{"id":746,"date":"2012-06-22T16:52:59","date_gmt":"2012-06-22T21:52:59","guid":{"rendered":"http:\/\/www.circlesofcareinc.org\/?page_id=746"},"modified":"2013-01-09T17:11:05","modified_gmt":"2013-01-09T23:11:05","slug":"general-application","status":"publish","type":"page","link":"https:\/\/www.circlesofcareinc.org\/es\/forms\/application\/general-application\/","title":{"rendered":"Solicitud General para Proveedores Potenciales"},"content":{"rendered":"<p>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_21' ><div id='gf_21' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Solicitud general para proveedores potenciales<\/h3>\n                            <p class='gform_description'><p>Si es un hogar con dos padres, ambos deber\u00e1n presentar una solicitud por separado<\/p> <p><strong>Si obtiene un error al hacer clic en <em>Submit<\/em> (enviar), haga clic en su navegador <em>Back<\/em> bot\u00f3n una vez. A continuaci\u00f3n, intente hacer clic en enviar de nuevo.<\/strong><\/p><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_21'  action=\"\/es\/wp-json\/wp\/v2\/pages\/746#gf_21\" data-formid='21' novalidate>\n        <div id='gf_progressbar_wrapper_21' class='gf_progressbar_wrapper' data-start-at-zero='1'>\n        \t<h3 class=\"gf_progressbar_title\">Paso <span class='gf_step_current_page'>1<\/span> de <span class='gf_step_page_count'>13<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_custom' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_custom percentbar_0' style='width:0%; color:#fff; background-color:#5c5ce5;'><span>0%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_21_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_21' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_21_1\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Informaci\u00f3n Personal<\/h2><\/li><li id=\"field_21_2\" class=\"gfield gfield--type-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 gfield_label_before_complex' >Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><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_21_2'>\n                            <span id='input_21_2_3_container' class='name_first gform-grid-col' >\n                                                    <input type='text' name='input_2.3' id='input_21_2_3' value=''   aria-required='true'    \/>\n                                                    <label for='input_21_2_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                               <\/span>\n                            <span id='input_21_2_6_container' class='name_last gform-grid-col' >\n                                                    <input type='text' name='input_2.6' id='input_21_2_6' value=''   aria-required='true'    \/>\n                                                    <label for='input_21_2_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/li><li id=\"field_21_4\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon 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_21_4'>Fecha de nacimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_4' id='input_21_4' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_21_4_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_21_4_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_21_4' class='gform_hidden' value='\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_21_3\" class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Correo electr\u00f3nico<\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_21_3_container'>\n                                <span id='input_21_3_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_3' id='input_21_3' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_21_3' class='gform-field-label gform-field-label--type-sub '>Introduce un email<\/label>\n                                <\/span>\n                                <span id='input_21_3_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_3_2' id='input_21_3_2' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_21_3_2' class='gform-field-label gform-field-label--type-sub '>Confirmar email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_21_5\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_5'>\u00bfQui\u00e9n lo refiri\u00f3 o c\u00f3mo se enter\u00f3 de Circles of Care?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_5' id='input_21_5' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_6\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Nombre de soltera<\/label><div class='ginput_container ginput_container_name'>\n                                    <input name='input_6' id='input_21_6' type='text' value='' class='medium'    aria-invalid=\"false\"   \/>\n                                <\/div><\/li><li id=\"field_21_7\" class=\"gfield gfield--type-address 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 gfield_label_before_complex' >Direcci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_21_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_21_7_1_container' >\n                                        <input type='text' name='input_7.1' id='input_21_7_1' value=''    aria-required='true'    \/>\n                                        <label for='input_21_7_1' id='input_21_7_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_21_7_2_container' >\n                                        <input type='text' name='input_7.2' id='input_21_7_2' value=''     aria-required='false'   \/>\n                                        <label for='input_21_7_2' id='input_21_7_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_21_7_3_container' >\n                                    <input type='text' name='input_7.3' id='input_21_7_3' value=''    aria-required='true'    \/>\n                                    <label for='input_21_7_3' id='input_21_7_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_21_7_4_container' >\n                                        <select name='input_7.4' id='input_21_7_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_21_7_4' id='input_21_7_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_21_7_5_container' >\n                                    <input type='text' name='input_7.5' id='input_21_7_5' value=''    aria-required='true'    \/>\n                                    <label for='input_21_7_5' id='input_21_7_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_7.6' id='input_21_7_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_21_8\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_8'>Condado<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_21_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_9\" class=\"gfield gfield--type-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_21_9'>Tel\u00e9fono de la casa<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_21_9' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_10\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_10'>Trabajo<\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_21_10' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_11\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_11'>Otro<\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_21_11' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_235\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >\u00bfQui\u00e9n es su proveedor de telefon\u00eda celular?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_235'>\n\t\t\t<li class='gchoice gchoice_21_235_0'>\n\t\t\t\t<input name='input_235' type='radio' value='ATT'  id='choice_21_235_0'    \/>\n\t\t\t\t<label for='choice_21_235_0' id='label_21_235_0' class='gform-field-label gform-field-label--type-inline'>ATT<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_235_1'>\n\t\t\t\t<input name='input_235' type='radio' value='Sprint'  id='choice_21_235_1'    \/>\n\t\t\t\t<label for='choice_21_235_1' id='label_21_235_1' class='gform-field-label gform-field-label--type-inline'>Sprint<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_235_2'>\n\t\t\t\t<input name='input_235' type='radio' value='TMobile'  id='choice_21_235_2'    \/>\n\t\t\t\t<label for='choice_21_235_2' id='label_21_235_2' class='gform-field-label gform-field-label--type-inline'>TMobile<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_235_3'>\n\t\t\t\t<input name='input_235' type='radio' value='Verizon'  id='choice_21_235_3'    \/>\n\t\t\t\t<label for='choice_21_235_3' id='label_21_235_3' class='gform-field-label gform-field-label--type-inline'>Verizon<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_235_4'>\n\t\t\t\t<input name='input_235' type='radio' value='gf_other_choice'  id='choice_21_235_4'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_21_235_other' name='input_235_other' type='text' value='Otro' aria-label='Otro' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Otro\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Otro\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_12\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_12'>\u00bfCu\u00e1nto tiempo ha vivido en la direcci\u00f3n mencionada arriba?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_21_12' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_14\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_14'>N\u00famero de licencia de conducir de Texas:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_21_14' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_15\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Estado civil:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_15'>\n\t\t\t<li class='gchoice gchoice_21_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='Casado(a)'  id='choice_21_15_0'    \/>\n\t\t\t\t<label for='choice_21_15_0' id='label_21_15_0' class='gform-field-label gform-field-label--type-inline'>Casado(a)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='Divorciado(a)'  id='choice_21_15_1'    \/>\n\t\t\t\t<label for='choice_21_15_1' id='label_21_15_1' class='gform-field-label gform-field-label--type-inline'>Divorciado(a)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_15_2'>\n\t\t\t\t<input name='input_15' type='radio' value='Separado(a)'  id='choice_21_15_2'    \/>\n\t\t\t\t<label for='choice_21_15_2' id='label_21_15_2' class='gform-field-label gform-field-label--type-inline'>Separado(a)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_15_3'>\n\t\t\t\t<input name='input_15' type='radio' value='Soltero(a)'  id='choice_21_15_3'    \/>\n\t\t\t\t<label for='choice_21_15_3' id='label_21_15_3' class='gform-field-label gform-field-label--type-inline'>Soltero(a)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_15_4'>\n\t\t\t\t<input name='input_15' type='radio' value='gf_other_choice'  id='choice_21_15_4'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_21_15_other' name='input_15_other' type='text' value='Otro' aria-label='Otro' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Otro\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Otro\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_16\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Etnia:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_16'>\n\t\t\t<li class='gchoice gchoice_21_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='Hispano'  id='choice_21_16_0'    \/>\n\t\t\t\t<label for='choice_21_16_0' id='label_21_16_0' class='gform-field-label gform-field-label--type-inline'>Hispano<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='Afroamericano'  id='choice_21_16_1'    \/>\n\t\t\t\t<label for='choice_21_16_1' id='label_21_16_1' class='gform-field-label gform-field-label--type-inline'>Afroamericano<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_16_2'>\n\t\t\t\t<input name='input_16' type='radio' value='Cauc\u00e1sico'  id='choice_21_16_2'    \/>\n\t\t\t\t<label for='choice_21_16_2' id='label_21_16_2' class='gform-field-label gform-field-label--type-inline'>Cauc\u00e1sico<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_16_3'>\n\t\t\t\t<input name='input_16' type='radio' value='Ind\u00edgena americano'  id='choice_21_16_3'    \/>\n\t\t\t\t<label for='choice_21_16_3' id='label_21_16_3' class='gform-field-label gform-field-label--type-inline'>Ind\u00edgena americano<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_16_4'>\n\t\t\t\t<input name='input_16' type='radio' value='gf_other_choice'  id='choice_21_16_4'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_21_16_other' name='input_16_other' type='text' value='Otro' aria-label='Otro' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Otro\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Otro\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_17\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Religi\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_17'>\n\t\t\t<li class='gchoice gchoice_21_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Cat\u00f3lica'  id='choice_21_17_0'    \/>\n\t\t\t\t<label for='choice_21_17_0' id='label_21_17_0' class='gform-field-label gform-field-label--type-inline'>Cat\u00f3lica<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='Luterano'  id='choice_21_17_1'    \/>\n\t\t\t\t<label for='choice_21_17_1' id='label_21_17_1' class='gform-field-label gform-field-label--type-inline'>Luterano<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_17_2'>\n\t\t\t\t<input name='input_17' type='radio' value='Protestante'  id='choice_21_17_2'    \/>\n\t\t\t\t<label for='choice_21_17_2' id='label_21_17_2' class='gform-field-label gform-field-label--type-inline'>Protestante<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_17_3'>\n\t\t\t\t<input name='input_17' type='radio' value='Jud\u00eda'  id='choice_21_17_3'    \/>\n\t\t\t\t<label for='choice_21_17_3' id='label_21_17_3' class='gform-field-label gform-field-label--type-inline'>Jud\u00eda<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_17_4'>\n\t\t\t\t<input name='input_17' type='radio' value='Bautista'  id='choice_21_17_4'    \/>\n\t\t\t\t<label for='choice_21_17_4' id='label_21_17_4' class='gform-field-label gform-field-label--type-inline'>Bautista<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_17_5'>\n\t\t\t\t<input name='input_17' type='radio' value='gf_other_choice'  id='choice_21_17_5'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_21_17_other' name='input_17_other' type='text' value='Otro' aria-label='Otro' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Otro\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Otro\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_18\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_18'>Si corresponde, mencione el nombre de la iglesia\/instituci\u00f3n