{"id":1397183,"date":"2025-12-19T14:50:20","date_gmt":"2025-12-19T19:50:20","guid":{"rendered":"https:\/\/fcsn.org\/?p=1397183"},"modified":"2025-12-19T14:50:20","modified_gmt":"2025-12-19T19:50:20","slug":"c2cmatchsurvey-3months","status":"publish","type":"post","link":"https:\/\/fcsn.org\/ar\/c2cmatchsurvey-3months\/","title":{"rendered":"C2C Respite Form Post-Match Survey (3 Months)"},"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 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#112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: 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-file-btn-bg-color-hover: #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                            <p class='gform_description'>Please answer a few questions below to let us know that your feedback of being a part of the Caregiver-to-Caregiver Respite Network. The Federation for Children with Special Needs is funded by grants which require us to collect data. Our registration is confidential and used to ensure we are supporting all communities. We do not share personal information nor do we sell to third parties.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_70'  action='\/ar\/wp-json\/wp\/v2\/posts\/1397183' data-formid='70' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LdJN-osAAAAAGaA3QLEIzmlcFHE8ixEcZ6Q6M7Y' data-tabindex='0'><input id=\"input_5768ae1726551de494782f0d20db768e\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_5768ae1726551de494782f0d20db768e\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_70' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_70_61\" class=\"gfield gfield--type-text 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_70_61'>Email<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_61' id='input_70_61' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_70_35\" class=\"gfield gfield--type-select 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_70_35'>Select your age group<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_35' id='input_70_35' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Under 18' >Under 18<\/option><option value='18-24' >18-24<\/option><option value='25-34' >25-34<\/option><option value='35-44' >35-44<\/option><option value='45-54' >45-54<\/option><option value='55-64' >55-64<\/option><option value='65 or above' >65 or above<\/option><option value='Prefer not to answer' >Prefer not to answer<\/option><\/select><\/div><\/div><div id=\"field_70_37\" class=\"gfield gfield--type-select 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_70_37'>Your primary language<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_37' id='input_70_37' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='American Sign Language' >American Sign Language<\/option><option value='Chinese' >Chinese<\/option><option value='English' >English<\/option><option value='Haitian Creole' >Haitian Creole<\/option><option value='Portuguese' >Portuguese<\/option><option value='Spanish' >Spanish<\/option><option value='Vietnamese' >Vietnamese<\/option><option value='Korean' >Korean<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_70_43\" class=\"gfield gfield--type-select 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_70_43'>Select your child&#039;s age group<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_43' id='input_70_43' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='0-3' >0-3<\/option><option value='3-6' >3-6<\/option><option value='7-13' >7-13<\/option><option value='14-21' >14-21<\/option><option value='22-26' >22-26<\/option><\/select><\/div><\/div><div id=\"field_70_36\" class=\"gfield gfield--type-select 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_70_36'>Does your child have any developmental disability?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_36' id='input_70_36' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Do not know' >Do not know<\/option><\/select><\/div><\/div><div id=\"field_70_45\" class=\"gfield gfield--type-select 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_70_45'>Does your child have any behavioral health needs?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_45' id='input_70_45' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Do not know' >Do not know<\/option><\/select><\/div><\/div><div id=\"field_70_44\" class=\"gfield gfield--type-select 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_70_44'>Is your child medically complex?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_44' id='input_70_44' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Do not know' >Do not know<\/option><\/select><\/div><\/div><fieldset id=\"field_70_25\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Is this your first time receiving respite?<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_70_25'>\n\t\t\t<div class='gchoice gchoice_70_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Yes'  id='choice_70_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_25_0' id='label_70_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_70_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_70_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_25_1' id='label_70_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_70_25_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Unsure'  id='choice_70_25_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_25_2' id='label_70_25_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_70_25_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Does not apply'  id='choice_70_25_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_25_3' id='label_70_25_3' class='gform-field-label gform-field-label--type-inline'>Does not apply<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_70_28\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Is this your first time providing respite?<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_70_28'>\n\t\t\t<div class='gchoice gchoice_70_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Yes'  id='choice_70_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_28_0' id='label_70_28_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_70_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='No'  id='choice_70_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_28_1' id='label_70_28_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_70_28_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Unsure'  id='choice_70_28_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_28_2' id='label_70_28_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_70_28_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Does not apply'  id='choice_70_28_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_28_3' id='label_70_28_3' class='gform-field-label gform-field-label--type-inline'>Does not apply<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_70_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-eleven-twelfths gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Since the match connection has been made, how many hours of respite have you received?