{"id":356,"date":"2026-08-18T15:40:24","date_gmt":"2026-08-18T15:40:24","guid":{"rendered":"https:\/\/www.palomar.edu\/basicneeds\/?page_id=356"},"modified":"2026-08-20T22:00:27","modified_gmt":"2026-08-20T22:00:27","slug":"basic-needs-intake-form","status":"publish","type":"page","link":"https:\/\/www.palomar.edu\/basicneeds\/basic-needs-intake-form\/","title":{"rendered":"Basic Needs Intake Form"},"content":{"rendered":"\n<p>Before you begin:<br>Use this form to connect with Palomar College Basic Needs for help with food, housing, transportation, financial hardship, hygiene, utilities, technology, childcare, and other essential needs. Submitting this form does not guarantee financial assistance. A Basic Needs team member will review your request and follow up with you.<\/p>\n\n\n\n<p>Immediate Emergencies:<br>This form is not monitored as an emergency-response system. If you or someone else is in immediate danger, call 911 or contact the appropriate emergency-response resource.<\/p>\n\n\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 InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-btn-bg-color-hover-tertiary: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Basic Needs Intake &#038; Resource Connection Form<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/basicneeds\/wp-json\/wp\/v2\/pages\/356' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_above description_above validation_above'><div id=\"field_2_6\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">About You<\/h3><\/div><fieldset id=\"field_2_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you currently a student at Palomar College?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_10'>\n\t\t\t<div class='gchoice gchoice_2_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='I am a student'  id='choice_2_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_10_0' id='label_2_10_0' class='gform-field-label gform-field-label--type-inline'>I am a student<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='I am not a student'  id='choice_2_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_10_1' id='label_2_10_1' class='gform-field-label gform-field-label--type-inline'>I am not a student<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_10_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='I don&#039;t know'  id='choice_2_10_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_10_2' id='label_2_10_2' class='gform-field-label gform-field-label--type-inline'>I don&#8217;t know<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_61\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you currently a student at Palomar College?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_61'>\n\t\t\t<div class='gchoice gchoice_2_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='I am a student'  id='choice_2_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_61_0' id='label_2_61_0' class='gform-field-label gform-field-label--type-inline'>I am a student<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='I am not a student'  id='choice_2_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_61_1' id='label_2_61_1' class='gform-field-label gform-field-label--type-inline'>I am not a student<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_61_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='I don&#039;t know'  id='choice_2_61_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_61_2' id='label_2_61_2' class='gform-field-label gform-field-label--type-inline'>I don&#8217;t know<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_7\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend 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_text\">(Required)<\/span><\/span><\/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_2_7'>\n                            \n                            <span id='input_2_7_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_2_7_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_7.3' id='input_2_7_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_2_7_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_2_7_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_7.6' id='input_2_7_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_9\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_9'><span class='gform-field-label__text'>Preferred\/Chosen Name (Optional)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_2_9' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_18\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_18'><span class='gform-field-label__text'>Pronouns (Optional)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_2_18' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_11\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_11'><span class='gform-field-label__text'>Palomar Student ID<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_2_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_12\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_12'><span class='gform-field-label__text'>Palomar Student Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_2_12' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_20\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_20'><span class='gform-field-label__text'>Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_20' id='input_2_20' type='tel' value='' class='large'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><fieldset id=\"field_2_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Preferred contact method<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_16'><div class='gchoice gchoice_2_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Palomar E-mail'  id='choice_2_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_1' id='label_2_16_1' class='gform-field-label gform-field-label--type-inline'>Palomar E-mail<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Phone Call'  id='choice_2_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_2' id='label_2_16_2' class='gform-field-label gform-field-label--type-inline'>Phone Call<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_17\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_17'><span class='gform-field-label__text'>Preferred Language<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_2_17' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_19\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Enrollment &amp; Academic Connection<\/h3><\/div><fieldset id=\"field_2_22\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Primary Campus \/ Center<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_22'><div class='gchoice gchoice_2_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='San Marcos'  id='choice_2_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_1' id='label_2_22_1' class='gform-field-label gform-field-label--type-inline'>San Marcos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value='Escondido'  id='choice_2_22_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_2' id='label_2_22_2' class='gform-field-label gform-field-label--type-inline'>Escondido<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.3' type='checkbox'  value='Rancho Bernardo'  id='choice_2_22_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_3' id='label_2_22_3' class='gform-field-label gform-field-label--type-inline'>Rancho Bernardo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.4' type='checkbox'  value='Fallbrook'  id='choice_2_22_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_4' id='label_2_22_4' class='gform-field-label gform-field-label--type-inline'>Fallbrook<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.5' type='checkbox'  value='Online\/Other'  id='choice_2_22_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_5' id='label_2_22_5' class='gform-field-label gform-field-label--type-inline'>Online\/Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Do you currently have an education plan on file?