religiosa:<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_21_18' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_21_241' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_21_2_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Guardar y continuar m\u00e1s tarde<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_21_2' class='gform_page' data-js='page-field-id-241' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_21_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_21_20\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Descripci\u00f3n del Ambiente de la Residencia\/Hogar Actual<\/h2><\/li><li id=\"field_21_21\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Type of Residence<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_21'>\n\t\t\t<li class='gchoice gchoice_21_21_0'>\n\t\t\t\t<input name='input_21' type='radio' value='Casa (Rentada)'  id='choice_21_21_0'    \/>\n\t\t\t\t<label for='choice_21_21_0' id='label_21_21_0' class='gform-field-label gform-field-label--type-inline'>Casa (Rentada)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_21_1'>\n\t\t\t\t<input name='input_21' type='radio' value='Casa (Propia)'  id='choice_21_21_1'    \/>\n\t\t\t\t<label for='choice_21_21_1' id='label_21_21_1' class='gform-field-label gform-field-label--type-inline'>Casa (Propia)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_21_2'>\n\t\t\t\t<input name='input_21' type='radio' value='Departamento'  id='choice_21_21_2'    \/>\n\t\t\t\t<label for='choice_21_21_2' id='label_21_21_2' class='gform-field-label gform-field-label--type-inline'>Departamento<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_21_3'>\n\t\t\t\t<input name='input_21' type='radio' value='Casa rodante'  id='choice_21_21_3'    \/>\n\t\t\t\t<label for='choice_21_21_3' id='label_21_21_3' class='gform-field-label gform-field-label--type-inline'>Casa rodante<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_21_4'>\n\t\t\t\t<input name='input_21' type='radio' value='D\u00faplex'  id='choice_21_21_4'    \/>\n\t\t\t\t<label for='choice_21_21_4' id='label_21_21_4' class='gform-field-label gform-field-label--type-inline'>D\u00faplex<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_22\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_22'>Valor aproximado de la residencia:<\/label><div class='ginput_container ginput_container_number'><input name='input_22' id='input_21_22' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_21_23\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Utilidades<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_23'>\n\t\t\t<li class='gchoice gchoice_21_23_0'>\n\t\t\t\t<input name='input_23' type='radio' value='Agua y drenaje de la ciudad'  id='choice_21_23_0'    \/>\n\t\t\t\t<label for='choice_21_23_0' id='label_21_23_0' class='gform-field-label gform-field-label--type-inline'>Agua y drenaje de la ciudad<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_23_1'>\n\t\t\t\t<input name='input_23' type='radio' value='Pozo y\/o fosa s\u00e9ptica'  id='choice_21_23_1'    \/>\n\t\t\t\t<label for='choice_21_23_1' id='label_21_23_1' class='gform-field-label gform-field-label--type-inline'>Pozo y\/o fosa s\u00e9ptica<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >El hogar est\u00e1 equipado con:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_21_24'><li class='gchoice gchoice_21_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Calefacci\u00f3n central'  id='choice_21_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_21_24_1' id='label_21_24_1' class='gform-field-label gform-field-label--type-inline'>Calefacci\u00f3n central<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_21_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='Aire acondicionado central'  id='choice_21_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_21_24_2' id='label_21_24_2' class='gform-field-label gform-field-label--type-inline'>Aire acondicionado central<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_21_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='Unidades de ventana'  id='choice_21_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_21_24_3' id='label_21_24_3' class='gform-field-label gform-field-label--type-inline'>Unidades de ventana<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_25\" class=\"gfield gfield--type-radio gfield--type-choice 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' >\u00bfCuenta el hogar con alguna conexi\u00f3n de gas utilizada para electrodom\u00e9sticos o boiler?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_25'>\n\t\t\t<li class='gchoice gchoice_21_25_0'>\n\t\t\t\t<input name='input_25' type='radio' value='S\u00ed'  id='choice_21_25_0'    \/>\n\t\t\t\t<label for='choice_21_25_0' id='label_21_25_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_25_1'>\n\t\t\t\t<input name='input_25' type='radio' value='No'  id='choice_21_25_1'    \/>\n\t\t\t\t<label for='choice_21_25_1' id='label_21_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_26\" class=\"gfield gfield--type-select 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_21_26'>Indique la cantidad de Plantas:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_21_26' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Uno' >Uno<\/option><option value='Dos' >Dos<\/option><option value='Tres' >Tres<\/option><option value='M\u00e1s de tres' >M\u00e1s de tres<\/option><\/select><\/div><\/li><li id=\"field_21_27\" class=\"gfield gfield--type-select 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_21_27'>Indique la cantidad de Habitaciones:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_27' id='input_21_27' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Uno' >Uno<\/option><option value='Dos' >Dos<\/option><option value='Tres' >Tres<\/option><option value='Cuatro' >Cuatro<\/option><option value='M\u00e1s de cuatro' >M\u00e1s de cuatro<\/option><\/select><\/div><\/li><li id=\"field_21_30\" class=\"gfield gfield--type-select 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_21_30'>Indique la cantidad de Ba\u00f1os:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_30' id='input_21_30' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Uno' >Uno<\/option><option value='Dos' >Dos<\/option><option value='Tres' >Tres<\/option><option value='M\u00e1s de tres' >M\u00e1s de tres<\/option><\/select><\/div><\/li><li id=\"field_21_28\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_28'>\u00bfD\u00f3nde estar\u00e1 la habitaci\u00f3n del menor en cuidados de crianza temporal?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_21_28' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_29\" class=\"gfield gfield--type-radio gfield--type-choice 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' >\u00bfTiene armas de fuego u otras armas en la casa?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_29'>\n\t\t\t<li class='gchoice gchoice_21_29_0'>\n\t\t\t\t<input name='input_29' type='radio' value='S\u00ed'  id='choice_21_29_0'    \/>\n\t\t\t\t<label for='choice_21_29_0' id='label_21_29_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_29_1'>\n\t\t\t\t<input name='input_29' type='radio' value='No'  id='choice_21_29_1'    \/>\n\t\t\t\t<label for='choice_21_29_1' id='label_21_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_31\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_31'>Si su respuesta es \u201cS\u00ed\u201d, indique en qu\u00e9 lugar y c\u00f3mo las guarda (deber\u00e1n tener doble candado).<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_21_31' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_32\" class=\"gfield gfield--type-radio gfield--type-choice 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' >\u00bfTiene mascotas en su casa o en su propiedad?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_32'>\n\t\t\t<li class='gchoice gchoice_21_32_0'>\n\t\t\t\t<input name='input_32' type='radio' value='S\u00ed'  id='choice_21_32_0'    \/>\n\t\t\t\t<label for='choice_21_32_0' id='label_21_32_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_32_1'>\n\t\t\t\t<input name='input_32' type='radio' value='No'  id='choice_21_32_1'    \/>\n\t\t\t\t<label for='choice_21_32_1' id='label_21_32_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_33\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_33'>Si su respuesta es \u201cS\u00ed\u201d, indique: Nombre, Edad, Tipo<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_33' id='input_21_33' class='textarea small'  aria-describedby=\"gfield_description_21_33\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_21_33'> **Tenga en cuenta que cada mascota deber\u00e1 tener la vacuna anual contra la rabia para que su hogar pueda obtener la licencia. **<\/div><\/li><li id=\"field_21_34\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfTiene piscina o trampol\u00edn?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_21_34'><li class='gchoice gchoice_21_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='Piscina'  id='choice_21_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_21_34_1' id='label_21_34_1' class='gform-field-label gform-field-label--type-inline'>Piscina<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_21_34_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.2' type='checkbox'  value='Trampol\u00edn'  id='choice_21_34_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_21_34_2' id='label_21_34_2' class='gform-field-label gform-field-label--type-inline'>Trampol\u00edn<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_35\" class=\"gfield gfield--type-textarea 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_21_35'>Proporcione las indicaciones necesarias para llegar a su casa:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_21_35' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_37\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Informati\u00f3n de Veh\u00edculos Motorizados:<\/h2><\/li><li id=\"field_21_41\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_41'>1.) A\u00f1o, Marca, Modelo, N\u00fam. de placa:<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_21_41' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_42\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_42'>2.) A\u00f1o, Marca, Modelo, N\u00fam. de placa:<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_21_42' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_43\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_43'>3.) A\u00f1o, Marca, Modelo, N\u00fam. de placa:<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_21_43' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_21_244' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriores'  \/> <input type='button' id='gform_next_button_21_244' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_21_3_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Guardar y continuar m\u00e1s tarde<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_21_3' class='gform_page' data-js='page-field-id-244' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_21_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_21_44\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Miembros Componen el Hogar:<\/h2><div class='gsection_description' id='gfield_description_21_44'>(Incluir a otros adultos, hermanos, hijos, etc.)<\/div><\/li><li id=\"field_21_45\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_45'>Nombre, Relaci\u00f3n, Fecha de nac., Edad, Sexo, Ocupaci\u00f3n para todos los miembros de la familia.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_45' id='input_21_45' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_46\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Miembros de la Familia Que No Viven en el Hogar:<\/h2><div class='gsection_description' id='gfield_description_21_46'>(Hijos Adultos) Las normas estatales exigen que las referencias se env\u00eden a los hijos adultos o que se haga un contacto telef\u00f3nico.<\/div><\/li><li id=\"field_21_48\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_48'>Nombre, Relaci\u00f3n, Fecha de nac., Edad, Sexo, SS#, Ocupaci\u00f3n para todos los miembros de la familia que no viven en el hogar.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_48' id='input_21_48' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_49\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >En caso de emergencia, favor de avisar a:<\/li><li id=\"field_21_50\" class=\"gfield gfield--type-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 gfield_label_before_complex' >Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><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_21_50'>\n                            <span id='input_21_50_3_container' class='name_first gform-grid-col' >\n                                                    <input type='text' name='input_50.3' id='input_21_50_3' value=''   aria-required='true'    \/>\n                                                    <label for='input_21_50_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                               <\/span>\n                            <span id='input_21_50_6_container' class='name_last gform-grid-col' >\n                                                    <input type='text' name='input_50.6' id='input_21_50_6' value=''   aria-required='true'    \/>\n                                                    <label for='input_21_50_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/li><li id=\"field_21_51\" class=\"gfield gfield--type-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_21_51'>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_51' id='input_21_51' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_52\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_52'>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_52' id='input_21_52' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_21_243' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriores'  \/> <input type='button' id='gform_next_button_21_243' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_21_4_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Guardar y continuar m\u00e1s tarde<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_21_4' class='gform_page' data-js='page-field-id-243' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_21_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_21_54\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Histotria Educativa:<\/h2><\/li><li id=\"field_21_55\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_55'>Escuela preparatoria: Nombre, Lugar, Fechas, \u00bfSe gradu\u00f3?\/\u00bfA\u00f1o?