" >Sudan<\/option><option value=\"Suriname\" >Suriname<\/option><option value=\"Sweden\" >Sweden<\/option><option value=\"Switzerland\" >Switzerland<\/option><option value=\"Syria\" >Syria<\/option><option value=\"Taiwan\" >Taiwan<\/option><option value=\"Tajikistan\" >Tajikistan<\/option><option value=\"Tanzania\" >Tanzania<\/option><option value=\"Thailand\" >Thailand<\/option><option value=\"Togo\" >Togo<\/option><option value=\"Tonga\" >Tonga<\/option><option value=\"Trinidad and Tobago\" >Trinidad and Tobago<\/option><option value=\"Tunisia\" >Tunisia<\/option><option value=\"Turkey\" >Turkey<\/option><option value=\"Turkmenistan\" >Turkmenistan<\/option><option value=\"Tuvalu\" >Tuvalu<\/option><option value=\"Uganda\" >Uganda<\/option><option value=\"Ukraine\" >Ukraine<\/option><option value=\"United Arab Emirates\" >United Arab Emirates<\/option><option value=\"United Kingdom\" >United Kingdom<\/option><option value=\"United States\" >United States<\/option><option value=\"Uruguay\" >Uruguay<\/option><option value=\"Uzbekistan\" >Uzbekistan<\/option><option value=\"Vanuatu\" >Vanuatu<\/option><option value=\"Vatican City\" >Vatican City<\/option><option value=\"Venezuela\" >Venezuela<\/option><option value=\"Vietnam\" >Vietnam<\/option><option value=\"Wales\" >Wales<\/option><option value=\"Yemen\" >Yemen<\/option><option value=\"Zambia\" >Zambia<\/option><option value=\"Zimbabwe\" >Zimbabwe<\/option><\/select>              <label for=\"wdform_3_country19\" class=\"mini_label\">Country<\/label><\/span><\/span><\/div><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"9\" class=\"wdform_row\"><div type=\"type_submitter_mail\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_submitter_mail\" ><div class=\"wdform-label-section wd-width-100  wd-flex-row\">    <label  for=\"wdform_9_element19\" class=\"wdform-label\">Email<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-width-100\" ><input type=\"text\" class=\"wd-width-100\" id=\"wdform_9_element19\" name=\"wdform_9_element19\" data-value=\"\" value=\"\" title=\"\" placeholder=\"\"   onchange=\"wd_check_email('9', '19', 'This is not a valid email address.')\" \/><\/div><\/div><\/div><div wdid=\"10\" class=\"wdform_row\"><div type=\"type_phone_new\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_phone_new\" ><div class=\"wdform-label-section wd-width-100 \">    <label  for=\"wdform_10_element19\" class=\"wdform-label\">Phone<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-width-100\" ><input type=\"text\"                       class=\"wd-width-100\"                       id=\"wdform_10_element19\"                       name=\"wdform_10_element19\"                       value=\"\"                       data-value=\"\"                       placeholder=\"\"  \/><\/div><\/div><\/div><div wdid=\"55\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_radio\" ><div class=\"wdform-label-section wd-width-100  wd-flex-wrap wd-flex-row\">    <label  class=\"wdform-label\">Dose the person to be registered live you.<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-100\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_55_element19\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row\"><input type=\"radio\"  id=\"wdform_55_element190\" name=\"wdform_55_element19\" value=\"Yes\" onclick=\"set_default(&quot;wdform_55&quot;,&quot;0&quot;,&quot;19&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_55_element190\"><span><\/span>Yes<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row\"><input type=\"radio\"  id=\"wdform_55_element191\" name=\"wdform_55_element19\" value=\"No\" onclick=\"set_default(&quot;wdform_55&quot;,&quot;1&quot;,&quot;19&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_55_element191\"><span><\/span>No<\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"56\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_address\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_address\" ><div class=\"wdform-label-section wd-width-100 wdform_address wd-flex-column\">    <label  for=\"wdform_56_street119\" class=\"wdform-label\">Address of person to be registered<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex wdform_address wd-flex-column wd-width-100\" ><span class=\"wd-width-100 wd-address\" id=\"wdform_56_address_0\">                <input class=\"wd-width-100 wdform_56_address_0\" type=\"text\" id=\"wdform_56_street119\" name=\"wdform_56_street119\" value=\"\"  \/>                <label