{"id":2629,"date":"2020-08-22T18:26:52","date_gmt":"2020-08-22T18:26:52","guid":{"rendered":"https:\/\/centraldcclinic.com\/?page_id=2629"},"modified":"2026-04-15T13:04:51","modified_gmt":"2026-04-15T13:04:51","slug":"family-reg","status":"publish","type":"page","link":"https:\/\/moremiinitiative.org\/pavilion\/family-reg\/","title":{"rendered":"Family Registration Form"},"content":{"rendered":"<p style=\"text-align: left;\"><div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_3_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_familyform\" >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\"><\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"3\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_3\" id=\"frm_hide_fields_3\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"familyform\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_3\" name=\"frm_submit_entry_3\" value=\"531b66f927\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/pavilion\/wp-json\/wp\/v2\/pages\/2629\" \/><div id=\"frm_field_25_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Family Representative Details<\/h3>\r\n\r\n\r\n<div id=\"frm_field_26_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_fourth\">\r\n    <label for=\"field_yxhea\" id=\"field_yxhea_label\" class=\"frm_primary_label\">Prefix\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[26]\" id=\"field_yxhea\"  data-sectionid=\"25\" data-placeholder=\"Select an option\"  data-frmval=\"Miss\" data-reqmsg=\"Prefix cannot be blank.\" aria-required=\"true\" data-invmsg=\"Prefix is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"Miss\" selected='selected'>Miss<\/option><option  value=\"Mr.\">Mr.<\/option><option  value=\"Mrs.\">Mrs.<\/option><option  value=\"Dr.\">Dr.<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_27_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_wtgpb\" id=\"field_wtgpb_label\" class=\"frm_primary_label\">Full Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_wtgpb\" name=\"item_meta[27]\" value=\"\"  data-sectionid=\"16\" data-reqmsg=\"Full Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_28_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_s4gl5\" id=\"field_s4gl5_label\" class=\"frm_primary_label\">Date of Birth\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_s4gl5\" name=\"item_meta[28]\" value=\"\"  data-sectionid=\"25\" maxlength=\"10\" data-reqmsg=\"Date of Birth cannot be blank.\" aria-required=\"true\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_29_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_fourth\">\r\n    <label for=\"field_iy8v1\" id=\"field_iy8v1_label\" class=\"frm_primary_label\">Gender\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[29]\" id=\"field_iy8v1\"  data-sectionid=\"25\" data-placeholder=\"Select an option\"  data-frmval=\"Male\" data-reqmsg=\"Gender cannot be blank.\" aria-required=\"true\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"Male\" selected='selected'>Male<\/option><option  value=\"Female\">Female<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_30_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_c13yn\" id=\"field_c13yn_label\" class=\"frm_primary_label\">Address\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_c13yn\" name=\"item_meta[30]\" value=\"\"  data-sectionid=\"25\" data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_31_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_bxk9h\" id=\"field_bxk9h_label\" class=\"frm_primary_label\">Phone No.\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_bxk9h\" name=\"item_meta[31]\" value=\"\"  data-sectionid=\"25\" data-reqmsg=\"Phone No. cannot be blank.\" aria-required=\"true\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_32_container\" class=\"frm_form_field form-field  frm_top_container frm_third\">\r\n    <label for=\"field_ve4wt\" id=\"field_ve4wt_label\" class=\"frm_primary_label\">Alternative Phone No.\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_ve4wt\" name=\"item_meta[32]\" value=\"\"  data-sectionid=\"25\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_33_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_fourth\">\r\n    <label for=\"field_7gd1s\" id=\"field_7gd1s_label\" class=\"frm_primary_label\">Email Address\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_7gd1s\" name=\"item_meta[33]\" value=\"\"  data-sectionid=\"25\" data-reqmsg=\"Email Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_34_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_72ts7\" id=\"field_72ts7_label\" class=\"frm_primary_label\">Marital Status\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[34]\" id=\"field_72ts7\"  data-sectionid=\"25\" data-placeholder=\"Select an option\"  data-frmval=\"Single\" data-reqmsg=\"Marital Status cannot be blank.