{"id":2412,"date":"2023-06-14T11:22:17","date_gmt":"2023-06-14T09:22:17","guid":{"rendered":"https:\/\/ga2len-adcare.net\/?page_id=2412"},"modified":"2023-06-14T11:22:17","modified_gmt":"2023-06-14T09:22:17","slug":"apply-now","status":"publish","type":"page","link":"https:\/\/ga2len-adcare.net\/apply-now\/","title":{"rendered":"Apply now"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1098.24px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_6' ><div id='gf_6' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">ADCARE Application form<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_6'  action='\/wp-json\/wp\/v2\/pages\/2412#gf_6' data-formid='6' novalidate>\n        <div id='gf_progressbar_wrapper_6' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>4<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_6_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><div id='gform_fields_6' class='gform_fields top_label form_sublabel_above description_above'><div id=\"field_6_4\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_4\" ><h3 class=\"gsection_title\">Center information<\/h3><\/div><div id=\"field_6_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_35\" ><label class='gfield_label gform-field-label' for='input_6_35'>Clinic name<\/label><div class='gfield_description' id='gfield_description_6_35'>This information will be public<\/div><div class='ginput_container ginput_container_text'><input name='input_35' id='input_6_35' type='text' value='' class='large'  aria-describedby=\"gfield_description_6_35\"    aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_6_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_1\" ><label class='gfield_label gform-field-label' for='input_6_1'>Center name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_6_1'>This information will be public<\/div><div class='ginput_container ginput_container_text'><input name='input_1' id='input_6_1' type='text' value='' class='large'  aria-describedby=\"gfield_description_6_1\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_6_34\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_34\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Center address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_6_34'>This information will be public<\/div>    \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_6_34' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_34_1_container' >\n                                        <label for='input_6_34_1' id='input_6_34_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_34.1' id='input_6_34_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_6_34_2_container' >\n                                        <label for='input_6_34_2' id='input_6_34_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_34.2' id='input_6_34_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_34_3_container' >\n                                    <label for='input_6_34_3' id='input_6_34_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_34.3' id='input_6_34_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_34_4_container' >\n                                        <label for='input_6_34_4' id='input_6_34_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                        <input type='text' name='input_34.4' id='input_6_34_4' value=''      aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_34_5_container' >\n                                    <label for='input_6_34_5' id='input_6_34_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                    <input type='text' name='input_34.5' id='input_6_34_5' value=''    aria-required='true'    \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_6_34_6_container' >\n                                        <label for='input_6_34_6' id='input_6_34_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                        <select name='input_34.6' id='input_6_34_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option> <\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><input type=\"hidden\" name=\"gpaa_coords_34\" class=\"gform_hidden\" value=\"\"><\/fieldset><div id=\"field_6_17\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_17\" ><label class='gfield_label gform-field-label' for='input_6_17'>Center email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_6_17'>This information will be public<\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_17' id='input_6_17' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_6_17\" \/>\n                        <\/div><\/div><div id=\"field_6_16\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_16\" ><label class='gfield_label gform-field-label' for='input_6_16'>Center phone<\/label><div class='gfield_description' id='gfield_description_6_16'>This information will be public<\/div><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_6_16' type='tel' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_6_16\"  \/><\/div><\/div><div id=\"field_6_29\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_29\" ><label class='gfield_label gform-field-label' for='input_6_29'>Center website<\/label><div class='gfield_description' id='gfield_description_6_29'>This information will be public<\/div><div class='ginput_container ginput_container_text'><input name='input_29' id='input_6_29' type='text' value='' class='large'  aria-describedby=\"gfield_description_6_29\"    aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_6_24' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"2\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"2\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_2' class='gform_page' data-js='page-field-id-24' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_2' class='gform_fields top_label form_sublabel_above description_above'><div id=\"field_6_6\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_6\" ><h3 class=\"gsection_title\">Department information<\/h3><\/div><div id=\"field_6_41\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_41\" ><label class='gfield_label gform-field-label' for='input_6_41'>Department email address<\/label><div class='gfield_description' id='gfield_description_6_41'>This