for=\"wdform_56_street119\" class=\"mini_label\">Street Address<\/label><\/span><span class=\"wd-width-100 wd-address\" id=\"wdform_56_address_1\">                <input class=\"wd-width-100 wdform_56_address_1\" type=\"text\" id=\"wdform_56_street219\" name=\"wdform_57_street219\" value=\"\"  \/>                <label for=\"wdform_56_street219\" class=\"mini_label\">Street Address Line 2<\/label><\/span><span class=\"wd-width-100 wd-flex wd-flex-row wd-flex-wrap wd-justify-content\"><span class=\"wd-width-49 wd-address\" id=\"wdform_56_address_2\">                <input class=\"wd-width-100 wdform_56_address_2\" type=\"text\" id=\"wdform_56_city19\" name=\"wdform_58_city19\" value=\"\"  \/>                <label for=\"wdform_56_city19\" class=\"mini_label\">City<\/label><\/span><span class=\"wd-width-49 wd-address\" id=\"wdform_56_address_3\">                <input class=\"wd-width-100 wdform_56_address_3\" type=\"text\" id=\"wdform_56_state19\" name=\"wdform_59_state19\" value=\"\"  \/>                <label for=\"wdform_56_state19\" class=\"mini_label\">State \/ Province \/ Region<\/label><\/span><span class=\"wd-width-49 wd-address\" id=\"wdform_56_address_4\">              <input class=\"wd-width-100 wdform_56_address_4\" type=\"text\" id=\"wdform_56_postal19\" name=\"wdform_60_postal19\" value=\"\"  \/>              <label for=\"wdform_56_postal19\" class=\"mini_label\">Postal \/ Zip Code<\/label><\/span><span class=\"wd-width-49 wd-address\" id=\"wdform_56_address_5\">              <select class=\"wd-width-100 wdform_56_address_5\"                      type=\"text\"                      id=\"wdform_56_country19\"                      name=\"wdform_61_country19\"                      onchange=\"wd_change_state_input('wdform_56', '19')\"                      ><option value=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" >Afghanistan<\/option><option value=\"Albania\" >Albania<\/option><option value=\"Algeria\" >Algeria<\/option><option value=\"Andorra\" >Andorra<\/option><option value=\"Angola\" >Angola<\/option><option value=\"Antigua and Barbuda\" >Antigua and Barbuda<\/option><option value=\"Argentina\" >Argentina<\/option><option value=\"Armenia\" >Armenia<\/option><option value=\"Australia\" >Australia<\/option><option value=\"Austria\" >Austria<\/option><option value=\"Azerbaijan\" >Azerbaijan<\/option><option value=\"Bahamas\" >Bahamas<\/option><option value=\"Bahrain\" >Bahrain<\/option><option value=\"Bangladesh\" >Bangladesh<\/option><option value=\"Barbados\" >Barbados<\/option><option value=\"Belarus\" >Belarus<\/option><option value=\"Belgium\" >Belgium<\/option><option value=\"Belize\" >Belize<\/option><option value=\"Benin\" >Benin<\/option><option value=\"Bhutan\" >Bhutan<\/option><option value=\"Bolivia\" >Bolivia<\/option><option value=\"Bosnia and Herzegovina\" >Bosnia and Herzegovina<\/option><option value=\"Botswana\" >Botswana<\/option><option value=\"Brazil\" >Brazil<\/option><option value=\"Brunei\" >Brunei<\/option><option value=\"Bulgaria\" >Bulgaria<\/option><option value=\"Burkina\" >Burkina Faso<\/option><option value=\"Burundi\" >Burundi<\/option><option value=\"Cambodia\" >Cambodia<\/option><option value=\"Cameroon\" >Cameroon<\/option><option value=\"Canada\" >Canada<\/option><option value=\"Cape Verde\" >Cape Verde<\/option><option value=\"Central African Republic\" >Central African Republic<\/option><option value=\"Chad\" >Chad<\/option><option value=\"Chile\" >Chile<\/option><option value=\"China\" >China<\/option><option value=\"Colombia\" >Colombia<\/option><option value=\"Comoros\" >Comoros<\/option><option value=\"Congo\" >Congo<\/option><option value=\"Congo (Brazzaville)\" >Congo (Brazzaville)<\/option><option value=\"Costa Rica\" >Costa Rica<\/option><option value=\"Cote d&#039;Ivoire\" >Cote d&#039;Ivoire<\/option><option value=\"Croatia\" >Croatia<\/option><option value=\"Cuba\" >Cuba<\/option><option value=\"Curacao\" >Curacao<\/option><option value=\"Cyprus\" >Cyprus<\/option><option value=\"Czech Republic\" >Czech Republic<\/option><option value=\"Denmark\" >Denmark<\/option><option value=\"Djibouti\" >Djibouti<\/option><option value=\"Dominica\" >Dominica<\/option><option value=\"Dominican Republic\" >Dominican Republic<\/option><option value=\"East Timor (Timor Timur\" >East Timor (Timor Timur)<\/option><option value=\"Ecuador\" >Ecuador<\/option><option value=\"Egypt\" >Egypt<\/option><option value=\"El Salvador\" >El Salvador<\/option><option value=\"Equatorial\" >Equatorial