{"id":111289,"date":"2025-07-23T22:52:00","date_gmt":"2025-07-24T05:52:00","guid":{"rendered":"https:\/\/extension.wsu.edu\/island\/?page_id=111289"},"modified":"2025-07-23T22:53:20","modified_gmt":"2025-07-24T05:53:20","slug":"wsu-4-h-incident-report-form","status":"publish","type":"page","link":"https:\/\/extension.wsu.edu\/island\/youth\/4-h-forms\/wsu-4-h-incident-report-form\/","title":{"rendered":"WSU 4-H Incident Report Form"},"content":{"rendered":"<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_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_50' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Washington State University Extension 4-H Incident Report Form<\/h2>\n                            <p class='gform_description'>Please report injuries directly to your Extension office within 48 hours. Submit this form to the county 4-H Extension Office within seven (7) days of the incident. Complete one form for each person involved. Also include any photographs, news clips, police reports, etc.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_50'  action='\/island\/wp-json\/wp\/v2\/pages\/111289' data-formid='50' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_50' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_50_1\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_1\"><h3 class=\"gsection_title\">EVENT INFORMATION<\/h3><\/div><div id=\"field_50_3\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_3\"><label class='gfield_label gform-field-label' for='input_50_3' >Name of 4-H Sponsored Event:<\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_50_3' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_50_4\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_4\"><label class='gfield_label gform-field-label' for='input_50_4' >Date(s) of Event:<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_50_4' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_50_5\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_5\"><label class='gfield_label gform-field-label' for='input_50_5' >Location of Event\/Address:<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_50_5' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_50_6\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_6\"><h3 class=\"gsection_title\">PERSON INVOLVED IN INCIDENT<\/h3><\/div><fieldset id=\"field_50_8\"  class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_8\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_50_8'>\n                            \n                            <span id='input_50_8_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.3' id='input_50_8_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_50_8_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_50_8_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.6' id='input_50_8_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_50_8_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_50_9\"  class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_9\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_50_9' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_50_9_1_container' >\n                                        <input type='text' name='input_9.1' id='input_50_9_1' value=''    aria-required='false'    \/>\n                                        <label for='input_50_9_1' id='input_50_9_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_50_9_2_container' >\n                                        <input type='text' name='input_9.2' id='input_50_9_2' value=''     aria-required='false'   \/>\n                                        <label for='input_50_9_2' id='input_50_9_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_50_9_3_container' >\n                                    <input type='text' name='input_9.3' id='input_50_9_3' value=''    aria-required='false'    \/>\n                                    <label for='input_50_9_3' id='input_50_9_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_50_9_4_container' >\n                                        <select name='input_9.4' id='input_50_9_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_50_9_4' id='input_50_9_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_50_9_5_container' >\n                                    <input type='text' name='input_9.5' id='input_50_9_5' value=''    aria-required='false'    \/>\n                                    <label for='input_50_9_5' id='input_50_9_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_9.6' id='input_50_9_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_50_10\"  class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_10\"><label class='gfield_label gform-field-label' for='input_50_10' >Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_50_10' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_50_11\"  class=\"gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_11\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Email<\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_50_11_container'>\n                                <span id='input_50_11_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_11' id='input_50_11' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_50_11' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_50_11_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_11_2' id='input_50_11_2' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_50_11_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><fieldset id=\"field_50_12\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_12\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Date of Birth<\/legend><div id='input_50_12' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_50_12_1_container'>\n                                            <input type='number'  name='input_12[]' id='input_50_12_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_50_12_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_50_12_2_container'>\n                                            <input type='number'  name='input_12[]' id='input_50_12_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_50_12_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_50_12_3_container'>\n                                            <input type='number'  name='input_12[]' id='input_50_12_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_50_12_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_50_13\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_13\"><legend class='gfield_label gform-field-label'  >Status at Event<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_50_13'>\n\t\t\t<div class='gchoice gchoice_50_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Enrolled 4-H Member'  id='choice_50_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_13_0' id='label_50_13_0' class='gform-field-label gform-field-label--type-inline'>Enrolled 4-H Member<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_50_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Non-Enrolled Member'  id='choice_50_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_13_1' id='label_50_13_1' class='gform-field-label gform-field-label--type-inline'>Non-Enrolled Member<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_50_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Active 4-H Leader'  id='choice_50_13_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_13_2' id='label_50_13_2' class='gform-field-label