{"id":25381,"date":"2021-09-08T15:48:13","date_gmt":"2021-09-08T22:48:13","guid":{"rendered":"https:\/\/www.camarenahealth.org\/formularios-de-consentimiento\/"},"modified":"2022-08-12T18:50:52","modified_gmt":"2022-08-13T01:50:52","slug":"formularios-de-consentimiento","status":"publish","type":"page","link":"https:\/\/www.camarenahealth.org\/es\/formularios-de-consentimiento\/","title":{"rendered":"Formularios de consentimiento"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"25381\" class=\"elementor elementor-25381 elementor-18336\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-a7597fe elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"a7597fe\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-277b1ff\" data-id=\"277b1ff\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-66687c7 elementor-widget elementor-widget-heading\" data-id=\"66687c7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Centro de Salud Escolar y Centro de Salud Escolar M\u00f3vil Formulario de consentimiento de los padres<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-61cec91 elementor-widget elementor-widget-wp-widget-gform_widget\" data-id=\"61cec91\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wp-widget-gform_widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<script src=\"https:\/\/www.camarenahealth.org\/wp-includes\/js\/dist\/dom-ready.min.js?ver=f77871ff7694fffea381\" id=\"wp-dom-ready-js\"><\/script>\n<script src=\"https:\/\/www.camarenahealth.org\/wp-includes\/js\/dist\/hooks.min.js?ver=dd5603f07f9220ed27f1\" id=\"wp-hooks-js\"><\/script>\n<script src=\"https:\/\/www.camarenahealth.org\/wp-includes\/js\/dist\/i18n.min.js?ver=c26c3dc7bed366793375\" id=\"wp-i18n-js\"><\/script>\n<script id=\"wp-i18n-js-after\">\nwp.i18n.setLocaleData( { 'text direction\\u0004ltr': [ 'ltr' ] } );\n\/\/# sourceURL=wp-i18n-js-after\n<\/script>\n<script id=\"wp-a11y-js-translations\">\n( function( domain, translations ) {\n\tvar localeData = translations.locale_data[ domain ] || translations.locale_data.messages;\n\tlocaleData[\"\"].domain = domain;\n\twp.i18n.setLocaleData( localeData, domain );\n} )( \"default\", {\"translation-revision-date\":\"2026-03-28 00:00:14+0000\",\"generator\":\"GlotPress\\\/4.0.3\",\"domain\":\"messages\",\"locale_data\":{\"messages\":{\"\":{\"domain\":\"messages\",\"plural-forms\":\"nplurals=2; plural=n != 1;\",\"lang\":\"es\"},\"Notifications\":[\"Avisos\"]}},\"comment\":{\"reference\":\"wp-includes\\\/js\\\/dist\\\/a11y.js\"}} );\n\/\/# sourceURL=wp-a11y-js-translations\n<\/script>\n<script src=\"https:\/\/www.camarenahealth.org\/wp-includes\/js\/dist\/a11y.min.js?ver=cb460b4676c94bd228ed\" id=\"wp-a11y-js\"><\/script>\n<script src=\"https:\/\/www.camarenahealth.org\/wp-includes\/js\/jquery\/jquery.min.js?ver=3.7.1\" id=\"jquery-core-js\"><\/script>\n<script src=\"https:\/\/www.camarenahealth.org\/wp-includes\/js\/jquery\/jquery-migrate.min.js?ver=3.4.1\" id=\"jquery-migrate-js\"><\/script>\n<script defer='defer' src=\"https:\/\/www.camarenahealth.org\/wp-content\/plugins\/gravityforms\/js\/jquery.json.min.js?ver=2.9.31\" id=\"gform_json-js\"><\/script>\n<script id=\"gform_gravityforms-js-extra\">\nvar gf_global = {\"gf_currency_config\":{\"name\":\"D\\u00f3lar Americano\",\"symbol_left\":\"$\",\"symbol_right\":\"\",\"symbol_padding\":\"\",\"thousand_separator\":\",\",\"decimal_separator\":\".\",\"decimals\":2,\"code\":\"USD\"},\"base_url\":\"https:\/\/www.camarenahealth.org\/wp-content\/plugins\/gravityforms\",\"number_formats\":[],\"spinnerUrl\":\"https:\/\/www.camarenahealth.org\/wp-content\/plugins\/gravityforms\/images\/spinner.svg\",\"version_hash\":\"699fc486be0c250161e3116cddb9ff8a\",\"strings\":{\"newRowAdded\":\"Nueva fila a\\u00f1adida.\",\"rowRemoved\":\"Fila eliminada\",\"formSaved\":\"Se ha guardado el formulario. El contenido incluye el enlace para volver y completar el formulario.\"}};\n\/\/# sourceURL=gform_gravityforms-js-extra\n<\/script>\n<script defer='defer' src=\"https:\/\/www.camarenahealth.org\/wp-content\/plugins\/gravityforms\/js\/gravityforms.min.js?ver=2.9.31\" id=\"gform_gravityforms-js\"><\/script>\n<script id=\"gform_conditional_logic-js-extra\">\nvar gf_legacy = {\"is_legacy\":\"\"};\n\/\/# sourceURL=gform_conditional_logic-js-extra\n<\/script>\n<script defer='defer' src=\"https:\/\/www.camarenahealth.org\/wp-content\/plugins\/gravityforms\/js\/conditional_logic.min.js?ver=2.9.31\" id=\"gform_conditional_logic-js\"><\/script>\n<script defer='defer' src=\"https:\/\/www.camarenahealth.org\/wp-content\/plugins\/gravityforms\/js\/jquery.maskedinput.min.js?ver=2.9.31\" id=\"gform_masked_input-js\"><\/script>\n<script defer='defer' src=\"https:\/\/www.camarenahealth.org\/wp-content\/plugins\/gravityforms\/js\/placeholders.jquery.min.js?ver=2.9.31\" id=\"gform_placeholder-js\"><\/script>\n<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_13' style='display:none'><div id='gf_13' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; se\u00f1ala los campos obligatorios<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_13' id='gform_13'  action='\/es\/wp-json\/wp\/v2\/pages\/25381#gf_13' data-formid='13' novalidate><div id='gf_page_steps_13' class='gf_page_steps'><div id='gf_step_13_1' class='gf_step gf_step_active gf_step_first'><span class='gf_step_number'>1<\/span><span class='gf_step_label'>Seleccione el idioma<\/span><\/div><div id='gf_step_13_2' class='gf_step gf_step_next gf_step_pending'><span class='gf_step_number'>2<\/span><span class='gf_step_label'>Informaci\u00f3n para estudiantes<\/span><\/div><div id='gf_step_13_3' class='gf_step gf_step_last gf_step_pending'><span class='gf_step_number'>3<\/span><span class='gf_step_label'>Formulario de consentimiento de los padres<\/span><\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_13_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_13' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_178\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_178'>Comments<\/label><div class='ginput_container'><input name='input_178' id='input_13_178' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_13_178'>Este campo es un campo de validaci\u00f3n y debe quedar sin cambios.<\/div><\/div><fieldset id=\"field_13_99\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Por favor, seleccione el idioma del formulario de consentimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_99'>\n\t\t\t<div class='gchoice gchoice_13_99_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='Ingl\u00e9s'  id='choice_13_99_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_99_0' id='label_13_99_0' class='gform-field-label gform-field-label--type-inline'>Ingl\u00e9s<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_99_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='Espa\u00f1ol'  id='choice_13_99_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_99_1' id='label_13_99_1' class='gform-field-label gform-field-label--type-inline'>Espa\u00f1ol<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_13_98' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente  &gt;'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_2' class='gform_page' data-js='page-field-id-98' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_6\" class=\"gfield gfield--type-text gfield--width-quarter hipaa_forms_first_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_6'>Padre\/tutor legal (nombre)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_13_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_7\" class=\"gfield gfield--type-text gfield--width-quarter hipaa_forms_last_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_7'>Padre\/tutor legal (apellido)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_13_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_34\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_34'>Relaci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_13_34' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_35\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Fecha de nacimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_13_35' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_13_35_1_container'>\n                                            <input type='number' maxlength='2' name='input_35[]' id='input_13_35_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_13_35_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mes<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_13_35_2_container'>\n                                            <input type='number' maxlength='2' name='input_35[]' id='input_13_35_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_13_35_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>D\u00eda<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_13_35_3_container'>\n                                            <input type='number' maxlength='4' name='input_35[]' id='input_13_35_3' value=''   aria-required='true'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                            <label for='input_13_35_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>A\u00f1o<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_13_40\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_40'>Padre\/tutor legal (nombre)<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_13_40' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_36\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_36'>Padre\/tutor legal (apellido)<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_13_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_38\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_38'>Relaci\u00f3n<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_13_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_39\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Fecha de nacimiento<\/legend><div id='input_13_39' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_13_39_1_container'>\n                                            <input