{"id":1882,"date":"2026-01-16T17:16:47","date_gmt":"2026-01-16T22:16:47","guid":{"rendered":"https:\/\/toplinemultist.wpengine.com\/shores-pediatrics\/?page_id=1882"},"modified":"2026-08-17T15:34:18","modified_gmt":"2026-08-17T19:34:18","slug":"school-forms-request","status":"publish","type":"page","link":"https:\/\/www.toplinemd.com\/shores-pediatrics\/school-forms-request\/","title":{"rendered":"School Forms Request"},"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 hundred-percent-fullwidth non-hundred-percent-height-scrolling lazyload header-img\" style=\"--awb-background-position:center top;--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-padding-bottom:0px;--awb-margin-bottom:0px;--awb-background-size:cover;--awb-flex-wrap:wrap;\" data-bg=\"https:\/\/www.toplinemd.com\/shores-pediatrics\/wp-content\/uploads\/sites\/310\/2025\/11\/Mask-group-20.png\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-center fusion-flex-justify-content-center fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;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-padding-left:3rem;--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:150px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:150px;--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%;\" data-scroll-devices=\"small-visibility,medium-visibility,large-visibility\"><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-sep-none fusion-title-center fusion-title-text fusion-title-size-one\" style=\"--awb-margin-top-small:0px;--awb-margin-right-small:0px;--awb-margin-bottom-small:20px;--awb-margin-left-small:0px;\"><h1 class=\"fusion-title-heading title-heading-center fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:48;line-height:1.21;\"><h1 style=\"color: #fff;font-size: 48px;font-weight: 400\">School Forms Request<\/h1><\/h1><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-flex-column custom-shape\" style=\"--awb-padding-bottom:0px;--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:0px;--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%;\" data-scroll-devices=\"small-visibility,medium-visibility,large-visibility\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-section-separator section-separator big-half-circle fusion-section-separator-1\" style=\"--awb-spacer-height:99px;--awb-svg-margin-left:1.92%;--awb-svg-margin-right:1.92%;--awb-svg-margin-left-medium:1.92%;--awb-svg-margin-right-medium:1.92%;--awb-svg-margin-left-small:1.92%;--awb-svg-margin-right-small:1.92%;--awb-divider-height:99px;--awb-spacer-padding-top:inherit;--awb-sep-padding:0;--awb-svg-padding:0;\"><div class=\"fusion-section-separator-svg\"><svg class=\"fusion-big-half-circle-candy\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" version=\"1.1\" width=\"100%\" height=\"100\" viewBox=\"0 0 100 100\" preserveAspectRatio=\"none\" fill=\"rgba(255,255,255,1)\"><path d=\"M0 100 C40 0 60 0 100 100 Z\"><\/path><\/svg><\/div><div class=\"fusion-section-separator-spacer\"><div class=\"fusion-section-separator-spacer-height\"><\/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-margin-bottom:100px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1289.6px;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_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_1' ><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/shores-pediatrics\/wp-json\/wp\/v2\/pages\/1882' data-formid='1' novalidate> \r\n <input type=\"hidden\" class=\"gforms-pum\" value=\"{&quot;closepopup&quot;:false,&quot;closedelay&quot;:0,&quot;openpopup&quot;:false,&quot;openpopup_id&quot;:0}\" \/>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_3\" 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\"  ><h4>Child's Name<\/h4><\/div><div id=\"field_1_6\" class=\"gfield gfield--type-text gfield--width-quarter hipaa_forms_first_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>First 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_6' id='input_1_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_7\" class=\"gfield gfield--type-text gfield--width-quarter hipaa_forms_last_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_7'>Last 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_7' id='input_1_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_8'>School 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_8' id='input_1_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_9\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Child&#039;s Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_1_9' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_9_1_container'>\n                                            <input type='number' maxlength='2' name='input_9[]' id='input_1_9_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_9_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_1_9_2_container'>\n                                            <input