{"id":3156,"date":"2024-08-25T08:00:44","date_gmt":"2024-08-25T15:00:44","guid":{"rendered":"https:\/\/www.palomar.edu\/eme\/?page_id=3156"},"modified":"2026-01-22T15:05:27","modified_gmt":"2026-01-22T23:05:27","slug":"cohort-67-application","status":"publish","type":"page","link":"https:\/\/www.palomar.edu\/eme\/cohort-67-application\/","title":{"rendered":"Cohort 68 Application"},"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_19' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Cohort 68 Paramedic Online Application<\/h2>\n                            <p class='gform_description'>Please fill out the following online application and submit all required supportive material to the EME Department by Friday, May 1st, 2026.<\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_19'  action='\/eme\/wp-json\/wp\/v2\/pages\/3156' data-formid='19' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_19' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_19_1\" class=\"gfield gfield--type-text gfield--input-type-text 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_19_1'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_19_1' type='text' value='' class='medium' maxlength='40'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_19_2\" class=\"gfield gfield--type-text gfield--input-type-text 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_19_2'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_19_2' type='text' value='' class='medium' maxlength='20'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_19_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_3'>Middle Initial<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_19_3' type='text' value='' class='medium' maxlength='2' aria-describedby=\"gfield_description_19_3\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_19_3'>Enter * if you do not have a middle name.<\/div><\/div><div id=\"field_19_6\" class=\"gfield gfield--type-text gfield--input-type-text 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_19_6'>Phone Number (Main Contact)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_19_6' type='text' value='' class='medium' maxlength='20'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_19_24\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_24'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_24' id='input_19_24' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_19_4\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_4'>Mailing Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_4' id='input_19_4' class='textarea medium'  aria-describedby=\"gfield_description_19_4\" maxlength='100'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_19_4'>Should you be selected for the program, we would need a correct mailing address to send your acceptance paperwork.<\/div><\/div><div id=\"field_19_7\" class=\"gfield gfield--type-text gfield--input-type-text 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_19_7'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_19_7' type='text' value='' class='medium' maxlength='25'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_19_9\" class=\"gfield gfield--type-text gfield--input-type-text 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_19_9'>Palomar College Student ID Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_19_9' type='text' value='' class='medium' maxlength='9'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_19_10\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Have you ever applied to the this Academy before?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_19_10'><div class='gchoice gchoice_19_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='Yes'  id='choice_19_10_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_10_1' id='label_19_10_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_19_10_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.2' type='checkbox'  value='No'  id='choice_19_10_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_10_2' id='label_19_10_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_19_33\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Have you completed Fire Academy?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_19_33'><div class='gchoice gchoice_19_33_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.1' type='checkbox'  value='Yes'  id='choice_19_33_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_33_1' id='label_19_33_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_19_33_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.2' type='checkbox'  value='No'  id='choice_19_33_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_33_2' id='label_19_33_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_35'>Please list when and where you completed your Fire Academy:<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_19_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_19_11\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Are you a High School graduate or a G.E.D. recipient?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_19_11'><div class='gchoice gchoice_19_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='Yes'  id='choice_19_11_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_11_1' id='label_19_11_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_19_11_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.2' type='checkbox'  value='No'  id='choice_19_11_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_11_2' id='label_19_11_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_12\" class=\"gfield gfield--type-text gfield--input-type-text 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_19_12'>Name and location of High School or G.E.D. training site<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_19_12' type='text' value='' class='medium' maxlength='100'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_19_13\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_19_13'>Schools attended other than high school (Name course of study and any degree(s) or certifications earned)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_13' id='input_19_13' class='textarea medium'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_19_14\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_14'>Name additional training pertaining to Paramedic training; including military training. (Name course of study and any degree(s) or certifications earned.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_14' id='input_19_14' class='textarea medium'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_19_15\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >EMT-B certification (Check all that apply)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_19_15'><div class='gchoice gchoice_19_15_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.1' type='checkbox'  value='California State Certification'  id='choice_19_15_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_15_1' id='label_19_15_1' class='gform-field-label gform-field-label--type-inline'>California State Certification<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_15_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.2' type='checkbox'  value='San Diego County Certification'  id='choice_19_15_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_15_2' id='label_19_15_2' class='gform-field-label gform-field-label--type-inline'>San Diego County Certification<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_15_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.3' type='checkbox'  value='Other California County Certification other than San Diego.'  id='choice_19_15_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_15_3' id='label_19_15_3' class='gform-field-label gform-field-label--type-inline'>Other California County Certification other than San Diego.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_15_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.4' type='checkbox'  value='National Registry Certification'  id='choice_19_15_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_15_4' id='label_19_15_4' class='gform-field-label gform-field-label--type-inline'>National Registry Certification<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_15_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.5' type='checkbox'  value='Other State EMT-B Certification'  id='choice_19_15_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_15_5' id='label_19_15_5' class='gform-field-label gform-field-label--type-inline'>Other State EMT-B Certification<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_19_17\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >CPR Certification (Must contain AED component).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_19_17'><div class='gchoice gchoice_19_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='Healthcare Provider  (American Heart Association)'  id='choice_19_17_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_17_1' id='label_19_17_1' class='gform-field-label gform-field-label--type-inline'>Healthcare Provider  (American Heart Association)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='CPR for the Professional Rescuer (American Red Cross)'  id='choice_19_17_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_17_2' id='label_19_17_2' class='gform-field-label gform-field-label--type-inline'>CPR for the Professional Rescuer (American Red Cross)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_17_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.3' type='checkbox'  value='Other (Must include AED certification)'  id='choice_19_17_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_17_3' id='label_19_17_3' class='gform-field-label gform-field-label--type-inline'>Other (Must include AED certification)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_19_18\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Form of Identification<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_19_18'><div class='gchoice gchoice_19_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='California State Driver&#039;s License or ID card'  id='choice_19_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_18_1' id='label_19_18_1' class='gform-field-label gform-field-label--type-inline'>California State Driver&#8217;s License or ID card<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='Other State Identification card or Driver&#039;s license'  id='choice_19_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_18_2' id='label_19_18_2' class='gform-field-label gform-field-label--type-inline'>Other State Identification card or Driver&#8217;s license<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_19\" class=\"gfield gfield--type-text gfield--input-type-text 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_19_19'>Physical Conditions or Limitations &#8211; Do you have any physical limitations that would prevent you from performing tasks involved in the Paramedic Academy?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_19_19' type='text' value='' class='medium' maxlength='30'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_19_20\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_20'>EMT Work Experience<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_20' id='input_19_20' class='textarea medium'  aria-describedby=\"gfield_description_19_20\" maxlength='500'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_19_20'>List all Prehospital experience, hospital experience and volunteer experience.\n\nPlease include locations<\/div><\/div><fieldset id=\"field_19_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Have you ever been convicted of a felony or misdemeanor offense, including entering a plea of &quot;No Contest&quot;, which resulted in you being imprisoned or , placed on probation?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_19_21'><div class='gchoice gchoice_19_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Yes'  id='choice_19_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_21_1' id='label_19_21_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_19_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='No'  id='choice_19_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_21_2' id='label_19_21_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_22\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_19_22'>Emergency Contact &#8211; List name, relationship, address, day and night phone number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_19_22' class='textarea medium'   maxlength='200'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_19_23\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_19_23'>Certification of Information &#8211; Completing this section verifies that all of the above information is correct to the best of your recollection. 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