{"id":709,"date":"2014-04-02T09:51:10","date_gmt":"2014-04-02T14:51:10","guid":{"rendered":"https:\/\/web.saumag.edu\/mac\/?page_id=709"},"modified":"2021-07-19T13:37:49","modified_gmt":"2021-07-19T18:37:49","slug":"registration-form","status":"publish","type":"page","link":"https:\/\/web.saumag.edu\/mac\/membership\/registration-form\/","title":{"rendered":"Membership Registration form"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\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\/* ]]> *\/\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_13' style='display:none'><div id='gf_13' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\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_13'  action='\/mac\/wp-json\/wp\/v2\/pages\/709#gf_13' data-formid='13' novalidate>\n        <div id='gf_progressbar_wrapper_13' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>7<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_14' style='width:14%;'><span>14%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_13_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_13' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_63\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2> Please note<\/h2>\n\nThis form is only for students who are 18 years of age and older. If you are under-aged, please visit the MAC for the paper version of the forms in order to gather the necessary parental consent signatures.<\/div><fieldset id=\"field_13_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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 am:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_74'>\n\t\t\t<div class='gchoice gchoice_13_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='a student'  id='choice_13_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_74_0' id='label_13_74_0' class='gform-field-label gform-field-label--type-inline'>a student<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='faculty'  id='choice_13_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_74_1' id='label_13_74_1' class='gform-field-label gform-field-label--type-inline'>faculty<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_74_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='staff'  id='choice_13_74_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_74_2' id='label_13_74_2' class='gform-field-label gform-field-label--type-inline'>staff<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_74_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='an alumni gold member'  id='choice_13_74_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_74_3' id='label_13_74_3' class='gform-field-label gform-field-label--type-inline'>an alumni gold member<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_74_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='faculty spouse'  id='choice_13_74_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_74_4' id='label_13_74_4' class='gform-field-label gform-field-label--type-inline'>faculty spouse<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_74_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='staff spouse'  id='choice_13_74_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_74_5' id='label_13_74_5' class='gform-field-label gform-field-label--type-inline'>staff spouse<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_75\" 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' >Alumni Gold Member Pass Options<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_75'>\n\t\t\t<div class='gchoice gchoice_13_75_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='One day pass'  id='choice_13_75_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_75_0' id='label_13_75_0' class='gform-field-label gform-field-label--type-inline'>One day pass<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_75_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Weekend pass'  id='choice_13_75_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_75_1' id='label_13_75_1' class='gform-field-label gform-field-label--type-inline'>Weekend pass<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_1\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Member Information<\/h3><\/div><div id=\"field_13_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_13_2'>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_13_2' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_3\" class=\"gfield gfield--type-address gfield--input-type-address 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' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_13_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_13_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_13_3_1' value=''    aria-required='true'    \/>\n                                        <label for='input_13_3_1' id='input_13_3_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_13_3_2_container' >\n                                        <input type='text' name='input_3.2' id='input_13_3_2' value=''     aria-required='false'   \/>\n                                        <label for='input_13_3_2' id='input_13_3_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_13_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_13_3_3' value=''    aria-required='true'    \/>\n                                    <label for='input_13_3_3' id='input_13_3_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_13_3_4_container' >\n                                        <select name='input_3.4' id='input_13_3_4'     aria-required='true'    ><option value='' ><\/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' selected='selected'>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_13_3_4' id='input_13_3_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_13_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_13_3_5' value=''    aria-required='true'    \/>\n                                    <label for='input_13_3_5' id='input_13_3_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_3.6' id='input_13_3_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_13_7\" 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\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_13_7_container'>\n                                <span id='input_13_7_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_7' id='input_13_7' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_13_7' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_13_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_13_7_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_13_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_13_8\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half 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_13_8'>Main phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_13_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_9\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half 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_13_9'>Cell phone<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_13_9' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_4\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_third gfield--width-third 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_13_4'>Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_13_4' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_5\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third gfield--width-third 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_13_5'>Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_13_5' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_6\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_third gfield--width-third 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_13_6'>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_6' id='input_13_6' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_10\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half 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_13_10'>Height<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_13_10' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_11\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half 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_13_11'>Weight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_13_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_12\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Emergency contact<\/h3><\/div><div id=\"field_13_13\" 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_13_13'>Emergency contact person<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_13_13' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_14\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half 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_13_14'>Relationship<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_13_14' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_15\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half 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_13_15'>Telephone 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_15' id='input_13_15' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_16\" 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_13_16'>Additional Information<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_16' id='input_13_16' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_13_17' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_2' class='gform_page' data-js='page-field-id-17' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_18\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Health questionnaire<\/h3><\/div><div id=\"field_13_19\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Regular physical activity is fun and healthy, and safe for most people. \n\nHowever, some individuals may have health-related risks that might require them to check with their physicians prior to starting an exercise program. \n\nTo help determine if there is a need for you to see your physician before starting an exercise program, please read the following questions and answer carefully.