{"id":62225,"date":"2025-08-10T11:37:02","date_gmt":"2025-08-10T15:37:02","guid":{"rendered":"https:\/\/gatransplant.blackbaudwp.com\/?page_id=62225"},"modified":"2025-08-10T11:53:19","modified_gmt":"2025-08-10T15:53:19","slug":"tfp-application","status":"publish","type":"page","link":"https:\/\/gatransplant.blackbaudwp.com\/es\/our-programs\/transplant-fundraising-program\/tfp-application\/","title":{"rendered":"Transplant Fundraising Program Application"},"content":{"rendered":"<h1>\n\t\t\tTransplant Fundraising Program Application\n\t\t<\/h1>\n\t\t\t<p>Debe completar esta solicitud lo mejor que pueda y proporcionar todos los documentos de respaldo para que lo revisen para recibir asistencia.&nbsp;&nbsp;<em>Please note: you can click &#8220;Save and Continue Later&#8221; at the bottom of the page, which will provide you with a link to access your application for 30 days. If you misplace this link or take longer than 30 days, you will lose any information previously entered.<\/em><\/p>\t\t\n\t\t\t<h3>Transplant Fundraising Program Application<\/h3>\n\t\t\n                            \n\t\t\t\t\t\t\t&#8220;*&#8221; indicates required fields\n                        <form method=\"post\" enctype=\"multipart\/form-data\" target=\"gform_ajax_frame_9\" id=\"gform_9\" class=\"compact\" action=\"https:\/\/gatransplant.blackbaudwp.com\/es\/our-programs\/transplant-fundraising-program\/tfp-application-2\/?fl_builder&#038;fl_builder_ui_iframe#gf_9\" data-formid=\"9\" novalidate=\"\" data-trp-original-action=\"https:\/\/gatransplant.blackbaudwp.com\/our-programs\/transplant-fundraising-program\/tfp-application-2\/?fl_builder&amp;fl_builder_ui_iframe#gf_9\">\n        \tStep 1 of 9 &#8211; General Information\n        \t\n                11%\n\t\t\t\t\t<fieldset id=\"field_9_1\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">Nombre*<\/legend>\n                                                    <select name=\"input_1.2\" id=\"input_9_1_2\" aria-required=\"false\">\n                          <option value=\"\"><\/option><option value=\"Mr.\">se\u00f1or.<\/option><option value=\"Mrs.\">Se\u00f1ora.<\/option><option value=\"Miss\">Pierda<\/option><option value=\"Ms.\">Em.<\/option><option value=\"Dr.\">Dr.<\/option><option value=\"Prof.\">Profe.<\/option><option value=\"Rev.\">Rvdo.<\/option>\n                      <\/select>\n                                                    <label for=\"input_9_1_2\" class=\"gform-field-label gform-field-label--type-sub\">T\u00edtulo<\/label>\n                                                    <input type=\"text\" name=\"input_1.3\" id=\"input_9_1_3\" value=\"\" aria-required=\"true\">\n                                                    <label for=\"input_9_1_3\" class=\"gform-field-label gform-field-label--type-sub\">Primero<\/label>\n                                                    <input type=\"text\" name=\"input_1.4\" id=\"input_9_1_4\" value=\"\" aria-required=\"false\">\n                                                    <label for=\"input_9_1_4\" class=\"gform-field-label gform-field-label--type-sub\">Medio<\/label>\n                                                    <input type=\"text\" name=\"input_1.6\" id=\"input_9_1_6\" value=\"\" aria-required=\"true\">\n                                                    <label for=\"input_9_1_6\" class=\"gform-field-label gform-field-label--type-sub\">\u00daltimo<\/label>\n                        <\/fieldset><fieldset id=\"field_9_23\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">Mailing Address*<\/legend>    \n                                        <input type=\"text\" name=\"input_23.1\" id=\"input_9_23_1\" value=\"\" aria-required=\"true\">\n                                        <label for=\"input_9_23_1\" id=\"input_9_23_1_label\" class=\"gform-field-label gform-field-label--type-sub\">Direcci\u00f3n<\/label>\n                                        <input type=\"text\" name=\"input_23.2\" id=\"input_9_23_2\" value=\"\" aria-required=\"false\">\n                                        <label for=\"input_9_23_2\" id=\"input_9_23_2_label\" class=\"gform-field-label gform-field-label--type-sub\">Condado<\/label>\n                                    <input type=\"text\" name=\"input_23.3\" id=\"input_9_23_3\" value=\"\" aria-required=\"true\">\n                                    <label for=\"input_9_23_3\" id=\"input_9_23_3_label\" class=\"gform-field-label gform-field-label--type-sub\">Ciudad<\/label>\n                                        <select name=\"input_23.4\" id=\"input_9_23_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\">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\">Distrito de Columbia<\/option><option value=\"Florida\">Florida<\/option><option value=\"Georgia\" selected=\"selected\">Georgia<\/option><option value=\"Guam\">Guam<\/option><option value=\"Hawaii\">Hawai<\/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\">Luisiana<\/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\">Misisip\u00ed<\/option><option value=\"Missouri\">Misuri<\/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\">Nuevo Mexico<\/option><option value=\"New York\">Nueva York<\/option><option value=\"North Carolina\">Carolina del Norte<\/option><option value=\"North Dakota\">Dakota del Norte<\/option><option value=\"Northern Mariana Islands\">Northern Mariana Islands<\/option><option value=\"Ohio\">Ohio<\/option><option value=\"Oklahoma\">Oklahoma<\/option><option value=\"Oregon\">Oreg\u00f3n<\/option><option value=\"Pennsylvania\">Pensilvania<\/option><option value=\"Puerto Rico\">Puerto Rico<\/option><option value=\"Rhode Island\">Rhode Island<\/option><option value=\"South Carolina\">Carolina del Sur<\/option><option value=\"South Dakota\">Dakota del Sur<\/option><option value=\"Tennessee\">Tennesse<\/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\">Virginia del Oeste<\/option><option value=\"Wisconsin\">Wisconsin<\/option><option value=\"Wyoming\">Wyoming<\/option><option value=\"Armed Forces Americas\">Fuerzas Armadas Am\u00e9ricas<\/option><option value=\"Armed Forces Europe\">Fuerzas Armadas de Europa<\/option><option value=\"Armed Forces Pacific\">Fuerzas Armadas del Pac\u00edfico<\/option><\/select>\n                                        <label for=\"input_9_23_4\" id=\"input_9_23_4_label\" class=\"gform-field-label gform-field-label--type-sub\">Estado<\/label>\n                                    <input type=\"text\" name=\"input_23.5\" id=\"input_9_23_5\" value=\"\" aria-required=\"true\">\n                                    <label for=\"input_9_23_5\" id=\"input_9_23_5_label\" class=\"gform-field-label gform-field-label--type-sub\">C\u00f3digo postal<\/label>\n                                <input type=\"hidden\" class=\"gform_hidden\" name=\"input_23.6\" id=\"input_9_23_6\" value=\"United States\">\n                <\/fieldset>This field is hidden when viewing the form<label class=\"gfield_label gform-field-label\" for=\"input_9_189\">Condado<\/label><input name=\"input_189\" id=\"input_9_189\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_25\">Tel\u00e9fono m\u00f3vil<\/label><input name=\"input_25\" id=\"input_9_25\" type=\"tel\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_24\">Tel\u00e9fono de casa<\/label><input name=\"input_24\" id=\"input_9_24\" type=\"tel\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_26\">Correo electr\u00f3nico*<\/label>\n                            <input name=\"input_26\" id=\"input_9_26\" type=\"email\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\">\n                        <label class=\"gfield_label gform-field-label\" for=\"input_9_191\">G\u00e9nero*<\/label><select name=\"input_191\" id=\"input_9_191\" class=\"large gfield_select\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"Male\">Masculino<\/option><option value=\"Female\">Hembra<\/option><option value=\"Prefer not to answer\">Prefiero no responder<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_110\">Marital Status*<\/label><select name=\"input_110\" id=\"input_9_110\" class=\"large gfield_select\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"Single\">Soltero<\/option><option value=\"Married\">Casado<\/option><option value=\"Divorced\">Divorciado<\/option><option value=\"Widowed\">Viudo<\/option><option value=\"Partnered\">Asociado<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_28\">Spouse\/Partner&#8217;s