type='number' maxlength='2' name='input_39[]' id='input_13_39_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_13_39_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mes<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_13_39_2_container'>\n                                            <input type='number' maxlength='2' name='input_39[]' id='input_13_39_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_13_39_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>D\u00eda<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_13_39_3_container'>\n                                            <input type='number' maxlength='4' name='input_39[]' id='input_13_39_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                            <label for='input_13_39_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>A\u00f1o<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_13_41\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_41'>Estudiante (Nombre)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_13_41' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_42\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_42'>Estudiante (Apellido)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_13_42' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-quarter gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >G\u00e9nero<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_12'>\n\t\t\t<div class='gchoice gchoice_13_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Hombre'  id='choice_13_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_12_0' id='label_13_12_0' class='gform-field-label gform-field-label--type-inline'>Hombre<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Mujer'  id='choice_13_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_12_1' id='label_13_12_1' class='gform-field-label gform-field-label--type-inline'>Mujer<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_43\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Fecha de nacimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_13_43' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_13_43_1_container'>\n                                            <input type='number' maxlength='2' name='input_43[]' id='input_13_43_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_13_43_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mes<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_13_43_2_container'>\n                                            <input type='number' maxlength='2' name='input_43[]' id='input_13_43_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_13_43_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>D\u00eda<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_13_43_3_container'>\n                                            <input type='number' maxlength='4' name='input_43[]' id='input_13_43_3' value=''   aria-required='true'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                            <label for='input_13_43_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>A\u00f1o<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_13_46\" class=\"gfield gfield--type-select gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_46'>Sitio de la escuela<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_46' id='input_13_46' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione uno<\/option><option value='Madera Sur' >Madera Sur<\/option><option value='Matilda Torress' >Matilda Torress<\/option><option value='Chowchilla High School' >Chowchilla High School<\/option><\/select><\/div><\/div><div id=\"field_13_167\" class=\"gfield gfield--type-select gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_167'>Distrito escolar<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_167' id='input_13_167' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione uno<\/option><option value='Distrito Escolar Unificado de Madera' >Distrito Escolar Unificado de Madera<\/option><option value='Chowchilla Union High School District' >Chowchilla Union High School District<\/option><\/select><\/div><\/div><div id=\"field_13_49\" class=\"gfield gfield--type-number gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_49'>Grado<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_49' id='input_13_49' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_13_45\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_45'>N\u00famero de identificaci\u00f3n del estudiante<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_13_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_51\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_18\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_18'>Direcci\u00f3n de la calle<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_13_18' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_20\" class=\"gfield gfield--type-text gfield--width-third gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_20'>Ciudad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_13_20' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_21\" class=\"gfield gfield--type-select gfield--width-third gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_21'>Estado<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_21' id='input_13_21' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' selected='selected'>California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='Distrito de Columbia' >Distrito de Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Haw\u00e1i' >Haw\u00e1i<\/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='Luisiana' >Luisiana<\/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='Nuevo Hampshire' >Nuevo Hampshire<\/option><option value='Nueva Jersey' >Nueva Jersey<\/option><option value='Nuevo M\u00e9xico' >Nuevo M\u00e9xico<\/option><option value='Nueva York' >Nueva York<\/option><option value='Carolina del Norte' >Carolina del Norte<\/option><option value='Dakota del Norte' >Dakota del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oreg\u00f3n' >Oreg\u00f3n<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='Carolina del Sur' >Carolina del Sur<\/option><option value='Dakota del Sur' >Dakota del Sur<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='Virginia Occidental' >Virginia Occidental<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Fuerzas Armadas de Am\u00e9rica' >Fuerzas Armadas de Am\u00e9rica<\/option><option value='Fuerzas Armadas de Europa' >Fuerzas Armadas de Europa<\/option><option value='Fuerzas Armadas del Pac\u00edfico' >Fuerzas Armadas del Pac\u00edfico<\/option><\/select><\/div><\/div><div id=\"field_13_22\" class=\"gfield gfield--type-number gfield--width-third gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_22'>C\u00f3digo postal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_22' id='input_13_22' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_13_23\" class=\"gfield gfield--type-phone gfield--width-quarter hipaa_forms_phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_23'>N\u00famero de tel\u00e9fono<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_23' id='input_13_23' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_169\" class=\"gfield gfield--type-email gfield--width-quarter hipaa_forms_email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_169'>Env\u00ede un correo electr\u00f3nico a<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_169' id='input_13_169' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_13_53\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_53'>Nombre de contacto alternativo<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_13_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_52\" class=\"gfield gfield--type-phone gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_52'>N\u00famero alternativo<\/label><div class='ginput_container ginput_container_phone'><input name='input_52' id='input_13_52' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_54\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Informaci\u00f3n sobre el seguro del estudiante: Marque todo lo que corresponda<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_13_54'><div class='gchoice gchoice_13_54_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.1' type='checkbox'  value='Seguro m\u00e9dico privado'  id='choice_13_54_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_54_1' id='label_13_54_1' class='gform-field-label gform-field-label--type-inline'>Seguro m\u00e9dico privado<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_54_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.2' type='checkbox'  value='Seguro dental'  id='choice_13_54_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_54_2' id='label_13_54_2' class='gform-field-label gform-field-label--type-inline'>Seguro dental<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_54_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.3' type='checkbox'  value='Medi-Cal'  id='choice_13_54_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_54_3' id='label_13_54_3' class='gform-field-label gform-field-label--type-inline'>Medi-Cal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_54_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.4' type='checkbox'  value='Sin cobertura'  id='choice_13_54_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_54_4' id='label_13_54_4' class='gform-field-label gform-field-label--type-inline'>Sin cobertura<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_54_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.5' type='checkbox'  value='Otros'  id='choice_13_54_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_54_5' id='label_13_54_5' class='gform-field-label gform-field-label--type-inline'>Otros<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_55\" class=\"gfield gfield--type-text gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_55'>Nombre del