{"id":1833,"date":"2025-03-31T05:36:10","date_gmt":"2025-03-31T10:36:10","guid":{"rendered":"https:\/\/www.toplinemd.com\/pediatric-pros\/?page_id=1833"},"modified":"2025-03-31T07:44:59","modified_gmt":"2025-03-31T12:44:59","slug":"request-camp-forms","status":"publish","type":"page","link":"https:\/\/www.toplinemd.com\/pediatric-pros\/request-camp-forms\/","title":{"rendered":"Request Camp Forms"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container has-pattern-background has-mask-background fusion-parallax-none nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-background-position:right center;--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-min-height:400px;--awb-background-image:url(&quot;https:\/\/www.toplinemd.com\/pediatric-pros\/wp-content\/uploads\/sites\/120\/2020\/11\/FAQ-Header-background-1024x213.jpg&quot;);--awb-background-size:cover;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-center fusion-flex-justify-content-center fusion-flex-content-wrap\" style=\"max-width:1216.8px;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_2 1_2 fusion-flex-column\" style=\"--awb-padding-top:20px;--awb-padding-bottom:20px;--awb-bg-color:rgba(54,180,229,0.4);--awb-bg-color-hover:rgba(54,180,229,0.4);--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:3.84%;--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\"><div class=\"fusion-title title fusion-title-1 fusion-title-center fusion-title-text fusion-title-size-one fusion-animated\" style=\"--awb-margin-top-small:0px;--awb-margin-right-small:0px;--awb-margin-bottom-small:20px;--awb-margin-left-small:0px;--awb-font-size:40px;\" data-animationType=\"fadeInUp\" data-animationDuration=\"0.5\" data-animationOffset=\"top-into-view\"><div class=\"title-sep-container title-sep-container-left\"><div class=\"title-sep sep- sep-solid\" style=\"border-color:#e0dede;\"><\/div><\/div><span class=\"awb-title-spacer\"><\/span><h1 class=\"fusion-title-heading title-heading-center fusion-responsive-typography-calculated\" style=\"margin:0;text-transform:uppercase;font-size:1em;--fontSize:40;line-height:1.15;\">Request Camp Forms<\/h1><span class=\"awb-title-spacer\"><\/span><div class=\"title-sep-container title-sep-container-right\"><div class=\"title-sep sep- sep-solid\" style=\"border-color:#e0dede;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 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:1216.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 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\"><div class=\"fusion-separator fusion-full-width-sep\" style=\"align-self: center;margin-left: auto;margin-right: auto;margin-bottom:15px;width:100%;\"><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-3 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:1216.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:3.84%;--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\"><div class=\"fusion-menu-anchor\" id=\"school-camp-request-forms\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-3 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>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_5' style='display:none'><div id='gf_5' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><h4>To request camp forms, please fill out the information below and make a payment. Please allow our office up to 48 BUSINESS hours to complete your request.<\/h4><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_5' id='gform_5'  action='\/pediatric-pros\/wp-json\/wp\/v2\/pages\/1833#gf_5' data-formid='5' novalidate> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_97\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_97'>LinkedIn<\/label><div class='ginput_container'><input name='input_97' id='input_5_97' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_5_97'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_5_24\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_5_71\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Child's Name<\/h3><\/div><fieldset id=\"field_5_1\" class=\"gfield gfield--type-name gfield--width-third hipaa_forms_first_name gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_5_1'>\n                            \n                            <span id='input_5_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_5_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_1_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><fieldset id=\"field_5_34\" class=\"gfield gfield--type-name gfield--width-third hipaa_forms_last_name gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix no_first_name no_middle_name has_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_5_34'>\n                            \n                            \n                            \n                            <span id='input_5_34_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_34.6' id='input_5_34_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_34_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_5_14\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Child&#039;s Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_5_14' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_5_14_1_container'>\n                                            <input type='number' maxlength='2' name='input_14[]' id='input_5_14_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_5_14_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_5_14_2_container'>\n                                            <input type='number' maxlength='2' name='input_14[]' id='input_5_14_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_5_14_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_5_14_3_container'>\n                                            <input type='number' maxlength='4' name='input_14[]' id='input_5_14_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_5_14_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_5_94\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_price gfield_price_5_94 gfield_product_5_94 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Upload Camp Forms<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_94'>\n\t\t\t<div class='gchoice gchoice_5_94_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='Yes|20'  