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_23'><div class='gchoice gchoice_2_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Yes'  id='choice_2_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_1' id='label_2_23_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='No'  id='choice_2_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_2' id='label_2_23_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_23_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.3' type='checkbox'  value='Unsure'  id='choice_2_23_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_3' id='label_2_23_3' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col_vertical gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Are you connected to any campus programs?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_24'><div class='gchoice gchoice_2_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='EOPs\/Foster Youth\/CalWORKSs'  id='choice_2_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_1' id='label_2_24_1' class='gform-field-label gform-field-label--type-inline'>EOPs\/Foster Youth\/CalWORKSs<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='DSPS'  id='choice_2_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_2' id='label_2_24_2' class='gform-field-label gform-field-label--type-inline'>DSPS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='Veterans'  id='choice_2_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_3' id='label_2_24_3' class='gform-field-label gform-field-label--type-inline'>Veterans<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.4' type='checkbox'  value='Rising Scholars'  id='choice_2_24_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_4' id='label_2_24_4' class='gform-field-label gform-field-label--type-inline'>Rising Scholars<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.5' type='checkbox'  value='Pride Center'  id='choice_2_24_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_5' id='label_2_24_5' class='gform-field-label gform-field-label--type-inline'>Pride Center<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.6' type='checkbox'  value='NSPIRE'  id='choice_2_24_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_6' id='label_2_24_6' class='gform-field-label gform-field-label--type-inline'>NSPIRE<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.7' type='checkbox'  value='Puente'  id='choice_2_24_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_7' id='label_2_24_7' class='gform-field-label gform-field-label--type-inline'>Puente<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.8' type='checkbox'  value='Umoja'  id='choice_2_24_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_8' id='label_2_24_8' class='gform-field-label gform-field-label--type-inline'>Umoja<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.9' type='checkbox'  value='TRIO NCEOC'  id='choice_2_24_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_9' id='label_2_24_9' class='gform-field-label gform-field-label--type-inline'>TRIO NCEOC<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.11' type='checkbox'  value='TRIO SSS'  id='choice_2_24_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_11' id='label_2_24_11' class='gform-field-label gform-field-label--type-inline'>TRIO SSS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.12' type='checkbox'  value='None\/Unsure'  id='choice_2_24_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_12' id='label_2_24_12' class='gform-field-label gform-field-label--type-inline'>None\/Unsure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.13' type='checkbox'  value='Other'  id='choice_2_24_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_13' id='label_2_24_13' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_26\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">What Support Are You Looking For?<\/h3><\/div><fieldset id=\"field_2_27\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col_vertical gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Check all that apply?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_27'><div class='gchoice gchoice_2_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='Food\/Groceries'  id='choice_2_27_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_1' id='label_2_27_1' class='gform-field-label gform-field-label--type-inline'>Food\/Groceries<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='Housing\/Shelter'  id='choice_2_27_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_2' id='label_2_27_2' class='gform-field-label gform-field-label--type-inline'>Housing\/Shelter<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_27_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.3' type='checkbox'  value='Rent\/Deposit'  id='choice_2_27_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_3' id='label_2_27_3' class='gform-field-label gform-field-label--type-inline'>Rent\/Deposit<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_27_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.4' type='checkbox'  value='Utilities'  id='choice_2_27_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_4' id='label_2_27_4' class='gform-field-label gform-field-label--type-inline'>Utilities<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_27_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.5' type='checkbox'  value='Transportation'  id='choice_2_27_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_5' id='label_2_27_5' class='gform-field-label gform-field-label--type-inline'>Transportation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_27_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.6' type='checkbox'  value='Vehicle repair'  id='choice_2_27_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_6' id='label_2_27_6' class='gform-field-label gform-field-label--type-inline'>Vehicle repair<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_27_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.7' type='checkbox'  value='Hygiene\/personal care'  id='choice_2_27_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_7' id='label_2_27_7' class='gform-field-label gform-field-label--type-inline'>Hygiene\/personal care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_27_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.8' type='checkbox'  value='Clothing'  id='choice_2_27_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_8' id='label_2_27_8' class='gform-field-label gform-field-label--type-inline'>Clothing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_27_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.9' type='checkbox'  value='Child\/Dependent care'  id='choice_2_27_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_9' id='label_2_27_9' class='gform-field-label gform-field-label--type-inline'>Child\/Dependent care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_27_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.11' type='checkbox'  value='Technology'  id='choice_2_27_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_11' id='label_2_27_11' class='gform-field-label gform-field-label--type-inline'>Technology<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_27_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.12' type='checkbox'  value='Health-related costs'  id='choice_2_27_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_12' id='label_2_27_12' class='gform-field-label gform-field-label--type-inline'>Health-related costs<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_27_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.13' type='checkbox'  value='Employment\/Income concern'  id='choice_2_27_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_13' id='label_2_27_13' class='gform-field-label gform-field-label--type-inline'>Employment\/Income concern<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_27_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.14' type='checkbox'  value='Financial Assitance'  id='choice_2_27_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_14' id='label_2_27_14' class='gform-field-label gform-field-label--type-inline'>Financial Assitance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_27_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.15' type='checkbox'  value='Other'  id='choice_2_27_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_15' id='label_2_27_15' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_28\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_28'><span class='gform-field-label__text'>Which need is more urgent right now?