\" aria-required=\"true\" data-invmsg=\"Marital Status is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"Single\" selected='selected'>Single<\/option><option  value=\"Married\">Married<\/option><option  value=\"Separated\">Separated<\/option><option  value=\"Divorced\">Divorced<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_35_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_yqm9o\" id=\"field_yqm9o_label\" class=\"frm_primary_label\">If Married, Name of Spouse \r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_yqm9o\" name=\"item_meta[35]\" value=\"\"  data-sectionid=\"25\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_36_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_qkwwq\" id=\"field_qkwwq_label\" class=\"frm_primary_label\">Occupation\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_qkwwq\" name=\"item_meta[36]\" value=\"\"  data-sectionid=\"25\" data-reqmsg=\"Occupation cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_37_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_q2gpd\" id=\"field_q2gpd_label\" class=\"frm_primary_label\">Employer\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_q2gpd\" name=\"item_meta[37]\" value=\"\"  data-sectionid=\"25\" data-reqmsg=\"Employer cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_39_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Emergency Contact<\/h3>\r\n\r\n\r\n<div id=\"frm_field_40_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_pk7d\" id=\"field_pk7d_label\" class=\"frm_primary_label\">Full Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_pk7d\" name=\"item_meta[40]\" value=\"\"  data-sectionid=\"39\" data-reqmsg=\"Full Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_41_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_pvigk\" id=\"field_pvigk_label\" class=\"frm_primary_label\">Relationship\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_pvigk\" name=\"item_meta[41]\" value=\"\"  data-sectionid=\"39\" data-reqmsg=\"Relationship cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_42_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_fourth\">\r\n    <label for=\"field_p1l16\" id=\"field_p1l16_label\" class=\"frm_primary_label\">Phone No.\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_p1l16\" name=\"item_meta[42]\" value=\"\"  data-sectionid=\"39\" data-reqmsg=\"Phone No. cannot be blank.\" aria-required=\"true\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_43_container\" class=\"frm_form_field form-field  frm_top_container frm_third\">\r\n    <label for=\"field_wjqj4\" id=\"field_wjqj4_label\" class=\"frm_primary_label\">Alternative Phone No.\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_wjqj4\" name=\"item_meta[43]\" value=\"\"  data-sectionid=\"39\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_44_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_ikkln\" id=\"field_ikkln_label\" class=\"frm_primary_label\">Total Number of Beneficiaries \r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"number\" id=\"field_ikkln\" name=\"item_meta[44]\" value=\"\"  data-sectionid=\"39\" data-reqmsg=\"Total Number of Beneficiaries  cannot be blank.\" aria-required=\"true\" data-invmsg=\"Number is invalid\" aria-invalid=\"false\"   min=\"0\" max=\"10\" step=\"any\"\/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_46_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Beneficiaries Details<\/h3>\r\n\r\n\r\n<div id=\"frm_field_47_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_eaue1\" id=\"field_eaue1_label\" class=\"frm_primary_label\">Full Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_eaue1\" name=\"item_meta[47]\" value=\"\"  data-sectionid=\"46\" data-reqmsg=\"Full Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_48_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_fourth\">\r\n    <label for=\"field_vm410\" id=\"field_vm410_label\" class=\"frm_primary_label\">Gender\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[48]\" id=\"field_vm410\"  data-sectionid=\"46\" data-placeholder=\"Select an option\"  data-frmval=\"New Option\" data-reqmsg=\"Gender cannot be blank.\" aria-required=\"true\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\"> <\/option><option  value=\"Male\">Male<\/option><option  value=\"Female\">Female<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_49_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_fourth\">\r\n    <label for=\"field_gz3y8\" id=\"field_gz3y8_label\" class=\"frm_primary_label\">Date of Birth\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_gz3y8\" name=\"item_meta[49]\" value=\"\"  data-sectionid=\"46\" maxlength=\"10\" data-reqmsg=\"Date of Birth cannot be blank.\" aria-required=\"true\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_50_container\" class=\"frm_form_field form-field  frm_top_container frm_third\">\r\n    <label for=\"field_gsu4p\" id=\"field_gsu4p_label\" class=\"frm_primary_label\">Full Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_gsu4p\" name=\"item_meta[50]\" value=\"\"  data-sectionid=\"46\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_51_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_kccgq\" id=\"field_kccgq_label\" class=\"frm_primary_label\">Gender\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[51]\" id=\"field_kccgq\"  data-sectionid=\"46\" data-placeholder=\"Select an option\"  data-frmval=\"New Option\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\"> <\/option><option  value=\"Male\">Male<\/option><option  value=\"Female\">Female<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_52_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_cmqzy\" id=\"field_cmqzy_label\" class=\"frm_primary_label\">Date of Birth\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_cmqzy\" name=\"item_meta[52]\" value=\"\"  data-sectionid=\"46\" maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_53_container\" class=\"frm_form_field form-field  frm_top_container frm_third\">\r\n    <label for=\"field_v8c3b\" id=\"field_v8c3b_label\" class=\"frm_primary_label\">Full Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_v8c3b\" name=\"item_meta[53]\" value=\"\"  data-sectionid=\"46\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_54_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_t1zoh\" id=\"field_t1zoh_label\" class=\"frm_primary_label\">Gender\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[54]\" id=\"field_t1zoh\"  