gform-field-label--type-inline'>Active 4-H Leader<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_50_13_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Parent'  id='choice_50_13_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_13_3' id='label_50_13_3' class='gform-field-label gform-field-label--type-inline'>Parent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_50_13_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Public'  id='choice_50_13_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_13_4' id='label_50_13_4' class='gform-field-label gform-field-label--type-inline'>Public<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_50_14\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_14\"><h3 class=\"gsection_title\">DATE AND TIME OF INCIDENT<\/h3><\/div><fieldset id=\"field_50_15\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_15\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Date<\/legend><div id='input_50_15' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_50_15_1_container'>\n                                            <input type='number'  name='input_15[]' id='input_50_15_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_50_15_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_50_15_2_container'>\n                                            <input type='number'  name='input_15[]' id='input_50_15_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_50_15_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_50_15_3_container'>\n                                            <input type='number'  name='input_15[]' id='input_50_15_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_50_15_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_50_16\"  class=\"gfield gfield--type-time gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_16\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Time<\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_50_16'>\n                            <input type='number' maxlength='2' name='input_16[]' id='input_50_16_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='false'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_50_16_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' maxlength='2' name='input_16[]' id='input_50_16_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_50_16_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_16[]' id='input_50_16_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_50_16_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><fieldset id=\"field_50_17\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_17\"><legend class='gfield_label gform-field-label'  >TYPE OF INCIDENT<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_50_17'>\n\t\t\t<div class='gchoice gchoice_50_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Behavioral'  id='choice_50_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_17_0' id='label_50_17_0' class='gform-field-label gform-field-label--type-inline'>Behavioral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_50_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Accident'  id='choice_50_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_17_1' id='label_50_17_1' class='gform-field-label gform-field-label--type-inline'>Accident<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_50_17_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Illness'  id='choice_50_17_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_17_2' id='label_50_17_2' class='gform-field-label gform-field-label--type-inline'>Illness<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_50_17_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Other'  id='choice_50_17_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_17_3' id='label_50_17_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_50_18\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_18\"><h3 class=\"gsection_title\">INITIAL REPORTING<\/h3><\/div><div id=\"field_50_19\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_19\"><label class='gfield_label gform-field-label' for='input_50_19' >Emergency Reported to<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_50_19' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_50_20\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_20\"><label class='gfield_label gform-field-label' for='input_50_20' >by way of<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_50_20' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_50_21\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_21\"><label class='gfield_label gform-field-label' for='input_50_21' >Extension\/Staff or Volunteer in charge at time of incident:<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_50_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_50_22\"  class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_22\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_50_22'>\n                            \n                            <span id='input_50_22_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_22.3' id='input_50_22_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_50_22_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_50_22_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_22.6' id='input_50_22_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_50_22_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_50_23\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_23\"><label class='gfield_label gform-field-label' for='input_50_23' >Role<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_50_23' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_50_24\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_24\"><label class='gfield_label gform-field-label' for='input_50_24' >Name of Parent\/Guardian<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_50_24' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_50_25\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_25\"><legend class='gfield_label gform-field-label'  >Was the parent notified?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_50_25'>\n\t\t\t<div class='gchoice gchoice_50_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Yes'  id='choice_50_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_25_0' id='label_50_25_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_50_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_50_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_25_1' id='label_50_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_50_25_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='N\/A'  id='choice_50_25_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_25_2' id='label_50_25_2' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_50_26\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_26\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Date<\/legend><div id='input_50_26' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_50_26_1_container'>\n                                            <input type='number'  name='input_26[]' id='input_50_26_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_50_26_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_50_26_2_container'>\n                                            <input type='number'  