seguro<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_13_55' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_56\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_56'>ID\/N\u00famero de p\u00f3liza<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_13_56' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_57\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_57'>Nombre del asegurado<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_13_57' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_58\" class=\"gfield gfield--type-text gfield--width-five-twelfths field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_58'>Nombre del seguro<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_13_58' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_59\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_59'>ID\/N\u00famero de p\u00f3liza<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_13_59' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_60\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_60'>Nombre del asegurado<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_13_60' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_63\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Etnia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_63'>\n\t\t\t<div class='gchoice gchoice_13_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Cauc\u00e1sico'  id='choice_13_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_63_0' id='label_13_63_0' class='gform-field-label gform-field-label--type-inline'>Cauc\u00e1sico<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Hispano\/Latino'  id='choice_13_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_63_1' id='label_13_63_1' class='gform-field-label gform-field-label--type-inline'>Hispano\/Latino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_63_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Afroamericano'  id='choice_13_63_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_63_2' id='label_13_63_2' class='gform-field-label gform-field-label--type-inline'>Afroamericano<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_63_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Ind\u00edgena Americano'  id='choice_13_63_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_63_3' id='label_13_63_3' class='gform-field-label gform-field-label--type-inline'>Ind\u00edgena Americano<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_63_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Asia'  id='choice_13_63_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_63_4' id='label_13_63_4' class='gform-field-label gform-field-label--type-inline'>Asia<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_63_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Isle\u00f1o del Pac\u00edfico'  id='choice_13_63_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_63_5' id='label_13_63_5' class='gform-field-label gform-field-label--type-inline'>Isle\u00f1o del Pac\u00edfico<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_63_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Multirracial'  id='choice_13_63_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_63_6' id='label_13_63_6' class='gform-field-label gform-field-label--type-inline'>Multirracial<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_63_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Otros'  id='choice_13_63_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_63_7' id='label_13_63_7' class='gform-field-label gform-field-label--type-inline'>Otros<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_63_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Declinaci\u00f3n al Estado'  id='choice_13_63_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_63_8' id='label_13_63_8' class='gform-field-label gform-field-label--type-inline'>Declinaci\u00f3n al Estado<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_62\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_62'>Si es otro, especifique:<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_13_62' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_68\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_13_64\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1. \u00bfEs usted o ha sido alguna vez paciente de Camarena Health?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_64'>\n\t\t\t<div class='gchoice gchoice_13_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='S\u00ed'  id='choice_13_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_64_0' id='label_13_64_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='No'  id='choice_13_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_64_1' id='label_13_64_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_65\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. \u00bfEs Camarena Health el proveedor de atenci\u00f3n primaria (PCP) de sus estudiantes?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_65'>\n\t\t\t<div class='gchoice gchoice_13_65_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='S\u00ed'  id='choice_13_65_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_65_0' id='label_13_65_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_65_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='No'  id='choice_13_65_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_65_1' id='label_13_65_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_66\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >3. \u00bfDesea solicitar nuestro Programa de Tarifas M\u00f3viles?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_66'>\n\t\t\t<div class='gchoice gchoice_13_66_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='S\u00ed'  id='choice_13_66_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_66_0' id='label_13_66_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_66_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='No'  id='choice_13_66_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_66_1' id='label_13_66_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_67\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. En los \u00faltimos 2 a\u00f1os, \u00bfha trabajado usted o alguien de su familia en alg\u00fan tipo de agricultura (trabajo agr\u00edcola) como: Sembrar, recoger, preparar la tierra, empaquetar, conducir un cami\u00f3n para cualquier tipo de trabajo agr\u00edcola, trabajar con ganado vivo, etc.?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_67'>\n\t\t\t<div class='gchoice gchoice_13_67_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='S\u00ed'  id='choice_13_67_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_67_0' id='label_13_67_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_67_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='No'  id='choice_13_67_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_67_1' id='label_13_67_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_69\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5. En los \u00faltimos 2 a\u00f1os, \u00bfha vivido usted o alg\u00fan miembro de su familia fuera de casa para trabajar en la agricultura?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_69'>\n\t\t\t<div class='gchoice gchoice_13_69_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='S\u00ed'  id='choice_13_69_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_69_0' id='label_13_69_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_69_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='No'  id='choice_13_69_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_69_1' id='label_13_69_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_70\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. \u00bfHa dejado usted o alg\u00fan miembro de su familia de emigrar para trabajar en la agricultura debido a una discapacidad o a la edad?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_70'>\n\t\t\t<div class='gchoice gchoice_13_70_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='S\u00ed'  id='choice_13_70_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_70_0' id='label_13_70_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_70_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='No'  id='choice_13_70_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_70_1' id='label_13_70_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_71\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_17\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br>\n<h3>Preguntas m\u00e9dicas sobre el estudiante<\/h3><\/div><fieldset id=\"field_13_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1. \u00bfEl estudiante est\u00e1 tomando actualmente alg\u00fan tipo de medicaci\u00f3n? (Esto incluye los medicamentos sin receta)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_72'>\n\t\t\t<div class='gchoice gchoice_13_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='S\u00ed'  id='choice_13_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_72_0' id='label_13_72_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='No'  id='choice_13_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_72_1' id='label_13_72_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_73\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_73'>En caso afirmativo, indique todos los medicamentos:<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_13_73' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. \u00bfTiene el estudiante alguna alergia?