\n\nAll information will be kept in the strictest confidentiality. \n<\/div><div id=\"field_13_28\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >I. Physical activity screening questions. Please choose &quot;Yes&quot; or &quot;No&quot;.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table aria-label='I. Physical activity screening questions. Please choose &quot;Yes&quot; or &quot;No&quot;.' class='gsurvey-likert' id='input_13_28'><thead><tr><td scope='col' class='gsurvey-likert-row-label'><\/td><th id='likert_col_1_13_28' scope='col'  class='gsurvey-likert-choice-label'>Yes<\/th><th id='likert_col_2_13_28' scope='col'  class='gsurvey-likert-choice-label'>No<\/th><\/tr><\/thead><tbody><tr><td id='likert_row_1_13_28' data-label='' class='gsurvey-likert-row-label'>Has your physician ever told you that you have a heart condition?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_28.1' type='radio' value='glikertrowc512c26a:glikertcol2808276170'  id='choice_13_28_1_1'    aria-labelledby='likert_row_1_13_28 likert_col_1_13_28'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_28.1' type='radio' value='glikertrowc512c26a:glikertcol28ae06b691'  id='choice_13_28_1_2'    aria-labelledby='likert_row_1_13_28 likert_col_2_13_28'\/><\/td><\/tr><tr><td id='likert_row_2_13_28' data-label='' class='gsurvey-likert-row-label'>Do you experience pain in your chest when you are physically active?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_28.2' type='radio' value='glikertrowd127e958:glikertcol2808276170'  id='choice_13_28_2_1'    aria-labelledby='likert_row_2_13_28 likert_col_1_13_28'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_28.2' type='radio' value='glikertrowd127e958:glikertcol28ae06b691'  id='choice_13_28_2_2'    aria-labelledby='likert_row_2_13_28 likert_col_2_13_28'\/><\/td><\/tr><tr><td id='likert_row_3_13_28' data-label='' class='gsurvey-likert-row-label'>In the past month, have you experienced chest pain when not performing physical  activity?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_28.3' type='radio' value='glikertrow34daa27a:glikertcol2808276170'  id='choice_13_28_3_1'    aria-labelledby='likert_row_3_13_28 likert_col_1_13_28'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_28.3' type='radio' value='glikertrow34daa27a:glikertcol28ae06b691'  id='choice_13_28_3_2'    aria-labelledby='likert_row_3_13_28 likert_col_2_13_28'\/><\/td><\/tr><tr><td id='likert_row_4_13_28' data-label='' class='gsurvey-likert-row-label'>Do you lose balance because of dizziness or do you ever lose consciousness?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_28.4' type='radio' value='glikertrow79de02fe:glikertcol2808276170'  id='choice_13_28_4_1'    aria-labelledby='likert_row_4_13_28 likert_col_1_13_28'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_28.4' type='radio' value='glikertrow79de02fe:glikertcol28ae06b691'  id='choice_13_28_4_2'    aria-labelledby='likert_row_4_13_28 likert_col_2_13_28'\/><\/td><\/tr><tr><td id='likert_row_5_13_28' data-label='' class='gsurvey-likert-row-label'>Do you have a bone or joint problem that could be aggravated by a change in your  level of physical activity?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_28.5' type='radio' value='glikertrowbff99770:glikertcol2808276170'  id='choice_13_28_5_1'    aria-labelledby='likert_row_5_13_28 likert_col_1_13_28'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_28.5' type='radio' value='glikertrowbff99770:glikertcol28ae06b691'  id='choice_13_28_5_2'    aria-labelledby='likert_row_5_13_28 likert_col_2_13_28'\/><\/td><\/tr><tr><td id='likert_row_6_13_28' data-label='' class='gsurvey-likert-row-label'>Is your physician currently prescribing medication for your blood pressure or heart condition?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_28.6' type='radio' value='glikertrow1196b690:glikertcol2808276170'  id='choice_13_28_6_1'    aria-labelledby='likert_row_6_13_28 likert_col_1_13_28'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_28.6' type='radio' value='glikertrow1196b690:glikertcol28ae06b691'  id='choice_13_28_6_2'    aria-labelledby='likert_row_6_13_28 likert_col_2_13_28'\/><\/td><\/tr><tr><td id='likert_row_7_13_28' data-label='' class='gsurvey-likert-row-label'>Do you know of any other reason why you should not participate in a program of physical activity?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_28.7' type='radio' value='glikertrow6a0843a3:glikertcol2808276170'  id='choice_13_28_7_1'    aria-labelledby='likert_row_7_13_28 likert_col_1_13_28'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_28.7' type='radio' value='glikertrow6a0843a3:glikertcol28ae06b691'  id='choice_13_28_7_2'    aria-labelledby='likert_row_7_13_28 likert_col_2_13_28'\/><\/td><\/tr><\/tbody><\/table><\/div><\/div><div id=\"field_13_21\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >If you answered \"yes\" to any of the above questions, it is recommended that you consult with your physician via phone or in person before participating in a physical activity program.<\/div><div id=\"field_13_29\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >II. General health history questions. Please choose &quot;Yes&quot; or &quot;No&quot;.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table aria-label='II. General health history questions. Please choose &quot;Yes&quot; or &quot;No&quot;.' class='gsurvey-likert' id='input_13_29'><thead><tr><td scope='col' class='gsurvey-likert-row-label'><\/td><th id='likert_col_1_13_29' scope='col'  class='gsurvey-likert-choice-label'>Yes<\/th><th id='likert_col_2_13_29' scope='col'  class='gsurvey-likert-choice-label'>No<\/th><\/tr><\/thead><tbody><tr><td id='likert_row_1_13_29' data-label='' class='gsurvey-likert-row-label'>Have you ever experienced a stroke?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_29.1' type='radio' value='glikertrow6727ab7d:glikertcol297385d223'  id='choice_13_29_1_1'    aria-labelledby='likert_row_1_13_29 likert_col_1_13_29'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_29.1' type='radio' value='glikertrow6727ab7d:glikertcol29a56a21f3'  id='choice_13_29_1_2'    aria-labelledby='likert_row_1_13_29 likert_col_2_13_29'\/><\/td><\/tr><tr><td id='likert_row_2_13_29' data-label='' class='gsurvey-likert-row-label'>Do you have diabetes?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_29.2' type='radio' value='glikertrow9c6e566e:glikertcol297385d223'  id='choice_13_29_2_1'    aria-labelledby='likert_row_2_13_29 likert_col_1_13_29'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_29.2' type='radio' value='glikertrow9c6e566e:glikertcol29a56a21f3'  id='choice_13_29_2_2'    aria-labelledby='likert_row_2_13_29 likert_col_2_13_29'\/><\/td><\/tr><tr><td id='likert_row_3_13_29' data-label='' class='gsurvey-likert-row-label'>Do you have asthma or another respiratory condition that causes difficulty with breathing?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_29.3' type='radio' value='glikertrow026002b7:glikertcol297385d223'  id='choice_13_29_3_1'    aria-labelledby='likert_row_3_13_29 likert_col_1_13_29'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_29.3' type='radio' value='glikertrow026002b7:glikertcol29a56a21f3'  id='choice_13_29_3_2'    aria-labelledby='likert_row_3_13_29 likert_col_2_13_29'\/><\/td><\/tr><tr><td id='likert_row_4_13_29' data-label='' class='gsurvey-likert-row-label'>Do you have orthopedic conditions that would restrict you in performing physical activity?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_29.4' type='radio' value='glikertrow2202efbc:glikertcol297385d223'  id='choice_13_29_4_1'    aria-labelledby='likert_row_4_13_29 likert_col_1_13_29'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_29.4' type='radio' value='glikertrow2202efbc:glikertcol29a56a21f3'  id='choice_13_29_4_2'    aria-labelledby='likert_row_4_13_29 likert_col_2_13_29'\/><\/td><\/tr><tr><td id='likert_row_5_13_29' data-label='' class='gsurvey-likert-row-label'>Have you ever been told by a physician that you have high blood pressure?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_29.5' type='radio' value='glikertrowc9a84d07:glikertcol297385d223'  id='choice_13_29_5_1'    aria-labelledby='likert_row_5_13_29 likert_col_1_13_29'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_29.5' type='radio' value='glikertrowc9a84d07:glikertcol29a56a21f3'  id='choice_13_29_5_2'    aria-labelledby='likert_row_5_13_29 likert_col_2_13_29'\/><\/td><\/tr><tr><td id='likert_row_6_13_29' data-label='' class='gsurvey-likert-row-label'>Have you ever been told by a physician that you have elevated blood lipids(cholesterol)<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_29.6' type='radio' value='glikertrow7d5bca05:glikertcol297385d223'  id='choice_13_29_6_1'    aria-labelledby='likert_row_6_13_29 likert_col_1_13_29'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_29.6' type='radio' value='glikertrow7d5bca05:glikertcol29a56a21f3'  id='choice_13_29_6_2'    aria-labelledby='likert_row_6_13_29 likert_col_2_13_29'\/><\/td><\/tr><tr><td id='likert_row_7_13_29' data-label='' class='gsurvey-likert-row-label'>Do you currently smoke?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_29.7' type='radio' value='glikertrow07afc454:glikertcol297385d223'  id='choice_13_29_7_1'    aria-labelledby='likert_row_7_13_29 likert_col_1_13_29'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_29.7' type='radio' value='glikertrow07afc454:glikertcol29a56a21f3'  id='choice_13_29_7_2'    aria-labelledby='likert_row_7_13_29 likert_col_2_13_29'\/><\/td><\/tr><tr><td id='likert_row_8_13_29' data-label='' class='gsurvey-likert-row-label'>Have you experienced within the past 6 months back pain or discomfort that prevented you from carrying out normal daily activities?