Guinea<\/option><option value=\"Eritrea\" >Eritrea<\/option><option value=\"Estonia\" >Estonia<\/option><option value=\"Eswatini\" >Eswatini<\/option><option value=\"Ethiopia\" >Ethiopia<\/option><option value=\"Fiji\" >Fiji<\/option><option value=\"Finland\" >Finland<\/option><option value=\"France\" >France<\/option><option value=\"Gabon\" >Gabon<\/option><option value=\"Gambia, The\" >Gambia, The<\/option><option value=\"Georgia\" >Georgia<\/option><option value=\"Germany\" >Germany<\/option><option value=\"Ghana\" >Ghana<\/option><option value=\"Greece\" >Greece<\/option><option value=\"Grenada\" >Grenada<\/option><option value=\"Guatemala\" >Guatemala<\/option><option value=\"Guinea\" >Guinea<\/option><option value=\"Guinea-Bissau\" >Guinea-Bissau<\/option><option value=\"Guyana\" >Guyana<\/option><option value=\"Haiti\" >Haiti<\/option><option value=\"Honduras\" >Honduras<\/option><option value=\"Hong Kong\" >Hong Kong<\/option><option value=\"Hungary\" >Hungary<\/option><option value=\"Iceland\" >Iceland<\/option><option value=\"India\" >India<\/option><option value=\"Indonesia\" >Indonesia<\/option><option value=\"Iran\" >Iran<\/option><option value=\"Iraq\" >Iraq<\/option><option value=\"Ireland\" >Ireland<\/option><option value=\"Israel\" >Israel<\/option><option value=\"Italy\" >Italy<\/option><option value=\"Jamaica\" >Jamaica<\/option><option value=\"Japan\" >Japan<\/option><option value=\"Jordan\" >Jordan<\/option><option value=\"Kazakhstan\" >Kazakhstan<\/option><option value=\"Kenya\" >Kenya<\/option><option value=\"Kiribati\" >Kiribati<\/option><option value=\"Korea, North\" >Korea, North<\/option><option value=\"Korea, South\" >Korea, South<\/option><option value=\"Kuwait\" >Kuwait<\/option><option value=\"Kyrgyzstan\" >Kyrgyzstan<\/option><option value=\"Laos\" >Laos<\/option><option value=\"Latvia\" >Latvia<\/option><option value=\"Lebanon\" >Lebanon<\/option><option value=\"Lesotho\" >Lesotho<\/option><option value=\"Liberia\" >Liberia<\/option><option value=\"Libya\" >Libya<\/option><option value=\"Liechtenstein\" >Liechtenstein<\/option><option value=\"Lithuania\" >Lithuania<\/option><option value=\"Luxembourg\" >Luxembourg<\/option><option value=\"Madagascar\" >Madagascar<\/option><option value=\"Malawi\" >Malawi<\/option><option value=\"Malaysia\" >Malaysia<\/option><option value=\"Maldives\" >Maldives<\/option><option value=\"Mali\" >Mali<\/option><option value=\"Malta\" >Malta<\/option><option value=\"Marshall Islands\" >Marshall Islands<\/option><option value=\"Mauritania\" >Mauritania<\/option><option value=\"Mauritius\" >Mauritius<\/option><option value=\"Mexico\" >Mexico<\/option><option value=\"Micronesia\" >Micronesia<\/option><option value=\"Moldova\" >Moldova<\/option><option value=\"Monaco\" >Monaco<\/option><option value=\"Mongolia\" >Mongolia<\/option><option value=\"Montenegro\" >Montenegro<\/option><option value=\"Morocco\" >Morocco<\/option><option value=\"Mozambique\" >Mozambique<\/option><option value=\"Myanmar\" >Myanmar<\/option><option value=\"Namibia\" >Namibia<\/option><option value=\"Nauru\" >Nauru<\/option><option value=\"Nepal\" >Nepal<\/option><option value=\"Netherlands\" >Netherlands<\/option><option value=\"New Zealand\" >New Zealand<\/option><option value=\"Nicaragua\" >Nicaragua<\/option><option value=\"Niger\" >Niger<\/option><option value=\"Nigeria\" >Nigeria<\/option><option value=\"North Macedonia\" >North Macedonia<\/option><option value=\"Norway\" >Norway<\/option><option value=\"Oman\" >Oman<\/option><option value=\"Pakistan\" >Pakistan<\/option><option value=\"Palau\" >Palau<\/option><option value=\"Palestine\" >Palestine<\/option><option value=\"Panama\" >Panama<\/option><option value=\"Papua New Guinea\" >Papua New Guinea<\/option><option value=\"Paraguay\" >Paraguay<\/option><option value=\"Peru\" >Peru<\/option><option value=\"Philippines\" >Philippines<\/option><option value=\"Poland\" >Poland<\/option><option value=\"Portugal\" >Portugal<\/option><option value=\"Puerto Rico\" >Puerto Rico<\/option><option value=\"Qatar\" >Qatar<\/option><option value=\"Romania\" >Romania<\/option><option value=\"Russia\" >Russia<\/option><option value=\"Rwanda\" >Rwanda<\/option><option value=\"Saint Kitts and Nevis\" >Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\" >Saint Lucia<\/option><option value=\"Saint Vincent\" >Saint Vincent<\/option><option value=\"Samoa\" >Samoa<\/option><option value=\"San Marino\" >San Marino<\/option><option value=\"Sao Tome