data-sectionid=\"46\" data-placeholder=\"Select an option\"  data-frmval=\"New Option\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\"> <\/option><option  value=\"Male\">Male<\/option><option  value=\"Female\">Female<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_55_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_nis80\" id=\"field_nis80_label\" class=\"frm_primary_label\">Date of Birth\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_nis80\" name=\"item_meta[55]\" value=\"\"  data-sectionid=\"46\" maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_56_container\" class=\"frm_form_field form-field  frm_top_container frm_third\">\r\n    <label for=\"field_n7r4g\" id=\"field_n7r4g_label\" class=\"frm_primary_label\">Full Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_n7r4g\" name=\"item_meta[56]\" value=\"\"  data-sectionid=\"46\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_57_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_ietny\" id=\"field_ietny_label\" class=\"frm_primary_label\">Gender\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[57]\" id=\"field_ietny\"  data-sectionid=\"46\" data-placeholder=\"Select an option\"  data-frmval=\"New Option\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\"> <\/option><option  value=\"Male\">Male<\/option><option  value=\"Female\">Female<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_58_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_zk8cw\" id=\"field_zk8cw_label\" class=\"frm_primary_label\">Date of Birth\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_zk8cw\" name=\"item_meta[58]\" value=\"\"  data-sectionid=\"46\" maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_59_container\" class=\"frm_form_field form-field  frm_top_container frm_third\">\r\n    <label for=\"field_vz6it\" id=\"field_vz6it_label\" class=\"frm_primary_label\">Full Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_vz6it\" name=\"item_meta[59]\" value=\"\"  data-sectionid=\"46\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_60_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_ytdqq\" id=\"field_ytdqq_label\" class=\"frm_primary_label\">Gender\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[60]\" id=\"field_ytdqq\"  data-sectionid=\"46\" data-placeholder=\"Select an option\"  data-frmval=\"New Option\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\"> <\/option><option  value=\"Male\">Male<\/option><option  value=\"Female\">Female<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_61_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_lh69d\" id=\"field_lh69d_label\" class=\"frm_primary_label\">Date of Birth\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_lh69d\" name=\"item_meta[61]\" value=\"\"  data-sectionid=\"46\" maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_62_container\" class=\"frm_form_field form-field  frm_top_container frm_third\">\r\n    <label for=\"field_v29f\" id=\"field_v29f_label\" class=\"frm_primary_label\">Full Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_v29f\" name=\"item_meta[62]\" value=\"\"  data-sectionid=\"46\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_63_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_jofnk\" id=\"field_jofnk_label\" class=\"frm_primary_label\">Gender\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[63]\" id=\"field_jofnk\"  data-sectionid=\"46\" data-placeholder=\"Select an option\"  data-frmval=\"New Option\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\"> <\/option><option  value=\"Male\">Male<\/option><option  value=\"Female\">Female<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_64_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_qxjxk\" id=\"field_qxjxk_label\" class=\"frm_primary_label\">Date of Birth\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_qxjxk\" name=\"item_meta[64]\" value=\"\"  data-sectionid=\"46\" maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_65_container\" class=\"frm_form_field form-field  frm_top_container frm_third\">\r\n    <label for=\"field_fk86r\" id=\"field_fk86r_label\" class=\"frm_primary_label\">Full Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_fk86r\" name=\"item_meta[65]\" value=\"\"  data-sectionid=\"46\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_66_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_sfjxs\" id=\"field_sfjxs_label\" class=\"frm_primary_label\">Gender\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[66]\" id=\"field_sfjxs\"  data-sectionid=\"46\" data-placeholder=\"Select an option\"  data-frmval=\"New Option\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\"> <\/option><option  value=\"Male\">Male<\/option><option  value=\"Female\">Female<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_67_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_6qr5w\" id=\"field_6qr5w_label\" class=\"frm_primary_label\">Date of Birth\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_6qr5w\" name=\"item_meta[67]\" value=\"\"  data-sectionid=\"46\" maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_68_container\" class=\"frm_form_field form-field  frm_top_container frm_third\">\r\n    <label for=\"field_zfijz\" id=\"field_zfijz_label\" class=\"frm_primary_label\">Full Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_zfijz\" name=\"item_meta[68]\" value=\"\"  