Online Inquiry
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<ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="FH_Name_First_A" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">First Name</label><input name="CST_1" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Name_Last_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name</label><input name="CST_2" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="FH_Name_First_B" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Adult #2 First Name</label><input name="CST_3" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Name_Last_B"> <i class="fa fa-font"></i><label class="er_fld_label">Last Name</label><input name="CST_4" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="FH_Address_Street_1"> <i class="fa fa-font"></i><label class="er_fld_label required">Home Street Address</label><input name="CST_5" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="FH_Address_City" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">City</label><input name="CST_6" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Address_County"> <i class="fa fa-font"></i><label class="er_fld_label required">County</label><input name="CST_7" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" map_to="FH_Address_State" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">State</label><select name="CST_8" class="er_fld_required"><option value="Alabama">Alabama</option><option value="Alaska">Alaska</option><option value="Arizona">Arizona</option><option value="Arkansas">Arkansas</option><option value="California">California</option><option value="Colorado">Colorado</option><option value="Connecticut">Connecticut</option><option value="Delaware">Delaware</option><option value="Florida">Florida</option><option value="Georgia">Georgia</option><option value="Hawaii">Hawaii</option><option value="Idaho">Idaho</option><option value="Illinois">Illinois</option><option value="Indiana">Indiana</option><option value="Iowa">Iowa</option><option value="Kansas">Kansas</option><option value="Kentucky">Kentucky</option><option value="Louisiana">Louisiana</option><option value="Maine">Maine</option><option value="Maryland">Maryland</option><option value="Massachusetts">Massachusetts</option><option value="Michigan">Michigan</option><option value="Minnesota">Minnesota</option><option value="Mississippi">Mississippi</option><option value="Missouri">Missouri</option><option value="Montana">Montana</option><option value="Nebraska">Nebraska</option><option value="Nevada">Nevada</option><option value="New Hampshire">New Hampshire</option><option value="New Jersey">New Jersey</option><option value="New Mexico">New Mexico</option><option value="New York">New York</option><option value="North Carolina">North Carolina</option><option value="North Dakota">North Dakota</option><option value="Ohio">Ohio</option><option value="Oklahoma">Oklahoma</option><option value="Oregon">Oregon</option><option value="Pennsylvania">Pennsylvania</option><option value="Rhode Island">Rhode Island</option><option value="South Carolina">South Carolina</option><option value="South Dakota">South Dakota</option><option value="Tennessee">Tennessee</option><option value="Texas" selected="">Texas</option><option value="Utah">Utah</option><option value="Vermont">Vermont</option><option value="Virginia">Virginia</option><option value="Washington">Washington</option><option value="West Virginia">West Virginia</option><option value="Wisconsin">Wisconsin</option><option value="Wyoming">Wyoming</option></select></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Address_Zip"> <i class="fa fa-font"></i><label class="er_fld_label required">Zip Code</label><input name="CST_9" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" map_to="Location"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Which of our office locations is closest to your home?</label><select name="CST_10" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Abilene">Abilene</option><option value="Austin">Austin</option><option value="DFW">DFW</option><option value="Houston">Houston</option><option value="San Antonio">San Antonio</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="FH_Phone_Home" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Home Phone</label><input name="CST_11" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_EMail"> <i class="fa fa-font"></i><label class="er_fld_label required">Email</label><input name="CST_12" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_selected" draggable="false" map_to="FH_ReferralSource"><i class="fa fa-caret-down"></i><label class="er_fld_label required">How did you hear about us?</label><select name="CST_13" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Billboard">Billboard</option><option value="Church/Pastor">Church/Pastor</option><option value="Community Event">Community Event</option><option value="Community Impact Newsletter">Community Impact Newsletter</option><option value="DFPS/CPS">DFPS/CPS</option><option value="Display Table at Event">Display Table at Event</option><option value="Exceptional Kids Magazine">Exceptional Kids Magazine</option><option value="Facebook">Facebook</option><option value="Indeed">Indeed</option><option value="Instagram">Instagram</option><option value="Mailer/Postcard received in the mail">Mailer/Postcard received in the mail</option><option value="Movie Theatre/EVO Cinemas Creekside 14 New Braunfels">Movie Theatre/EVO Cinemas Creekside 14 New Braunfels</option><option value="Movie Theatre/Santikos Entertainment New Braunfels">Movie Theatre/Santikos Entertainment New Braunfels</option><option value="Neighborhood News">Neighborhood News</option><option value="News/TV">News/TV</option><option value="Other">Other</option><option value="Other Agency">Other Agency</option><option value="Pathways Employee">Pathways Employee</option><option value="Pathways Foster/Adoptive Parent">Pathways Foster/Adoptive Parent</option><option value="Pathways Newsletter">Pathways Newsletter</option><option value="Pathways Website">Pathways Website</option><option value="Radio">Radio</option><option value="Social Media">Social Media</option><option value="SSCC">SSCC</option><option value="Twitter">Twitter</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space:normal;" draggable="false" map_to="FH_Interest"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Interested In:</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_14" value="Foster Care">Foster Care</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_14" value="Foster/Adoption">Foster/Adoption</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_14" value="Adoption">Adoption</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_14" value="Respite">Respite</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_14" value="Kinship">Kinship</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_14" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_14_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" map_to="FH_Inquiry_Why_Parents"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Why do you want to be a foster/adoptive parent?</label><textarea name="CST_15" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" map_to="FH_Inquiry_Comments"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Do you have any questions or comments?</label><textarea name="CST_17" style="width:100%;"></textarea></li></ul><ul id="er_row_last" class="er_fld_row"><li class="er_fld_type_text" draggable="false"> <i class="fa fa-font"></i><label class="er_fld_label">How many children would you like to foster?</label><input name="CST_18" type="text"></li></ul>
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