id='choice_5_94_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_94\"   \/>\n\t\t\t\t\t<label for='choice_5_94_0' id='label_5_94_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_94_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='No|0'  id='choice_5_94_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_94_1' id='label_5_94_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_94'>$20 For Camp Forms Upload<\/div><\/fieldset><div id=\"field_5_88\" class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_5_88'>Upload Camp Forms<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_5_88' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_5_88&quot;,&quot;container&quot;:&quot;gform_multifile_upload_5_88&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_5_88&quot;,&quot;filelist&quot;:&quot;gform_preview_5_88&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.toplinemd.com\\\/pediatric-pros\\\/?gf_page=c9ec85876ce8f39&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.toplinemd.com\\\/pediatric-pros\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.toplinemd.com\\\/pediatric-pros\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;2560000b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:5,&quot;field_id&quot;:88,&quot;_gform_file_upload_nonce_5_88&quot;:&quot;a2d62d54d8&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;5&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_5_88&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_5_88' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_5_88' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_5_88\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_88'>Max. file size: 2 MB, Max. files: 5.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_88'><\/ul> <div id='gform_preview_5_88' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_90\" class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_5_90'>Upload Medication or Allergy Forms<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_5_90' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_5_90&quot;,&quot;container&quot;:&quot;gform_multifile_upload_5_90&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_5_90&quot;,&quot;filelist&quot;:&quot;gform_preview_5_90&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.toplinemd.com\\\/pediatric-pros\\\/?gf_page=c9ec85876ce8f39&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.toplinemd.com\\\/pediatric-pros\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.toplinemd.com\\\/pediatric-pros\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;2560000b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:5,&quot;field_id&quot;:90,&quot;_gform_file_upload_nonce_5_90&quot;:&quot;73a8a29436&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;5&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_5_90&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_5_90' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_5_90' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_5_90\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_90'>Max. file size: 2 MB, Max. files: 5.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_90'><\/ul> <div id='gform_preview_5_90' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_92\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-half gfield_price gfield_price_5_92 gfield_product_5_92 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_92'>Camp Form 3040 (Yellow)<\/label><div class='ginput_container ginput_container_select'><select name='input_92' id='input_5_92' class='large gfield_select'  aria-describedby=\"gfield_description_5_92\"   aria-invalid=\"false\" ><option value='Form 3040 - Qty: 0|0' >Form 3040 - Qty: 0<\/option><option value='Form 3040  - Qty: 1|5' >Form 3040  - Qty: 1<\/option><option value='Form 3040  - Qty: 2|10' >Form 3040  - Qty: 2<\/option><option value='Form 3040  - Qty: 3|15' >Form 3040  - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_5_92'>$5 for Form 3040<\/div><\/div><div id=\"field_5_93\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-half gfield_price gfield_price_5_93 gfield_product_5_93 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_93'>Camp Form 680 (Blue)<\/label><div class='ginput_container ginput_container_select'><select name='input_93' id='input_5_93' class='large gfield_select'  aria-describedby=\"gfield_description_5_93\"   aria-invalid=\"false\" ><option value='Form 680 - Qty: 0|0' >Form 680 - Qty: 0<\/option><option value='Form 680 - Qty: 1|5' >Form 680 - Qty: 1<\/option><option value='Form 680 - Qty: 2|10' >Form 680 - Qty: 2<\/option><option value='Form 680 - Qty: 3|15' >Form 680 - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_5_93'>$5 for Form 680<\/div><\/div><div id=\"field_5_86\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-third gfield_price gfield_price_5_86 gfield_product_5_86 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' for='input_5_86'>Vaccination History<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_86' id='input_5_86' class='large gfield_select'  aria-describedby=\"gfield_description_5_86\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Select From Below|0' >Select From Below<\/option><option value='Vaccination History - Qty: 0|0' >Vaccination History - Qty: 0<\/option><option value='Vaccination History - Qty: 1|5' >Vaccination History - Qty: 1<\/option><option value='Vaccination History - Qty: 2|10' >Vaccination History - Qty: 2<\/option><option value='Vaccination History - Qty: 3|15' >Vaccination History - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_5_86'>$5 for Vaccination Form <br><span>&nbsp;<\/span><\/div><\/div><div id=\"field_5_67\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-third gfield_price gfield_price_5_67 gfield_product_5_67 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' for='input_5_67'>Over the Counter Medication Form<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_67' id='input_5_67' class='large gfield_select'  aria-describedby=\"gfield_description_5_67\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Select From Below|0' >Select From Below<\/option><option value='OTC Medication Form - Qty: 0|0' >OTC Medication Form - Qty: 0<\/option><option value='OTC Medication Form - Qty: 1|5' >OTC Medication