data-sectionid=\"46\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_69_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_z54sn\" id=\"field_z54sn_label\" class=\"frm_primary_label\">Gender\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[69]\" id=\"field_z54sn\"  data-sectionid=\"46\" data-placeholder=\"Select an option\"  data-frmval=\"New Option\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\"> <\/option><option  value=\"Male\">Male<\/option><option  value=\"Female\">Female<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_70_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_wof5y\" id=\"field_wof5y_label\" class=\"frm_primary_label\">Date of Birth\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_wof5y\" name=\"item_meta[70]\" value=\"\"  data-sectionid=\"46\" maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_71_container\" class=\"frm_form_field form-field  frm_top_container frm_third\">\r\n    <label for=\"field_sfr17\" id=\"field_sfr17_label\" class=\"frm_primary_label\">Full Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_sfr17\" name=\"item_meta[71]\" value=\"\"  data-sectionid=\"46\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_72_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_97p8i\" id=\"field_97p8i_label\" class=\"frm_primary_label\">Gender\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[72]\" id=\"field_97p8i\"  data-sectionid=\"46\" data-placeholder=\"Select an option\"  data-frmval=\"New Option\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\"> <\/option><option  value=\"Male\">Male<\/option><option  value=\"Female\">Female<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_73_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_it9bj\" id=\"field_it9bj_label\" class=\"frm_primary_label\">Date of Birth\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_it9bj\" name=\"item_meta[73]\" value=\"\"  data-sectionid=\"46\" maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_74_container\" class=\"frm_form_field form-field  frm_top_container frm_third\">\r\n    <label for=\"field_6xsis\" id=\"field_6xsis_label\" class=\"frm_primary_label\">Full Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_6xsis\" name=\"item_meta[74]\" value=\"\"  data-sectionid=\"46\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_75_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_a5f4d\" id=\"field_a5f4d_label\" class=\"frm_primary_label\">Gender\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[75]\" id=\"field_a5f4d\"  data-sectionid=\"46\" data-placeholder=\"Select an option\"  data-frmval=\"New Option\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\"> <\/option><option  value=\"Male\">Male<\/option><option  value=\"Female\">Female<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_76_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_krn80\" id=\"field_krn80_label\" class=\"frm_primary_label\">Date of Birth\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_krn80\" name=\"item_meta[76]\" value=\"\"  data-sectionid=\"46\" maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_77_container\" class=\"frm_form_field form-field  frm_top_container frm_half\">\r\n    <label for=\"field_pkac1\" id=\"field_pkac1_label\" class=\"frm_primary_label\">\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_pkac1\" name=\"item_meta[77]\" value=\"\"  readonly=\"readonly\"  data-sectionid=\"46\" placeholder=\"Call us if you exhaust the above fields\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_79_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Payment Details<\/h3>\r\n\r\n\r\n<div id=\"frm_field_80_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_5op6l\" id=\"field_5op6l_label\" class=\"frm_primary_label\">Full Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_5op6l\" name=\"item_meta[80]\" value=\"\"  data-sectionid=\"79\" data-reqmsg=\"Full Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_81_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_fourth\">\r\n    <label for=\"field_zx4dy\" id=\"field_zx4dy_label\" class=\"frm_primary_label\">Phone No.\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_zx4dy\" name=\"item_meta[81]\" value=\"\"  data-sectionid=\"79\" data-reqmsg=\"Phone No. cannot be blank.\" aria-required=\"true\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_82_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_228vu\" id=\"field_228vu_label\" class=\"frm_primary_label\">Alternative Phone No.\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_228vu\" name=\"item_meta[82]\" value=\"\"  data-sectionid=\"79\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_83_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third vertical_radio\">\r\n    <div  id=\"field_t8pwz_label\" class=\"frm_primary_label\">Mode of Payment\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_t8pwz_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_83-79-0\">\t\t\t<label  for=\"field_t8pwz-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[83]\" id=\"field_t8pwz-0\" value=\"Cash\"\n\t\t data-sectionid=\"79\" data-reqmsg=\"Mode of Payment cannot be blank.\" data-invmsg=\"Mode of Payment is invalid\"   \/> Cash<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_83-79-1\">\t\t\t<label  for=\"field_t8pwz-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[83]\" id=\"field_t8pwz-1\" value=\"Cheque\"\n\t\t data-sectionid=\"79\" data-reqmsg=\"Mode of Payment cannot be blank.