<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_2_28' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_29\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Urgency<\/h3><\/div><fieldset id=\"field_2_30\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col_vertical gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Do any of these apply right now?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_30'><div class='gchoice gchoice_2_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='I do not have a safe place to stay tonight'  id='choice_2_30_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_1' id='label_2_30_1' class='gform-field-label gform-field-label--type-inline'>I do not have a safe place to stay tonight<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='I may lose my housing soon'  id='choice_2_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_2' id='label_2_30_2' class='gform-field-label gform-field-label--type-inline'>I may lose my housing soon<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.3' type='checkbox'  value='I received an eviction\/pay-or-quit notice'  id='choice_2_30_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_3' id='label_2_30_3' class='gform-field-label gform-field-label--type-inline'>I received an eviction\/pay-or-quit notice<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.4' type='checkbox'  value='My utilities may be shut off'  id='choice_2_30_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_4' id='label_2_30_4' class='gform-field-label gform-field-label--type-inline'>My utilities may be shut off<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.5' type='checkbox'  value='I do not have enough food for the next few days'  id='choice_2_30_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_5' id='label_2_30_5' class='gform-field-label gform-field-label--type-inline'>I do not have enough food for the next few days<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.6' type='checkbox'  value='Transportation is preventing me from attending class\/work'  id='choice_2_30_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_6' id='label_2_30_6' class='gform-field-label gform-field-label--type-inline'>Transportation is preventing me from attending class\/work<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.7' type='checkbox'  value='Another urgent concern'  id='choice_2_30_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_7' id='label_2_30_7' class='gform-field-label gform-field-label--type-inline'>Another urgent concern<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.8' type='checkbox'  value='None of these'  id='choice_2_30_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_8' id='label_2_30_8' class='gform-field-label gform-field-label--type-inline'>None of these<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_31\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Tell Us What is Happening<\/h3><\/div><div id=\"field_2_32\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_32'><span class='gform-field-label__text'>In a few sentences, what has recently come up or changed?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_2_32' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_33\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_33'><span class='gform-field-label__text'>When did the situation begin or change?<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_33' id='input_2_33' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_34\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_34'><span class='gform-field-label__text'>How is this affecting your ability to attend class, complete coursework, work, or stay enrolled?<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_2_34' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_35\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Housing &amp; Household<\/h3><\/div><fieldset id=\"field_2_36\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col_vertical gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Current Housing situation<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_36'><div class='gchoice gchoice_2_36_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.1' type='checkbox'  value='Stable Housing'  id='choice_2_36_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_1' id='label_2_36_1' class='gform-field-label gform-field-label--type-inline'>Stable Housing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_36_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.2' type='checkbox'  value='Staying temporarily with others'  id='choice_2_36_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_2' id='label_2_36_2' class='gform-field-label gform-field-label--type-inline'>Staying temporarily with others<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_36_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.3' type='checkbox'  value='Hotel\/Motel'  id='choice_2_36_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_3' id='label_2_36_3' class='gform-field-label gform-field-label--type-inline'>Hotel\/Motel<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_36_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.4' type='checkbox'  value='Shelter\/Transitional Housing'  id='choice_2_36_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_4' id='label_2_36_4' class='gform-field-label gform-field-label--type-inline'>Shelter\/Transitional Housing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_36_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.5' type='checkbox'  value='Vehicle\/Outdoor\/Unsheltered'  id='choice_2_36_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_5' id='label_2_36_5' class='gform-field-label gform-field-label--type-inline'>Vehicle\/Outdoor\/Unsheltered<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_36_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.6' type='checkbox'  value='At risk of losing housing'  id='choice_2_36_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_6' id='label_2_36_6' class='gform-field-label gform-field-label--type-inline'>At risk of losing housing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_36_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.7' type='checkbox'  value='Other'  id='choice_2_36_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_7' id='label_2_36_7' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_37\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_37'><span class='gform-field-label__text'>Who lives in your household \/ Who do you financially support?<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_37' id='input_2_37' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_38\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Income &amp; Resources<\/h3><\/div><fieldset id=\"field_2_39\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Has your income or work situation changed recently?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_39'><div class='gchoice gchoice_2_39_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.1' type='checkbox'  value='Yes'  id='choice_2_39_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_39_1' id='label_2_39_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_39_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.2' type='checkbox'  value='No'  id='choice_2_39_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_39_2' id='label_2_39_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_39_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.3' type='checkbox'  value='Not applicable'  id='choice_2_39_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_39_3' id='label_2_39_3' class='gform-field-label gform-field-label--type-inline'>Not applicable<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_40\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_40'><span class='gform-field-label__text'>If yes, briefly explain.