Name<\/label><input name=\"input_28\" id=\"input_9_28\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_29\">Fecha de nacimiento*<\/label>\n                            <input name=\"input_29\" id=\"input_9_29\" type=\"text\" value=\"\" class=\"datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon\" placeholder=\"mm\/dd\/yyyy\" aria-describedby=\"input_9_29_date_format\" aria-invalid=\"false\" aria-required=\"true\">\n                            MM slash DD slash YYYY\n                        <input type=\"hidden\" id=\"gforms_calendar_icon_input_9_29\" class=\"gform_hidden\" value=\"https:\/\/gatransplant.blackbaudwp.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg\"><label class=\"gfield_label gform-field-label\" for=\"input_9_31\">Social Security Number*<\/label><input name=\"input_31\" id=\"input_9_31\" type=\"text\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_119\"># Adults in Household*<\/label><input name=\"input_119\" id=\"input_9_119\" type=\"number\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_120\"># of children living in household*<\/label><input name=\"input_120\" id=\"input_9_120\" type=\"number\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_9_120\">18 a\u00f1os o menos<label class=\"gfield_label gform-field-label\" for=\"input_9_118\">Total # de personas que viven en el hogar<\/label><input name=\"input_118\" id=\"input_9_118\" type=\"text\" step=\"any\" value=\"\" class=\"large gform-text-input-reset\" readonly=\"readonly\" aria-invalid=\"false\">\n                         <input type=\"button\" id=\"gform_next_button_9_10\" class=\"gform_next_button gform-theme-button button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"next\" value=\"pr\u00f3ximo\"> <button type=\"button\" id=\"gform_save_9_2_link\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"save-continue\" class=\"gform_save_link gform-theme-button gform-theme-button--secondary button\"> Guardar y continuar m\u00e1s tarde<\/button>\n                        <label class=\"gfield_label gform-field-label\" for=\"input_9_114\">Carrera (opcional)<\/label><select name=\"input_114\" id=\"input_9_114\" class=\"large gfield_select\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"African American\">afroamericano<\/option><option value=\"Asian-American\">Asi\u00e1tico americano<\/option><option value=\"Asian-Pacific Islander\">Isle\u00f1o del Pac\u00edfico asi\u00e1tico<\/option><option value=\"Black\">Negro<\/option><option value=\"Hispanic\">Hispano<\/option><option value=\"Native American\">Nativo americano<\/option><option value=\"White, Non-Hispanic\">Blanco, no hispano<\/option><option value=\"Other\">Otro<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_115\">Otra Raza<\/label><input name=\"input_115\" id=\"input_9_115\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_116\">Nivel de educaci\u00f3n (opcional)<\/label><select name=\"input_116\" id=\"input_9_116\" class=\"large gfield_select\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"GED\">GED<\/option><option value=\"Attended High School\">Asisti\u00f3 a la escuela secundaria<\/option><option value=\"High School Graduate\">Graduado de preparatoria<\/option><option value=\"Technical Certificate\/Diploma\">Certificado \/ Diploma t\u00e9cnico<\/option><option value=\"Currently Enrolled in College\">Actualmente inscrito en la universidad<\/option><option value=\"Attended College\">Ir a la universidad<\/option><option value=\"Associates Degree\">Grado Asociado<\/option><option value=\"Bachelors Degree\">Licenciatura<\/option><option value=\"Post-Graduate Degree\">Poste grado graduado<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_22\"># de a\u00f1os<\/label><input name=\"input_22\" id=\"input_9_22\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_117\">Work Status*<\/label><select name=\"input_117\" id=\"input_9_117\" class=\"large gfield_select\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"Currently Employed\">Actualmente empleado<\/option><option value=\"Medically Disabled\">M\u00e9dicamente discapacitado<\/option><option value=\"Retired\">Retirado<\/option><option value=\"Unemployed\">Desempleados<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_40\">Since When (Date)*<\/label>\n                            <input name=\"input_40\" id=\"input_9_40\" type=\"text\" value=\"\" class=\"datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon\" placeholder=\"mm\/dd\/yyyy\" aria-describedby=\"input_9_40_date_format\" aria-invalid=\"false\" aria-required=\"true\">\n                            MM slash DD slash YYYY\n                        <input type=\"hidden\" id=\"gforms_calendar_icon_input_9_40\" class=\"gform_hidden\" value=\"https:\/\/gatransplant.blackbaudwp.