Form - Qty: 1<\/option><option value='OTC Medication Form - Qty: 2|10' >OTC Medication Form - Qty: 2<\/option><option value='OTC Medication Form - Qty: 3|15' >OTC Medication Form - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_5_67'>$5 for OTC Meds Form\n*Must upload form to be filled in<\/div><\/div><div id=\"field_5_66\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-third gfield_price gfield_price_5_66 gfield_product_5_66 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' for='input_5_66'>Allergy &amp; Rx Meds Form<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_66' id='input_5_66' class='large gfield_select'  aria-describedby=\"gfield_description_5_66\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Select From Below|0' >Select From Below<\/option><option value='Allergy &amp; Rx Meds Form - Qty: 0|0' >Allergy &amp; Rx Meds Form - Qty: 0<\/option><option value='Allergy &amp; Rx Meds Form - Qty: 1|10' >Allergy &amp; Rx Meds Form - Qty: 1<\/option><option value='Allergy &amp; Rx Meds Form - Qty: 2|20' >Allergy &amp; Rx Meds Form - Qty: 2<\/option><option value='Allergy &amp; Rx Meds Form - Qty: 3|30' >Allergy &amp; Rx Meds Form - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_5_66'>$10 for Allergy & Rx Meds Form\n*Must upload form to be filled in<\/div><\/div><div id=\"field_5_82\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_5_72\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Questions for camp form.<\/h3><\/div><fieldset id=\"field_5_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Will your child be taking any medications at camp this summer?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_74'>\n\t\t\t<div class='gchoice gchoice_5_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Yes'  id='choice_5_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_74_0' id='label_5_74_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='No'  id='choice_5_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_74_1' id='label_5_74_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_76\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Will your child be eating a regular or special diet while at camp?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_76'>\n\t\t\t<div class='gchoice gchoice_5_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Yes'  id='choice_5_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_76_0' id='label_5_76_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='No'  id='choice_5_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_76_1' id='label_5_76_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_79\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have there been any changes in your child\u2019s health since their last visit?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_79'>\n\t\t\t<div class='gchoice gchoice_5_79_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='Yes'  id='choice_5_79_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_79_0' id='label_5_79_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_79_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='No'  id='choice_5_79_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_79_1' id='label_5_79_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_80\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does your child have any medication or food allergies?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_80'>\n\t\t\t<div class='gchoice gchoice_5_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Yes'  id='choice_5_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_80_0' id='label_5_80_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='No'  id='choice_5_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_80_1' id='label_5_80_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_32\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_5_84\" class=\"gfield gfield--type-phone gfield--width-half hipaa_forms_phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_84'>Contact Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_84' id='input_5_84' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_38\" class=\"gfield gfield--type-email gfield--width-half hipaa_forms_email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_38'>Contact Email<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_38' id='input_5_38' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_83\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-full gfield_price gfield_price_5_83 gfield_product_5_83 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' for='input_5_83'>Delivery Method<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_83' id='input_5_83' class='large gfield_select'  aria-describedby=\"gfield_description_5_83\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Pick Up|0' >Pick Up<\/option><option value='Email|20' >Email<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_5_83'>For a $20 convenience fee, the forms may be emailed to you.<\/div><\/div><div id=\"field_5_44\" class=\"gfield gfield--type-total gfield--width-full gfield_price gfield_price_5_ gfield_total gfield_total_5_ field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  aria-atomic=\"true\" aria-live=\"polite\" ><label class='gfield_label gform-field-label' for='input_5_44'>Total<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t\t<input type='text' readonly name='input_44' id='input_5_44' value='$0.00' class='gform-text-input-reset ginput_total ginput_total_5' \/>\n\t\t\t\t\t\t<\/div><\/div><div id=\"field_5_96\" class=\"gfield gfield--type-select gfield--width-full hipaa_forms_office_location field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_5_96'>Office Location<\/label><div class='ginput_container ginput_container_select'><select name='input_96' id='input_5_96' class='large gfield_select'     aria-invalid=\"false\" ><option value='PPAFORMS@femwell.com' selected='selected'>Pediatric Pros<\/option><\/select><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'>  <input type='hidden' name='gform_ajax' value='form_id=5&amp;title=&amp;description=1&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=fc48f9ebaea8ee043d0a0f5a08e8bc42' \/>\n           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