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_55' id='input_21_55' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_56\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_56'>Instituto Terciario\/Universidad: Nombre, Lugar, Fecha, \u00bfSe gradu\u00f3?\/\u00bfA\u00f1o?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_56' id='input_21_56' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_57\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_57'>Escuela vocacional: Nombre, Lugar, Fecha, \u00bfSe gradu\u00f3?\/\u00bfA\u00f1o?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_57' id='input_21_57' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_58\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_58'>Otro tipo de educaci\u00f3n:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_58' id='input_21_58' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_60\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Historia Laboral: (\u00faltimos 10 a\u00f1os)<\/h2><\/li><li id=\"field_21_61\" class=\"gfield gfield--type-textarea 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_21_61'>Fechas; Lugar de trabajo; Ciudad, Estado; Puesto; Salario; Raz\u00f3n porque dej\u00f3 el trabajo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_61' id='input_21_61' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_62\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_62'>Servicio militar: Divisi\u00f3n, Fechas de servicio, Rango, Tipo de baja:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_62' id='input_21_62' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_21_245' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriores'  \/> <input type='button' id='gform_next_button_21_245' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_21_5_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Guardar y continuar m\u00e1s tarde<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_21_5' class='gform_page' data-js='page-field-id-245' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_21_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_21_64\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Historial M\u00e9dico:<\/h2><\/li><li id=\"field_21_65\" class=\"gfield gfield--type-textarea 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_21_65'>Describa todos sus problemas de salud de mayor y menor importancia:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_65' id='input_21_65' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_66\" class=\"gfield gfield--type-radio gfield--type-choice 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' >\u00bfRecibe usted o alg\u00fan miembro del hogar tratamiento por alguna enfermedad f\u00edsica o psicol\u00f3gica?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_66'>\n\t\t\t<li class='gchoice gchoice_21_66_0'>\n\t\t\t\t<input name='input_66' type='radio' value='S\u00ed'  id='choice_21_66_0'    \/>\n\t\t\t\t<label for='choice_21_66_0' id='label_21_66_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_66_1'>\n\t\t\t\t<input name='input_66' type='radio' value='No'  id='choice_21_66_1'    \/>\n\t\t\t\t<label for='choice_21_66_1' id='label_21_66_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_67\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_67'>Si su respuesta es \u201cS\u00ed\u201d, explique:<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_21_67' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_68\" class=\"gfield gfield--type-radio gfield--type-choice 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' >\u00bfToma alg\u00fan medicamento?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_68'>\n\t\t\t<li class='gchoice gchoice_21_68_0'>\n\t\t\t\t<input name='input_68' type='radio' value='S\u00ed'  id='choice_21_68_0'    \/>\n\t\t\t\t<label for='choice_21_68_0' id='label_21_68_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_68_1'>\n\t\t\t\t<input name='input_68' type='radio' value='No'  id='choice_21_68_1'    \/>\n\t\t\t\t<label for='choice_21_68_1' id='label_21_68_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_69\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_69'>Si su respuesta es \u201cS\u00ed\u201d, Nombre, Cantidad\/Frecuencia, Raz\u00f3n:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_69' id='input_21_69' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_79\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >*******Tenga en cuenta que se requiere que cada miembro de la familia se haga las pruebas de tuberculosis para que su hogar pueda obtener la licencia.<\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_21_246' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriores'  \/> <input type='button' id='gform_next_button_21_246' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_21_6_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Guardar y continuar m\u00e1s tarde<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_21_6' class='gform_page' data-js='page-field-id-246' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_21_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_21_70\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Antecedentes Penales:<\/h2><\/li><li id=\"field_21_72\" class=\"gfield gfield--type-radio gfield--type-choice 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' >\u00bfHan sido arrestados alguna vez usted, su c\u00f3nyuge o alg\u00fan familiar que viva en su hogar?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_72'>\n\t\t\t<li class='gchoice gchoice_21_72_0'>\n\t\t\t\t<input name='input_72' type='radio' value='No'  id='choice_21_72_0'    \/>\n\t\t\t\t<label for='choice_21_72_0' id='label_21_72_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_72_1'>\n\t\t\t\t<input name='input_72' type='radio' value='S\u00ed'  id='choice_21_72_1'    \/>\n\t\t\t\t<label for='choice_21_72_1' id='label_21_72_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_73\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_73'>Si su respuesta es \u201cS\u00ed\u201d, explique:<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_21_73' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_74\" class=\"gfield gfield--type-radio gfield--type-choice 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' >\u00bfHan sido usted, su c\u00f3nyuge o alg\u00fan familiar que viva en su hogar, sujetos de una denuncia con respecto a un episodio grave de abuso o conducta negligente para con un ni\u00f1o a nivel emocional, sexual o f\u00edsico?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_74'>\n\t\t\t<li class='gchoice gchoice_21_74_0'>\n\t\t\t\t<input name='input_74' type='radio' value='No'  id='choice_21_74_0'    \/>\n\t\t\t\t<label for='choice_21_74_0' id='label_21_74_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_74_1'>\n\t\t\t\t<input name='input_74' type='radio' value='S\u00ed'  id='choice_21_74_1'    \/>\n\t\t\t\t<label for='choice_21_74_1' id='label_21_74_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_75\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_75'>Si su respuesta es \u201cS\u00ed\u201d, explique. Proporcione fechas y circunstancias:<\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_21_75' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_76\" class=\"gfield gfield--type-radio gfield--type-choice 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' >\u00bfSe ha visto involucrado alguno de sus hijos en asuntos del tribunal de menores?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_76'>\n\t\t\t<li class='gchoice gchoice_21_76_0'>\n\t\t\t\t<input name='input_76' type='radio' value='No'  id='choice_21_76_0'    \/>\n\t\t\t\t<label for='choice_21_76_0' id='label_21_76_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_76_1'>\n\t\t\t\t<input name='input_76' type='radio' value='S\u00ed'  id='choice_21_76_1'    \/>\n\t\t\t\t<label for='choice_21_76_1' id='label_21_76_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_77\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_77'>Si su respuesta es \u201cS\u00ed\u201d, explique:<\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_21_77' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_78\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong><u>Nota: Se llevar\u00e1 a cabo una indagaci\u00f3n de antecedentes penales de los solicitantes y todos los miembros del hogar que tengan 14 a\u00f1os de edad o m\u00e1s, as\u00ed como de los visitantes que frecuentan el hogar. Se define el t\u00e9rmino \u201cfrecuentar\u201d como hacer m\u00e1s de dos visitas al hogar en un periodo de 30 d\u00edas.<\/u><\/strong><\/p> <p><strong><u>Lo siguiente podr\u00eda impedir que una persona sea padre de crianza temporal, sea un miembro del hogar de cuidados de crianza temporal o un visitante frecuente en dicho hogar: Cualquier tipo de delito menor o grave, como los delitos contra una persona, robo, exhibicionismo p\u00fablico, acoso, reclutamiento de menores para fines sexuales, no detener ni denunciar un acometimiento sexual grave contra un menor, poner un arma de fuego al alcance de un menor, delitos relacionados con la ebriedad, cualquier tipo de faltas menores y toda adjudicaci\u00f3n diferida de alguno de los delitos anteriores.<\/u><\/strong><\/p> <p><strong><u>Cualquier otro cargo que pudiera tener una persona, ser\u00e1 evaluado y se determinar\u00e1 si permitiremos otorgar la licencia. Algunos de los factores utilizados en nuestras evaluaciones incluyen el tipo de cargo, el tiempo que ha pasado desde que se present\u00f3 el cargo y la edad del solicitante al momento de la presentaci\u00f3n de los cargos.<\/u><\/strong><\/p><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_21_247' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriores'  \/> <input type='button' id='gform_next_button_21_247' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_21_7_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Guardar y continuar m\u00e1s tarde<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_21_7' class='gform_page' data-js='page-field-id-247' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_21_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_21_81\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Recursos Locales y Comunitarios :<\/h2><\/li><li id=\"field_21_82\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_82'>\u00bfEn qu\u00e9 distrito escolar vive?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_21_82' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_83\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >\u00bfEn qu\u00e9 distrito escolar vive? <\/li><li id=\"field_21_84\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_84'>Primaria:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_21_84' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_85\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_85'>Secundaria:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_21_85' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_86\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_86'>Preparatoria:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_21_86' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_87\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_87'>Otra escuela especializada:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_21_87' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_88\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_88'>\u00bfQu\u00e9 centros de cuidados m\u00e9dicos se encuentran en el lugar donde vive? \u00bfA qu\u00e9 distancia se encuentran?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_21_88' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_89\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_89'>Indique otros recursos comunitarios del \u00e1rea donde vive (por ejemplo, biblioteca, ni\u00f1os exploradores, YMCA, cines, pistas de patinaje):<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_89' id='input_21_89' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_21_248' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriores'  \/> <input type='button' id='gform_next_button_21_248' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_21_8_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Guardar y continuar m\u00e1s tarde<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_21_8' class='gform_page' data-js='page-field-id-248' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_21_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_21_91\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Capacidades e Intereses Especiales:<\/h2><\/li><li id=\"field_21_92\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_92'>Idiomas extranjeros\/Fluidez:<\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_21_92' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_93\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_93'>Intereses y pasatiempos:<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_21_93' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_94\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_94'>Actividades sociales en las que participa:<\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_21_94' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_95\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_95'>Organizaciones profesionales a las que pertenece:<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_21_95' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_96\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_96'>Voluntario en el que ha participado:<\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_21_96' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_21_249' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriores'  \/> <input type='button' id='gform_next_button_21_249' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_21_9_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Guardar y continuar m\u00e1s tarde<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_21_9' class='gform_page' data-js='page-field-id-249' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_21_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_21_98\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Preguntas Generales:<\/h2><\/li><li id=\"field_21_99\" class=\"gfield gfield--type-textarea 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_21_99'>\u00bfPor qu\u00e9 desea ser un proveedor de cuidados de crianza temporal?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_99' id='input_21_99' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_100\" class=\"gfield gfield--type-textarea 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_21_100'>\u00bfQu\u00e9 siente que usted y su familia pueden ofrecerle a un ni\u00f1o bajo cuidados de crianza temporal si viviera en su hogar?