and Principe\" >Sao Tome and Principe<\/option><option value=\"Saudi Arabia\" >Saudi Arabia<\/option><option value=\"Senegal\" >Senegal<\/option><option value=\"Serbia\" >Serbia<\/option><option value=\"Seychelles\" >Seychelles<\/option><option value=\"Sierra Leone\" >Sierra Leone<\/option><option value=\"Singapore\" >Singapore<\/option><option value=\"Slovakia\" >Slovakia<\/option><option value=\"Slovenia\" >Slovenia<\/option><option value=\"Solomon Islands\" >Solomon Islands<\/option><option value=\"Somalia\" >Somalia<\/option><option value=\"South Africa\" >South Africa<\/option><option value=\"South Sudan\" >South Sudan<\/option><option value=\"Spain\" >Spain<\/option><option value=\"Sri Lanka\" >Sri Lanka<\/option><option value=\"Sudan\" >Sudan<\/option><option value=\"Suriname\" >Suriname<\/option><option value=\"Sweden\" >Sweden<\/option><option value=\"Switzerland\" >Switzerland<\/option><option value=\"Syria\" >Syria<\/option><option value=\"Taiwan\" >Taiwan<\/option><option value=\"Tajikistan\" >Tajikistan<\/option><option value=\"Tanzania\" >Tanzania<\/option><option value=\"Thailand\" >Thailand<\/option><option value=\"Togo\" >Togo<\/option><option value=\"Tonga\" >Tonga<\/option><option value=\"Trinidad and Tobago\" >Trinidad and Tobago<\/option><option value=\"Tunisia\" >Tunisia<\/option><option value=\"Turkey\" >Turkey<\/option><option value=\"Turkmenistan\" >Turkmenistan<\/option><option value=\"Tuvalu\" >Tuvalu<\/option><option value=\"Uganda\" >Uganda<\/option><option value=\"Ukraine\" >Ukraine<\/option><option value=\"United Arab Emirates\" >United Arab Emirates<\/option><option value=\"United Kingdom\" >United Kingdom<\/option><option value=\"United States\" >United States<\/option><option value=\"Uruguay\" >Uruguay<\/option><option value=\"Uzbekistan\" >Uzbekistan<\/option><option value=\"Vanuatu\" >Vanuatu<\/option><option value=\"Vatican City\" >Vatican City<\/option><option value=\"Venezuela\" >Venezuela<\/option><option value=\"Vietnam\" >Vietnam<\/option><option value=\"Wales\" >Wales<\/option><option value=\"Yemen\" >Yemen<\/option><option value=\"Zambia\" >Zambia<\/option><option value=\"Zimbabwe\" >Zimbabwe<\/option><\/select>              <label for=\"wdform_56_country19\" class=\"mini_label\">Country<\/label><\/span><\/span><\/div><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"62\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_own_select\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_own_select\" ><div class=\"wdform-label-section wd-width-100 wdform_select wd-flex-row\">    <label  for=\"wdform_62_element19\" class=\"wdform-label\">Length of stay<\/label><\/div><div class=\"wdform-element-section wd-flex wdform_select wd-flex-row wd-width-100\" ><select class=\"wd-width-100\" id=\"wdform_62_element19\" name=\"wdform_62_element19\" ><option value=\"\" selected=\"selected\">Select value<\/option><option value=\"Short Term under 6 months\" >Short Term under 6 months<\/option><option value=\"Long Term over 6 months\" >Long Term over 6 months<\/option><\/select><\/div><\/div><\/div><div wdid=\"11\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_own_select\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_own_select\" ><div class=\"wdform-label-section wd-width-100 wdform_select wd-flex-row\">    <label  for=\"wdform_11_element19\" class=\"wdform-label\">Select Your Trip<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex wdform_select wd-flex-row wd-width-100\" ><select class=\"wd-width-100\" id=\"wdform_11_element19\" name=\"wdform_11_element19\" ><option value=\"vacation\" selected=\"selected\">Vacation<\/option><option value=\"I want to retire in Barbados\" >I want to retire in barbados<\/option><option value=\"Health visit\" >Health visit<\/option><option value=\"Vacation and events\" >Vacation and events<\/option><option value=\"Recreation\" >Recreation<\/option><option value=\"Business\" >Business<\/option><\/select><\/div><\/div><\/div><div wdid=\"12\" class=\"wdform_row\"><div type=\"type_text\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_text\" ><div class=\"wdform-label-section wd-width-100  wd-flex-row wd-align-items-center\">    <label  for=\"wdform_12_element19\" class=\"wdform-label\">How long will you be staying with us<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-align-items-center wd-width-100\" ><input type=\"text\"                           class=\"wd-width-100\"                           id=\"wdform_12_element19\"                           