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg\"><label class=\"gfield_label gform-field-label\" for=\"input_9_39\">Nombre del empleador<\/label><input name=\"input_39\" id=\"input_9_39\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\"><fieldset id=\"field_9_42\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">Fuente actual de ingresos<\/legend>(por favor marque todos los que apliquen)\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_42.1\" type=\"checkbox\" value=\"Full-Time Employment\" id=\"choice_9_42_1\" aria-describedby=\"gfield_description_9_42\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_42_1\" id=\"label_9_42_1\" class=\"gform-field-label gform-field-label--type-inline\">Empleo a tiempo completo<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_42.2\" type=\"checkbox\" value=\"Working Spouse\" id=\"choice_9_42_2\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_42_2\" id=\"label_9_42_2\" class=\"gform-field-label gform-field-label--type-inline\">C\u00f3nyuge que trabaja<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_42.3\" type=\"checkbox\" value=\"Part-Time Employment\" id=\"choice_9_42_3\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_42_3\" id=\"label_9_42_3\" class=\"gform-field-label gform-field-label--type-inline\">Trabajo de medio tiempo<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_42.4\" type=\"checkbox\" value=\"Parent(s) Income\" id=\"choice_9_42_4\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_42_4\" id=\"label_9_42_4\" class=\"gform-field-label gform-field-label--type-inline\">Ingresos de los padres<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_42.5\" type=\"checkbox\" value=\"Retirement Pension\" id=\"choice_9_42_5\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_42_5\" id=\"label_9_42_5\" class=\"gform-field-label gform-field-label--type-inline\">Pensi\u00f3n de retiro<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_42.6\" type=\"checkbox\" value=\"Social Security Retirement\" id=\"choice_9_42_6\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_42_6\" id=\"label_9_42_6\" class=\"gform-field-label gform-field-label--type-inline\">Jubilaci\u00f3n del Seguro Social<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_42.7\" type=\"checkbox\" value=\"Social Security Disability (SSDI)\" id=\"choice_9_42_7\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_42_7\" id=\"label_9_42_7\" class=\"gform-field-label gform-field-label--type-inline\">Discapacidad del Seguro Social (SSDI)<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_42.8\" type=\"checkbox\" value=\"Supplemental Security Income (SSI)\" id=\"choice_9_42_8\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_42_8\" id=\"label_9_42_8\" class=\"gform-field-label gform-field-label--type-inline\">Ingreso de seguridad suplementario (SSI)<\/label>\n\t\t\t\t\t\t\t<\/fieldset><fieldset id=\"field_9_43\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">Fuente actual de cobertura sanitaria<\/legend>(por favor marque todos los que apliquen)\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_43.1\" type=\"checkbox\" value=\"Insurance\" id=\"choice_9_43_1\" aria-describedby=\"gfield_description_9_43\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_43_1\" id=\"label_9_43_1\" class=\"gform-field-label gform-field-label--type-inline\">Seguro<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_43.2\" type=\"checkbox\" value=\"Spouse's Insurance\" id=\"choice_9_43_2\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_43_2\" id=\"label_9_43_2\" class=\"gform-field-label