\" data-invmsg=\"Mode of Payment is invalid\"   \/> Cheque<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_84_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third vertical_radio\">\r\n    <div  id=\"field_k9q6f_label\" class=\"frm_primary_label\">Mode of Bill Delivery\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_k9q6f_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_84-79-0\">\t\t\t<label  for=\"field_k9q6f-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[84]\" id=\"field_k9q6f-0\" value=\"Email\"\n\t\t data-sectionid=\"79\" data-reqmsg=\"Mode of Bill Delivery cannot be blank.\" data-invmsg=\"Mode of Bill Delivery is invalid\"   \/> Email<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_84-79-1\">\t\t\t<label  for=\"field_k9q6f-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[84]\" id=\"field_k9q6f-1\" value=\"Pick-Up from clinic\"\n\t\t data-sectionid=\"79\" data-reqmsg=\"Mode of Bill Delivery cannot be blank.\" data-invmsg=\"Mode of Bill Delivery is invalid\"   \/> Pick-Up from clinic<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_84-79-2\">\t\t\t<label  for=\"field_k9q6f-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[84]\" id=\"field_k9q6f-2\" value=\"Delivery at a fee\"\n\t\t data-sectionid=\"79\" data-reqmsg=\"Mode of Bill Delivery cannot be blank.\" data-invmsg=\"Mode of Bill Delivery is invalid\"   \/> Delivery at a fee<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_86_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Family Name<\/h3>\r\n\r\n\r\n<div id=\"frm_field_87_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_z0tfz\" id=\"field_z0tfz_label\" class=\"frm_primary_label\">Kindly provide a name you will want your family to be addressed with. This name will also be documented and use for all official purposes\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_z0tfz\" name=\"item_meta[87]\" value=\"\"  data-sectionid=\"86\" data-reqmsg=\"Kindly provide a name you will want your family to be addressed with. This name will also be documented and use for all official purposes cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\" aria-describedby=\"frm_desc_field_z0tfz\"  \/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_z0tfz\">E.g (The Daniels, Enchils, The Family Dogbe (T.F.D), Larsey Group, Sakyi Foundation)<\/div>\r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_89_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Declaration<\/h3>\r\n\r\n\r\n<div id=\"frm_field_90_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_ec1oq\" id=\"field_ec1oq_label\" class=\"frm_primary_label\">Your Full Name to confirm Agreement\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_ec1oq\" name=\"item_meta[90]\" value=\"\"  data-sectionid=\"89\" data-reqmsg=\"Your Full Name to confirm Agreement cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\" aria-describedby=\"frm_desc_field_ec1oq\"  \/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_ec1oq\">I, hereby declare that the information provided to Central Dansoman Clinic Limited (C.D.C) is truthful, thereby granting C.D.C the right to verify the authenticity of the above information. C.D.C shall not be held liable for any wrong information provided by the client under any circumstance. <\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_91_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_psr11\" id=\"field_psr11_label\" class=\"frm_primary_label\">Date of Approval\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_psr11\" name=\"item_meta[91]\" value=\"\"  data-sectionid=\"89\" maxlength=\"10\" data-reqmsg=\"Date of Approval cannot be blank.\" aria-required=\"true\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_234_container\">\n\t\t\t<label for=\"field_8g8uy\" >\n\t\t\t\tIf you are human, leave this field blank.\t\t\t<\/label>\n\t\t\t<input  id=\"field_8g8uy\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[234]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"CPQO4OG8hnal3svfiTKpRNiPWtF6Q9ByxNPveIFEwUY=\" \/><div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"  >Submit<\/button>\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n","protected":false},"excerpt":{"rendered":"Family Representative Details Prefix * MissMr.Mrs.Dr. Full Name * Date of Birth * Gender * MaleFemale Address * Phone No. * Alternative Phone No. Email Address * Marital Status * SingleMarriedSeparatedDivorced If Married, Name of Spouse Occupation * Employer * Emergency Contact Full Name * Relationship * Phone No. * Alternative Phone No. Total Number [...]","protected":false},"author":4,"featured_media":2658,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-2629","page","type-page","status-publish","has-post-thumbnail","hentry"],"_links":{"self":[{"href":"https:\/\/moremiinitiative.org\/pavilion\/wp-json\/wp\/v2\/pages\/2629","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/moremiinitiative.org\/pavilion\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/moremiinitiative.org\/pavilion\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/moremiinitiative.org\/pavilion\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/moremiinitiative.org\/pavilion\/wp-json\/wp\/v2\/comments?post=2629"}],"version-history":[{"count":1,"href":"https:\/\/moremiinitiative.org\/pavilion\/wp-json\/wp\/v2\/pages\/2629\/revisions"}],"predecessor-version":[{"id":12663,"href":"https:\/\/moremiinitiative.org\/pavilion\/wp-json\/wp\/v2\/pages\/2629\/revisions\/12663"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/moremiinitiative.org\/pavilion\/wp-json\/wp\/v2\/media\/2658"}],"wp:attachment":[{"href":"https:\/\/moremiinitiative.org\/pavilion\/wp-json\/wp\/v2\/media?parent=2629"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}