name=\"wdform_12_element19\"                           value=\"\"                           data-value=\"\"                           title=\"\"                           placeholder=\"\"                                                       \/><\/div><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"41\" class=\"wdform_row\"><div type=\"type_date_new\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_date_new\" ><div class=\"wdform-label-section wd-width-100  wd-flex-row\">    <label  for=\"wdform_41_element19\" class=\"wdform-label\">Expected date of arrival<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-width-100\" ><input class=\"wd-width-100\" autocomplete=\"off\" onchange=\"wd_validate(this)\" data-form-id=\"19\" data-wdid=\"41\" data-valid-type=\"date\" type=\"text\" id=\"wdform_41_element19\" data-value=\"\" value=\"\" name=\"wdform_41_element19\"   \/><span id=\"fm-calendar-41\" class=\"dashicons dashicons-calendar-alt wd-calendar-button wd-hidden\"><\/span><input type=\"hidden\" class=\"hidden_date\" data-format=\"mm\/dd\/yy\" data-min=\"\" data-max=\"\" id=\"wdform_41_button19\" value=\"\" \/><\/div><\/div><\/div><div wdid=\"42\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_date_new\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_date_new\" ><div class=\"wdform-label-section wd-width-100  wd-flex-row\">    <label  for=\"wdform_42_element19\" class=\"wdform-label\">Departure Date<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-width-100\" ><input class=\"wd-width-100\" autocomplete=\"off\" onchange=\"wd_validate(this)\" data-form-id=\"19\" data-wdid=\"42\" data-valid-type=\"date\" type=\"text\" id=\"wdform_42_element19\" data-value=\"\" value=\"\" name=\"wdform_42_element19\"   \/><span id=\"fm-calendar-42\" class=\"dashicons dashicons-calendar-alt wd-calendar-button wd-hidden\"><\/span><input type=\"hidden\" class=\"hidden_date\" data-format=\"mm\/dd\/yy\" data-min=\"\" data-max=\"\" id=\"wdform_42_button19\" value=\"\" \/><\/div><\/div><\/div><div wdid=\"19\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_own_select\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_own_select\" ><div class=\"wdform-label-section wd-width-100 wdform_select wd-flex-row\">    <label  for=\"wdform_19_element19\" class=\"wdform-label\">I would like  to <\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex wdform_select wd-flex-row wd-width-100\" ><select class=\"wd-width-100\" id=\"wdform_19_element19\" name=\"wdform_19_element19\" ><option value=\"Select\" selected=\"selected\">Select<\/option><option value=\"Buy a home\" >Buy a home<\/option><option value=\"Rent a home\" >Rent a home<\/option><option value=\"Integrate into a bajan family\" >Integrate into a bajan family<\/option><option value=\"Live in a care facility\" >Live in a care facility<\/option><option value=\"Share a home\" >Share a home<\/option><option value=\"Live independently\" >Live independently<\/option><option value=\"Rent an appartment\" >Rent an appartment<\/option><option value=\"Share an appartment\" >Share an appartment<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"13\" class=\"wdform_row\"><div type=\"type_own_select\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_own_select\" ><div class=\"wdform-label-section wd-width-100 wdform_select wd-flex-row\">    <label  for=\"wdform_13_element19\" class=\"wdform-label\">Select your accommodations <\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex wdform_select wd-flex-row wd-width-100\" ><select class=\"wd-width-100\" id=\"wdform_13_element19\" name=\"wdform_13_element19\" ><option value=\"Hotel\" selected=\"selected\">Hotel<\/option><option value=\"Villa\" >Villa<\/option><option value=\"Guest House\" >Guest House<\/option><option value=\"Private Apartment\" >Private Apartment<\/option><option value=\"Shared Apartment\" >Shared Apartment<\/option><option value=\"Stay With Bajan Family\" >Stay With Bajan Family<\/option><\/select><\/div><\/div><\/div><div wdid=\"14\" class=\"wdform_row\"><div type=\"type_own_select\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_own_select\" ><div class=\"wdform-label-section wd-width-100 wdform_select wd-flex-row\">    <label  for=\"wdform_14_element19\" class=\"wdform-label\">Select living arrangemens<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex wdform_select wd-flex-row wd-width-100\" ><select class=\"wd-width-100\" id=\"wdform_14_element19\" name=\"wdform_14_element19\" ><option