name='input_26[]' id='input_50_26_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_50_26_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_50_26_3_container'>\n                                            <input type='number'  name='input_26[]' id='input_50_26_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_50_26_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_50_27\"  class=\"gfield gfield--type-time gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_27\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Time<\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_50_27'>\n                            <input type='number' maxlength='2' name='input_27[]' id='input_50_27_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='false'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_50_27_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' maxlength='2' name='input_27[]' id='input_50_27_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_50_27_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_27[]' id='input_50_27_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_50_27_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><div id=\"field_50_28\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_28\"><label class='gfield_label gform-field-label' for='input_50_28' >By whom?<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_50_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_50_30\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_30\"><label class='gfield_label gform-field-label' for='input_50_30' >Name of Emergency Contact<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_50_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_50_29\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_29\"><legend class='gfield_label gform-field-label'  >Was the Emergency Contact Notified?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_50_29'>\n\t\t\t<div class='gchoice gchoice_50_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_50_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_29_0' id='label_50_29_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_50_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_50_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_29_1' id='label_50_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_50_29_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='N\/A'  id='choice_50_29_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_29_2' id='label_50_29_2' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_50_31\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_31\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Date<\/legend><div id='input_50_31' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_50_31_1_container'>\n                                            <input type='number'  name='input_31[]' id='input_50_31_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_50_31_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_50_31_2_container'>\n                                            <input type='number'  name='input_31[]' id='input_50_31_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_50_31_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_50_31_3_container'>\n                                            <input type='number'  name='input_31[]' id='input_50_31_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_50_31_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_50_32\"  class=\"gfield gfield--type-time gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_32\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Time<\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_50_32'>\n                            <input type='number' maxlength='2' name='input_32[]' id='input_50_32_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='false'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_50_32_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' maxlength='2' name='input_32[]' id='input_50_32_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_50_32_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_32[]' id='input_50_32_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_50_32_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><div id=\"field_50_33\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_33\"><label class='gfield_label gform-field-label' for='input_50_33' >by whom?<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_50_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_50_35\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_35\"><legend class='gfield_label gform-field-label'  >TYPE OF MEDICAL CARE RECEIVED<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_50_35'>\n\t\t\t<div class='gchoice gchoice_50_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='First Response'  id='choice_50_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_35_0' id='label_50_35_0' class='gform-field-label gform-field-label--type-inline'>First Response<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_50_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Ambulance'  id='choice_50_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_35_1' id='label_50_35_1' class='gform-field-label gform-field-label--type-inline'>Ambulance<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_50_35_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Emergency'  id='choice_50_35_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_35_2' id='label_50_35_2' class='gform-field-label gform-field-label--type-inline'>Emergency<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_50_35_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Hospital'  id='choice_50_35_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_35_3' id='label_50_35_3' class='gform-field-label gform-field-label--type-inline'>Hospital<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_50_35_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='N\/A'  id='choice_50_35_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_35_4' id='label_50_35_4' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_50_36\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_36\"><label class='gfield_label gform-field-label' for='input_50_36' >Adult(s) On the Scene?<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_50_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_50_37\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_37\"><label class='gfield_label gform-field-label' for='input_50_37' >Adults Rendering Aid?