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_74'>\n\t\t\t<div class='gchoice gchoice_13_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='S\u00ed'  id='choice_13_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_74_0' id='label_13_74_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='No'  id='choice_13_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_74_1' id='label_13_74_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_75\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_75'>En caso afirmativo, indique todas las alergias:<\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_13_75' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_77\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_77'>3. \u00bfCu\u00e1l es su farmacia preferida? (Nombre)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_13_77' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_76\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_76'>Direcci\u00f3n de la farmacia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_13_76' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_171\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Acuerdo de los padres o tutores legales<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_171.1' id='input_13_171_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_13_171_1' >Certifico que la informaci\u00f3n anterior es verdadera y exacta a mi leal saber y entender.<\/label><input type='hidden' name='input_171.2' value='Certifico que la informaci\u00f3n anterior es verdadera y exacta a mi leal saber y entender.' class='gform_hidden' \/><input type='hidden' name='input_171.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_13_165\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_100\" class=\"gfield gfield--type-text gfield--width-quarter hipaa_forms_first_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_100'>Padre\/Guardi\u00e1n Legal (Nombre)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_13_100' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_101\" class=\"gfield gfield--type-text gfield--width-quarter hipaa_forms_last_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_101'>Padre\/Guardi\u00e1n Legal (Apellido)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_13_101' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_102\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_102'>Relaci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_102' id='input_13_102' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_103\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Fecha de Nacimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_13_103' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_13_103_1_container'>\n                                            <input type='number' maxlength='2' name='input_103[]' id='input_13_103_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_13_103_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mes<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_13_103_2_container'>\n                                            <input type='number' maxlength='2' name='input_103[]' id='input_13_103_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_13_103_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>D\u00eda<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_13_103_3_container'>\n                                            <input type='number' maxlength='4' name='input_103[]' id='input_13_103_3' value=''   aria-required='true'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                            <label for='input_13_103_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>A\u00f1o<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_13_104\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_104'>Padre\/Guardi\u00e1n Legal (Nombre)<\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_13_104' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_105\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_105'>Padre\/Guardi\u00e1n Legal (Apellido)<\/label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_13_105' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_106\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_106'>Relaci\u00f3n<\/label><div class='ginput_container ginput_container_text'><input name='input_106' id='input_13_106' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_107\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Fecha de Nacimiento<\/legend><div id='input_13_107' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_13_107_1_container'>\n                                            <input type='number' maxlength='2' name='input_107[]' id='input_13_107_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_13_107_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mes<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_13_107_2_container'>\n                                            <input type='number' maxlength='2' name='input_107[]' id='input_13_107_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_13_107_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>D\u00eda<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_13_107_3_container'>\n                                            <input type='number' maxlength='4' name='input_107[]' id='input_13_107_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                            <label for='input_13_107_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>A\u00f1o<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_13_108\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_108'>Estudiante (Nombre)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_108' id='input_13_108' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_109\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_109'>Estudiante (Apellido)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_109' id='input_13_109' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_110\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-quarter gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >G\u00e9nero<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_110'>\n\t\t\t<div class='gchoice gchoice_13_110_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_110' type='radio' value='Masculino'  id='choice_13_110_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_110_0' id='label_13_110_0' class='gform-field-label gform-field-label--type-inline'>Masculino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_110_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_110' type='radio' value='Masculina'  id='choice_13_110_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_110_1' id='label_13_110_1' class='gform-field-label gform-field-label--type-inline'>Masculina<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_111\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Fecha de Nacimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_13_111' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_13_111_1_container'>\n                                            <input type='number' maxlength='2' name='input_111[]' id='input_13_111_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_13_111_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mes<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_13_111_2_container'>\n                                            <input type='number' maxlength='2' name='input_111[]' id='input_13_111_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_13_111_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>D\u00eda<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_13_111_3_container'>\n                                            <input type='number' maxlength='4' name='input_111[]' id='input_13_111_3' value=''   aria-required='true'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                            <label for='input_13_111_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>A\u00f1o<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_13_112\" class=\"gfield gfield--type-select gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_112'>Ubicaci\u00f3n de la Escuela<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_112' id='input_13_112' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Elegir Uno<\/option><option value='Madera Sur' >Madera Sur<\/option><option value='Matilda Torress' >Matilda Torress<\/option><option value='Unidad M\u00f3vil de Salud del Distrito Escolar Unificado del Condado de Mariposa' >Unidad M\u00f3vil de Salud del Distrito Escolar Unificado del Condado de Mariposa<\/option><\/select><\/div><\/div><div id=\"field_13_168\" class=\"gfield gfield--type-select gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_168'>Distrito Escolar<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_168' id='input_13_168' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Elegir Uno<\/option><option value='Distrito Escolar Unificado de Madera' >Distrito Escolar Unificado de Madera<\/option><option value='Distrito Escolar Unificado del Condado de Mariposa' >Distrito Escolar Unificado del Condado de Mariposa<\/option><\/select><\/div><\/div><div id=\"field_13_114\" class=\"gfield gfield--type-number gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_114'>Grado<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_114' id='input_13_114' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_13_115\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_115'># de Estudiante<\/label><div class='ginput_container ginput_container_text'><input name='input_115' id='input_13_115' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_166\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_117\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_117'>Direcci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_117' id='input_13_117' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_118\" class=\"gfield gfield--type-text gfield--width-third gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_118'>Ciudad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_118' id='input_13_118' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_119\" class=\"gfield gfield--type-select gfield--width-third gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_119'>Estado<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_119' id='input_13_119' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' selected='selected'>California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='Distrito