value=\"Assisted living\" selected=\"selected\">Assisted living<\/option><option value=\"Independent Living\" >Independent Living<\/option><option value=\"Help with mobality\" >Help with mobality<\/option><option value=\"Shared  Living\" >Shared  Living<\/option><option value=\"Care Assistance\" >Care Assistance<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"15\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_checkbox\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_checkbox\" ><div class=\"wdform-label-section wd-width-100  wd-flex-wrap wd-flex-row\">    <label  class=\"wdform-label\">Events and Activity<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-100\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_15_element19\" value=\"\" \/><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\"  id=\"wdform_15_element190\" name=\"wdform_15_element190\" value=\"Barbados Tour\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_15_element190\"><span><\/span>Barbados Tour<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\"  id=\"wdform_15_element191\" name=\"wdform_15_element191\" value=\"Garden Dinners\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_15_element191\"><span><\/span>Garden Dinners<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\"  id=\"wdform_15_element192\" name=\"wdform_15_element192\" value=\"Group Beach Events\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_15_element192\"><span><\/span>Group Beach Events<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\"  id=\"wdform_15_element193\" name=\"wdform_15_element193\" value=\"Evening Entertainment\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_15_element193\"><span><\/span>Evening Entertainment<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\"  id=\"wdform_15_element194\" name=\"wdform_15_element194\" value=\"group Lunch Tours\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_15_element194\"><span><\/span>Group Lunch Tours<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\"  id=\"wdform_15_element195\" name=\"wdform_15_element195\" value=\"Water Therapy (Sea and Pool)\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_15_element195\"><span><\/span>Water Therapy (Sea and Pool)<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\"  id=\"wdform_15_element196\" name=\"wdform_15_element196\" value=\"Foot Ritual\"  checked=\"checked\"  \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_15_element196\"><span><\/span>Foot Ritual (free)<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\" other=\"1\" id=\"wdform_15_element197\" name=\"wdform_15_element197\" value=\"Other. Please Specify\" onclick=\"if(set_checked(&quot;wdform_15&quot;,&quot;7&quot;,&quot;19&quot;)) show_other_input(&quot;wdform_15&quot;,&quot;19&quot;);\"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_15_element197\"><span><\/span>Other. Please Specify<\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"24\" class=\"wdform_row\"><div type=\"type_editor\" class=\"wdform-field\"><h1 style=\"font-size: 40px; text-align: center;\">Medical Information<\/h1><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"17\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_radio\" ><div class=\"wdform-label-section wd-width-100  wd-flex-wrap wd-flex-row\">    <label  class=\"wdform-label\">Do you have any medical condition we need to know about<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-100\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_17_element19\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row\"><input type=\"radio\"  id=\"wdform_17_element190\" name=\"wdform_17_element19\" value=\"Yes\" onclick=\"set_default(&quot;wdform_17&quot;,&quot;0&quot;,&quot;19&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_17_element190\"><span><\/span>Yes<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row\"><input type=\"radio\"  id=\"wdform_17_element191\" name=\"wdform_17_element19\" value=\"No\" onclick=\"set_default(&quot;wdform_17&quot;,&quot;1&quot;,&quot;19&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_17_element191\"><span><\/span>No<\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"70\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_checkbox\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_checkbox\" ><div class=\"wdform-label-section wd-width-100  wd-flex-wrap wd-flex-row\">    <label  class=\"wdform-label\">Medical