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_100' id='input_21_100' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_101\" class=\"gfield gfield--type-textarea 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_21_101'>Describa brevemente su ni\u00f1ez, incluyendo el lugar donde viv\u00eda, la manera en que fue disciplinado, c\u00f3mo se comunicaba su familia, etc.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_101' id='input_21_101' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_102\" class=\"gfield gfield--type-radio gfield--type-choice 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' >\u00bfHa estado alg\u00fan miembro de su familia bajo cuidados de crianza temporal o ha proporcionado este tipo de cuidados?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_102'>\n\t\t\t<li class='gchoice gchoice_21_102_0'>\n\t\t\t\t<input name='input_102' type='radio' value='No'  id='choice_21_102_0'    \/>\n\t\t\t\t<label for='choice_21_102_0' id='label_21_102_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_102_1'>\n\t\t\t\t<input name='input_102' type='radio' value='S\u00ed'  id='choice_21_102_1'    \/>\n\t\t\t\t<label for='choice_21_102_1' id='label_21_102_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_103\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_103'>Si su respuesta es \u201cS\u00ed\u201d, indique por cu\u00e1nto tiempo<\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_21_103' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_104\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_104'>Si usted mismo ha proporcionado cuidados de crianza temporal antes o lo hace actualmente, proporcione informaci\u00f3n con respecto a qu\u00e9 agencias le otorgaron la licencia y las fechas en que \u00e9stas le otorgaron la licencia.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_104' id='input_21_104' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_105\" class=\"gfield gfield--type-textarea 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_21_105'>\u00bfC\u00f3mo manejar\u00eda la situaci\u00f3n financiera si el cheque de reembolso por cuidados de crianza temporal no llegara en el momento que lo espera? \u00bfTiene alguna otra fuente de ingresos confiable?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_105' id='input_21_105' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_106\" class=\"gfield gfield--type-textarea 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_21_106'>\u00bfQu\u00e9 m\u00e9todos disciplinarios cree que son adecuados para los menores?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_106' id='input_21_106' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_107\" class=\"gfield gfield--type-textarea 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_21_107'>Describa su experiencia respecto al trabajo con menores que tienen problemas emocionales, f\u00edsicos o de conducta y qu\u00e9 ha aprendido de esa experiencia:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_107' id='input_21_107' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_108\" class=\"gfield gfield--type-textarea 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_21_108'>\u00bfAlguna vez ha aceptado a una persona en su casa por un periodo largo? Si su respuesta es \u201cS\u00ed\u201d, explique:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_108' id='input_21_108' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_109\" class=\"gfield gfield--type-textarea 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_21_109'>Describa una semana normal para usted, incluyendo lo que hace en su tiempo libre:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_109' id='input_21_109' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_110\" class=\"gfield gfield--type-textarea 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_21_110'>Describa el uso de alcohol y\/o drogas (es decir, cantidad y frecuencia de consumo):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_110' id='input_21_110' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_111\" class=\"gfield gfield--type-textarea 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_21_111'>\u00bfC\u00f3mo maneja su ira y frustraciones hacia los dem\u00e1s, particularmente, hacia los ni\u00f1os y adolescentes?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_111' id='input_21_111' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_112\" class=\"gfield gfield--type-textarea 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_21_112'>\u00bfDe que manera responde al hecho de que otra persona le supervise?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_112' id='input_21_112' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_113\" class=\"gfield gfield--type-textarea 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_21_113'>\u00bfDe qu\u00e9 manera considera que la supervisi\u00f3n podr\u00eda ayudarle?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_113' id='input_21_113' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_114\" class=\"gfield gfield--type-textarea 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_21_114'>\u00bfDe que manera cambiar\u00eda su estilo de vida con un ni\u00f1o bajo cuidados de crianza temporal en su hogar?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_114' id='input_21_114' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_115\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >\u00bfQu\u00e9 cree que har\u00eda que un menor...<\/li><li id=\"field_21_116\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_116'>se escapara?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_116' id='input_21_116' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_117\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_117'>se hiciera da\u00f1o a s\u00ed mismo o a los dem\u00e1s?<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_21_117' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_118\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_118'>cometiera da\u00f1os a la propiedad?<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_21_118' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_119\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_119'>hiciera berrinches?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_119' id='input_21_119' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_120\" class=\"gfield gfield--type-textarea 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_21_120'>\u00bfQu\u00e9 podr\u00eda hacer usted para evitar algunas de las situaciones anteriores?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_120' id='input_21_120' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_21_250' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriores'  \/> <input type='button' id='gform_next_button_21_250' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_21_10_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Guardar y continuar m\u00e1s tarde<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_21_10' class='gform_page' data-js='page-field-id-250' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_21_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_21_122\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Preguntas Subjetivas:<\/h2><\/li><li id=\"field_21_123\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Mi familia me educ\u00f3 para que valore:<\/li><li id=\"field_21_124\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_124'>A:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_21_124' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_125\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_125'>B:<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_21_125' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_126\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_126'>C:<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_21_126' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_127\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Mis tres puntos fuertes principales son:<\/li><li id=\"field_21_128\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_128'>A:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_128' id='input_21_128' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_129\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_129'>B:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_21_129' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_130\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_130'>C:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_130' id='input_21_130' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_131\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Mis tres flaquezas principales son:<\/li><li id=\"field_21_132\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_132'>A:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_21_132' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_133\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_133'>B:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_133' id='input_21_133' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_134\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_134'>C:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_134' id='input_21_134' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_135\" class=\"gfield gfield--type-textarea 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_21_135'>Mis tres flaquezas principales son:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_135' id='input_21_135' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_136\" class=\"gfield gfield--type-textarea 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_21_136'>Espero que un ni\u00f1o bajo mis cuidados:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_136' id='input_21_136' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_137\" class=\"gfield gfield--type-textarea 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_21_137'>Me doy cuenta que estoy agotado cuando:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_137' id='input_21_137' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_138\" class=\"gfield gfield--type-textarea 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_21_138'>Quiero aprender m\u00e1s sobre:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_138' id='input_21_138' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_21_251' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriores'  \/> <input type='button' id='gform_next_button_21_251' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_21_11_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Guardar y continuar m\u00e1s tarde<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_21_11' class='gform_page' data-js='page-field-id-251' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_21_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_21_140\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Referencias:<\/h2><div class='gsection_description' id='gfield_description_21_140'>**Se deben proporcionar nombres completos y direcciones con c\u00f3digo postal****<\/div><\/li><li id=\"field_21_141\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Miembro de la Familia:<\/li><li id=\"field_21_142\" class=\"gfield gfield--type-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 gfield_label_before_complex' >Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><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_21_142'>\n                            <span id='input_21_142_3_container' class='name_first gform-grid-col' >\n                                                    <input type='text' name='input_142.3' id='input_21_142_3' value=''   aria-required='true'    \/>\n                                                    <label for='input_21_142_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                               <\/span>\n                            <span id='input_21_142_6_container' class='name_last gform-grid-col' >\n                                                    <input type='text' name='input_142.6' id='input_21_142_6' value=''   aria-required='true'    \/>\n                                                    <label for='input_21_142_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/li><li id=\"field_21_143\" class=\"gfield gfield--type-address 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 gfield_label_before_complex' >Direcci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_21_143' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_21_143_1_container' >\n                                        <input type='text' name='input_143.1' id='input_21_143_1' value=''    aria-required='true'    \/>\n                                        <label for='input_21_143_1' id='input_21_143_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_21_143_2_container' >\n                                        <input type='text' name='input_143.2' id='input_21_143_2' value=''     aria-required='false'   \/>\n                                        <label for='input_21_143_2' id='input_21_143_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_21_143_3_container' >\n                                    <input type='text' name='input_143.3' id='input_21_143_3' value=''    aria-required='true'    \/>\n                                    <label for='input_21_143_3' id='input_21_143_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_21_143_4_container' >\n                                        <select name='input_143.4' id='input_21_143_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_21_143_4' id='input_21_143_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_21_143_5_container' >\n                                    <input type='text' name='input_143.5' id='input_21_143_5' value=''    aria-required='true'    \/>\n                                    <label for='input_21_143_5' id='input_21_143_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_143.6' id='input_21_143_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_21_144\" class=\"gfield gfield--type-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_21_144'>N\u00fam. 