information will <b>not<\/b> be public<\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_41' id='input_6_41' type='email' value='' class='large'     aria-invalid=\"false\" aria-describedby=\"gfield_description_6_41\" \/>\n                        <\/div><\/div><div id=\"field_6_42\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_42\" ><label class='gfield_label gform-field-label' for='input_6_42'>Department phone<\/label><div class='gfield_description' id='gfield_description_6_42'>This information will <b>not<\/b> be public<\/div><div class='ginput_container ginput_container_phone'><input name='input_42' id='input_6_42' type='tel' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_6_42\"  \/><\/div><\/div><div id=\"field_6_36\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_36\" ><label class='gfield_label gform-field-label' for='input_6_36'>Department mail address<\/label><div class='gfield_description' id='gfield_description_6_36'>This information will <b>not<\/b> be public<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_36' id='input_6_36' class='textarea large'  aria-describedby=\"gfield_description_6_36\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_39\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_39\" ><h3 class=\"gsection_title\">Department head<\/h3><\/div><div id=\"field_6_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half copy-32-to-22 gwcopy field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_32\" ><label class='gfield_label gform-field-label' for='input_6_32'>Head of department name<\/label><div class='gfield_description' id='gfield_description_6_32'>This information will be public<\/div><div class='ginput_container ginput_container_text'><input name='input_32' id='input_6_32' type='text' value='' class='large'  aria-describedby=\"gfield_description_6_32\"    aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_6_8\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half copy-8-to-38 gwcopy field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_8\" ><label class='gfield_label gform-field-label' for='input_6_8'>Head of department email address<\/label><div class='gfield_description' id='gfield_description_6_8'>This information will <b>not<\/b> be public<\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_8' id='input_6_8' type='email' value='' class='large'     aria-invalid=\"false\" aria-describedby=\"gfield_description_6_8\" \/>\n                        <\/div><\/div><div id=\"field_6_40\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_40\" ><h3 class=\"gsection_title\">Department deputy<\/h3><\/div><div id=\"field_6_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_33\" ><label class='gfield_label gform-field-label' for='input_6_33'>Department deputy name<\/label><div class='gfield_description' id='gfield_description_6_33'>This information will be public<\/div><div class='ginput_container ginput_container_text'><input name='input_33' id='input_6_33' type='text' value='' class='large'  aria-describedby=\"gfield_description_6_33\"    aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_6_7\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_7\" ><label class='gfield_label gform-field-label' for='input_6_7'>Department deputy email address<\/label><div class='gfield_description' id='gfield_description_6_7'>This information will <b>not<\/b> be public<\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_6_7' type='email' value='' class='large'     aria-invalid=\"false\" aria-describedby=\"gfield_description_6_7\" \/>\n                        <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_25' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"1\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"1\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_6_25' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"3\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"3\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_3' class='gform_page' data-js='page-field-id-25' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_3' class='gform_fields top_label form_sublabel_above description_above'><div id=\"field_6_12\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_12\" ><h3 class=\"gsection_title\">Application<\/h3><\/div><div id=\"field_6_13\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_13\" ><p>Dear Professor Zuberbier,<\/p>\n\n<p>I wish to join the GA&sup2;LEN\/ Atopic Dermatitis Centres of Reference and Excellence (ADCARE) network and hereby apply for our center to become an ADCARE.<\/p><\/div><div id=\"field_6_15\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_15\" ><label class='gfield_label gform-field-label' for='input_6_15'>Please explain why you want to become a Atopic Dermatitis Center of Reference and Excellence:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_15' id='input_6_15' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_6_18\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_above gfield--no-description field_description_above hidden_label gfield_visibility_visible\"  data-js-reload=\"field_6_18\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<\/legend><div class='ginput_container ginput_container_consent'><input name='input_18.1' id='input_6_18_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_18_1' >I have read the 32 requirements (see page: \u201c<a href=\"\/wp-content\/uploads\/2023\/06\/00-BLANK-GA\u00b2LEN-ADCARE-AUDIT-REPORT-2020.pdf\" target=\"_blank\">GA\u00b2LEN ADCARE requirements and deliverables<\/a>\u201d) and confirm that our center fulfils the requirements and deliverables.<\/label><input type='hidden' name='input_18.2' value='I have read the 32 requirements (see page: \u201c&lt;a href=&quot;\/wp-content\/uploads\/2023\/06\/00-BLANK-GA\u00b2LEN-ADCARE-AUDIT-REPORT-2020.pdf&quot; target=&quot;_blank&quot;&gt;GA\u00b2LEN ADCARE requirements and deliverables&lt;\/a&gt;\u201d) and confirm that our center fulfils the requirements and deliverables.' class='gform_hidden' \/><input type='hidden' name='input_18.