de Columbia' >Distrito de Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Haw\u00e1i' >Haw\u00e1i<\/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='Luisiana' >Luisiana<\/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='Nuevo Hampshire' >Nuevo Hampshire<\/option><option value='Nueva Jersey' >Nueva Jersey<\/option><option value='Nuevo M\u00e9xico' >Nuevo M\u00e9xico<\/option><option value='Nueva York' >Nueva York<\/option><option value='Carolina del Norte' >Carolina del Norte<\/option><option value='Dakota del Norte' >Dakota del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oreg\u00f3n' >Oreg\u00f3n<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='Carolina del Sur' >Carolina del Sur<\/option><option value='Dakota del Sur' >Dakota del Sur<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='Virginia Occidental' >Virginia Occidental<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Fuerzas Armadas de Am\u00e9rica' >Fuerzas Armadas de Am\u00e9rica<\/option><option value='Fuerzas Armadas de Europa' >Fuerzas Armadas de Europa<\/option><option value='Fuerzas Armadas del Pac\u00edfico' >Fuerzas Armadas del Pac\u00edfico<\/option><\/select><\/div><\/div><div id=\"field_13_120\" class=\"gfield gfield--type-number gfield--width-third gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_120'>C\u00f3digo postal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_120' id='input_13_120' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_13_121\" class=\"gfield gfield--type-phone gfield--width-quarter hipaa_forms_phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_121'>N\u00famero de tel\u00e9fono<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_121' id='input_13_121' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_170\" class=\"gfield gfield--type-email gfield--width-quarter hipaa_forms_email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_170'>Correo electr\u00f3nico<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_170' id='input_13_170' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_13_123\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_123'>Nombre de Contacto Alterno<\/label><div class='ginput_container ginput_container_text'><input name='input_123' id='input_13_123' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_122\" class=\"gfield gfield--type-phone gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_122'>N\u00famero alternativo<\/label><div class='ginput_container ginput_container_phone'><input name='input_122' id='input_13_122' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_124\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Informaci\u00f3n de Seguro M\u00e9dico del Estudiante: Marque todo lo que aplique<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_13_124'><div class='gchoice gchoice_13_124_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.1' type='checkbox'  value='Seguro M\u00e9dico Privado'  id='choice_13_124_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_124_1' id='label_13_124_1' class='gform-field-label gform-field-label--type-inline'>Seguro M\u00e9dico Privado<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_124_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.2' type='checkbox'  value='Seguro Dental'  id='choice_13_124_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_124_2' id='label_13_124_2' class='gform-field-label gform-field-label--type-inline'>Seguro Dental<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_124_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.3' type='checkbox'  value='Medi-Cal'  id='choice_13_124_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_124_3' id='label_13_124_3' class='gform-field-label gform-field-label--type-inline'>Medi-Cal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_124_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.4' type='checkbox'  value='No Cobertura'  id='choice_13_124_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_124_4' id='label_13_124_4' class='gform-field-label gform-field-label--type-inline'>No Cobertura<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_124_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.5' type='checkbox'  value='Otro'  id='choice_13_124_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_124_5' id='label_13_124_5' class='gform-field-label gform-field-label--type-inline'>Otro<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_125\" class=\"gfield gfield--type-text gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_125'>Nombre del Seguro<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_13_125' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_126\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_126'>ID\/# de P\u00f3liza<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_126' id='input_13_126' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_127\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_127'>Nombre del Asegurado<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_127' id='input_13_127' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_128\" class=\"gfield gfield--type-text gfield--width-five-twelfths field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_128'>Nombre del Seguro<\/label><div class='ginput_container ginput_container_text'><input name='input_128' id='input_13_128' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_129\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_129'>ID\/# de P\u00f3liza<\/label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_13_129' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_130\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_130'>Nombre del Asegurado<\/label><div class='ginput_container ginput_container_text'><input name='input_130' id='input_13_130' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_131\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Etnicidad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_131'>\n\t\t\t<div class='gchoice gchoice_13_131_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='Blanco'  id='choice_13_131_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_131_0' id='label_13_131_0' class='gform-field-label gform-field-label--type-inline'>Blanco<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_131_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='Hispano\/Latino'  id='choice_13_131_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_131_1' id='label_13_131_1' class='gform-field-label gform-field-label--type-inline'>Hispano\/Latino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_131_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='Afro-Americano'  id='choice_13_131_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_131_2' id='label_13_131_2' class='gform-field-label gform-field-label--type-inline'>Afro-Americano<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_131_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='Nativo Americano'  id='choice_13_131_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_131_3' id='label_13_131_3' class='gform-field-label gform-field-label--type-inline'>Nativo Americano<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_131_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='Asi\u00e1tico'  id='choice_13_131_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_131_4' id='label_13_131_4' class='gform-field-label gform-field-label--type-inline'>Asi\u00e1tico<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_131_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='Islas del Pac\u00edfico'  id='choice_13_131_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_131_5' id='label_13_131_5' class='gform-field-label gform-field-label--type-inline'>Islas del Pac\u00edfico<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_131_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='Multirracial'  id='choice_13_131_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_131_6' id='label_13_131_6' class='gform-field-label gform-field-label--type-inline'>Multirracial<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_131_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='Otro'  id='choice_13_131_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_131_7' id='label_13_131_7' class='gform-field-label gform-field-label--type-inline'>Otro<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_131_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='Declina a contestar'  id='choice_13_131_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_131_8' id='label_13_131_8' class='gform-field-label gform-field-label--type-inline'>Declina a contestar<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_132\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_132'>Otro:<\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_13_132' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_133\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_13_134\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1. \u00bfEres o has sido paciente de Camarena Health?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_134'>\n\t\t\t<div class='gchoice gchoice_13_134_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='Si'  id='choice_13_134_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_134_0' id='label_13_134_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_134_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='No'  id='choice_13_134_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_134_1' id='label_13_134_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_135\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. \u00bfEs Camarena Health el proveedor de cuidado primario del estudiante?