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_144' id='input_21_144' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_236\" class=\"gfield gfield--type-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_21_236'>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_236' id='input_21_236' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_21_145\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Persona que no es familiar (2):<\/li><li id=\"field_21_146\" class=\"gfield gfield--type-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 gfield_label_before_complex' >Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><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_21_146'>\n                            <span id='input_21_146_3_container' class='name_first gform-grid-col' >\n                                                    <input type='text' name='input_146.3' id='input_21_146_3' value=''   aria-required='true'    \/>\n                                                    <label for='input_21_146_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                               <\/span>\n                            <span id='input_21_146_6_container' class='name_last gform-grid-col' >\n                                                    <input type='text' name='input_146.6' id='input_21_146_6' value=''   aria-required='true'    \/>\n                                                    <label for='input_21_146_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/li><li id=\"field_21_147\" class=\"gfield gfield--type-address 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 gfield_label_before_complex' >Direcci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_21_147' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_21_147_1_container' >\n                                        <input type='text' name='input_147.1' id='input_21_147_1' value=''    aria-required='true'    \/>\n                                        <label for='input_21_147_1' id='input_21_147_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_21_147_2_container' >\n                                        <input type='text' name='input_147.2' id='input_21_147_2' value=''     aria-required='false'   \/>\n                                        <label for='input_21_147_2' id='input_21_147_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_21_147_3_container' >\n                                    <input type='text' name='input_147.3' id='input_21_147_3' value=''    aria-required='true'    \/>\n                                    <label for='input_21_147_3' id='input_21_147_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_21_147_4_container' >\n                                        <select name='input_147.4' id='input_21_147_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_21_147_4' id='input_21_147_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_21_147_5_container' >\n                                    <input type='text' name='input_147.5' id='input_21_147_5' value=''    aria-required='true'    \/>\n                                    <label for='input_21_147_5' id='input_21_147_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_147.6' id='input_21_147_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_21_148\" class=\"gfield gfield--type-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_21_148'>N\u00fam. 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_148' id='input_21_148' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_237\" class=\"gfield gfield--type-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_21_237'>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_237' id='input_21_237' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_21_149\" class=\"gfield gfield--type-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 gfield_label_before_complex' >Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><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_21_149'>\n                            <span id='input_21_149_3_container' class='name_first gform-grid-col' >\n                                                    <input type='text' name='input_149.3' id='input_21_149_3' value=''   aria-required='true'    \/>\n                                                    <label for='input_21_149_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                               <\/span>\n                            <span id='input_21_149_6_container' class='name_last gform-grid-col' >\n                                                    <input type='text' name='input_149.6' id='input_21_149_6' value=''   aria-required='true'    \/>\n                                                    <label for='input_21_149_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/li><li id=\"field_21_150\" class=\"gfield gfield--type-address 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 gfield_label_before_complex' >Direcci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_21_150' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_21_150_1_container' >\n                                        <input type='text' name='input_150.1' id='input_21_150_1' value=''    aria-required='true'    \/>\n                                        <label for='input_21_150_1' id='input_21_150_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_21_150_2_container' >\n                                        <input type='text' name='input_150.2' id='input_21_150_2' value=''     aria-required='false'   \/>\n                                        <label for='input_21_150_2' id='input_21_150_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_21_150_3_container' >\n                                    <input type='text' name='input_150.3' id='input_21_150_3' value=''    aria-required='true'    \/>\n                                    <label for='input_21_150_3' id='input_21_150_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_21_150_4_container' >\n                                        <select name='input_150.4' id='input_21_150_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_21_150_4' id='input_21_150_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_21_150_5_container' >\n                                    <input type='text' name='input_150.5' id='input_21_150_5' value=''    aria-required='true'    \/>\n                                    <label for='input_21_150_5' id='input_21_150_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_150.6' id='input_21_150_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_21_151\" class=\"gfield gfield--type-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_21_151'>N\u00fam. 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_151' id='input_21_151' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_238\" class=\"gfield gfield--type-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_21_238'>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_238' id='input_21_238' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_21_152\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Empleador\/Compa\u00f1ero de trabajo:<\/li><li id=\"field_21_153\" class=\"gfield gfield--type-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 gfield_label_before_complex' >Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><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_21_153'>\n                            <span id='input_21_153_3_container' class='name_first gform-grid-col' >\n                                                    <input type='text' name='input_153.3' id='input_21_153_3' value=''   aria-required='true'    \/>\n                                                    <label for='input_21_153_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                               <\/span>\n                            <span id='input_21_153_6_container' class='name_last gform-grid-col' >\n                                                    <input type='text' name='input_153.6' id='input_21_153_6' value=''   aria-required='true'    \/>\n                                                    <label for='input_21_153_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/li><li id=\"field_21_154\" class=\"gfield gfield--type-address 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 gfield_label_before_complex' >Direcci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_21_154' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_21_154_1_container' >\n                                        <input type='text' name='input_154.1' id='input_21_154_1' value=''    aria-required='true'    \/>\n                                        <label for='input_21_154_1' id='input_21_154_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_21_154_2_container' >\n                                        <input type='text' name='input_154.2' id='input_21_154_2' value=''     aria-required='false'   \/>\n                                        <label for='input_21_154_2' id='input_21_154_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_21_154_3_container' >\n                                    <input type='text' name='input_154.3' id='input_21_154_3' value=''    aria-required='true'    \/>\n                                    <label for='input_21_154_3' id='input_21_154_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_21_154_4_container' >\n                                        <select name='input_154.4' id='input_21_154_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_21_154_4' id='input_21_154_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_21_154_5_container' >\n                                    <input type='text' name='input_154.5' id='input_21_154_5' value=''    aria-required='true'    \/>\n                                    <label for='input_21_154_5' id='input_21_154_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_154.6' id='input_21_154_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_21_155\" class=\"gfield gfield--type-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_21_155'>N\u00fam. 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_155' id='input_21_155' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_239\" class=\"gfield gfield--type-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_21_239'>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_239' id='input_21_239' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_21_156\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >******Se debe incluir la direcci\u00f3n completa con el c\u00f3digo postal*****<\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_21_252' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriores'  \/> <input type='button' id='gform_next_button_21_252' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_21_12_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Guardar y continuar m\u00e1s tarde<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_21_12' class='gform_page' data-js='page-field-id-252' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_21_12' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_21_158\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Circles of Care- Lista de Referencia Para Tolerancia de Conductas<\/h2><\/li><li id=\"field_21_159\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Esta hoja se deber\u00e1 completar como parte del proceso de concesi\u00f3n de licencia. Esta lista se repasar\u00e1 junto con el trabajador de COC y se discutir\u00e1n \u00e1reas espec\u00edficas. Se utilizar\u00e1 para considerar las colocaciones en custodia de cuidados en el futuro. Marque la columna que mejor describa la reacci\u00f3n de su familia para cada punto y su capacidad para trabajar con dichas conductas y problemas. Haga m\u00e1s comentarios si lo considera apropiado. Si los esposos tienen opiniones diferentes, pueden marcar columnas distintas; por lo tanto, ponga \u201cEO\u201d para esposo y \u201cEA\u201d para esposa.<\/li><li id=\"field_21_160\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Depresi\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_160'>\n\t\t\t<li class='gchoice gchoice_21_160_0'>\n\t\t\t\t<input name='input_160' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_160_0'    \/>\n\t\t\t\t<label for='choice_21_160_0' id='label_21_160_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_160_1'>\n\t\t\t\t<input name='input_160' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_160_1'    \/>\n\t\t\t\t<label for='choice_21_160_1' id='label_21_160_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_160_2'>\n\t\t\t\t<input name='input_160' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_160_2'    \/>\n\t\t\t\t<label for='choice_21_160_2' id='label_21_160_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_161\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_161'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_161' id='input_21_161' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_162\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Aislamiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_162'>\n\t\t\t<li class='gchoice gchoice_21_162_0'>\n\t\t\t\t<input name='input_162' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_162_0'    \/>\n\t\t\t\t<label for='choice_21_162_0' id='label_21_162_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_162_1'>\n\t\t\t\t<input name='input_162' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_162_1'    \/>\n\t\t\t\t<label for='choice_21_162_1' id='label_21_162_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_162_2'>\n\t\t\t\t<input name='input_162' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_162_2'    \/>\n\t\t\t\t<label for='choice_21_162_2' id='label_21_162_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_168\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_168'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_168' id='input_21_168' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_167\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Destrucci\u00f3n de la propiedad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_167'>\n\t\t\t<li class='gchoice gchoice_21_167_0'>\n\t\t\t\t<input name='input_167' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_167_0'    \/>\n\t\t\t\t<label for='choice_21_167_0' id='label_21_167_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_167_1'>\n\t\t\t\t<input name='input_167' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_167_1'    \/>\n\t\t\t\t<label for='choice_21_167_1' id='label_21_167_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_167_2'>\n\t\t\t\t<input name='input_167' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_167_2'    \/>\n\t\t\t\t<label for='choice_21_167_2' id='label_21_167_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_169\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_169'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_169' id='input_21_169' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_166\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Se