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_70_26'>The way our program defines respite is anything that helps you experience a break from caregiving. Some of our caregivers may have had the caregiver they were matched with come to their home and engage their child in play or other activity while they run an errand or take time to exercise, rest or do something else they enjoy. Others may have swapped school drop off and pick up duties with their match which also freed up some time in their day. Yet others exchanged time in the community with their children and received as well as provided a break from caregiving. Please reflect on your match experience and let us know approximately how many hours of respite you have received since you have been matched.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_70_26'>\n\t\t\t<div class='gchoice gchoice_70_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='0'  id='choice_70_26_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_70_26\"   \/>\n\t\t\t\t\t<label for='choice_70_26_0' id='label_70_26_0' class='gform-field-label gform-field-label--type-inline'>0<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_70_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='1-5'  id='choice_70_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_26_1' id='label_70_26_1' class='gform-field-label gform-field-label--type-inline'>1-5<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_70_26_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='5-10'  id='choice_70_26_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_26_2' id='label_70_26_2' class='gform-field-label gform-field-label--type-inline'>5-10<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_70_26_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='10-15'  id='choice_70_26_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_26_3' id='label_70_26_3' class='gform-field-label gform-field-label--type-inline'>10-15<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_70_26_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='15-20'  id='choice_70_26_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_26_4' id='label_70_26_4' class='gform-field-label gform-field-label--type-inline'>15-20<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_70_26_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='more than 20'  id='choice_70_26_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_26_5' id='label_70_26_5' class='gform-field-label gform-field-label--type-inline'>more than 20<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_70_46\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Since you have been part of the C2C Network, how often have you receive respite care?<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_70_46'>\n\t\t\t<div class='gchoice gchoice_70_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Weekly'  id='choice_70_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_46_0' id='label_70_46_0' class='gform-field-label gform-field-label--type-inline'>Weekly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_70_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Monthly'  id='choice_70_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_46_1' id='label_70_46_1' class='gform-field-label gform-field-label--type-inline'>Monthly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_70_46_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Occasionally'  id='choice_70_46_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_46_2' id='label_70_46_2' class='gform-field-label gform-field-label--type-inline'>Occasionally<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_70_38\" class=\"gfield gfield--type-select 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_70_38'>Did the program help enhance your quality of life as a caregiver?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_38' id='input_70_38' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Strongly Agree' >Strongly Agree<\/option><option value='Agree' >Agree<\/option><option value='Neutral' >Neutral<\/option><option value='Disagree' >Disagree<\/option><option value='Strongly Disagree' >Strongly Disagree<\/option><\/select><\/div><\/div><div id=\"field_70_49\" class=\"gfield gfield--type-text 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_70_49'>Please share why\/why not<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_49' id='input_70_49' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_70_59\" class=\"gfield gfield--type-checkbox gfield--type-choice 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' >What activities did you engage in during respite?<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_70_59'><div class='gchoice gchoice_70_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='Run Errands'  id='choice_70_59_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_59_1' id='label_70_59_1' class='gform-field-label gform-field-label--type-inline'>Run Errands<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_59_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.2' type='checkbox'  value='Cook'  id='choice_70_59_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_59_2' id='label_70_59_2' class='gform-field-label gform-field-label--type-inline'>Cook<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_59_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.3' type='checkbox'  value='Clean'  id='choice_70_59_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_59_3' id='label_70_59_3' class='gform-field-label gform-field-label--type-inline'>Clean<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_59_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.4' type='checkbox'  value='Work (Paid)'  id='choice_70_59_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_59_4' id='label_70_59_4' class='gform-field-label gform-field-label--type-inline'>Work (Paid)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_59_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.5' type='checkbox'  value='Work (Volunteer)'  id='choice_70_59_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_59_5' id='label_70_59_5' class='gform-field-label gform-field-label--type-inline'>Work (Volunteer)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_59_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.6' type='checkbox'  value='Go out to eat'  id='choice_70_59_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_59_6' id='label_70_59_6' class='gform-field-label gform-field-label--type-inline'>Go out to eat<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_59_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.7' type='checkbox'  value='Time with partner'  id='choice_70_59_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_59_7' id='label_70_59_7' class='gform-field-label gform-field-label--type-inline'>Time with partner<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_59_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.8' type='checkbox'  value='Time with friends'  id='choice_70_59_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_59_8' id='label_70_59_8' class='gform-field-label gform-field-label--type-inline'>Time with friends<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_59_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.9' type='checkbox'  value='Time with family'  id='choice_70_59_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_59_9' id='label_70_59_9' class='gform-field-label gform-field-label--type-inline'>Time with