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_135'>\n\t\t\t<div class='gchoice gchoice_13_135_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_135' type='radio' value='Si'  id='choice_13_135_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_135_0' id='label_13_135_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_135_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_135' type='radio' value='No'  id='choice_13_135_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_135_1' id='label_13_135_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_136\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >3. \u00bfLe gustar\u00eda aplicar para nuestro Programa de Descuento?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_136'>\n\t\t\t<div class='gchoice gchoice_13_136_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='Si'  id='choice_13_136_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_136_0' id='label_13_136_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_136_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='No'  id='choice_13_136_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_136_1' id='label_13_136_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_137\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. \u00bfEn los \u00faltimos 2 a\u00f1os, usted o alguien de su familia, trabaja en alg\u00fan tipo de agricultura (&quot;trabajo de campo&quot;) como: Plantando, cosechando, preparando la tierra, en un empacadora, manejando una camioneta para cualquier trabajo relacionado con la agricultura, o con ganado, etc.?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_137'>\n\t\t\t<div class='gchoice gchoice_13_137_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='Si'  id='choice_13_137_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_137_0' id='label_13_137_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_137_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='No'  id='choice_13_137_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_137_1' id='label_13_137_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_138\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5. \u00bfEn los \u00faltimos 2 a\u00f1os, usted o alguien de su familia vivi\u00f3 fuera de su hogar para trabajar en la agricultura?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_138'>\n\t\t\t<div class='gchoice gchoice_13_138_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_138' type='radio' value='Si'  id='choice_13_138_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_138_0' id='label_13_138_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_138_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_138' type='radio' value='No'  id='choice_13_138_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_138_1' id='label_13_138_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_139\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. \u00bfUsted o alguien de su familia han dejado de emigrar para trabajar en la agricultura debido a discapacidad o edad?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_139'>\n\t\t\t<div class='gchoice gchoice_13_139_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='Si'  id='choice_13_139_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_139_0' id='label_13_139_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_139_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='No'  id='choice_13_139_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_139_1' id='label_13_139_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_140\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_141\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br>\n<h3>Preguntas m\u00e9dicas sobre el estudiante<\/h3><\/div><fieldset id=\"field_13_142\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1. \u00bfEst\u00e1 el Estudiante tomando medicamentos? (Incluyendo medicamentos sin receta)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_142'>\n\t\t\t<div class='gchoice gchoice_13_142_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_142' type='radio' value='Si'  id='choice_13_142_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_142_0' id='label_13_142_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_142_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_142' type='radio' value='No'  id='choice_13_142_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_142_1' id='label_13_142_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_143\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_143'>Si es as\u00ed, liste todos los medicamentos:<\/label><div class='ginput_container ginput_container_text'><input name='input_143' id='input_13_143' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_144\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. \u00bfTiene el Estudiante alguna alergia?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_144'>\n\t\t\t<div class='gchoice gchoice_13_144_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_144' type='radio' value='Si'  id='choice_13_144_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_144_0' id='label_13_144_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_144_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_144' type='radio' value='No'  id='choice_13_144_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_144_1' id='label_13_144_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_145\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_145'>Si es as\u00ed, liste todas las alergias:<\/label><div class='ginput_container ginput_container_text'><input name='input_145' id='input_13_145' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_146\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_146'>3. \u00bfCu\u00e1l es su farmacia preferida? (Nombre)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_146' id='input_13_146' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_147\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_147'>Direcci\u00f3n de la Farmacia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_147' id='input_13_147' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_172\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Acuerdo del Padre o Tutor Legal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_172.1' id='input_13_172_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_13_172_1' >Certifico que la informaci\u00f3n anterior es verdadera y correcta a mi mejor conocimiento.<\/label><input type='hidden' name='input_172.2' value='Certifico que la informaci\u00f3n anterior es verdadera y correcta a mi mejor conocimiento.' class='gform_hidden' \/><input type='hidden' name='input_172.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_50' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='&lt; Anterior'  \/> <input type='button' id='gform_next_button_13_50' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente  &gt;'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_3' class='gform_page' data-js='page-field-id-50' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_81\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_81'>Nombre del estudiante<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_13_81' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_82\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Fecha<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_13_82' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_13_82_1_container'>\n                                            <input type='number' maxlength='2' name='input_82[]' id='input_13_82_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_13_82_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mes<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_13_82_2_container'>\n                                            <input type='number' maxlength='2' name='input_82[]' id='input_13_82_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_13_82_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>D\u00eda<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_13_82_3_container'>\n                                            <input type='number' maxlength='4' name='input_82[]' id='input_13_82_3' value=''   aria-required='true'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                            <label for='input_13_82_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>A\u00f1o<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_13_83\" class=\"gfield gfield--type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_83'>Grado<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_83' id='input_13_83' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_13_84\" class=\"gfield gfield--type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_84'>Sitio de la escuela<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_84' id='input_13_84' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione uno<\/option><option value='Madera Sur' >Madera Sur<\/option><option value='Matilda Torress' >Matilda Torress<\/option><option value='Unidad M\u00f3vil de Salud del Distrito Escolar Unificado del Condado de Mariposa' >Unidad M\u00f3vil de Salud del Distrito Escolar Unificado del Condado de Mariposa<\/option><\/select><\/div><\/div><div id=\"field_13_85\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_85'>N\u00famero de identificaci\u00f3n del estudiante<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_13_85' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Por favor, marque al lado del lugar donde su hijo\/estudiante acceder\u00e1 a la atenci\u00f3n:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_87'>\n\t\t\t<div class='gchoice gchoice_13_87_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='Centro de salud basado en la escuela Matilda Torres (Madera)'  id='choice_13_87_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_87_0' id='label_13_87_0' class='gform-field-label gform-field-label--type-inline'>Centro de salud basado en la escuela Matilda Torres (Madera)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_87_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='Centro de salud escolar de Madera South (Madera)'  id='choice_13_87_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_87_1' id='label_13_87_1' class='gform-field-label gform-field-label--type-inline'>Centro de salud escolar de Madera South (Madera)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_87_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='Unidad M\u00f3vil de Salud Escolar (Mariposa)'  id='choice_13_87_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_87_2' id='label_13_87_2' class='gform-field-label gform-field-label--type-inline'>Unidad M\u00f3vil de Salud Escolar (Mariposa)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_88\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Autorizo a un m\u00e9dico o a otro personal designado del centro de salud a prestar los siguientes servicios de acuerdo con todas las normas federales y estatales\nleyes:<\/div><fieldset id=\"field_13_89\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Servicios m\u00e9dicos: ex\u00e1menes f\u00edsicos completos, gesti\u00f3n de enfermedades agudas y cr\u00f3nicas, ex\u00e1menes f\u00edsicos deportivos, universitarios y laborales, vacunas, primeros auxilios, ex\u00e1menes de la vista y del o\u00eddo, pruebas de laboratorio (anemia, orina) y derivaciones a un nivel de atenci\u00f3n superior, seg\u00fan proceda.