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_29.8' type='radio' value='glikertrow942fb81d:glikertcol297385d223'  id='choice_13_29_8_1'    aria-labelledby='likert_row_8_13_29 likert_col_1_13_29'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_29.8' type='radio' value='glikertrow942fb81d:glikertcol29a56a21f3'  id='choice_13_29_8_2'    aria-labelledby='likert_row_8_13_29 likert_col_2_13_29'\/><\/td><\/tr><tr><td id='likert_row_9_13_29' data-label='' class='gsurvey-likert-row-label'>Are you pregnant?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_29.9' type='radio' value='glikertrowcfa1cb25:glikertcol297385d223'  id='choice_13_29_9_1'    aria-labelledby='likert_row_9_13_29 likert_col_1_13_29'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_29.9' type='radio' value='glikertrowcfa1cb25:glikertcol29a56a21f3'  id='choice_13_29_9_2'    aria-labelledby='likert_row_9_13_29 likert_col_2_13_29'\/><\/td><\/tr><tr><td id='likert_row_10_13_29' data-label='' class='gsurvey-likert-row-label'>Do you currently exercise less than one hour per week?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_29.11' type='radio' value='glikertrowfccb9034:glikertcol297385d223'  id='choice_13_29_11_1'    aria-labelledby='likert_row_10_13_29 likert_col_1_13_29'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_29.11' type='radio' value='glikertrowfccb9034:glikertcol29a56a21f3'  id='choice_13_29_11_2'    aria-labelledby='likert_row_10_13_29 likert_col_2_13_29'\/><\/td><\/tr><tr><td id='likert_row_11_13_29' data-label='' class='gsurvey-likert-row-label'>Are you currently taking any medications that might impact your ability to safely perform physical activity?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_29.12' type='radio' value='glikertrowb031e121:glikertcol297385d223'  id='choice_13_29_12_1'    aria-labelledby='likert_row_11_13_29 likert_col_1_13_29'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_29.12' type='radio' value='glikertrowb031e121:glikertcol29a56a21f3'  id='choice_13_29_12_2'    aria-labelledby='likert_row_11_13_29 likert_col_2_13_29'\/><\/td><\/tr><\/tbody><\/table><\/div><\/div><div id=\"field_13_23\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >By submitting this form I understand that I am voluntarily participating in an athletic or physical activity at The MAC with full knowledge and understanding and appreciation of the risk of injury inherent in any physical exercise, massage or therapy program, physical activity, or athletic activity and expressly assume all risk of injury and even death, which could occur by reason of my participation. I release The MAC from any liability and agree not to sue the MAC with respect to any cause of action for bodily injury, property damage, or death occurring to me as a result of my participation in the activity.\n\nI understand that all personal property brought to the MAC is brought at my sole risk as its theft, damage, or loss.\n<\/div><fieldset id=\"field_13_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Please click below to acknowledge and agree with the terms of the Activity release agreement for adults.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_24'>\n\t\t\t<div class='gchoice gchoice_13_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='I understand and agree'  id='choice_13_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_24_0' id='label_13_24_0' class='gform-field-label gform-field-label--type-inline'>I understand and agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_25' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_13_25' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_3' class='gform_page' data-js='page-field-id-25' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_26\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Health history<\/h3><\/div><div id=\"field_13_27\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Regular physical activity is safe for most people. However, some individuals should check with their doctor before they start an exercise program. \n\nTo help us determine if you should consult with your doctor before starting to exercise with ( your organization), please read the following questions carefully and answer each one honestly. All information will be kept confidential. \n\n<\/div><div id=\"field_13_30\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Please check &quot;Yes&quot; or &quot;No&quot;.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table aria-label='Please check &quot;Yes&quot; or &quot;No&quot;.' class='gsurvey-likert' id='input_13_30'><thead><tr><td scope='col' class='gsurvey-likert-row-label'><\/td><th id='likert_col_1_13_30' scope='col'  class='gsurvey-likert-choice-label'>Yes<\/th><th id='likert_col_2_13_30' scope='col'  class='gsurvey-likert-choice-label'>No<\/th><\/tr><\/thead><tbody><tr><td id='likert_row_1_13_30' data-label='' class='gsurvey-likert-row-label'>Do you have a heart condition?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_30.1' type='radio' value='glikertrow9cd48b6a:glikertcol30e955410b'  id='choice_13_30_1_1'    aria-labelledby='likert_row_1_13_30 likert_col_1_13_30'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_30.1' type='radio' value='glikertrow9cd48b6a:glikertcol302f5214c1'  id='choice_13_30_1_2'    aria-labelledby='likert_row_1_13_30 likert_col_2_13_30'\/><\/td><\/tr><tr><td id='likert_row_2_13_30' data-label='' class='gsurvey-likert-row-label'>Have you ever experienced a stroke?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_30.2' type='radio' value='glikertrowe60461b7:glikertcol30e955410b'  id='choice_13_30_2_1'    aria-labelledby='likert_row_2_13_30 likert_col_1_13_30'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_30.2' type='radio' value='glikertrowe60461b7:glikertcol302f5214c1'  id='choice_13_30_2_2'    aria-labelledby='likert_row_2_13_30 likert_col_2_13_30'\/><\/td><\/tr><tr><td id='likert_row_3_13_30' data-label='' class='gsurvey-likert-row-label'>Do you have epilepsy?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_30.3' type='radio' value='glikertrowc2a07ffc:glikertcol30e955410b'  id='choice_13_30_3_1'    aria-labelledby='likert_row_3_13_30 likert_col_1_13_30'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_30.3' type='radio' value='glikertrowc2a07ffc:glikertcol302f5214c1'  id='choice_13_30_3_2'    aria-labelledby='likert_row_3_13_30 likert_col_2_13_30'\/><\/td><\/tr><tr><td id='likert_row_4_13_30' data-label='' class='gsurvey-likert-row-label'>Are you pregnant?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_30.4' type='radio' value='glikertrow65bc585f:glikertcol30e955410b'  id='choice_13_30_4_1'    aria-labelledby='likert_row_4_13_30 likert_col_1_13_30'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_30.4' type='radio' value='glikertrow65bc585f:glikertcol302f5214c1'  id='choice_13_30_4_2'    aria-labelledby='likert_row_4_13_30 likert_col_2_13_30'\/><\/td><\/tr><tr><td id='likert_row_5_13_30' data-label='' class='gsurvey-likert-row-label'>Do you have diabetes?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_30.5' type='radio' value='glikertrow4c07899b:glikertcol30e955410b'  id='choice_13_30_5_1'    aria-labelledby='likert_row_5_13_30 likert_col_1_13_30'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_30.5' type='radio' value='glikertrow4c07899b:glikertcol302f5214c1'  id='choice_13_30_5_2'    aria-labelledby='likert_row_5_13_30 likert_col_2_13_30'\/><\/td><\/tr><tr><td id='likert_row_6_13_30' data-label='' class='gsurvey-likert-row-label'>Do you have emphysema?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_30.6' type='radio' value='glikertrow2b36a823:glikertcol30e955410b'  id='choice_13_30_6_1'    aria-labelledby='likert_row_6_13_30 likert_col_1_13_30'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_30.6' type='radio' value='glikertrow2b36a823:glikertcol302f5214c1'  id='choice_13_30_6_2'    aria-labelledby='likert_row_6_13_30 likert_col_2_13_30'\/><\/td><\/tr><tr><td id='likert_row_7_13_30' data-label='' class='gsurvey-likert-row-label'>Do you feel pain in your chest when you engage in physical activity?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_30.7' type='radio' value='glikertrowd245f346:glikertcol30e955410b'  id='choice_13_30_7_1'    aria-labelledby='likert_row_7_13_30 likert_col_1_13_30'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_30.7' type='radio' value='glikertrowd245f346:glikertcol302f5214c1'  id='choice_13_30_7_2'    aria-labelledby='likert_row_7_13_30 likert_col_2_13_30'\/><\/td><\/tr><tr><td id='likert_row_8_13_30' data-label='' class='gsurvey-likert-row-label'>Do you have chronic bronchitis?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_30.8' type='radio' value='glikertrow6ac3c3ef:glikertcol30e955410b'  id='choice_13_30_8_1'    aria-labelledby='likert_row_8_13_30 likert_col_1_13_30'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_30.8' type='radio' value='glikertrow6ac3c3ef:glikertcol302f5214c1'  id='choice_13_30_8_2'    aria-labelledby='likert_row_8_13_30 likert_col_2_13_30'\/><\/td><\/tr><tr><td id='likert_row_9_13_30' data-label='' class='gsurvey-likert-row-label'>In the past month, have you had chest pain when you were not doing physical activity?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_30.9' type='radio' value='glikertrow8d23b053:glikertcol30e955410b'  id='choice_13_30_9_1'    aria-labelledby='likert_row_9_13_30 likert_col_1_13_30'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_30.9' type='radio' value='glikertrow8d23b053:glikertcol302f5214c1'  id='choice_13_30_9_2'    aria-labelledby='likert_row_9_13_30 likert_col_2_13_30'\/><\/td><\/tr><tr><td id='likert_row_10_13_30' data-label='' class='gsurvey-likert-row-label'>Do you ever lose consciousness or do you ever lose control of your balance due to chronic dizziness?