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_19\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_19\" ><b>Please note:<\/b> Some of the information listed above (including the center\u2019s name and address, contact information for patients, website and logo) may be published on the ADCARE website. You can find examples of our centers' profiles on the \"Centers\" tab of the ADCARE website: <a href=\"\/centers\" target=\"_blank\">HERE<\/a><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_26' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"2\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"2\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_6_26' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"4\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"4\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_4' class='gform_page' data-js='page-field-id-26' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_4' class='gform_fields top_label form_sublabel_above description_above'><div id=\"field_6_28\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_28\" ><h3 class=\"gsection_title\">Verify information<\/h3><div class='gsection_description' id='gfield_description_6_28'>Please verify your information before submitting your application. If you need to change your submitted information, click \"Previous\" at the bottom of this page to go back<\/div><\/div><div id=\"field_6_27\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_27\" >{all_fields}<\/div><div id=\"field_6_22\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_22\" ><label class='gfield_label gform-field-label' for='input_6_22'>Applicant name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_6_22' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_6_38\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_38\" ><label class='gfield_label gform-field-label' for='input_6_38'>Applicant email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_38' id='input_6_38' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_6_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_20\" ><label class='gfield_label gform-field-label' for='input_6_20'>Application date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_20' id='input_6_20' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_6_23\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_23\" ><label class='gfield_label gform-field-label' for='input_6_23'>Applicant signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_6_23_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><input type='hidden' class='gform_hidden' name='input_6_23_valid' id='input_6_23_valid' \/><canvas id='input_6_23' width='600' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_6_43\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_6_43\" ><\/div><div id=\"field_6_45\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_above gfield--no-description field_description_above hidden_label gfield_visibility_visible\"  data-js-reload=\"field_6_45\" ><label class='gfield_label gform-field-label' for='input_6_45'>CAPTCHA<\/label><div id='input_6_45' class='ginput_container ginput_recaptcha' data-sitekey='6Lezv2ApAAAAALeklWp7_M7WrGodwiT9ccOKrHa-'  data-theme='light' data-tabindex='-1' data-size='invisible' data-badge='bottomright'><\/div><\/div><\/div><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_6' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='if(window[\"gf_submitting_6\"]){return false;}  if( !jQuery(\"#gform_6\")[0].checkValidity || jQuery(\"#gform_6\")[0].checkValidity()){window[\"gf_submitting_6\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_6\"]){return false;} if( !jQuery(\"#gform_6\")[0].checkValidity || jQuery(\"#gform_6\")[0].checkValidity()){window[\"gf_submitting_6\"]=true;}  jQuery(\"#gform_6\").trigger(\"submit\",[true]); }' \/> <input type='submit' id='gform_submit_button_6' class='gform_button button' value='Submit application'  onclick='if(window[\"gf_submitting_6\"]){return false;}  if( !jQuery(\"#gform_6\")[0].checkValidity || jQuery(\"#gform_6\")[0].checkValidity()){window[\"gf_submitting_6\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_6\"]){return false;} if( !jQuery(\"#gform_6\")[0].checkValidity || jQuery(\"#gform_6\")[0].checkValidity()){window[\"gf_submitting_6\"]=true;}  jQuery(\"#gform_6\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_6' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='6' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_6' value='WyJ7XCIxOC4xXCI6XCI2OGQ5OWJmMDgyOTUwOWE4MzcyNzVhZWRlYWQ2ZDRkY1wiLFwiMTguMlwiOlwiOWZmODBiMDRkYjc0MDYzYjM5Yzk3ZTAyYjBmZDRlMzFcIixcIjE4LjNcIjpcIjY4ZmY3NjRiNGI4OTU3NDJiNDhmODhkNjUzYjg2YzczXCJ9IiwiN2NlMzI4OTFjMGYxZDE4MWEzMGUxODYwYzQ0NWViOWEiXQ==' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_6' id='gform_target_page_number_6' value='2' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_6' id='gform_source_page_number_6' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/div><\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 6, 'https:\/\/ga2len-adcare.net\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_6').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_6');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_6').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_6').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_6').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_6').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_6').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_6').val();gformInitSpinner( 6, 'https:\/\/ga2len-adcare.net\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [6, current_page]);window['gf_submitting_6'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_6').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_6').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [6]);window['gf_submitting_6'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_6').text());}, 50);}else{jQuery('#gform_6').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"6\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);                if (event.defaultPrevented) {                return;         }        const 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