{"id":1781,"date":"2023-10-12T12:49:23","date_gmt":"2023-10-12T19:49:23","guid":{"rendered":"https:\/\/www.palomar.edu\/dental\/?page_id=1781"},"modified":"2025-05-07T09:09:51","modified_gmt":"2025-05-07T16:09:51","slug":"internship-request-form","status":"publish","type":"page","link":"https:\/\/www.palomar.edu\/dental\/internship-request-form\/","title":{"rendered":""},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_21' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Internship Request 2026<\/h2>\n                            <p class='gform_description'>This form is for Dental Clinics with active contracts at Palomar College. If you are interested in receiving interns but do not have a contract with us yet or need to renew a contract, please send an email to dentalassist@palomar.edu.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_21'  action='\/dental\/wp-json\/wp\/v2\/pages\/1781' data-formid='21' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_21' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_21_10\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Dental Office Contact Information<\/h3><div class='gsection_description' id='gfield_description_21_10'>Please state the contact information for the point of contact for this location. <\/div><\/div><div id=\"field_21_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_1'>Dental Office<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_1' id='input_21_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_22\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_22'>Type of Office<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_21_22' type='text' value='' class='large'    placeholder='Pediatric, Oral Surgery, etc.'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_2\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_2'>Office Contact Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_21_2' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_5'>Title<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_5' id='input_21_5' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_21_7\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Contact Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_21_7_container'>\n                                <span id='input_21_7_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_7' id='input_21_7' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_21_7' class='gform-field-label gform-field-label--type-sub '>Email Address<\/label>\n                                <\/span>\n                                <span id='input_21_7_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_7_2' id='input_21_7_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_21_7_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><div id=\"field_21_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_4'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_21_4' type='tel' value='' class='large'  placeholder='(###) ###-####' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_21_6\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Office Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_21_6' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_21_6_1_container' >\n                                        <input type='text' name='input_6.1' id='input_21_6_1' value=''    aria-required='true'    \/>\n                                        <label for='input_21_6_1' id='input_21_6_1_label' class='gform-field-label gform-field-label--type-sub '>Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_21_6_3_container' >\n                                    <input type='text' name='input_6.3' id='input_21_6_3' value=''    aria-required='true'    \/>\n                                    <label for='input_21_6_3' id='input_21_6_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_21_6_4_container' >\n                                        <select name='input_6.4' id='input_21_6_4'     aria-required='true'    ><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_21_6_4' id='input_21_6_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_21_6_5_container' >\n                                    <input type='text' name='input_6.5' id='input_21_6_5' value=''    aria-required='true'    \/>\n                                    <label for='input_21_6_5' id='input_21_6_5_label' class='gform-field-label gform-field-label--type-sub '>Zip<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_6.6' id='input_21_6_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_21_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does your office have an RDA on staff?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_21_29'>\n\t\t\t<div class='gchoice gchoice_21_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_21_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_21_29_0' id='label_21_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_21_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_21_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_21_29_1' id='label_21_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_21_9\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Hours Available<\/h3><div class='gsection_description' id='gfield_description_21_9'>Palomar College Dental Assisting interns are assigned Monday, Tuesday and Thursday every week between the 2nd week of January to the 2nd week of May, except the first two weeks where students can intern Mondays thru Fridays to complete 50 hours. \n\nPlease indicate the times they will be expected to start work, when your office has a scheduled lunch break, and the time your office closes. \n\nNOTE: Students must be dismissed by 7pm. \n\nFor Session I the student will directly coordinate with you in completing the 50 clinical hours they need. The rest of the schedules will be done Mondays, Tuesdays and Thursdays.