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_89'>\n\t\t\t<div class='gchoice gchoice_13_89_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_89' type='radio' value='S\u00ed'  id='choice_13_89_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_89_0' id='label_13_89_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_89_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_89' type='radio' value='No'  id='choice_13_89_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_89_1' id='label_13_89_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_90\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Servicios dentales: ex\u00e1menes dentales, radiograf\u00edas, limpieza, sellantes, tratamiento con fl\u00faor, empastes, extracciones, endodoncias y coronas<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_90'>\n\t\t\t<div class='gchoice gchoice_13_90_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='S\u00ed'  id='choice_13_90_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_90_0' id='label_13_90_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_90_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='No'  id='choice_13_90_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_90_1' id='label_13_90_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_91\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Servicios de asesoramiento\/terapia: gesti\u00f3n de crisis, depresi\u00f3n, ansiedad, modificaciones del comportamiento, terapia de enfoque de soluciones, problemas de relaci\u00f3n y familiares, estr\u00e9s, baja autoestima, problemas de imagen corporal, trastornos de la alimentaci\u00f3n y otros problemas de salud mental.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_91'>\n\t\t\t<div class='gchoice gchoice_13_91_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='S\u00ed'  id='choice_13_91_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_91_0' id='label_13_91_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_91_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='No'  id='choice_13_91_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_91_1' id='label_13_91_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_173\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Acuerdo de consentimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_173.1' id='input_13_173_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_13_173_1' >Doy mi consentimiento para el intercambio de informaci\u00f3n m\u00e9dica de mi hijo\/a entre el distrito escolar y el Centro de Salud Escolar de Camarena Health\/y o la Unidad M\u00f3vil de Salud Escolar de Camarena Health con el fin de prestar los servicios autorizados anteriormente. Este intercambio de informaci\u00f3n m\u00e9dica ser\u00e1 bidireccional entre el distrito escolar y Camarena Health. Entiendo que los registros m\u00e9dicos de los estudiantes de Camarena Health se mantendr\u00e1n como registros m\u00e9dicos confidenciales separados de los registros escolares, pero pueden ser compartidos con otros proveedores de atenci\u00f3n m\u00e9dica para los fines de la atenci\u00f3n y el tratamiento de mi hijo. Entiendo que mi hijo\/hija no recibir\u00e1 servicios en el Centro de Salud Escolar de Camarena Health a menos que un formulario de consentimiento est\u00e9 en el archivo. Entiendo que puedo retirar este consentimiento en cualquier momento durante la inscripci\u00f3n de mi hijo mediante una notificaci\u00f3n por escrito. En caso contrario, se aplicar\u00e1 mientras dure la escolarizaci\u00f3n de mi hijo.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_173.2' value='Doy mi consentimiento para el intercambio de informaci\u00f3n m\u00e9dica de mi hijo\/a entre el distrito escolar y el Centro de Salud Escolar de Camarena Health\/y o la Unidad M\u00f3vil de Salud Escolar de Camarena Health con el fin de prestar los servicios autorizados anteriormente. Este intercambio de informaci\u00f3n m\u00e9dica ser\u00e1 bidireccional entre el distrito escolar y Camarena Health. Entiendo que los registros m\u00e9dicos de los estudiantes de Camarena Health se mantendr\u00e1n como registros m\u00e9dicos confidenciales separados de los registros escolares, pero pueden ser compartidos con otros proveedores de atenci\u00f3n m\u00e9dica para los fines de la atenci\u00f3n y el tratamiento de mi hijo. Entiendo que mi hijo\/hija no recibir\u00e1 servicios en el Centro de Salud Escolar de Camarena Health a menos que un formulario de consentimiento est\u00e9 en el archivo. Entiendo que puedo retirar este consentimiento en cualquier momento durante la inscripci\u00f3n de mi hijo mediante una notificaci\u00f3n por escrito. En caso contrario, se aplicar\u00e1 mientras dure la escolarizaci\u00f3n de mi hijo.' class='gform_hidden' \/><input type='hidden' name='input_173.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_13_174\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Acuerdo de autorizaci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_174.1' id='input_13_174_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_13_174_1' >Autorizo al Centro de Salud Escolar Camarena a divulgar informaci\u00f3n sobre el tratamiento a terceros pagadores u otros con el prop\u00f3sito de facturar o por cualquier raz\u00f3n que pueda ser requerida para cumplir con los estatutos o la regulaci\u00f3n de acuerdo con la pr\u00e1ctica m\u00e9dica aceptada. Entiendo que soy responsable de cualquier cargo\/tasa que no cubra mi compa\u00f1\u00eda de seguros.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_174.2' value='Autorizo al Centro de Salud Escolar Camarena a divulgar informaci\u00f3n sobre el tratamiento a terceros pagadores u otros con el prop\u00f3sito de facturar o por cualquier raz\u00f3n que pueda ser requerida para cumplir con los estatutos o la regulaci\u00f3n de acuerdo con la pr\u00e1ctica m\u00e9dica aceptada. Entiendo que soy responsable de cualquier cargo\/tasa que no cubra mi compa\u00f1\u00eda de seguros.' class='gform_hidden' \/><input type='hidden' name='input_174.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_13_93\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >***POR FAVOR, TENGA EN CUENTA QUE TODOS LOS NI\u00d1OS MENORES DE 13 A\u00d1OS DEBEN IR ACOMPA\u00d1ADOS DE SUS PADRES O TUTORES, INCLUSO CON ESTE CONSENTIMIENTO.\nEL FORMULARIO SE ENCUENTRA EN LOS ARCHIVOS DE CAMARENA HEALTH Y DEL DISTRITO ESCOLAR.<\/div><fieldset id=\"field_13_95\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nombre del padre\/tutor legal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_13_95'>\n                            \n                            <span id='input_13_95_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_95.3' id='input_13_95_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_13_95_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_13_95_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_95.6' id='input_13_95_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_13_95_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_13_163\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_163'>Nombre del Estudiante<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_163' id='input_13_163' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_150\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Fecha de Nacimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_13_150' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_13_150_1_container'>\n                                            <input type='number' maxlength='2' name='input_150[]' id='input_13_150_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_13_150_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mes<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_13_150_2_container'>\n                                            <input type='number' maxlength='2' name='input_150[]' id='input_13_150_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_13_150_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>D\u00eda<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_13_150_3_container'>\n                                            <input type='number' maxlength='4' name='input_150[]' id='input_13_150_3' value=''   aria-required='true'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                            <label for='input_13_150_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>A\u00f1o<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_13_151\" class=\"gfield gfield--type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_151'>Grado<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_151' id='input_13_151' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_13_152\" class=\"gfield