<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_50_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_50_39\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_39\"><h3 class=\"gsection_title\">Witness #1<\/h3><\/div><fieldset id=\"field_50_40\"  class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_40\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_50_40'>\n                            \n                            <span id='input_50_40_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_40.3' id='input_50_40_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_50_40_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_50_40_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_40.6' id='input_50_40_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_50_40_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_50_41\"  class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_41\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_50_41' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_50_41_1_container' >\n                                        <input type='text' name='input_41.1' id='input_50_41_1' value=''    aria-required='false'    \/>\n                                        <label for='input_50_41_1' id='input_50_41_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_50_41_2_container' >\n                                        <input type='text' name='input_41.2' id='input_50_41_2' value=''     aria-required='false'   \/>\n                                        <label for='input_50_41_2' id='input_50_41_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_50_41_3_container' >\n                                    <input type='text' name='input_41.3' id='input_50_41_3' value=''    aria-required='false'    \/>\n                                    <label for='input_50_41_3' id='input_50_41_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_50_41_4_container' >\n                                        <select name='input_41.4' id='input_50_41_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_50_41_4' id='input_50_41_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_50_41_5_container' >\n                                    <input type='text' name='input_41.5' id='input_50_41_5' value=''    aria-required='false'    \/>\n                                    <label for='input_50_41_5' id='input_50_41_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_41.6' id='input_50_41_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_50_42\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_42\"><label class='gfield_label gform-field-label' for='input_50_42' >Where located at time of incident?<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_50_42' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_50_43\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_43\"><h3 class=\"gsection_title\">Witness #2<\/h3><\/div><fieldset id=\"field_50_45\"  class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_45\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_50_45'>\n                            \n                            <span id='input_50_45_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_45.3' id='input_50_45_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_50_45_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_50_45_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_45.6' id='input_50_45_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_50_45_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_50_44\"  class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_44\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_50_44' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_50_44_1_container' >\n                                        <input type='text' name='input_44.1' id='input_50_44_1' value=''    aria-required='false'    \/>\n                                        <label for='input_50_44_1' id='input_50_44_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_50_44_2_container' >\n                                        <input type='text' name='input_44.2' id='input_50_44_2' value=''     aria-required='false'   \/>\n                                        <label for='input_50_44_2' id='input_50_44_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_50_44_3_container' >\n                                    <input type='text' name='input_44.3' id='input_50_44_3' value=''    aria-required='false'    \/>\n                                    <label for='input_50_44_3' id='input_50_44_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_50_44_4_container' >\n                                        <select name='input_44.4' id='input_50_44_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_50_44_4' id='input_50_44_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_50_44_5_container' >\n                                    <input type='text' name='input_44.5' id='input_50_44_5' value=''    aria-required='false'    \/>\n                                    <label for='input_50_44_5' id='input_50_44_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_44.6' id='input_50_44_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_50_46\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_46\"><label class='gfield_label gform-field-label' for='input_50_46' >Where located at time of incident?<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_50_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_50_47\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_47\"><h3 class=\"gsection_title\">Witness #3<\/h3><\/div><fieldset id=\"field_50_48\"  class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_48\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_50_48'>\n                            \n                            <span id='input_50_48_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_48.3' id='input_50_48_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_50_48_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_50_48_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_48.6' id='input_50_48_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_50_48_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_50_49\"  class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_49\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_50_49' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_50_49_1_container' >\n                                        <input type='text' name='input_49.1' id='input_50_49_1' value=''    aria-required='false'    \/>\n                                        <label for='input_50_49_1' id='input_50_49_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_50_49_2_container' >\n                                        <input type='text' name='input_49.2' id='input_50_49_2' value=''     aria-required='false'   \/>\n                                        <label for='input_50_49_2' id='input_50_49_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_50_49_3_container' >\n                                    <input type='text' name='input_49.3' id='input_50_49_3' value=''    aria-required='false'    \/>\n                                    <label for='input_50_49_3' id='input_50_49_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_50_49_4_container' >\n                                        <select name='input_49.4' id='input_50_49_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_50_49_4' id='input_50_49_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_50_49_5_container' >\n                                    <input type='text' name='input_49.5' id='input_50_49_5' value=''    aria-required='false'    \/>\n                                    <label for='input_50_49_5' id='input_50_49_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_49.6' id='input_50_49_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_50_50\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_50\"><label class='gfield_label gform-field-label' for='input_50_50' >Where located at time of incident?<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_50_50' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_50_51\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_51\"><h3 class=\"gsection_title\">DESCRIPTION OF INCIDENT<\/h3><\/div><div id=\"field_50_54\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_54\"><label class='gfield_label gform-field-label' for='input_50_54' >1. Sequence of Activities: (e.g. at the beginning of the club meeting, during leisure time, after the workshop). What led up to the incident?