autolastima<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_166'>\n\t\t\t<li class='gchoice gchoice_21_166_0'>\n\t\t\t\t<input name='input_166' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_166_0'    \/>\n\t\t\t\t<label for='choice_21_166_0' id='label_21_166_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_166_1'>\n\t\t\t\t<input name='input_166' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_166_1'    \/>\n\t\t\t\t<label for='choice_21_166_1' id='label_21_166_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_166_2'>\n\t\t\t\t<input name='input_166' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_166_2'    \/>\n\t\t\t\t<label for='choice_21_166_2' id='label_21_166_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_170\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_170'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_170' id='input_21_170' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_165\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Hiperactividad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_165'>\n\t\t\t<li class='gchoice gchoice_21_165_0'>\n\t\t\t\t<input name='input_165' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_165_0'    \/>\n\t\t\t\t<label for='choice_21_165_0' id='label_21_165_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_165_1'>\n\t\t\t\t<input name='input_165' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_165_1'    \/>\n\t\t\t\t<label for='choice_21_165_1' id='label_21_165_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_165_2'>\n\t\t\t\t<input name='input_165' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_165_2'    \/>\n\t\t\t\t<label for='choice_21_165_2' id='label_21_165_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_171\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_171'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_171' id='input_21_171' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_164\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Conducta desafiante<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_164'>\n\t\t\t<li class='gchoice gchoice_21_164_0'>\n\t\t\t\t<input name='input_164' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_164_0'    \/>\n\t\t\t\t<label for='choice_21_164_0' id='label_21_164_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_164_1'>\n\t\t\t\t<input name='input_164' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_164_1'    \/>\n\t\t\t\t<label for='choice_21_164_1' id='label_21_164_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_164_2'>\n\t\t\t\t<input name='input_164' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_164_2'    \/>\n\t\t\t\t<label for='choice_21_164_2' id='label_21_164_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_172\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_172'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_172' id='input_21_172' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_163\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Agresividad oral<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_163'>\n\t\t\t<li class='gchoice gchoice_21_163_0'>\n\t\t\t\t<input name='input_163' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_163_0'    \/>\n\t\t\t\t<label for='choice_21_163_0' id='label_21_163_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_163_1'>\n\t\t\t\t<input name='input_163' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_163_1'    \/>\n\t\t\t\t<label for='choice_21_163_1' id='label_21_163_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_163_2'>\n\t\t\t\t<input name='input_163' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_163_2'    \/>\n\t\t\t\t<label for='choice_21_163_2' id='label_21_163_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_173\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_173'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_173' id='input_21_173' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_174\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Agresividad f\u00edsica<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_174'>\n\t\t\t<li class='gchoice gchoice_21_174_0'>\n\t\t\t\t<input name='input_174' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_174_0'    \/>\n\t\t\t\t<label for='choice_21_174_0' id='label_21_174_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_174_1'>\n\t\t\t\t<input name='input_174' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_174_1'    \/>\n\t\t\t\t<label for='choice_21_174_1' id='label_21_174_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_174_2'>\n\t\t\t\t<input name='input_174' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_174_2'    \/>\n\t\t\t\t<label for='choice_21_174_2' id='label_21_174_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_175\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_175'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_175' id='input_21_175' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_176\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Discapacidad f\u00edsica grave<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_176'>\n\t\t\t<li class='gchoice gchoice_21_176_0'>\n\t\t\t\t<input name='input_176' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_176_0'    \/>\n\t\t\t\t<label for='choice_21_176_0' id='label_21_176_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_176_1'>\n\t\t\t\t<input name='input_176' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_176_1'    \/>\n\t\t\t\t<label for='choice_21_176_1' id='label_21_176_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_176_2'>\n\t\t\t\t<input name='input_176' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_176_2'    \/>\n\t\t\t\t<label for='choice_21_176_2' id='label_21_176_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_177\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_177'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_177' id='input_21_177' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_178\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Dificultades de aprendizaje<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_178'>\n\t\t\t<li class='gchoice gchoice_21_178_0'>\n\t\t\t\t<input name='input_178' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_178_0'    \/>\n\t\t\t\t<label for='choice_21_178_0' id='label_21_178_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_178_1'>\n\t\t\t\t<input name='input_178' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_178_1'    \/>\n\t\t\t\t<label for='choice_21_178_1' id='label_21_178_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_178_2'>\n\t\t\t\t<input name='input_178' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_178_2'    \/>\n\t\t\t\t<label for='choice_21_178_2' id='label_21_178_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_179\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_179'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_179' id='input_21_179' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_180\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Ademanes nerviosos<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_180'>\n\t\t\t<li class='gchoice gchoice_21_180_0'>\n\t\t\t\t<input name='input_180' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_180_0'    \/>\n\t\t\t\t<label for='choice_21_180_0' id='label_21_180_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_180_1'>\n\t\t\t\t<input name='input_180' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_180_1'    \/>\n\t\t\t\t<label for='choice_21_180_1' id='label_21_180_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_180_2'>\n\t\t\t\t<input name='input_180' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_180_2'    \/>\n\t\t\t\t<label for='choice_21_180_2' id='label_21_180_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_181\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_181'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_181' id='input_21_181' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_182\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Retraso mental<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_182'>\n\t\t\t<li class='gchoice gchoice_21_182_0'>\n\t\t\t\t<input name='input_182' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_182_0'    \/>\n\t\t\t\t<label for='choice_21_182_0' id='label_21_182_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_182_1'>\n\t\t\t\t<input name='input_182' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_182_1'    \/>\n\t\t\t\t<label for='choice_21_182_1' id='label_21_182_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_182_2'>\n\t\t\t\t<input name='input_182' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_182_2'    \/>\n\t\t\t\t<label for='choice_21_182_2' id='label_21_182_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_183\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_183'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_183' id='input_21_183' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_184\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Sefecto del habla<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_184'>\n\t\t\t<li class='gchoice gchoice_21_184_0'>\n\t\t\t\t<input name='input_184' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_184_0'    \/>\n\t\t\t\t<label for='choice_21_184_0' id='label_21_184_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_184_1'>\n\t\t\t\t<input name='input_184' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_184_1'    \/>\n\t\t\t\t<label for='choice_21_184_1' id='label_21_184_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_184_2'>\n\t\t\t\t<input name='input_184' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_184_2'    \/>\n\t\t\t\t<label for='choice_21_184_2' id='label_21_184_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_185\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_185'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_185' id='input_21_185' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_186\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Llanto o queja<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_186'>\n\t\t\t<li class='gchoice gchoice_21_186_0'>\n\t\t\t\t<input name='input_186' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_186_0'    \/>\n\t\t\t\t<label for='choice_21_186_0' id='label_21_186_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_186_1'>\n\t\t\t\t<input name='input_186' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_186_1'    \/>\n\t\t\t\t<label for='choice_21_186_1' id='label_21_186_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_186_2'>\n\t\t\t\t<input name='input_186' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_186_2'    \/>\n\t\t\t\t<label for='choice_21_186_2' id='label_21_186_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_187\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_187'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_187' id='input_21_187' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_194\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Pensamientos suicidas<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_194'>\n\t\t\t<li class='gchoice gchoice_21_194_0'>\n\t\t\t\t<input name='input_194' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_194_0'    \/>\n\t\t\t\t<label for='choice_21_194_0' id='label_21_194_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_194_1'>\n\t\t\t\t<input name='input_194' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_194_1'    \/>\n\t\t\t\t<label for='choice_21_194_1' id='label_21_194_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_194_2'>\n\t\t\t\t<input name='input_194' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_194_2'    \/>\n\t\t\t\t<label for='choice_21_194_2' id='label_21_194_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_195\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_195'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_195' id='input_21_195' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_188\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Ser contest\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_188'>\n\t\t\t<li class='gchoice gchoice_21_188_0'>\n\t\t\t\t<input name='input_188' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_188_0'    \/>\n\t\t\t\t<label for='choice_21_188_0' id='label_21_188_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_188_1'>\n\t\t\t\t<input name='input_188' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_188_1'    \/>\n\t\t\t\t<label for='choice_21_188_1' id='label_21_188_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_188_2'>\n\t\t\t\t<input name='input_188' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_188_2'    \/>\n\t\t\t\t<label for='choice_21_188_2' id='label_21_188_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_189\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_189'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_189' id='input_21_189' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_190\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Malos h\u00e1bitos de higiene<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_190'>\n\t\t\t<li class='gchoice gchoice_21_190_0'>\n\t\t\t\t<input name='input_190' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_190_0'    \/>\n\t\t\t\t<label for='choice_21_190_0' id='label_21_190_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_190_1'>\n\t\t\t\t<input name='input_190' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_190_1'    \/>\n\t\t\t\t<label for='choice_21_190_1' id='label_21_190_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_190_2'>\n\t\t\t\t<input name='input_190' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_190_2'    \/>\n\t\t\t\t<label for='choice_21_190_2' id='label_21_190_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_191\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_191'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_191' id='input_21_191' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_192\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Comer en exceso<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_192'>\n\t\t\t<li class='gchoice gchoice_21_192_0'>\n\t\t\t\t<input name='input_192' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_192_0'    \/>\n\t\t\t\t<label for='choice_21_192_0' id='label_21_192_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_192_1'>\n\t\t\t\t<input