type='number' maxlength='2' name='input_9[]' id='input_1_9_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_9_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_1_9_3_container'>\n                                            <input type='number' maxlength='4' name='input_9[]' id='input_1_9_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_9_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_1_10\" 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\"  ><h4>Check All Forms That Are Needed ($10 Per Form)<\/h4><\/div><div id=\"field_1_13\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-quarter gfield_price gfield_price_1_13 gfield_product_1_13 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_13'>School Form (Yellow Form)<\/label><div class='ginput_container ginput_container_select'><select name='input_13' id='input_1_13' class='large gfield_select'  aria-describedby=\"gfield_description_1_13\"   aria-invalid=\"false\" ><option value='Yellow\/Blue Form - Qty: 0|0' >Yellow\/Blue Form - Qty: 0<\/option><option value='Yellow\/Blue Form - Qty: 1|10' >Yellow\/Blue Form - Qty: 1<\/option><option value='Yellow\/Blue Form - Qty: 2|20' >Yellow\/Blue Form - Qty: 2<\/option><option value='Yellow\/Blue Form - Qty: 3|30' >Yellow\/Blue Form - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_13'>Form D3040 (Yellow Form \/ Physical)<\/div><\/div><div id=\"field_1_38\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-quarter gfield_price gfield_price_1_38 gfield_product_1_38 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_38'>School Form (Blue Form)<\/label><div class='ginput_container ginput_container_select'><select name='input_38' id='input_1_38' class='large gfield_select'  aria-describedby=\"gfield_description_1_38\"   aria-invalid=\"false\" ><option value='Yellow\/Blue Form - Qty: 0|0' >Yellow\/Blue Form - Qty: 0<\/option><option value='Yellow\/Blue Form - Qty: 1|10' >Yellow\/Blue Form - Qty: 1<\/option><option value='Yellow\/Blue Form - Qty: 2|20' >Yellow\/Blue Form - Qty: 2<\/option><option value='Yellow\/Blue Form - Qty: 3|30' >Yellow\/Blue Form - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_38'>Form D680 (Blue Form \/ Vaccines)<\/div><\/div><div id=\"field_1_14\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-quarter gfield_price gfield_price_1_14 gfield_product_1_14 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'>Athletic Form<\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_1_14' class='large gfield_select'  aria-describedby=\"gfield_description_1_14\"   aria-invalid=\"false\" ><option value='Athletic Form - Qty: 0|0' >Athletic Form - Qty: 0<\/option><option value='Athletic Form - Qty: 1|10' >Athletic Form - Qty: 1<\/option><option value='Athletic Form - Qty: 2|20' >Athletic Form - Qty: 2<\/option><option value='Athletic Form - Qty: 3|30' >Athletic Form - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_14'>(Archdiocese\/Catholic Parochial School)<\/div><\/div><div id=\"field_1_15\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-quarter gfield_price gfield_price_1_15 gfield_product_1_15 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_15'>Athletic Form (All Other Schools)<\/label><div class='ginput_container ginput_container_select'><select name='input_15' id='input_1_15' class='large gfield_select'  aria-describedby=\"gfield_description_1_15\"   aria-invalid=\"false\" ><option value='Form EL2 - Qty: 0|0' >Form EL2 - Qty: 0<\/option><option value='Form EL2 - Qty: 1|10' >Form EL2 - Qty: 1<\/option><option value='Form EL2 - Qty: 2|20' >Form EL2 - Qty: 2<\/option><option value='Form EL2 - Qty: 3|30' >Form EL2 - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_15'>(Form EL2)<\/div><\/div><fieldset id=\"field_1_16\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Vaccination History (Free Of Charge)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_16'><div class='gchoice gchoice_1_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Vaccination History'  id='choice_1_16_1'   aria-describedby=\"gfield_description_1_16\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_1' id='label_1_16_1' class='gform-field-label gform-field-label--type-inline'>Vaccination History<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_16'>(NOT sufficient for SCHOOL ENTRY)<\/div><\/fieldset><div id=\"field_1_25\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>2nd Child's Name (If Applicable)<\/h4><\/div><div id=\"field_1_21\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_21'>First Name<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_1_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_22\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_22'>Last Name<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_1_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_23\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_23'>School Name<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_1_23' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_24\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Child&#039;s