family<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_59_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.11' type='checkbox'  value='Leisure activities'  id='choice_70_59_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_59_11' id='label_70_59_11' class='gform-field-label gform-field-label--type-inline'>Leisure activities<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_59_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.12' type='checkbox'  value='Exercise\/ Sports'  id='choice_70_59_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_59_12' id='label_70_59_12' class='gform-field-label gform-field-label--type-inline'>Exercise\/ Sports<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_59_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.13' type='checkbox'  value='Other'  id='choice_70_59_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_59_13' id='label_70_59_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_70_57\" class=\"gfield gfield--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_70_57'>If other, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_70_57' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_70_60\" class=\"gfield gfield--type-checkbox gfield--type-choice 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' >What activities did your child engage in during respite?<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_70_60'><div class='gchoice gchoice_70_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='Homework'  id='choice_70_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_60_1' id='label_70_60_1' class='gform-field-label gform-field-label--type-inline'>Homework<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_60_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.2' type='checkbox'  value='Socialize with friends'  id='choice_70_60_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_60_2' id='label_70_60_2' class='gform-field-label gform-field-label--type-inline'>Socialize with friends<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_60_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.3' type='checkbox'  value='Socialize with family'  id='choice_70_60_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_60_3' id='label_70_60_3' class='gform-field-label gform-field-label--type-inline'>Socialize with family<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_60_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.4' type='checkbox'  value='Socialize with respite provider'  id='choice_70_60_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_60_4' id='label_70_60_4' class='gform-field-label gform-field-label--type-inline'>Socialize with respite provider<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_60_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.5' type='checkbox'  value='Board Games'  id='choice_70_60_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_60_5' id='label_70_60_5' class='gform-field-label gform-field-label--type-inline'>Board Games<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_60_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.6' type='checkbox'  value='Video Games'  id='choice_70_60_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_60_6' id='label_70_60_6' class='gform-field-label gform-field-label--type-inline'>Video Games<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_60_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.7' type='checkbox'  value='Crafts'  id='choice_70_60_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_60_7' id='label_70_60_7' class='gform-field-label gform-field-label--type-inline'>Crafts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_60_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.8' type='checkbox'  value='Reading'  id='choice_70_60_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_60_8' id='label_70_60_8' class='gform-field-label gform-field-label--type-inline'>Reading<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_60_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.9' type='checkbox'  value='TV'  id='choice_70_60_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_60_9' id='label_70_60_9' class='gform-field-label gform-field-label--type-inline'>TV<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_60_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.11' type='checkbox'  value='Sports\/ Exercise'  id='choice_70_60_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_60_11' id='label_70_60_11' class='gform-field-label gform-field-label--type-inline'>Sports\/ Exercise<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_60_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.12' type='checkbox'  value='Walk\/Run'  id='choice_70_60_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_60_12' id='label_70_60_12' class='gform-field-label gform-field-label--type-inline'>Walk\/Run<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_60_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.13' type='checkbox'  value='Play in the park'  id='choice_70_60_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_60_13' id='label_70_60_13' class='gform-field-label gform-field-label--type-inline'>Play in the park<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_60_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.14' type='checkbox'  value='Cleaning'  id='choice_70_60_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_60_14' id='label_70_60_14' class='gform-field-label gform-field-label--type-inline'>Cleaning<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_60_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.15' type='checkbox'  value='Cooking'  id='choice_70_60_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_60_15' id='label_70_60_15' class='gform-field-label gform-field-label--type-inline'>Cooking<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_60_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.16' type='checkbox'  value='Shopping'  id='choice_70_60_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_60_16' id='label_70_60_16' class='gform-field-label gform-field-label--type-inline'>Shopping<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_70_60_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.17' type='checkbox'  value='Other'  id='choice_70_60_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_70_60_17' id='label_70_60_17' 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_70_58\" class=\"gfield gfield--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_70_58'>If other, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_70_58' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_70_52\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Was this program responsive to your cultural and\/or linguistic needs?<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_70_52'>\n\t\t\t<div class='gchoice gchoice_70_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Yes'  id='choice_70_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_52_0' id='label_70_52_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_70_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='No'  id='choice_70_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_52_1' id='label_70_52_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_70_52_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Unsure'  id='choice_70_52_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_52_2' id='label_70_52_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_70_53\" class=\"gfield gfield--type-text 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_70_53'>Comment why\/why not?