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_30.11' type='radio' value='glikertrow3ccfdc88:glikertcol30e955410b'  id='choice_13_30_11_1'    aria-labelledby='likert_row_10_13_30 likert_col_1_13_30'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_30.11' type='radio' value='glikertrow3ccfdc88:glikertcol302f5214c1'  id='choice_13_30_11_2'    aria-labelledby='likert_row_10_13_30 likert_col_2_13_30'\/><\/td><\/tr><tr><td id='likert_row_11_13_30' data-label='' class='gsurvey-likert-row-label'>Are you currently being treated for a bone or joint problem that restricts you from engaging in physical activity?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_30.12' type='radio' value='glikertrowfede3340:glikertcol30e955410b'  id='choice_13_30_12_1'    aria-labelledby='likert_row_11_13_30 likert_col_1_13_30'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_30.12' type='radio' value='glikertrowfede3340:glikertcol302f5214c1'  id='choice_13_30_12_2'    aria-labelledby='likert_row_11_13_30 likert_col_2_13_30'\/><\/td><\/tr><tr><td id='likert_row_12_13_30' data-label='' class='gsurvey-likert-row-label'>Has a physician ever told you or are you aware that you have high blood pressure?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_30.13' type='radio' value='glikertrow14746a87:glikertcol30e955410b'  id='choice_13_30_13_1'    aria-labelledby='likert_row_12_13_30 likert_col_1_13_30'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_30.13' type='radio' value='glikertrow14746a87:glikertcol302f5214c1'  id='choice_13_30_13_2'    aria-labelledby='likert_row_12_13_30 likert_col_2_13_30'\/><\/td><\/tr><tr><td id='likert_row_13_13_30' data-label='' class='gsurvey-likert-row-label'>Has anyone in your immediate family(parent\/brother\/sister) had a heart attack, stroke or cardiovascular disease before age 55?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_30.14' type='radio' value='glikertrow458ec84f:glikertcol30e955410b'  id='choice_13_30_14_1'    aria-labelledby='likert_row_13_13_30 likert_col_1_13_30'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_30.14' type='radio' value='glikertrow458ec84f:glikertcol302f5214c1'  id='choice_13_30_14_2'    aria-labelledby='likert_row_13_13_30 likert_col_2_13_30'\/><\/td><\/tr><tr><td id='likert_row_14_13_30' data-label='' class='gsurvey-likert-row-label'>Has a physician ever told you or are you aware that you have high cholesterol level?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_30.15' type='radio' value='glikertrowc277e0c4:glikertcol30e955410b'  id='choice_13_30_15_1'    aria-labelledby='likert_row_14_13_30 likert_col_1_13_30'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_30.15' type='radio' value='glikertrowc277e0c4:glikertcol302f5214c1'  id='choice_13_30_15_2'    aria-labelledby='likert_row_14_13_30 likert_col_2_13_30'\/><\/td><\/tr><tr><td id='likert_row_15_13_30' data-label='' class='gsurvey-likert-row-label'>Do you currently smoke?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_30.16' type='radio' value='glikertrowc6fd4755:glikertcol30e955410b'  id='choice_13_30_16_1'    aria-labelledby='likert_row_15_13_30 likert_col_1_13_30'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_30.16' type='radio' value='glikertrowc6fd4755:glikertcol302f5214c1'  id='choice_13_30_16_2'    aria-labelledby='likert_row_15_13_30 likert_col_2_13_30'\/><\/td><\/tr><tr><td id='likert_row_16_13_30' data-label='' class='gsurvey-likert-row-label'>Are you a male over 44 years of age?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_30.17' type='radio' value='glikertrow3cb1b6dd:glikertcol30e955410b'  id='choice_13_30_17_1'    aria-labelledby='likert_row_16_13_30 likert_col_1_13_30'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_30.17' type='radio' value='glikertrow3cb1b6dd:glikertcol302f5214c1'  id='choice_13_30_17_2'    aria-labelledby='likert_row_16_13_30 likert_col_2_13_30'\/><\/td><\/tr><tr><td id='likert_row_17_13_30' data-label='' class='gsurvey-likert-row-label'>Are you a female over 54 years of age?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_30.18' type='radio' value='glikertrowf6b6b7ff:glikertcol30e955410b'  id='choice_13_30_18_1'    aria-labelledby='likert_row_17_13_30 likert_col_1_13_30'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_30.18' type='radio' value='glikertrowf6b6b7ff:glikertcol302f5214c1'  id='choice_13_30_18_2'    aria-labelledby='likert_row_17_13_30 likert_col_2_13_30'\/><\/td><\/tr><tr><td id='likert_row_18_13_30' data-label='' class='gsurvey-likert-row-label'>Are you currently exercising LESS than 1 hour per week? If you answered no, Please list you activities.<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_30.19' type='radio' value='glikertrow1747a156:glikertcol30e955410b'  id='choice_13_30_19_1'    aria-labelledby='likert_row_18_13_30 likert_col_1_13_30'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_30.19' type='radio' value='glikertrow1747a156:glikertcol302f5214c1'  id='choice_13_30_19_2'    aria-labelledby='likert_row_18_13_30 likert_col_2_13_30'\/><\/td><\/tr><tr><td id='likert_row_19_13_30' data-label='' class='gsurvey-likert-row-label'>Are you currently taking any medication?<\/td><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_30.21' type='radio' value='glikertrow989f53f4:glikertcol30e955410b'  id='choice_13_30_21_1'    aria-labelledby='likert_row_19_13_30 likert_col_1_13_30'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_30.21' type='radio' value='glikertrow989f53f4:glikertcol302f5214c1'  id='choice_13_30_21_2'    aria-labelledby='likert_row_19_13_30 likert_col_2_13_30'\/><\/td><\/tr><\/tbody><\/table><\/div><\/div><div id=\"field_13_31\" class=\"gfield gfield--type-text 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_13_31'>If you answered &quot;No&quot; to whether or not you are currently exercising LESS that 1 hour per week, please list your activities.<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_13_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_32\" class=\"gfield gfield--type-text 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_13_32'>If you are currently taking medication, please list the medications and their purpose.<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_13_32' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_33\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col 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 are your specific fitness goals at the MAC? (Indicate 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_13_33'><div class='gchoice gchoice_13_33_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.1' type='checkbox'  value='Increase strength and endurance'  id='choice_13_33_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_33_1' id='label_13_33_1' class='gform-field-label gform-field-label--type-inline'>Increase strength and endurance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_33_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.2' type='checkbox'  value='Improve cardiovascular fitness'  id='choice_13_33_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_33_2' id='label_13_33_2' class='gform-field-label gform-field-label--type-inline'>Improve cardiovascular fitness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_33_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.3' type='checkbox'  value='Reduce body fat'  id='choice_13_33_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_33_3' id='label_13_33_3' class='gform-field-label gform-field-label--type-inline'>Reduce body fat<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_33_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.4' type='checkbox'  value='Exercise regularly'  id='choice_13_33_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_33_4' id='label_13_33_4' class='gform-field-label gform-field-label--type-inline'>Exercise regularly<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_33_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.5' type='checkbox'  value='Sports conditioning'  id='choice_13_33_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_33_5' id='label_13_33_5' class='gform-field-label gform-field-label--type-inline'>Sports conditioning<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_33_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.6' type='checkbox'  value='Improve flexibility'  id='choice_13_33_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_33_6' id='label_13_33_6' class='gform-field-label gform-field-label--type-inline'>Improve flexibility<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_33_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.7' type='checkbox'  value='Improve muscle tone'  id='choice_13_33_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_33_7' id='label_13_33_7' class='gform-field-label gform-field-label--type-inline'>Improve muscle tone<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_33_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.8' type='checkbox'  value='Increase muscle mass'  id='choice_13_33_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_33_8' id='label_13_33_8' class='gform-field-label gform-field-label--type-inline'>Increase muscle mass<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_33_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.9' type='checkbox'  value='Injury rehabilitation'  id='choice_13_33_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_33_9' id='label_13_33_9' class='gform-field-label gform-field-label--type-inline'>Injury