name='input_192' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_192_1'    \/>\n\t\t\t\t<label for='choice_21_192_1' id='label_21_192_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_192_2'>\n\t\t\t\t<input name='input_192' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_192_2'    \/>\n\t\t\t\t<label for='choice_21_192_2' id='label_21_192_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_193\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_193'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_193' id='input_21_193' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_197\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Anorexia\/bulimia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_197'>\n\t\t\t<li class='gchoice gchoice_21_197_0'>\n\t\t\t\t<input name='input_197' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_197_0'    \/>\n\t\t\t\t<label for='choice_21_197_0' id='label_21_197_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_197_1'>\n\t\t\t\t<input name='input_197' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_197_1'    \/>\n\t\t\t\t<label for='choice_21_197_1' id='label_21_197_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_197_2'>\n\t\t\t\t<input name='input_197' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_197_2'    \/>\n\t\t\t\t<label for='choice_21_197_2' id='label_21_197_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_196\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_196'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_196' id='input_21_196' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_198\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Escaparse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_198'>\n\t\t\t<li class='gchoice gchoice_21_198_0'>\n\t\t\t\t<input name='input_198' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_198_0'    \/>\n\t\t\t\t<label for='choice_21_198_0' id='label_21_198_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_198_1'>\n\t\t\t\t<input name='input_198' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_198_1'    \/>\n\t\t\t\t<label for='choice_21_198_1' id='label_21_198_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_198_2'>\n\t\t\t\t<input name='input_198' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_198_2'    \/>\n\t\t\t\t<label for='choice_21_198_2' id='label_21_198_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_199\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_199'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_199' id='input_21_199' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_200\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Uso de malas palabras<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_200'>\n\t\t\t<li class='gchoice gchoice_21_200_0'>\n\t\t\t\t<input name='input_200' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_200_0'    \/>\n\t\t\t\t<label for='choice_21_200_0' id='label_21_200_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_200_1'>\n\t\t\t\t<input name='input_200' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_200_1'    \/>\n\t\t\t\t<label for='choice_21_200_1' id='label_21_200_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_200_2'>\n\t\t\t\t<input name='input_200' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_200_2'    \/>\n\t\t\t\t<label for='choice_21_200_2' id='label_21_200_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_201\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_201'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_201' id='input_21_201' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_202\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Fumar (cigarrillos, etc.)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_202'>\n\t\t\t<li class='gchoice gchoice_21_202_0'>\n\t\t\t\t<input name='input_202' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_202_0'    \/>\n\t\t\t\t<label for='choice_21_202_0' id='label_21_202_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_202_1'>\n\t\t\t\t<input name='input_202' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_202_1'    \/>\n\t\t\t\t<label for='choice_21_202_1' id='label_21_202_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_202_2'>\n\t\t\t\t<input name='input_202' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_202_2'    \/>\n\t\t\t\t<label for='choice_21_202_2' id='label_21_202_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_203\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_203'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_203' id='input_21_203' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_204\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Pelearse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_204'>\n\t\t\t<li class='gchoice gchoice_21_204_0'>\n\t\t\t\t<input name='input_204' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_204_0'    \/>\n\t\t\t\t<label for='choice_21_204_0' id='label_21_204_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_204_1'>\n\t\t\t\t<input name='input_204' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_204_1'    \/>\n\t\t\t\t<label for='choice_21_204_1' id='label_21_204_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_204_2'>\n\t\t\t\t<input name='input_204' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_204_2'    \/>\n\t\t\t\t<label for='choice_21_204_2' id='label_21_204_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_205\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_205'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_205' id='input_21_205' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_206\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Robar<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_206'>\n\t\t\t<li class='gchoice gchoice_21_206_0'>\n\t\t\t\t<input name='input_206' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_206_0'    \/>\n\t\t\t\t<label for='choice_21_206_0' id='label_21_206_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_206_1'>\n\t\t\t\t<input name='input_206' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_206_1'    \/>\n\t\t\t\t<label for='choice_21_206_1' id='label_21_206_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_206_2'>\n\t\t\t\t<input name='input_206' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_206_2'    \/>\n\t\t\t\t<label for='choice_21_206_2' id='label_21_206_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_219\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_219'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_219' id='input_21_219' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_207\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Tomar alcohol<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_207'>\n\t\t\t<li class='gchoice gchoice_21_207_0'>\n\t\t\t\t<input name='input_207' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_207_0'    \/>\n\t\t\t\t<label for='choice_21_207_0' id='label_21_207_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_207_1'>\n\t\t\t\t<input name='input_207' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_207_1'    \/>\n\t\t\t\t<label for='choice_21_207_1' id='label_21_207_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_207_2'>\n\t\t\t\t<input name='input_207' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_207_2'    \/>\n\t\t\t\t<label for='choice_21_207_2' id='label_21_207_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_220\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_220'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_220' id='input_21_220' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_208\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Abuso de drogas\/otras sustancias<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_208'>\n\t\t\t<li class='gchoice gchoice_21_208_0'>\n\t\t\t\t<input name='input_208' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_208_0'    \/>\n\t\t\t\t<label for='choice_21_208_0' id='label_21_208_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_208_1'>\n\t\t\t\t<input name='input_208' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_208_1'    \/>\n\t\t\t\t<label for='choice_21_208_1' id='label_21_208_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_208_2'>\n\t\t\t\t<input name='input_208' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_208_2'    \/>\n\t\t\t\t<label for='choice_21_208_2' id='label_21_208_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_218\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_218'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_218' id='input_21_218' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_209\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Impulsos sexuales<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_209'>\n\t\t\t<li class='gchoice gchoice_21_209_0'>\n\t\t\t\t<input name='input_209' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_209_0'    \/>\n\t\t\t\t<label for='choice_21_209_0' id='label_21_209_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_209_1'>\n\t\t\t\t<input name='input_209' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_209_1'    \/>\n\t\t\t\t<label for='choice_21_209_1' id='label_21_209_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_209_2'>\n\t\t\t\t<input name='input_209' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_209_2'    \/>\n\t\t\t\t<label for='choice_21_209_2' id='label_21_209_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_221\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_221'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_221' id='input_21_221' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_210\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Masturbaci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_210'>\n\t\t\t<li class='gchoice gchoice_21_210_0'>\n\t\t\t\t<input name='input_210' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_210_0'    \/>\n\t\t\t\t<label for='choice_21_210_0' id='label_21_210_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_210_1'>\n\t\t\t\t<input name='input_210' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_210_1'    \/>\n\t\t\t\t<label for='choice_21_210_1' id='label_21_210_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_210_2'>\n\t\t\t\t<input name='input_210' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_210_2'    \/>\n\t\t\t\t<label for='choice_21_210_2' id='label_21_210_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_222\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_222'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_222' id='input_21_222' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_211\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Enuresis (mojar la cama)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_211'>\n\t\t\t<li class='gchoice gchoice_21_211_0'>\n\t\t\t\t<input name='input_211' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_211_0'    \/>\n\t\t\t\t<label for='choice_21_211_0' id='label_21_211_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_211_1'>\n\t\t\t\t<input name='input_211' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_211_1'    \/>\n\t\t\t\t<label for='choice_21_211_1' id='label_21_211_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_211_2'>\n\t\t\t\t<input name='input_211' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_211_2'    \/>\n\t\t\t\t<label for='choice_21_211_2' id='label_21_211_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_223\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_223'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_223' id='input_21_223' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_212\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Encopresis (evacuaciones incontrolables)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_212'>\n\t\t\t<li class='gchoice gchoice_21_212_0'>\n\t\t\t\t<input name='input_212' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_212_0'    \/>\n\t\t\t\t<label for='choice_21_212_0' id='label_21_212_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_212_1'>\n\t\t\t\t<input name='input_212' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_212_1'    \/>\n\t\t\t\t<label for='choice_21_212_1' id='label_21_212_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_212_2'>\n\t\t\t\t<input name='input_212' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_212_2'    \/>\n\t\t\t\t<label for='choice_21_212_2' id='label_21_212_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_225\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_225'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_225' id='input_21_225' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_213\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Embarazo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_213'>\n\t\t\t<li class='gchoice gchoice_21_213_0'>\n\t\t\t\t<input name='input_213' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_213_0'    \/>\n\t\t\t\t<label for='choice_21_213_0' id='label_21_213_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_213_1'>\n\t\t\t\t<input name='input_213' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_213_1'    \/>\n\t\t\t\t<label for='choice_21_213_1' id='label_21_213_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_213_2'>\n\t\t\t\t<input name='input_213' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_213_2'    \/>\n\t\t\t\t<label for='choice_21_213_2' id='label_21_213_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_226\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_226'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_226' id='input_21_226' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_214\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Berrinches<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_214'>\n\t\t\t<li class='gchoice gchoice_21_214_0'>\n\t\t\t\t<input name='input_214' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_214_0'    \/>\n\t\t\t\t<label for='choice_21_214_0' id='label_21_214_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_214_1'>\n\t\t\t\t<input name='input_214' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_214_1'    \/>\n\t\t\t\t<label for='choice_21_214_1' id='label_21_214_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_214_2'>\n\t\t\t\t<input name='input_214' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_214_2'    \/>\n\t\t\t\t<label for='choice_21_214_2' id='label_21_214_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_224\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_224'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_224' id='input_21_224' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_215\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Conducta: Decir mentiras<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_21_215'>\n\t\t\t<li class='gchoice gchoice_21_215_0'>\n\t\t\t\t<input name='input_215' type='radio' value='Podr\u00eda Manejarla'  id='choice_21_215_0'    \/>\n\t\t\t\t<label for='choice_21_215_0' id='label_21_215_0' class='gform-field-label gform-field-label--type-inline'>Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_215_1'>\n\t\t\t\t<input name='input_215' type='radio' value='Ser\u00eda Posible Manejarla'  id='choice_21_215_1'    \/>\n\t\t\t\t<label for='choice_21_215_1' id='label_21_215_1' class='gform-field-label gform-field-label--type-inline'>Ser\u00eda Posible Manejarla<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_21_215_2'>\n\t\t\t\t<input name='input_215' type='radio' value='No Podr\u00eda Manejarla'  id='choice_21_215_2'    \/>\n\t\t\t\t<label for='choice_21_215_2' id='label_21_215_2' class='gform-field-label gform-field-label--type-inline'>No Podr\u00eda Manejarla<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_21_227\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_227'>Calidad, grado, alcance o m\u00e1s comentarios.