Date of Birth<\/legend><div id='input_1_24' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_24_1_container'>\n                                            <input type='number' maxlength='2' name='input_24[]' id='input_1_24_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_24_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_1_24_2_container'>\n                                            <input type='number' maxlength='2' name='input_24[]' id='input_1_24_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_24_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_1_24_3_container'>\n                                            <input type='number' maxlength='4' name='input_24[]' id='input_1_24_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_24_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_1_20\" 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\"  ><h4>Check All Forms That Are Needed ($10 Per Form)<\/h4><\/div><div id=\"field_1_39\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-quarter gfield_price gfield_price_1_39 gfield_product_1_39 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_39'>School Form (Yellow Form)<\/label><div class='ginput_container ginput_container_select'><select name='input_39' id='input_1_39' class='large gfield_select'  aria-describedby=\"gfield_description_1_39\"   aria-invalid=\"false\" ><option value='Yellow\/Blue Form - Qty: 0|0' >Yellow\/Blue Form - Qty: 0<\/option><option value='Yellow\/Blue Form - Qty: 1|10' >Yellow\/Blue Form - Qty: 1<\/option><option value='Yellow\/Blue Form - Qty: 2|20' >Yellow\/Blue Form - Qty: 2<\/option><option value='Yellow\/Blue Form - Qty: 3|30' >Yellow\/Blue Form - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_39'>Form D3040 (Yellow Form \/ Physical)<\/div><\/div><div id=\"field_1_40\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-quarter gfield_price gfield_price_1_40 gfield_product_1_40 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_40'>School Form (Blue Form)<\/label><div class='ginput_container ginput_container_select'><select name='input_40' id='input_1_40' class='large gfield_select'  aria-describedby=\"gfield_description_1_40\"   aria-invalid=\"false\" ><option value='Yellow\/Blue Form - Qty: 0|0' >Yellow\/Blue Form - Qty: 0<\/option><option value='Yellow\/Blue Form - Qty: 1|10' >Yellow\/Blue Form - Qty: 1<\/option><option value='Yellow\/Blue Form - Qty: 2|20' >Yellow\/Blue Form - Qty: 2<\/option><option value='Yellow\/Blue Form - Qty: 3|30' >Yellow\/Blue Form - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_40'>Form D680 (Blue Form \/ Vaccines)<\/div><\/div><div id=\"field_1_41\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-quarter gfield_price gfield_price_1_41 gfield_product_1_41 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_41'>Athletic Form<\/label><div class='ginput_container ginput_container_select'><select name='input_41' id='input_1_41' class='large gfield_select'  aria-describedby=\"gfield_description_1_41\"   aria-invalid=\"false\" ><option value='Athletic Form - Qty: 0|0' >Athletic Form - Qty: 0<\/option><option value='Athletic Form - Qty: 1|10' >Athletic Form - Qty: 1<\/option><option value='Athletic Form - Qty: 2|20' >Athletic Form - Qty: 2<\/option><option value='Athletic Form - Qty: 3|30' >Athletic Form - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_41'>(Archdiocese\/Catholic Parochial School)<\/div><\/div><div id=\"field_1_42\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-quarter gfield_price gfield_price_1_42 gfield_product_1_42 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_42'>Athletic Form (All Other Schools)<\/label><div class='ginput_container ginput_container_select'><select name='input_42' id='input_1_42' class='large gfield_select'  aria-describedby=\"gfield_description_1_42\"   aria-invalid=\"false\" ><option value='Form EL2 - Qty: 0|0' >Form EL2 - Qty: 0<\/option><option value='Form EL2 - Qty: 1|10' >Form EL2 - Qty: 1<\/option><option value='Form EL2 - Qty: 2|20' >Form EL2 - Qty: 2<\/option><option value='Form EL2 - Qty: 3|30' >Form EL2 - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_42'>(Form EL2)<\/div><\/div><fieldset id=\"field_1_29\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Vaccination History (Free Of Charge)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_29'><div class='gchoice gchoice_1_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Vaccination History'  id='choice_1_29_1'   aria-describedby=\"gfield_description_1_29\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_29_1' id='label_1_29_1' class='gform-field-label gform-field-label--type-inline'>Vaccination History<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_29'>(NOT sufficient for SCHOOL ENTRY)<\/div><\/fieldset><div id=\"field_1_31\" class=\"gfield gfield--type-text 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_1_31'>Contact Email<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_31' id='input_1_31' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_32\" 