<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_40' id='input_2_40' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_2_41\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col_vertical gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Which resources do you currently receive or use?<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_41'><div class='gchoice gchoice_2_41_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.1' type='checkbox'  value='Financial Aid \/ CADAA'  id='choice_2_41_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_41_1' id='label_2_41_1' class='gform-field-label gform-field-label--type-inline'>Financial Aid \/ CADAA<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_41_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.2' type='checkbox'  value='CalFresh'  id='choice_2_41_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_41_2' id='label_2_41_2' class='gform-field-label gform-field-label--type-inline'>CalFresh<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_41_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.3' type='checkbox'  value='CalWORKSs'  id='choice_2_41_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_41_3' id='label_2_41_3' class='gform-field-label gform-field-label--type-inline'>CalWORKSs<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_41_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.4' type='checkbox'  value='Medi-Cal'  id='choice_2_41_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_41_4' id='label_2_41_4' class='gform-field-label gform-field-label--type-inline'>Medi-Cal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_41_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.5' type='checkbox'  value='VA Benefits'  id='choice_2_41_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_41_5' id='label_2_41_5' class='gform-field-label gform-field-label--type-inline'>VA Benefits<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_41_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.6' type='checkbox'  value='EOPS \/ categorical support'  id='choice_2_41_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_41_6' id='label_2_41_6' class='gform-field-label gform-field-label--type-inline'>EOPS \/ categorical support<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_41_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.7' type='checkbox'  value='Family \/ friend support'  id='choice_2_41_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_41_7' id='label_2_41_7' class='gform-field-label gform-field-label--type-inline'>Family \/ friend support<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_41_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.8' type='checkbox'  value='Community agency support'  id='choice_2_41_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_41_8' id='label_2_41_8' class='gform-field-label gform-field-label--type-inline'>Community agency support<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_41_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.9' type='checkbox'  value='None\/Unsure'  id='choice_2_41_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_41_9' id='label_2_41_9' class='gform-field-label gform-field-label--type-inline'>None\/Unsure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_41_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.11' type='checkbox'  value='Other'  id='choice_2_41_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_41_11' id='label_2_41_11' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_42\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Have you already asked another Palomar office\/program for help with this same need?<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_42'><div class='gchoice gchoice_2_42_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.1' type='checkbox'  value='Yes'  id='choice_2_42_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_42_1' id='label_2_42_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_42_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.2' type='checkbox'  value='No'  id='choice_2_42_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_42_2' id='label_2_42_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_42_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.3' type='checkbox'  value='Unsure'  id='choice_2_42_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_42_3' id='label_2_42_3' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_43\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_43'><span class='gform-field-label__text'>If yes, which office\/program and what support was requested\/received?<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_43' id='input_2_43' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_44\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Follow-Up<\/h3><\/div><fieldset id=\"field_2_45\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>How would you prefer to meet?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_45'><div class='gchoice gchoice_2_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='In-person'  id='choice_2_45_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_45_1' id='label_2_45_1' class='gform-field-label gform-field-label--type-inline'>In-person<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_45_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.2' type='checkbox'  value='Phone'  id='choice_2_45_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_45_2' id='label_2_45_2' class='gform-field-label gform-field-label--type-inline'>Phone<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_45_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.3' type='checkbox'  value='Zoom\/virtual'  id='choice_2_45_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_45_3' id='label_2_45_3' class='gform-field-label gform-field-label--type-inline'>Zoom\/virtual<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_45_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.4' type='checkbox'  value='No Preference'  id='choice_2_45_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_45_4' id='label_2_45_4' class='gform-field-label gform-field-label--type-inline'>No Preference<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_47\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_47'><span class='gform-field-label__text'>Best days\/times for follow-up<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_47' id='input_2_47' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_2_48\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Do you need accessibility or language accommodation for the meeting?<\/span><span class=\"gfield_required\"><span class=\"gfield_required 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I understand that a Basic Needs team member may contact me to learn more about my situation and connect me with campus or community resources. I authorize Basic Needs staff to verify my Palomar enrollment and other minimum eligibility information needed to determine which College-funded supports may be available to me.<\/div><\/div><div class='ginput_container ginput_container_consent'><input name='input_60.1' id='input_2_60_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_2_60\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_60_1' ><span class='gform-field-label__text'>I agree.<\/span><\/label><input type='hidden' name='input_60.2' value='I agree.' class='gform_hidden' \/><input type='hidden' name='input_60.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' 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