<\/label><div class='ginput_container ginput_container_text'><input name='input_227' id='input_21_227' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_21_253' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriores'  \/> <input type='button' id='gform_next_button_21_253' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_21_13_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Guardar y continuar m\u00e1s tarde<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_21_13' class='gform_page' data-js='page-field-id-253' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_21_13' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_21_228\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Firma del proveedor<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_name'>\n                                    <input name='input_228' id='input_21_228' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_21_228\"  \/>\n                                <\/div><div class='gfield_description' id='gfield_description_21_228'>Al ingresar su nombre, que est\u00e1 firmando el formulario de arriba y verificar que toda la informaci\u00f3n es correcta.<\/div><\/li><li id=\"field_21_229\" class=\"gfield gfield--type-date gfield--input-type-datefield 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 gfield_label_before_complex' >Fecha<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_21_229' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_21_229_1_container'>\n                                            <input type='number' maxlength='2' name='input_229[]' id='input_21_229_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_21_229_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_21_229_2_container'>\n                                            <input type='number' maxlength='2' name='input_229[]' id='input_21_229_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_21_229_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_21_229_3_container'>\n                                            <input type='number' maxlength='4' name='input_229[]' id='input_21_229_3' value=''   aria-required='true'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                            <label for='input_21_229_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>A\u00f1o<\/label>\n                                       <\/div>\n                                   <\/div><\/div><\/li><li id=\"field_21_231\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>\u00a1Usted est\u00e1 casi listo!<\/h3> <p>Esta es la p\u00e1gina final de la aplicaci\u00f3n. Su solicitud no se ha presentado todav\u00eda. Por favor, lea la informaci\u00f3n en esta p\u00e1gina y rellena todos los campos de firma en la parte inferior. A continuaci\u00f3n, haga clic en \"Enviar\" y espere a que el mensaje de confirmaci\u00f3n. Si usted no ve un mensaje de confirmaci\u00f3n, p\u00f3ngase en contacto con Circles of Care para asistencia.<\/p> <h4><u>Derecho de Preferencia para denegar el reconocimiento y la tarifa de Licenciatura Pol\u00edtica de Reembolso<\/u><\/h4> <p>Circles of Care de reservas el derecho de negar la licencia de cuidado de crianza o solicitantes de adopci\u00f3n en cualquier momento durante el proceso de concesi\u00f3n de licencias.<\/p> <p>Los padres de crianza y adoptivos que aplican con Circles of Care aplicar como proveedores potenciales para ser autorizados por los Circles of Care. El procedimiento de concesi\u00f3n de licencias es un \"proceso\" que implica muchos pasos y tiene muchos requisitos. Algunas de las medidas incluyen una revisi\u00f3n del FBI, estudio en el hogar, la capacitaci\u00f3n, verificaci\u00f3n de antecedentes y las inspecciones de origen. Cada paso y requisito es una oportunidad para los Circles of Care para evaluar los solicitantes para determinar si los solicitantes son una buena opci\u00f3n para nuestro organismo y puede satisfacer las necesidades de los ni\u00f1os que servimos. Circles of Care de reservas el derecho de negar el potencial de guarda y solicitantes de adopci\u00f3n en cualquier momento durante el proceso de concesi\u00f3n de licencias.<\/p> <p>Circles of Care no es responsable de ninguna p\u00e9rdida de trabajo o salario por el tiempo y esfuerzo que el solicitante pasa a pasar por el proceso de concesi\u00f3n de licencias, independientemente de si es o no la licencia se produce.<\/p> <p>Adem\u00e1s, como parte del proceso de concesi\u00f3n de licencias, hay ciertos requisitos que incluyen: controles del FBI fondo, inspecciones de incendios, inspecciones y pruebas de TB que incurren en un costo para los solicitantes. Circles of Care reembolsa hasta una cierta cantidad para gastos de inspecci\u00f3n y pruebas de TB. La cantidad del reembolso Circles of Care pagar\u00e1 puede cambiar de a\u00f1o en a\u00f1o en funci\u00f3n de los presupuestos. Los solicitantes deben informarse y conocer el reembolso actual de esos costos y los factores que en su decisi\u00f3n de continuar con la licencia.<\/p> <p>Los solicitantes no deben programar u obtener los requisitos que tienen asociados honorarios, a menos que se le indique por Circles of Care. Los importes de reembolso previstos por Circles of Care s\u00f3lo se pagar\u00e1 al solicitante si Circles of Care hab\u00eda ordenado espec\u00edficamente a los solicitantes para obtener estos requisitos.<\/p> <p>No hay suministros o reparaciones que puedan ser necesarias para aprobar las inspecciones son pagados por los Circles of Care ni reembolsar\u00e1 al solicitante, independientemente de si el solicitante tiene licencia.<\/p> <h4><u>Fuego y Reconocimiento de la Salud Inspecciones<\/u><\/h4> <p>Como parte de la evaluaci\u00f3n de una licencia a un hogar de acogida potencial, todos los hogares deben recibir inspecciones de incendios y de salud del departamento de salud del condado y los departamentos de bomberos de la ciudad o del estado. Una vez licenciado, estas inspecciones deben repetirse cada dos (2) a\u00f1os para viviendas habituales y hogares de grupo, una vez al a\u00f1o.<\/p> <p>Circles of Care reembolsar\u00e1 hogares por parte del coste de las inspecciones. Las tasas de inspecci\u00f3n var\u00edan seg\u00fan la ciudad y del condado y los Circles of Care cantidad de atenci\u00f3n reembolsar\u00e1 puede cambiar en funci\u00f3n de los presupuestos. Por favor, pregunte acerca de lo que el reembolso de inspecci\u00f3n y la tarifa actual es factor que en su decisi\u00f3n de obtener la licencia bolso. Para los nuevos hogares potenciales, este reembolso se realiza despu\u00e9s de que el hogar est\u00e1 oficialmente autorizado o denegado y para los hogares actuales, una vez que los informes de inspecci\u00f3n se han entregado a los Circles of Care.<\/p> <p>Circles of Care reembolsa el costo de la comisi\u00f3n de inspecci\u00f3n solamente. Circles of Care de no pagar o reembolsarle cualquier cosa que se requiere para hacer a su casa para pasar estas inspecciones como tener alarmas de incendio, extintores de incendio o de reparaci\u00f3n y mantenimiento que los inspectores se sienten que se necesita en su hogar.<\/p> <p>Las cosas comunes necesarios para pasar las inspecciones:<\/p> <p><u>Requerido para el fuego\n:<\/u><br \/> Extintor de incendios<br \/>\nLas alarmas contra incendios en cada piso si 2 pisos<br \/>\nDetector de mon\u00f3xido de carbono si la casa est\u00e1 equipada con gas<br \/>\nEl aparato de aire acondicionado reparado o revisado por empresa de aire acondicionado<\/p> <p><u>Para la salud:<\/u><br \/> \nBotiqu\u00edn de primeros auxilios<br \/> \nProtectores de ni\u00f1os en la cubierta en contactos el\u00e9ctricos<\/p><\/li><li id=\"field_21_232\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Applicant Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_name'>\n                                    <input name='input_232' id='input_21_232' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_21_232\"  \/>\n                                <\/div><div class='gfield_description' id='gfield_description_21_232'>Al ingresar su nombre, que est\u00e1 firmando el formulario de arriba y verificar que toda la informaci\u00f3n es correcta. Si usted est\u00e1 en un hogar de dos padres, una aplicaci\u00f3n separada tiene que ser presentada por ambos padres.<\/div><\/li><li id=\"field_21_234\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Una vez que haga clic en Submit (enviar), espere el mensaje de confirmaci\u00f3n. Si obtiene un error al hacer clic en Submit (enviar), haga clic en su navegador <em>Back<\/em> bot\u00f3n una vez, e intente de nuevo hacer clic en Submit (enviar). No utilice el bot\u00f3n de actualizaci\u00f3n del explorador a menos que desee borrar el formulario y empezar de nuevo.<\/p><\/li><li id=\"field_21_240\" class=\"gfield gfield--type-captcha field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_240'>CAPTCHA<\/label><div id='input_21_240' class='ginput_container ginput_recaptcha' data-sitekey='6Leyq_oUAAAAAA50V2yZ6XUNo4fHQq_pyr--jbQF'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/li><\/ul><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_21' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_21' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_21_footer_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Guardar y continuar m\u00e1s tarde<\/a>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_21' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_21' id='gform_theme_21' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_21' id='gform_style_settings_21' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_21' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='21' \/>\n            <input type='hidden' class='gform_hidden' name='gform_save' id='gform_save_21' value='' \/>\n                             <input type='hidden' class='gform_hidden' name='gform_resume_token' id='gform_resume_token_21' value='' \/>\n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='a+HzMymNkOFlfTahdteqttrCY3ZzoS2frRyE2JoRBeTAwH09GgiYb604UjvRTDuK21r+e8mMyXJAWy94gz+jVxHf6IAksVZ0+A51OIyiVcjOO3Q=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_21' value='WyJbXSIsIjFhNWZlZDEzMGY1NjEwYjczYzAyMTYwMTQxYWQ1ZDczIl0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_21' id='gform_target_page_number_21' value='2' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_21' id='gform_source_page_number_21' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n             <\/div><\/div>\n                        <p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"ak_\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_2\" name=\"ak_js\" value=\"216\"\/><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\ndocument.getElementById( \"ak_js_2\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n\/* ]]> *\/\n<\/script>\n<\/p><\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 21, '\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_21').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_21');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_21').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_21').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_21').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_21').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_21').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_21').val();gformInitSpinner( 21, '\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [21, current_page]);window['gf_submitting_21'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_21').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_21').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [21]);window['gf_submitting_21'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_21').text());}else{jQuery('#gform_21').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"21\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_21\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_21\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_21\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 21, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n<\/p>","protected":false},"excerpt":{"rendered":"","protected":false},"author":3700,"featured_media":0,"parent":731,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_cbd_carousel_blocks":"[]","footnotes":""},"class_list":["post-746","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.circlesofcareinc.org\/es\/wp-json\/wp\/v2\/pages\/746","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.circlesofcareinc.org\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.circlesofcareinc.org\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.circlesofcareinc.org\/es\/wp-json\/wp\/v2\/users\/3700"}],"replies":[{"embeddable":true,"href":"https:\/\/www.circlesofcareinc.org\/es\/wp-json\/wp\/v2\/comments?post=746"}],"version-history":[{"count":11,"href":"https:\/\/www.circlesofcareinc.org\/es\/wp-json\/wp\/v2\/pages\/746\/revisions"}],"predecessor-version":[{"id":1221,"href":"https:\/\/www.circlesofcareinc.org\/es\/wp-json\/wp\/v2\/pages\/746\/revisions\/1221"}],"up":[{"embeddable":true,"href":"https:\/\/www.circlesofcareinc.org\/es\/wp-json\/wp\/v2\/pages\/731"}],"wp:attachment":[{"href":"https:\/\/www.circlesofcareinc.org\/es\/wp-json\/wp\/v2\/media?parent=746"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}