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_1_32'>Contact Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_32' id='input_1_32' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_34\" class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_34'>Delivery Method<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_34' id='input_1_34' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Email' >Email<\/option><option value='Pick Up In Person (Miami Shores)' >Pick Up In Person (Miami Shores)<\/option><\/select><\/div><\/div><div id=\"field_1_35\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-half gfield_price gfield_price_1_35 gfield_product_1_35 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_35'>Delivery Speed<\/label><div class='ginput_container ginput_container_select'><select name='input_35' id='input_1_35' class='large gfield_select'     aria-invalid=\"false\" ><option value='Standard (Ready in 5 Business Days. No Extra Cost)|0' >Standard (Ready in 5 Business Days. No Extra Cost)<\/option><option value='Rush (Ready in 2 Business Days. Adds $5 to Order|5' >Rush (Ready in 2 Business Days. Adds $5 to Order<\/option><\/select><\/div><\/div><div id=\"field_1_19\" class=\"gfield gfield--type-total gfield--width-full gfield_price gfield_price_1_ gfield_total gfield_total_1_ 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_1_19'>Total<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t\t<input type='text' readonly name='input_19' id='input_1_19' value='$0.00' class='gform-text-input-reset ginput_total ginput_total_1' \/>\n\t\t\t\t\t\t<\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' 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value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/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_1\" name=\"ak_js\" value=\"72\"\/><script>\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n<\/script>\n<\/p><\/form>\n                        <\/div><script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 1, 'https:\/\/www.toplinemd.com\/shores-pediatrics\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_1').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_1');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_1').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_1').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_1').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_1').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_1').val();gformInitSpinner( 1, 'https:\/\/www.toplinemd.com\/shores-pediatrics\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [1, current_page]);window['gf_submitting_1'] = 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_1').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [1]);window['gf_submitting_1'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_1').text());}else{jQuery('#gform_1').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"1\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_1\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_1\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_1\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 1, current_page );            if ( visibilityTestDiv ) {                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class=\"fusion-builder-row fusion-row fusion-flex-align-items-center fusion-flex-justify-content-center fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-blend:overlay;--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-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--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-text fusion-text-1\" style=\"--awb-font-size:30px;\"><h2 class=\"wh3-h2-60\" style=\"text-align: center;\">BOOK AN APPOINTMENT TODAY!<\/h2>\n<\/div><div style=\"text-align:center;\"><a class=\"fusion-button button-flat button-xlarge button-default fusion-button-default button-1 fusion-button-default-span fusion-button-default-type button-font\" style=\"--button-border-radius-top-left:14px;--button-border-radius-top-right:14px;--button-border-radius-bottom-right:14px;--button-border-radius-bottom-left:14px;--button_text_transform:uppercase;--button_typography-font-family:&quot;Libre Franklin&quot;;--button_typography-font-style:normal;--button_typography-font-weight:700;\" target=\"_self\" href=\"\/shores-pediatrics\/contact\/\"><span class=\"fusion-button-text awb-button__text awb-button__text--default\">Request an appointment<\/span><\/a><\/div><\/div><\/div><\/div><\/div>\n<\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"100-width.php","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-1882","page","type-page","status-publish","hentry"],"aioseo_notices":[],"aioseo_head":"\n\t\t<!-- All in One SEO 5.0.1.1 - aioseo.com -->\n\t<meta name=\"description\" content=\"Need school, camp, or athletic forms for your child? 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