gfield--type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_152'>Ubicaci\u00f3n de la Escuela<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_152' id='input_13_152' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Elegir Uno<\/option><option value='Madera Sur' >Madera Sur<\/option><option value='Matilda Torress' >Matilda Torress<\/option><option value='Unidad M\u00f3vil de Salud del Distrito Escolar Unificado del Condado de Mariposa' >Unidad M\u00f3vil de Salud del Distrito Escolar Unificado del Condado de Mariposa<\/option><\/select><\/div><\/div><div id=\"field_13_153\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_153'># de Estudiante<\/label><div class='ginput_container ginput_container_text'><input name='input_153' id='input_13_153' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_154\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Por favor, marque al lado del lugar donde su hijo\/a y su familia acceder\u00e1n atenci\u00f3n:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_154'>\n\t\t\t<div class='gchoice gchoice_13_154_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Centro de Salud de la Escuela Secundaria Matilda Torres (Madera)'  id='choice_13_154_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_154_0' id='label_13_154_0' class='gform-field-label gform-field-label--type-inline'>Centro de Salud de la Escuela Secundaria Matilda Torres (Madera)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_154_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Centro de Salud de la Escuela Secundaria Madera South (Madera)'  id='choice_13_154_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_154_1' id='label_13_154_1' class='gform-field-label gform-field-label--type-inline'>Centro de Salud de la Escuela Secundaria Madera South (Madera)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_154_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Unidad M\u00f3vil de Salud Escolar (Mariposa)'  id='choice_13_154_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_154_2' id='label_13_154_2' class='gform-field-label gform-field-label--type-inline'>Unidad M\u00f3vil de Salud Escolar (Mariposa)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_155\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Autorizo a un m\u00e9dico o personal designado por el centro de salud a proporcionar los siguientes servicios de acuerdo a todas las leyes federales y estatales:<\/div><fieldset id=\"field_13_156\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Servicios m\u00e9dicos: ex\u00e1menes f\u00edsicos completos, manejo de enfermedades agudas y cr\u00f3nicas, ex\u00e1menes f\u00edsicos para deportes, escuela y empleo, vacunas, primeros auxilios, ex\u00e1menes de la visi\u00f3n y o\u00eddo, ex\u00e1menes de laboratorio (anemia, orina), y referencias a un nivel de atenci\u00f3n m\u00e1s alto como sea apropiado<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_156'>\n\t\t\t<div class='gchoice gchoice_13_156_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_156' type='radio' value='Si'  id='choice_13_156_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_156_0' id='label_13_156_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_156_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_156' type='radio' value='No'  id='choice_13_156_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_156_1' id='label_13_156_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_157\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Servicios Dentales: ex\u00e1menes dentales, rayos-x-, limpiezas, selladores, tratamientos de fluoruro, rellenos, extracciones, tratamiento de nervio y coronas<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_157'>\n\t\t\t<div class='gchoice gchoice_13_157_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_157' type='radio' value='Si'  id='choice_13_157_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_157_0' id='label_13_157_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_157_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_157' type='radio' value='No'  id='choice_13_157_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_157_1' id='label_13_157_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_158\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Servicios de Consejer\u00eda\/Terapia: manejo de crisis, depresi\u00f3n, ansiedad, modificaci\u00f3n del comportamiento, terapia enfocada en soluciones, asuntos de relaciones y familia, estr\u00e9s, baja autoestima, problemas de su imagen, desorden de alimentaci\u00f3n, y otros problemas de la salud del comportamiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_158'>\n\t\t\t<div class='gchoice gchoice_13_158_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_158' type='radio' value='Si'  id='choice_13_158_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_158_0' id='label_13_158_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_158_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_158' type='radio' value='No'  id='choice_13_158_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_158_1' id='label_13_158_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_175\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Acuerdo de consentimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_175.1' id='input_13_175_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_13_175_1' >Doy mi consentimiento para el intercambio de la informaci\u00f3n m\u00e9dica de mi hijo\/a entre el distrito escolar y Camarena Health School Based Health Center o con la Unidad M\u00f3vil de Salud Escolar de Camarena Health con el prop\u00f3sito de proporcionar los servicios que he autorizado anteriormente. Este intercambio de informaci\u00f3n m\u00e9dica debe ser bidireccional entre el distrito escolar y Camarena Health. Entiendo que el expediente m\u00e9dico del estudiante en Camarena Health se mantendr\u00e1 como un expediente confidencial y separado del expediente de la escuela, pero se puede compartir con otros proveedores de salud con el prop\u00f3sito del cuidado de salud y tratamiento de mi hijo\/a.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_175.2' value='Doy mi consentimiento para el intercambio de la informaci\u00f3n m\u00e9dica de mi hijo\/a entre el distrito escolar y Camarena Health School Based Health Center o con la Unidad M\u00f3vil de Salud Escolar de Camarena Health con el prop\u00f3sito de proporcionar los servicios que he autorizado anteriormente. Este intercambio de informaci\u00f3n m\u00e9dica debe ser bidireccional entre el distrito escolar y Camarena Health. Entiendo que el expediente m\u00e9dico del estudiante en Camarena Health se mantendr\u00e1 como un expediente confidencial y separado del expediente de la escuela, pero se puede compartir con otros proveedores de salud con el prop\u00f3sito del cuidado de salud y tratamiento de mi hijo\/a.' class='gform_hidden' \/><input type='hidden' name='input_175.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_13_176\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Acuerdo de entendimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_176.1' id='input_13_176_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_13_176_1' >Entiendo que mi hijo\/a no recibir\u00e1 servicios en Camarena Health School Based Health Center a menos que un formulario de consentimiento est\u00e9 en su expediente. Entiendo que en cualquier momento puedo retirar este consentimiento a trav\u00e9s de un aviso escrito durante la inscripci\u00f3n escolar de mi hijo\/a. De lo contrario, ser\u00e1 vigente durante el transcurso de la asistencia de mi hijo\/a en la escuela.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_176.2' value='Entiendo que mi hijo\/a no recibir\u00e1 servicios en Camarena Health School Based Health Center a menos que un formulario de consentimiento est\u00e9 en su expediente. Entiendo que en cualquier momento puedo retirar este consentimiento a trav\u00e9s de un aviso escrito durante la inscripci\u00f3n escolar de mi hijo\/a. De lo contrario, ser\u00e1 vigente durante el transcurso de la asistencia de mi hijo\/a en la escuela.' class='gform_hidden' \/><input type='hidden' name='input_176.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_13_177\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Acuerdo de autorizaci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_177.1' id='input_13_177_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_13_177_1' >Autorizo a Camarena Health School Based Health Center a compartir informaci\u00f3n sobre el tratamiento a terceras personas, personas con el prop\u00f3sito de facturaci\u00f3n, o por cualquier motivo que pueda ser requerido para cumplir con los estatutos y regulaciones de acuerdo con la pr\u00e1ctica m\u00e9dica aceptada. Entiendo que yo soy responsable por recargos\/pagos no cubiertos por mi compa\u00f1\u00eda de seguro.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_177.2' value='Autorizo a Camarena Health School Based Health Center a compartir informaci\u00f3n sobre el tratamiento a terceras personas, personas con el prop\u00f3sito de facturaci\u00f3n, o por cualquier motivo que pueda ser requerido para cumplir con los estatutos y regulaciones de acuerdo con la pr\u00e1ctica m\u00e9dica aceptada. Entiendo que yo soy responsable por recargos\/pagos no cubiertos por mi compa\u00f1\u00eda de seguro.' class='gform_hidden' \/><input type='hidden' name='input_177.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_13_159\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >***POR FAVOR, TENGA EN CUENTA QUE TODOS LOS NI\u00d1OS MENORES DE 13 A\u00d1OS DEBEN ESTAR ACOMPA\u00d1ADOS POR UN PADRE O TUTOR, INCLUSO SI ESTE FORMULARIO DE CONSENTIMIENTO EST\u00c1 EN EL ARCHIVO DE CAMARENA HEALTH Y EL DISTRITO ESCOLAR.<\/div><fieldset id=\"field_13_160\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label 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