{"id":950,"date":"2014-11-17T21:39:14","date_gmt":"2014-11-17T21:39:14","guid":{"rendered":"http:\/\/projecthomelessconnect.org\/staging\/?page_id=950"},"modified":"2018-12-28T22:52:05","modified_gmt":"2018-12-29T06:52:05","slug":"assistance","status":"publish","type":"page","link":"https:\/\/projecthomelessconnect.org\/staging\/programs\/assistance\/","title":{"rendered":"Information Request Form"},"content":{"rendered":"<p><strong>Contact us for assistance by completing the form below.<\/strong><\/p>\n<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_3' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/staging\/wp-json\/wp\/v2\/pages\/950' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_1'>\n                            \n                            <span id='input_3_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_3_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_3_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_3_19\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>How would you like us to get in touch with you? 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id='input_3_3' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_3_4\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>What three main services do you need information about?<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_4'><li class='gchoice gchoice_3_4_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.1' type='checkbox'  value='Benefits - Medi-Cal, Food stamps (Cal-Fresh), General Assistance (GA), SSI or SSDI.'  id='choice_3_4_1'   aria-describedby=\"gfield_description_3_4\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_4_1' id='label_3_4_1' class='gform-field-label gform-field-label--type-inline'>Benefits - Medi-Cal, Food stamps (Cal-Fresh), General Assistance (GA), SSI or SSDI.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_4_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.2' type='checkbox'  value='Dental care - General and dentures'  id='choice_3_4_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_4_2' id='label_3_4_2' class='gform-field-label gform-field-label--type-inline'>Dental care - General and dentures<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_4_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.3' type='checkbox'  value='DMV Identification card'  id='choice_3_4_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_4_3' id='label_3_4_3' class='gform-field-label gform-field-label--type-inline'>DMV Identification card<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_4_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.4' type='checkbox'  value='Shelter Information'  id='choice_3_4_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_4_4' id='label_3_4_4' class='gform-field-label gform-field-label--type-inline'>Shelter Information<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_4_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.5' type='checkbox'  value='Coordinated Entry'  id='choice_3_4_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_4_5' id='label_3_4_5' class='gform-field-label gform-field-label--type-inline'>Coordinated Entry<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_4_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.6' type='checkbox'  value='Food Resources'  id='choice_3_4_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_4_6' id='label_3_4_6' class='gform-field-label gform-field-label--type-inline'>Food Resources<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_4_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.7' type='checkbox'  value='Clothing'  id='choice_3_4_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_4_7' id='label_3_4_7' class='gform-field-label gform-field-label--type-inline'>Clothing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_4_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.8' type='checkbox'  value='Personal hygiene items'  id='choice_3_4_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_4_8' id='label_3_4_8' class='gform-field-label gform-field-label--type-inline'>Personal hygiene items<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_4_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.9' type='checkbox'  value='Prescription and reading glasses'  id='choice_3_4_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_4_9' id='label_3_4_9' class='gform-field-label gform-field-label--type-inline'>Prescription and reading glasses<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice 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