rehabilitation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_33_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.11' type='checkbox'  value='Other'  id='choice_13_33_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_33_11' id='label_13_33_11' 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_13_34\" 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_13_34'>If other, please specify:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_13_34' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_35\" 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' >What are your specific health goals at the MAC? (Indicate 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_13_35'><div class='gchoice gchoice_13_35_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.1' type='checkbox'  value='Reduce stress'  id='choice_13_35_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_35_1' id='label_13_35_1' class='gform-field-label gform-field-label--type-inline'>Reduce stress<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_35_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.2' type='checkbox'  value='Control blood pressure'  id='choice_13_35_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_35_2' id='label_13_35_2' class='gform-field-label gform-field-label--type-inline'>Control blood pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_35_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.3' type='checkbox'  value='Stop smoking'  id='choice_13_35_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_35_3' id='label_13_35_3' class='gform-field-label gform-field-label--type-inline'>Stop smoking<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_35_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.4' type='checkbox'  value='Improve productivity'  id='choice_13_35_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_35_4' id='label_13_35_4' class='gform-field-label gform-field-label--type-inline'>Improve productivity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_35_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.5' type='checkbox'  value='Feel better overall'  id='choice_13_35_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_35_5' id='label_13_35_5' class='gform-field-label gform-field-label--type-inline'>Feel better overall<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_35_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.6' type='checkbox'  value='Improve nutritional habits'  id='choice_13_35_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_35_6' id='label_13_35_6' class='gform-field-label gform-field-label--type-inline'>Improve nutritional habits<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_35_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.7' type='checkbox'  value='Control cholesterol'  id='choice_13_35_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_35_7' id='label_13_35_7' class='gform-field-label gform-field-label--type-inline'>Control cholesterol<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_35_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.8' type='checkbox'  value='Achieve balance in life'  id='choice_13_35_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_35_8' id='label_13_35_8' class='gform-field-label gform-field-label--type-inline'>Achieve balance in life<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_35_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.9' type='checkbox'  value='Reduce back pain'  id='choice_13_35_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_35_9' id='label_13_35_9' class='gform-field-label gform-field-label--type-inline'>Reduce back pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_35_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.11' type='checkbox'  value='Increase my health awareness'  id='choice_13_35_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_35_11' id='label_13_35_11' class='gform-field-label gform-field-label--type-inline'>Increase my health awareness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_35_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.12' type='checkbox'  value='Other'  id='choice_13_35_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_35_12' id='label_13_35_12' 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_13_36\" class=\"gfield gfield--type-text gfield--input-type-text gf_list_2col 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_13_36'>If other, please specify:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_13_36' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_37\" 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' >What motivated you to join the MAC? (Indicate 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_13_37'><div class='gchoice gchoice_13_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='Convenience \/ location'  id='choice_13_37_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_37_1' id='label_13_37_1' class='gform-field-label gform-field-label--type-inline'>Convenience \/ location<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_37_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.2' type='checkbox'  value='Peer support'  id='choice_13_37_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_37_2' id='label_13_37_2' class='gform-field-label gform-field-label--type-inline'>Peer support<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_37_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.3' type='checkbox'  value='Medical reasons'  id='choice_13_37_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_37_3' id='label_13_37_3' class='gform-field-label gform-field-label--type-inline'>Medical reasons<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_37_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.4' type='checkbox'  value='Other'  id='choice_13_37_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_37_4' id='label_13_37_4' 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_13_38\" 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_13_38'>If other, please specify:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_13_38' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_39\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >I have read, understood, and completed this health history questionnaire. I made sure to seek out answers to any questionsto my full satisfaction. <\/div><fieldset id=\"field_13_40\" 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' >By checking this box, I am acknowledging that I have read and understood the statement listed above.<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_13_40'><div class='gchoice gchoice_13_40_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.1' type='checkbox'  value='I agree and understand.'  id='choice_13_40_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_40_1' id='label_13_40_1' class='gform-field-label gform-field-label--type-inline'>I agree and understand.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_41' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_13_41' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_4' class='gform_page' data-js='page-field-id-41' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_42\" 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\">Health\/fitness pre-participation screening questionnaire for students<\/h3><div class='gsection_description' id='gfield_description_13_42'>Assess your health needs by marking all <strong>TRUE<\/strong> statements.<\/div><\/div><fieldset id=\"field_13_43\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >History - you have had:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_13_43'><div class='gchoice gchoice_13_43_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.1' type='checkbox'  value='Heart attack'  id='choice_13_43_1'   aria-describedby=\"gfield_description_13_43\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_1' id='label_13_43_1' class='gform-field-label gform-field-label--type-inline'>Heart attack<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.2' type='checkbox'  value='Heart surgery'  id='choice_13_43_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_2' id='label_13_43_2' class='gform-field-label gform-field-label--type-inline'>Heart surgery<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.3' type='checkbox'  value='Cardiac catherization'  id='choice_13_43_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_3' id='label_13_43_3' class='gform-field-label gform-field-label--type-inline'>Cardiac catherization<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.4' type='checkbox'  value='Pacemaker\/ implantable cardiac defibrillator\/ rhythm disturbance'  id='choice_13_43_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_4' id='label_13_43_4' class='gform-field-label gform-field-label--type-inline'>Pacemaker\/ implantable cardiac defibrillator\/ rhythm disturbance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.5' type='checkbox'  value='Heart valve disease'  id='choice_13_43_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_5' id='label_13_43_5' class='gform-field-label gform-field-label--type-inline'>Heart valve disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.6' type='checkbox'  value='Heart failure'  id='choice_13_43_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_6' id='label_13_43_6' class='gform-field-label gform-field-label--type-inline'>Heart failure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.7' type='checkbox'  value='Heart transplantation'  id='choice_13_43_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_7' id='label_13_43_7' class='gform-field-label gform-field-label--type-inline'>Heart transplantation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_43_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.8' type='checkbox'  value='Congenial heart disease'  id='choice_13_43_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_43_8' id='label_13_43_8' class='gform-field-label gform-field-label--type-inline'>Congenial heart disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_13_43'>If you marked any of the statements in this section, consult your healthcare provider before engaging in exercise. You may need to use a facility with a medically qualified staff.