Conditions<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-100\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_70_element19\" value=\"\" \/><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\"  id=\"wdform_70_element190\" name=\"wdform_70_element190\" value=\"Heart Disease\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_70_element190\"><span><\/span>Heart Disease<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\"  id=\"wdform_70_element191\" name=\"wdform_70_element191\" value=\"High Blood Pressure\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_70_element191\"><span><\/span>High Blood Pressure<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\"  id=\"wdform_70_element192\" name=\"wdform_70_element192\" value=\"Congestive Heart Failure\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_70_element192\"><span><\/span>Congestive Heart Failure<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\"  id=\"wdform_70_element193\" name=\"wdform_70_element193\" value=\"COPD\/ Chronic obstructive pulmonary disease\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_70_element193\"><span><\/span>COPD\/ Chronic obstructive pulmonary disease<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\"  id=\"wdform_70_element194\" name=\"wdform_70_element194\" value=\"Oxygen Dependency\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_70_element194\"><span><\/span>Oxygen Dependency<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\"  id=\"wdform_70_element195\" name=\"wdform_70_element195\" value=\"Diabetic\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_70_element195\"><span><\/span>Diabetic<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\"  id=\"wdform_70_element196\" name=\"wdform_70_element196\" value=\"Stroke\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_70_element196\"><span><\/span>Stroke<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\"  id=\"wdform_70_element197\" name=\"wdform_70_element197\" value=\"Osteoporosis\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_70_element197\"><span><\/span>Osteoporosis<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\"  id=\"wdform_70_element198\" name=\"wdform_70_element198\" value=\"Catheter\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_70_element198\"><span><\/span>Catheter<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\"  id=\"wdform_70_element199\" name=\"wdform_70_element199\" value=\"Arthritis\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_70_element199\"><span><\/span>Arthritis<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\"  id=\"wdform_70_element1910\" name=\"wdform_70_element1910\" value=\"Cancer\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_70_element1910\"><span><\/span>Cancer<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\"  id=\"wdform_70_element1911\" name=\"wdform_70_element1911\" value=\"No to all\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_70_element1911\"><span><\/span>No to all<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row\"><input type=\"checkbox\" other=\"1\" id=\"wdform_70_element1912\" name=\"wdform_70_element1912\" value=\"other\" onclick=\"if(set_checked(&quot;wdform_70&quot;,&quot;12&quot;,&quot;19&quot;)) show_other_input(&quot;wdform_70&quot;,&quot;19&quot;);\"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_70_element1912\"><span><\/span>other<\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"18\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_radio\" ><div class=\"wdform-label-section wd-width-100  wd-flex-wrap wd-flex-row\">    <label  class=\"wdform-label\">We use an (EMR) electronic medical records program to make sure that we understand you medical conditions.  Will you consent to the use of our program while in or care.<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-100\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_18_element19\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row\"><input type=\"radio\"  id=\"wdform_18_element190\" name=\"wdform_18_element19\" value=\"Yes\" onclick=\"set_default(&quot;wdform_18&quot;,&quot;0&quot;,&quot;19&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_18_element190\"><span><\/span>Yes<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row\"><input type=\"radio\"  id=\"wdform_18_element191\" name=\"wdform_18_element19\" value=\"No\" onclick=\"set_default(&quot;wdform_18&quot;,&quot;1&quot;,&quot;19&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_18_element191\"><span><\/span>No<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"43\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_editor\" class=\"wdform-field\"><p>By not consenting to the use of our EMR program, you are solely responsible for all health problems while you are in our care.