<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_53' id='input_70_53' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_70_54\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Have you been able to access C2C trainings in your language of choice?<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_70_54'>\n\t\t\t<div class='gchoice gchoice_70_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Yes'  id='choice_70_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_54_0' id='label_70_54_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_70_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='No'  id='choice_70_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_54_1' id='label_70_54_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_70_54_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Unsure'  id='choice_70_54_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_54_2' id='label_70_54_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_70_55\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Have you been able to find C2C information and resources in your language of choice?<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_70_55'>\n\t\t\t<div class='gchoice gchoice_70_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Yes'  id='choice_70_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_55_0' id='label_70_55_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_70_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='No'  id='choice_70_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_55_1' id='label_70_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_70_55_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Unsure'  id='choice_70_55_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_55_2' id='label_70_55_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_70_48\" class=\"gfield gfield--type-select 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_70_48'>How helpful have you found the frequency of staff engagement and support?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_48' id='input_70_48' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Extremely helpful' >Extremely helpful<\/option><option value='Very helpful' >Very helpful<\/option><option value='Moderately helpful' >Moderately helpful<\/option><option value='Slightly helpful' >Slightly helpful<\/option><option value='Not at all helpful' >Not at all helpful<\/option><\/select><\/div><\/div><div id=\"field_70_56\" class=\"gfield gfield--type-select 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_70_56'>How satisfied are you with your respite experience?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_56' id='input_70_56' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Very Satisfied' >Very Satisfied<\/option><option value='Satisfied' >Satisfied<\/option><option value='Neutral' >Neutral<\/option><option value='Unsatisfied' >Unsatisfied<\/option><option value='Very Unsatisfied' >Very Unsatisfied<\/option><\/select><\/div><\/div><fieldset id=\"field_70_40\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Have you accessed the C2C Learning Platform: LearnWorlds?<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_70_40'>\n\t\t\t<div class='gchoice gchoice_70_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Yes'  id='choice_70_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_40_0' id='label_70_40_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_70_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='No'  id='choice_70_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_40_1' id='label_70_40_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_70_40_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Unsure'  id='choice_70_40_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_40_2' id='label_70_40_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_70_41\" class=\"gfield gfield--type-select 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_70_41'>How satisfied are you with the use of the Learning Platform?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_41' id='input_70_41' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Very Satisfied' >Very Satisfied<\/option><option value='Satisfied' >Satisfied<\/option><option value='Neutral' >Neutral<\/option><option value='Unsatisfied' >Unsatisfied<\/option><option value='Very Unsatisfied' >Very Unsatisfied<\/option><\/select><\/div><\/div><div id=\"field_70_42\" class=\"gfield gfield--type-select 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_70_42'>How satisfied are you with the content of the Learning Platform?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_42' id='input_70_42' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Very Satisfied' >Very Satisfied<\/option><option value='Satisfied' >Satisfied<\/option><option value='Neutral' >Neutral<\/option><option value='Unsatisfied' >Unsatisfied<\/option><option value='Very Unsatisfied' >Very Unsatisfied<\/option><\/select><\/div><\/div><div id=\"field_70_18\" class=\"gfield gfield--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_70_18'>Briefly describe your respite experience<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_18' id='input_70_18' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_70_39\" class=\"gfield gfield--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_70_39'>Please share any suggestions\/feedback on how we can improve the Caregiver to Caregiver Respite Network<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_39' id='input_70_39' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_70_47\" class=\"gfield gfield--type-radio gfield--type-choice 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' >I give permission to the Federation for Children with Special Needs to share my feedback about the program in their marketing and outreach materials.<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_70_47'>\n\t\t\t<div class='gchoice gchoice_70_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Yes'  id='choice_70_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_47_0' id='label_70_47_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_70_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='No'  id='choice_70_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_70_47_1' id='label_70_47_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_70_64\" class=\"gfield gfield--type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_64' id='input_70_64' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_70_65\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_65'>Post Custom Field<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_70_65' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_70_66\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_70_66'>Post Custom Field<\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_70_66' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' 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