<\/div><\/fieldset><fieldset id=\"field_13_44\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Symptoms - you have had:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_13_44'><div class='gchoice gchoice_13_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='You experience chest discomfort with exertion'  id='choice_13_44_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_44_1' id='label_13_44_1' class='gform-field-label gform-field-label--type-inline'>You experience chest discomfort with exertion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_44_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.2' type='checkbox'  value='You experience unreasonable breathlessness'  id='choice_13_44_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_44_2' id='label_13_44_2' class='gform-field-label gform-field-label--type-inline'>You experience unreasonable breathlessness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_44_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.3' type='checkbox'  value='You experience dizziness, fainting, blackouts.'  id='choice_13_44_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_44_3' id='label_13_44_3' class='gform-field-label gform-field-label--type-inline'>You experience dizziness, fainting, blackouts.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_44_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.4' type='checkbox'  value='You take heart medications.'  id='choice_13_44_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_44_4' id='label_13_44_4' class='gform-field-label gform-field-label--type-inline'>You take heart medications.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_45\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Other health issues:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_13_45'><div class='gchoice gchoice_13_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='You have musculoskeletal problems.'  id='choice_13_45_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_45_1' id='label_13_45_1' class='gform-field-label gform-field-label--type-inline'>You have musculoskeletal problems.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_45_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.2' type='checkbox'  value='You have concerns about the safety of exercise.'  id='choice_13_45_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_45_2' id='label_13_45_2' class='gform-field-label gform-field-label--type-inline'>You have concerns about the safety of exercise.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_45_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.3' type='checkbox'  value='You take prescription medication(s).'  id='choice_13_45_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_45_3' id='label_13_45_3' class='gform-field-label gform-field-label--type-inline'>You take prescription medication(s).<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_45_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.4' type='checkbox'  value='You are pregnant.'  id='choice_13_45_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_45_4' id='label_13_45_4' class='gform-field-label gform-field-label--type-inline'>You are pregnant.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_46\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Cardiovascular risk factors:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_13_46'><div class='gchoice gchoice_13_46_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.1' type='checkbox'  value='You smoke.'  id='choice_13_46_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_46_1' id='label_13_46_1' class='gform-field-label gform-field-label--type-inline'>You smoke.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_46_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.2' type='checkbox'  value='Your blood pressure is greater than 140\/90.'  id='choice_13_46_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_46_2' id='label_13_46_2' class='gform-field-label gform-field-label--type-inline'>Your blood pressure is greater than 140\/90.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_46_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.3' type='checkbox'  value='You don&#039;t know your blood pressure.'  id='choice_13_46_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_46_3' id='label_13_46_3' class='gform-field-label gform-field-label--type-inline'>You don't know your blood pressure.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_46_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.4' type='checkbox'  value='You take blood pressure medication.'  id='choice_13_46_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_46_4' id='label_13_46_4' class='gform-field-label gform-field-label--type-inline'>You take blood pressure medication.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_46_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.5' type='checkbox'  value='Your cholesterol is &gt;240 mg\/dL.'  id='choice_13_46_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_46_5' id='label_13_46_5' class='gform-field-label gform-field-label--type-inline'>Your cholesterol is &gt;240 mg\/dL.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_46_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.6' type='checkbox'  value='You don&#039;t know your cholesterol level.'  id='choice_13_46_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_46_6' id='label_13_46_6' class='gform-field-label gform-field-label--type-inline'>You don't know your cholesterol level.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_46_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.7' type='checkbox'  value='You are diabetic or take medicine to control your blood sugar.'  id='choice_13_46_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_46_7' id='label_13_46_7' class='gform-field-label gform-field-label--type-inline'>You are diabetic or take medicine to control your blood sugar.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_46_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.8' type='checkbox'  value='You are physically inactive (ex. you get less than 30 minutes of physical activity on at least 3 days per wk)'  id='choice_13_46_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_46_8' id='label_13_46_8' class='gform-field-label gform-field-label--type-inline'>You are physically inactive (ex. you get less than 30 minutes of physical activity on at least 3 days per wk)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_46_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.9' type='checkbox'  value='You are more than 20 pounds overweight.'  id='choice_13_46_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_46_9' id='label_13_46_9' class='gform-field-label gform-field-label--type-inline'>You are more than 20 pounds overweight.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_47\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >If you marked two or more of the statements from the \"Symptoms\", \"Other health issues\", and \"Cardiovascular risk factors\" sections, you should consult your healthcare provider before engaging in exercise. You might benefit from using a facility with a professionally qualified exercise staff to guide your exercise program.\n\nIf <strong>none of the above is true for you<\/strong>, you should be able to exercise safely without consulting your healthcare provider in almost any facility that meets your exercise needs.<\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_48' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_13_48' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_5' class='gform_page' data-js='page-field-id-48' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_49\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Mulerider Activity Center<\/h3><\/div><fieldset id=\"field_13_50\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Please check if you have a history of the following:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_13_50'><div class='gchoice gchoice_13_50_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.1' type='checkbox'  value='Heart attack'  id='choice_13_50_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_50_1' id='label_13_50_1' class='gform-field-label gform-field-label--type-inline'>Heart attack<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_50_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.2' type='checkbox'  value='Heart surgery'  id='choice_13_50_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_50_2' id='label_13_50_2' class='gform-field-label gform-field-label--type-inline'>Heart surgery<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_50_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.3' type='checkbox'  value='Cardiac catheterization'  id='choice_13_50_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_50_3' id='label_13_50_3' class='gform-field-label gform-field-label--type-inline'>Cardiac catheterization<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_50_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.4' type='checkbox'  value='Coronary angioplasty (PTCA)'  id='choice_13_50_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_50_4' id='label_13_50_4' class='gform-field-label gform-field-label--type-inline'>Coronary angioplasty (PTCA)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_50_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.5' type='checkbox'  value='Pacemaker\/ implantable cardiac defibrillator\/ rhythm disturbance'  id='choice_13_50_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_50_5' id='label_13_50_5' class='gform-field-label gform-field-label--type-inline'>Pacemaker\/ implantable cardiac defibrillator\/ rhythm disturbance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_50_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.6' type='checkbox'  value='Heart valve disease'  id='choice_13_50_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_50_6' id='label_13_50_6' class='gform-field-label gform-field-label--type-inline'>Heart valve disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_50_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.7' type='checkbox'  value='Congestive heart failure'  id='choice_13_50_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_50_7' id='label_13_50_7' class='gform-field-label gform-field-label--type-inline'>Congestive heart failure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_50_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.8' type='checkbox'  value='Heart transplantation'  id='choice_13_50_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_50_8' id='label_13_50_8' class='gform-field-label gform-field-label--type-inline'>Heart transplantation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_50_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.9' type='checkbox'  value='Congenital heart disease'  id='choice_13_50_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_50_9' id='label_13_50_9' class='gform-field-label gform-field-label--type-inline'>Congenital heart disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_51\" 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_13_51'>Date of the attack:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_13_51' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_52\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half 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_13_52'>Heart surgery: CABx:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_13_52' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_53\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half 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_13_53'>Stent #:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_13_53' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_54\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Please check if you have any of the following symptoms:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_13_54'><div class='gchoice gchoice_13_54_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.1' type='checkbox'  value='Experience chest discomfort with exertion'  id='choice_13_54_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_54_1' id='label_13_54_1' class='gform-field-label gform-field-label--type-inline'>Experience chest discomfort with exertion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_54_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.2' type='checkbox'  value='Experience unreasonable breathlessness'  id='choice_13_54_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_54_2' id='label_13_54_2' class='gform-field-label gform-field-label--type-inline'>Experience unreasonable breathlessness<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_13_55\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Please mark ALL true statements.<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_13_55'><div class='gchoice gchoice_13_55_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.1' type='checkbox'  value='You are a man older than 45 years.'  id='choice_13_55_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_55_1' id='label_13_55_1' class='gform-field-label gform-field-label--type-inline'>You are a man older than 45 years.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_55_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.2' type='checkbox'  value='You are a woman older than 55 years or you have had a hysterectomy or you are post- menopausal.'  id='choice_13_55_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_55_2' id='label_13_55_2' class='gform-field-label gform-field-label--type-inline'>You are a woman older than 55 years or you have had a hysterectomy or you are post- menopausal.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_55_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.3' type='checkbox'  value='You smoke.'  id='choice_13_55_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_55_3' id='label_13_55_3' class='gform-field-label gform-field-label--type-inline'>You smoke.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_55_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.4' type='checkbox'  value='Your blood pressure is greater than 140\/90 mmHg.'  id='choice_13_55_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_55_4' id='label_13_55_4' class='gform-field-label gform-field-label--type-inline'>Your blood pressure is greater than 140\/90 mmHg.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_55_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.5' type='checkbox'  value='You take blood pressure medication.'  id='choice_13_55_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_55_5' id='label_13_55_5' class='gform-field-label gform-field-label--type-inline'>You take blood pressure medication.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_55_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.6' type='checkbox'  value='Your blood cholesterol is greater than 240\/mg\/dL'  id='choice_13_55_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_55_6' id='label_13_55_6' class='gform-field-label gform-field-label--type-inline'>Your blood cholesterol is greater than 240\/mg\/dL<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_55_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.7' type='checkbox'  value='You have a close blood relative who had a heart attack before age 55(father or brother) or age 65 (mother or sister)'  id='choice_13_55_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_55_7' id='label_13_55_7' class='gform-field-label gform-field-label--type-inline'>You have a close blood relative who had a heart attack before age 55(father or brother) or age 65 (mother or sister)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_55_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.8' type='checkbox'  value='You are diabetic or take medicine to control your blood sugar.'  id='choice_13_55_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_55_8' id='label_13_55_8' class='gform-field-label gform-field-label--type-inline'>You are diabetic or take medicine to control your blood sugar.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_55_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.9' type='checkbox'  value='You have been diagnosed with kidney disease.'  id='choice_13_55_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_55_9' id='label_13_55_9' class='gform-field-label gform-field-label--type-inline'>You have been diagnosed with kidney disease.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_55_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.11' type='checkbox'  value='You have pulmonary (lung) problems.'  id='choice_13_55_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_55_11' id='label_13_55_11' class='gform-field-label gform-field-label--type-inline'>You have pulmonary (lung) problems.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_55_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.12' type='checkbox'  value='You have been diagnosed with thyroid or other endocronological disorder.'  id='choice_13_55_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_55_12' id='label_13_55_12' class='gform-field-label gform-field-label--type-inline'>You have been diagnosed with thyroid or other endocronological disorder.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_55_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.13' type='checkbox'  value='You have respiratory problems, such as asthma, chronic bronchitis, emphysema or COPD.'  id='choice_13_55_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_55_13' id='label_13_55_13' class='gform-field-label gform-field-label--type-inline'>You have respiratory problems, such as asthma, chronic bronchitis, emphysema or COPD.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_55_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.14' type='checkbox'  value='You have muscular problems.'  id='choice_13_55_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_55_14' id='label_13_55_14' class='gform-field-label gform-field-label--type-inline'>You have muscular problems.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_55_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.15' type='checkbox'  value='You have arthritis, rheumatism, or gout.'  id='choice_13_55_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_55_15' id='label_13_55_15' class='gform-field-label gform-field-label--type-inline'>You have arthritis, rheumatism, or gout.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_55_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.16' type='checkbox'  value='You have other orthopedic problems.'  id='choice_13_55_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_55_16' id='label_13_55_16' class='gform-field-label gform-field-label--type-inline'>You have other orthopedic problems.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_55_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.17' type='checkbox'  value='You are pregnant.'  id='choice_13_55_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_55_17' id='label_13_55_17' class='gform-field-label gform-field-label--type-inline'>You are pregnant.