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_54' id='input_50_54' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_50_53\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_53\"><label class='gfield_label gform-field-label' for='input_50_53' >2. Location: Where did the accident occur in the space? Where were the other participants\/leaders?  A diagram may be helpful.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_53' id='input_50_53' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_50_60\"  class=\"gfield gfield--type-post_image gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_60\"><legend class='gfield_label gform-field-label'  >Add a diagram or image below (if applicable)<\/legend><div class='ginput_complex ginput_container ginput_container_post_image gform-grid-row'><span class='ginput_full gform-grid-col'><input name='input_60' id='input_50_60' type='file' class='large'   aria-invalid=\"false\" aria-describedby=\"extensions_message_50_60\" \/><span id='extensions_message_50_60' class='gfield_description gform_fileupload_rules'>Accepted file types: jpg, jpeg, png, gif.<\/span><label for='input_50_60' class='gform-field-label gform-field-label--type-sub ginput_post_image_file' >File<\/label><\/span><span class='ginput_full ginput_post_image_alt gform-grid-col' ><input type='text' name='input_60.2' id='input_50_60_2' value=''  \/><label for='input_50_60_2' class='gform-field-label gform-field-label--type-sub'>Alternative Text<\/label><\/span><span class='ginput_full ginput_post_image_title gform-grid-col' ><input type='text' name='input_60.1' id='input_50_60_1' value=''  \/><label for='input_50_60_1' class='gform-field-label gform-field-label--type-sub'>Title<\/label><\/span><span class='ginput_full ginput_post_image_description gform-grid-col' ><input type='text' name='input_60.7' id='input_50_60_7' value=''  \/><label for='input_50_60_7' class='gform-field-label gform-field-label--type-sub'>Description<\/label><\/span><\/div><\/fieldset><div id=\"field_50_55\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_55\"><label class='gfield_label gform-field-label' for='input_50_55' >3. Exactly what was the person doing and how did the incident occur? What was going on? Who was involved?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_55' id='input_50_55' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_50_56\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_56\"><label class='gfield_label gform-field-label' for='input_50_56' >4. What steps could have been taken to prevent the incident or minimize the impact of the incident?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_56' id='input_50_56' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_50_57\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_57\"><label class='gfield_label gform-field-label' for='input_50_57' >5. Action taken at the time of incident:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_57' id='input_50_57' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_50_58\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_58\"><label class='gfield_label gform-field-label' for='input_50_58' >6. Action(s) taken as a follow-up to the incident (if applicable):<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_58' id='input_50_58' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_50_59\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_59\"><legend class='gfield_label gform-field-label'  >Follow-Up Report Needed?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_50_59'>\n\t\t\t<div class='gchoice gchoice_50_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Yes'  id='choice_50_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_59_0' id='label_50_59_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_50_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='No'  id='choice_50_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_50_59_1' id='label_50_59_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_50_61\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_61\"><h3 class=\"gsection_title\">Signatures: Person(s) Completing All or Part of the Report:<\/h3><\/div><fieldset id=\"field_50_62\"  class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_62\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Name #1<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_50_62'>\n                            \n                            <span id='input_50_62_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_62.3' id='input_50_62_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_50_62_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_50_62_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_62.6' id='input_50_62_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_50_62_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_50_63\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_63\"><label class='gfield_label gform-field-label' for='input_50_63' >Signature #1<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_50_63' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_50_64\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_64\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Date<\/legend><div id='input_50_64' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_50_64_1_container'>\n                                            <input type='number'  name='input_64[]' id='input_50_64_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_50_64_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_50_64_2_container'>\n                                            <input type='number'  name='input_64[]' id='input_50_64_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_50_64_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_50_64_3_container'>\n                                            <input type='number'  name='input_64[]' id='input_50_64_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_50_64_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_50_65\"  class=\"gfield gfield--type-time gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_65\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Time<\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_50_65'>\n                            <input type='number' maxlength='2' name='input_65[]' id='input_50_65_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='false'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_50_65_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' maxlength='2' name='input_65[]' id='input_50_65_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_50_65_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_65[]' id='input_50_65_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_50_65_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><fieldset id=\"field_50_66\"  class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_66\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Name #2<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_50_66'>\n                            \n                            <span