<\/p><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"32\" class=\"wdform_row\"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_radio\" ><div class=\"wdform-label-section wd-width-100  wd-flex-wrap wd-flex-row\">    <label  class=\"wdform-label\">Do you have a physician<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-100\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_32_element19\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row\"><input type=\"radio\"  id=\"wdform_32_element190\" name=\"wdform_32_element19\" value=\"Yes\" onclick=\"set_default(&quot;wdform_32&quot;,&quot;0&quot;,&quot;19&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_32_element190\"><span><\/span>Yes<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row\"><input type=\"radio\"  id=\"wdform_32_element191\" name=\"wdform_32_element19\" value=\"No\" onclick=\"set_default(&quot;wdform_32&quot;,&quot;1&quot;,&quot;19&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_32_element191\"><span><\/span>No<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"33\" class=\"wdform_row\"><div type=\"type_text\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_text\" ><div class=\"wdform-label-section wd-width-100  wd-flex-row wd-align-items-center\">    <label  for=\"wdform_33_element19\" class=\"wdform-label\">Name of physician and contact number<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-align-items-center wd-width-100\" ><input type=\"text\"                           class=\"wd-width-100\"                           id=\"wdform_33_element19\"                           name=\"wdform_33_element19\"                           value=\"\"                           data-value=\"\"                           title=\"\"                           placeholder=\"\"                                                       \/><\/div><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"31\" class=\"wdform_row\" style=\"position: relative; left: 0px; top: 0px;\"><div type=\"type_text\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_text\" ><div class=\"wdform-label-section wd-width-100  wd-flex-row wd-align-items-center\">    <label  for=\"wdform_31_element19\" class=\"wdform-label\">Person to contact in case of emergency, relationship and phone#<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-align-items-center wd-width-100\" ><input type=\"text\"                           class=\"wd-width-100\"                           id=\"wdform_31_element19\"                           name=\"wdform_31_element19\"                           value=\"\"                           data-value=\"\"                           title=\"\"                           placeholder=\"\"                                                       \/><\/div><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"66\" class=\"wdform_row\"><div type=\"type_editor\" class=\"wdform-field\"><p>By submitting this form you will be redirected to make an appointment to complete your registration.<\/p><p>Thanks in advance<\/p><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"46\" class=\"wdform_row\"><div type=\"type_send_copy\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column fm-type_send_copy\" ><div class=\"wdform-element-section wd-flex  checkbox-div wd-flex-row-reverse wd-align-items-center wd-justify-content-right wd-width-100\" ><input type=\"checkbox\"                             class=\"wd-flex-row\"                             id=\"wdform_46_element19\"                             name=\"wdform_46_element19\"                                                           \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse\" for=\"wdform_46_element19\" class=\"wdform-label\"><span><\/span>Send a copy of this message to yourself<\/label><span class=\"wdform-required\">*<\/span><\/div><\/div><\/div><\/div><div class=\"wdform_column\"><div wdid=\"45\" class=\"wdform_row\"><div type=\"type_recaptcha\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row fm-type_recaptcha\" ><div class=\"wdform-label-section wd-width-30 wd-hidden wd-flex-row\">    <label  class=\"wdform-label\">reCAPTCHA<\/label><\/div><div 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