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_55_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.18' type='checkbox'  value='You have Multiple Sclerosis.'  id='choice_13_55_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_55_18' id='label_13_55_18' class='gform-field-label gform-field-label--type-inline'>You have Multiple Sclerosis.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_55_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.19' type='checkbox'  value='You have been diagnosed with osteoporosis.'  id='choice_13_55_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_55_19' id='label_13_55_19' class='gform-field-label gform-field-label--type-inline'>You have been diagnosed with osteoporosis.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_55_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.21' type='checkbox'  value='You are 20 lbs. or more overweight.'  id='choice_13_55_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_55_21' id='label_13_55_21' class='gform-field-label gform-field-label--type-inline'>You are 20 lbs. or more overweight.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_56\" class=\"gfield gfield--type-text 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_13_56'>What is the name of your blood pressure medication?<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_13_56' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_57\" class=\"gfield gfield--type-text 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_13_57'>Which relative had the heart attack, and at what age?<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_13_57' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_58\" class=\"gfield gfield--type-text 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_13_58'>What medicine do you take to control your blood sugar?<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_13_58' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_59\" class=\"gfield gfield--type-text 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_13_59'>What are your O2 requirements for your lung problems?<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_13_59' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_60\" 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_13_60'>Do you have any other medical conditions we need to be aware of?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_60' id='input_13_60' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_13_61\" 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_13_61'>Please list any previous surgeries you have undergone, and their dates.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_61' id='input_13_61' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_13_62\" 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_13_62'>List any medications you are taking, the dosage, and their usage.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_62' id='input_13_62' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_64' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_13_64' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_6' class='gform_page' data-js='page-field-id-64' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_66\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Release and Healthcare Verification<\/h3><\/div><div id=\"field_13_65\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >I, the undersigned, agree to indemnify and hold harmless, Southern Arkansas University, and employees from any claims, damages and actions of any kind or nature, whether at law or in equity, arising from my participation in the Southern Arkansas University Mulerider Activity Center, provided that such liability is not attributable to the sole negligence of the University. \n\nI realize that my participation in this activity involves risk of injury, including but not limited to tendonitis, strains, sprains, bursitis, fractures, delayed muscle soreness, contusions, abrasions, serious eye damage and even the possibility of death. Also, I recognize that there are many other risks of injury including serious and disabling injuries which may arise due to my participation in this activity and that it is not possible to specifically list each and every individual injury risk. By signing this form I desire, consent and voluntarily choose to take part in all such activities. Knowing the material risks and appreciating, knowing and reasonably anticipating that other injuries and death is a possibility, I assume all the risks normally incident to the nature of the activities and agree that the University or any of its employees conducting such activities will not be responsible for any damages or injuries resulting to me. \n\nFurthermore, I also confirm that I have appropriate healthcare insurance for this activity or if not, that I will not rely upon the University for medical expenses. Also, I understand that any injury incurred and the resulting medical expense from that injury will be my responsibility and the University will not be responsible for any related expenses.\n<\/div><fieldset id=\"field_13_67\" 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' >I acknowledge the release and healthcare verification listed above, and understand that by submitting the form I am agreeing to its terms.<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_13_67'><div class='gchoice gchoice_13_67_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.1' type='checkbox'  value='I understand and agree'  id='choice_13_67_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_67_1' id='label_13_67_1' class='gform-field-label gform-field-label--type-inline'>I understand and agree<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_68\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >I hereby give express written permission for my photograph to be used in the advertising and promotion of Southern Arkansas University, Magnolia, Arkansas. This includes printed as well as electronic publications (web pages).  <\/div><fieldset id=\"field_13_69\" 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' >I understand and agree to the terms of the photo release.<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_13_69'><div class='gchoice gchoice_13_69_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.1' type='checkbox'  value='Yes'  id='choice_13_69_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_69_1' id='label_13_69_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_70' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_13_70' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_7' class='gform_page' data-js='page-field-id-70' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_71\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Agreement and Release of Liability Form<\/h3><\/div><div id=\"field_13_72\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><ol>\n<li>In consideration of gaining membership or being allowed to participate in the activities and programs of the Mulerider Activity Center and to use its facilities, equipment, and machinery, I do hereby waive, release and forever discharge Southern Arkansas University and it officers, agents, employee, representatives, executors, and all other persons from any and all responsibilities or liability for injuries or damages resulting from my participation in all activities or my use of equipment or machinery in the above-mentioned facilities or arising out of my participation in any activities at said facility. I do also hereby release all of those mentioned and any others acting upon their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my participation in any activities of the Mulerider Activity Center or the use of any equipment at the Mulerider Activity Center.<\/li>\n\n<li>I understand and am aware that strength, feasibility, and aerobic exercise, including the use of equipment, is a potentially hazardous activity. I also understand that fitness activities involve a risk of injury and even death and I am voluntarily participating in these activities in these activities and using equipment and machinery with knowledge of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury or death.<\/li>\n\n<li>I do hereby further declare myself to by physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation in any of the activities and programs of the Mulerider Activity Center or use of equipment or machinery except as hereinafter stated. I do hereby acknowledge that I have been informed of the need for a physician\u2019s approval for my participation in an exercise\/fitness activity or in the use of exercise equipment and machinery. I also acknowledge that it has been recommended that I have a yearly or more frequent physical examination and consultation with the physician as to physical activity, exercise, and use of exercise and training equipment so that I might have recommendations concerning these fitness activities and equipment use. I acknowledge that I have either had a physical examination and have been given a physician\u2019s permission to participate, or that I have decided to participate in activity and\/or use of equipment and machinery without the approval of my physician and do hereby assume all responsibility for my participation and activities, and utilization of equipment and machinery in my activities.<\/li>\n<\/ol>\n<\/div><fieldset id=\"field_13_73\" 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' >By submitting this form I am agreeing to the terms outlined in the &quot;Agreement and Release of Liability Form&quot;, as well as all the other releases and signatures submitted throughout the form.<span class=\"gfield_required\"><span 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