id='input_50_66_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_66.3' id='input_50_66_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_50_66_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_50_66_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_66.6' id='input_50_66_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_50_66_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_50_67\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_67\"><label class='gfield_label gform-field-label' for='input_50_67' >Signature #2<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_50_67' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_50_68\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_68\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Date<\/legend><div id='input_50_68' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_50_68_1_container'>\n                                            <input type='number'  name='input_68[]' id='input_50_68_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_50_68_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_50_68_2_container'>\n                                            <input type='number'  name='input_68[]' id='input_50_68_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_50_68_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_50_68_3_container'>\n                                            <input type='number'  name='input_68[]' id='input_50_68_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_50_68_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_50_69\"  class=\"gfield gfield--type-time gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_69\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Time<\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_50_69'>\n                            <input type='number' maxlength='2' name='input_69[]' id='input_50_69_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='false'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_50_69_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' maxlength='2' name='input_69[]' id='input_50_69_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_50_69_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_69[]' id='input_50_69_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_50_69_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><fieldset id=\"field_50_70\"  class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_70\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Name #3<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_50_70'>\n                            \n                            <span id='input_50_70_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_70.3' id='input_50_70_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_50_70_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_50_70_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_70.6' id='input_50_70_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_50_70_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_50_71\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_71\"><label class='gfield_label gform-field-label' for='input_50_71' >Signature #3<\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_50_71' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_50_72\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_72\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Date<\/legend><div id='input_50_72' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_50_72_1_container'>\n                                            <input type='number'  name='input_72[]' id='input_50_72_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_50_72_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_50_72_2_container'>\n                                            <input type='number'  name='input_72[]' id='input_50_72_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_50_72_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_50_72_3_container'>\n                                            <input type='number'  name='input_72[]' id='input_50_72_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_50_72_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_50_73\"  class=\"gfield gfield--type-time gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_73\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Time<\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_50_73'>\n                            <input type='number' maxlength='2' name='input_73[]' id='input_50_73_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='false'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_50_73_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' maxlength='2' name='input_73[]' id='input_50_73_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_50_73_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_73[]' id='input_50_73_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_50_73_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><div id=\"field_50_74\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_74\"><h3 class=\"gsection_title\">4-H Faculty and\/or Staff<\/h3><\/div><fieldset id=\"field_50_75\"  class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_75\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_50_75'>\n                            \n                            <span id='input_50_75_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_75.3' id='input_50_75_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_50_75_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_50_75_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_75.6' id='input_50_75_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_50_75_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_50_76\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_76\"><label class='gfield_label gform-field-label' for='input_50_76' >Signature<\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_50_76' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_50_77\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_50_77\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Date<\/legend><div id='input_50_77' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_50_77_1_container'>\n                                            <input type='number'  name='input_77[]' id='input_50_77_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_50_77_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_50_77_2_container'>\n                                            <input type='number'  name='input_77[]' id='input_50_77_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_50_77_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_50_77_3_container'>\n                                            <input type='number'  name='input_77[]' id='input_50_77_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_50_77_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_50_78\"  class=\"gfield gfield--type-time gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  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min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_50_78_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_78[]' id='input_50_78_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_50_78_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><\/div><\/div>\n        <div class='gform_footer 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