<\/div><\/div><fieldset id=\"field_21_12\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Monday Hours<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Start Time (ex. 8 AM)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Lunch Break (ex. 12-1 PM)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">End Time (ex. 5 PM)<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_12_cell1 gform-grid-col' data-label='Start Time (ex. 8 AM)'><input aria-invalid='false' aria-required=\"true\"  aria-label='Start Time (ex. 8 AM), Row 1' data-aria-label-template='Start Time (ex. 8 AM), Row {0}' type='text' name='input_12[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_12_cell2 gform-grid-col' data-label='Lunch Break (ex. 12-1 PM)'><input aria-invalid='false' aria-required=\"true\"  aria-label='Lunch Break (ex. 12-1 PM), Row 1' data-aria-label-template='Lunch Break (ex. 12-1 PM), Row {0}' type='text' name='input_12[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_12_cell3 gform-grid-col' data-label='End Time (ex. 5 PM)'><input aria-invalid='false' aria-required=\"true\"  aria-label='End Time (ex. 5 PM), Row 1' data-aria-label-template='End Time (ex. 5 PM), Row {0}' type='text' name='input_12[]' value=''   \/><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_21_14\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Tuesday Hours<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Start Time (ex. 8 AM)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Lunch Break (ex. 12-1 PM)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">End Time (ex. 5 PM)<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_14_cell1 gform-grid-col' data-label='Start Time (ex. 8 AM)'><input aria-invalid='false' aria-required=\"true\"  aria-label='Start Time (ex. 8 AM), Row 1' data-aria-label-template='Start Time (ex. 8 AM), Row {0}' type='text' name='input_14[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_14_cell2 gform-grid-col' data-label='Lunch Break (ex. 12-1 PM)'><input aria-invalid='false' aria-required=\"true\"  aria-label='Lunch Break (ex. 12-1 PM), Row 1' data-aria-label-template='Lunch Break (ex. 12-1 PM), Row {0}' type='text' name='input_14[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_14_cell3 gform-grid-col' data-label='End Time (ex. 5 PM)'><input aria-invalid='false' aria-required=\"true\"  aria-label='End Time (ex. 5 PM), Row 1' data-aria-label-template='End Time (ex. 5 PM), Row {0}' type='text' name='input_14[]' value=''   \/><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_21_13\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Thursday Hours<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Start Time (ex. 8 AM)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Lunch Break (ex. 12-1 PM)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">End Time (ex. 5 PM)<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_13_cell1 gform-grid-col' data-label='Start Time (ex. 8 AM)'><input aria-invalid='false' aria-required=\"true\"  aria-label='Start Time (ex. 8 AM), Row 1' data-aria-label-template='Start Time (ex. 8 AM), Row {0}' type='text' name='input_13[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_13_cell2 gform-grid-col' data-label='Lunch Break (ex. 12-1 PM)'><input aria-invalid='false' aria-required=\"true\"  aria-label='Lunch Break (ex. 12-1 PM), Row 1' data-aria-label-template='Lunch Break (ex. 12-1 PM), Row {0}' type='text' name='input_13[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_13_cell3 gform-grid-col' data-label='End Time (ex. 5 PM)'><input aria-invalid='false' aria-required=\"true\"  aria-label='End Time (ex. 5 PM), Row 1' data-aria-label-template='End Time (ex. 5 PM), Row {0}' type='text' name='input_13[]' value=''   \/><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_21_15\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Sessions Available<\/h3><div class='gsection_description' id='gfield_description_21_15'>Three sessions are available to host Palomar College Dental Assisting interns. \nPlease indicate which session(s) and the number of interns your office can accommodate.<\/div><\/div><div id=\"field_21_16\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_16'># of Interns for Session I<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_21_16'>Session I: January 12-30<\/div><div class='ginput_container ginput_container_number'><input name='input_16' id='input_21_16' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_21_16\" \/><\/div><\/div><fieldset id=\"field_21_28\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >First two weeks of January<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_28.1' id='input_21_28_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_21_28_1' >I understand that students will directly coordinate with the office for the schedules to meet the 50 hours requirement.<\/label><input type='hidden' name='input_28.2' value='I understand that students will directly coordinate with the office for the schedules to meet the 50 hours requirement.' class='gform_hidden' \/><input type='hidden' name='input_28.3' value='15' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_21_20\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_20'># of Interns for Session II<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_21_20'>Session II: February 9 to March 12<\/div><div class='ginput_container ginput_container_number'><input name='input_20' id='input_21_20' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_21_20\" \/><\/div><\/div><div id=\"field_21_19\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_19'># of Interns for Session III<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_21_19'>Session III: March 16 to April 24 (excludes Spring Break March 23 to 27)<\/div><div class='ginput_container ginput_container_number'><input name='input_19' id='input_21_19' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_21_19\" \/><\/div><\/div><fieldset id=\"field_21_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does your clinic require the student to submit any forms or documents? Ex. Proof of immunizations, etc.<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_21_25'>\n\t\t\t<div class='gchoice gchoice_21_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Yes'  id='choice_21_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_21_25_0' id='label_21_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_21_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_21_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_21_25_1' id='label_21_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_21_27\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_27'>Please list your requirements below<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_27' id='input_21_27' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_21_30\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_30'>Contact Person and Number the Student will Contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_21_30'>The student will contact this person after being assigned to your site. <\/div><div class='ginput_container ginput_container_text'><input name='input_30' id='input_21_30' type='text' value='' class='large'  aria-describedby=\"gfield_description_21_30\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_21' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_21' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_21' id='gform_theme_21' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_21' id='gform_style_settings_21' value='{&quot;inputPrimaryColor&quot;:&quot;#204ce5&quot;}' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_21' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='21' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_21' value='WyJ7XCIyOVwiOltcIjI5M2UzODRjYTZkMWIxYzlkZDdmOTY2OTdiNTRhZWUwXCIsXCIxMWUzMWQwYTBhNzA5ODIxNGNlYWZhODA2MDg1YTg1ZVwiXSxcIjI4LjFcIjpcImNhMTVhMmY3MDY1ODk0NTAyNzljY2JlN2ZjODFhZGViXCIsXCIyOC4yXCI6XCIyZmRiOGM1ZTk1YzA0M2JjMTQ2YzgyMWMwZDVhNTI5OFwiLFwiMjguM1wiOlwiN2UyNTBiZWQ5YTczOTBhYTE0MzA3MDA2NDA0YTg0NzZcIixcIjI1XCI6W1wiMjkzZTM4NGNhNmQxYjFjOWRkN2Y5NjY5N2I1NGFlZTBcIixcIjExZTMxZDBhMGE3MDk4MjE0Y2VhZmE4MDYwODVhODVlXCJdfSIsIjhlOTVkMWI4OGQ3ZDkyYTBlODEwNTkzZWZmNzdmYjQ0Il0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_21' id='gform_target_page_number_21' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_21' id='gform_source_page_number_21' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"ak_\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"208\"\/><script>\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n<\/script>\n<\/p><\/form>\n                        <\/div><script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 21, 'https:\/\/www.palomar.edu\/dental\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_21').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_21');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_21').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_21').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_21').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_21').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_21').val();gformInitSpinner( 21, 'https:\/\/www.palomar.edu\/dental\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [21, current_page]);window['gf_submitting_21'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_21').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [21]);window['gf_submitting_21'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_21').text());}else{jQuery('#gform_21').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"21\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_21\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_21\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_21\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 21, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} );\n<\/script>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":11323,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"jetpack_post_was_ever_published":false,"footnotes":""},"class_list":["post-1781","page","type-page","status-publish","hentry"],"acf":[],"jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/P6So7D-sJ","_links":{"self":[{"href":"https:\/\/www.palomar.edu\/dental\/wp-json\/wp\/v2\/pages\/1781","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.palomar.edu\/dental\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.palomar.edu\/dental\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.palomar.edu\/dental\/wp-json\/wp\/v2\/users\/11323"}],"replies":[{"embeddable":true,"href":"https:\/\/www.palomar.edu\/dental\/wp-json\/wp\/v2\/comments?post=1781"}],"version-history":[{"count":4,"href":"https:\/\/www.palomar.edu\/dental\/wp-json\/wp\/v2\/pages\/1781\/revisions"}],"predecessor-version":[{"id":2127,"href":"https:\/\/www.palomar.edu\/dental\/wp-json\/wp\/v2\/pages\/1781\/revisions\/2127"}],"wp:attachment":[{"href":"https:\/\/www.palomar.edu\/dental\/wp-json\/wp\/v2\/media?parent=1781"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}