gform-field-label--type-inline\">Spouse&#8217;s Insurance<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_43.3\" type=\"checkbox\" value=\"Medicare\" id=\"choice_9_43_3\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_43_3\" id=\"label_9_43_3\" class=\"gform-field-label gform-field-label--type-inline\">Seguro m\u00e9dico del estado<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_43.4\" type=\"checkbox\" value=\"Medicaid\" id=\"choice_9_43_4\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_43_4\" id=\"label_9_43_4\" class=\"gform-field-label gform-field-label--type-inline\">Seguro de enfermedad<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_43.5\" type=\"checkbox\" value=\"QMB Medicaid\" id=\"choice_9_43_5\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_43_5\" id=\"label_9_43_5\" class=\"gform-field-label gform-field-label--type-inline\">QMB Medicaid<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_43.6\" type=\"checkbox\" value=\"Spend-down Medicaid\" id=\"choice_9_43_6\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_43_6\" id=\"label_9_43_6\" class=\"gform-field-label gform-field-label--type-inline\">Medicaid de reducci\u00f3n de gastos<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_43.7\" type=\"checkbox\" value=\"COBRA\" id=\"choice_9_43_7\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_43_7\" id=\"label_9_43_7\" class=\"gform-field-label gform-field-label--type-inline\">COBRA<\/label>\n\t\t\t\t\t\t\t<\/fieldset><label class=\"gfield_label gform-field-label\" for=\"input_9_192\">Proveedor de seguros<\/label><select name=\"input_192\" id=\"input_9_192\" class=\"large gfield_select\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"BCBS\">BCBS<\/option><option value=\"United Healthcare\">United Healthcare<\/option><option value=\"Humana\">Humana<\/option><option value=\"Kaiser\">Emperador<\/option><option value=\"Aetna\">Aetna<\/option><option value=\"Other\">Otro<\/option><\/select><fieldset id=\"field_9_45\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">Marque todo lo que le corresponda:<\/legend>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_45.1\" type=\"checkbox\" value=\"Recipient\" id=\"choice_9_45_1\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_45_1\" id=\"label_9_45_1\" class=\"gform-field-label gform-field-label--type-inline\">Recipiente<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_45.2\" type=\"checkbox\" value=\"Candidate\" id=\"choice_9_45_2\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_45_2\" id=\"label_9_45_2\" class=\"gform-field-label gform-field-label--type-inline\">Candidato<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_45.3\" type=\"checkbox\" value=\"Living Donor\" id=\"choice_9_45_3\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_45_3\" id=\"label_9_45_3\" class=\"gform-field-label gform-field-label--type-inline\">Donante vivo<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_45.4\" type=\"checkbox\" value=\"JumpStart Client\" id=\"choice_9_45_4\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_45_4\" id=\"label_9_45_4\" class=\"gform-field-label gform-field-label--type-inline\">Cliente JumpStart<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_45.5\" type=\"checkbox\" value=\"TNT Attendee\" id=\"choice_9_45_5\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_45_5\" id=\"label_9_45_5\" class=\"gform-field-label gform-field-label--type-inline\">Asistente de TNT<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_45.6\" type=\"checkbox\" value=\"Fundraising Workshop Attendee\" id=\"choice_9_45_6\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_45_6\" id=\"label_9_45_6\" class=\"gform-field-label gform-field-label--type-inline\">Asistente al taller de recaudaci\u00f3n de fondos<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_45.7\" type=\"checkbox\" value=\"Mentor\/Mentee\" id=\"choice_9_45_7\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_45_7\" id=\"label_9_45_7\" class=\"gform-field-label gform-field-label--type-inline\">Mentor \/ Mentee<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_45.8\" type=\"checkbox\" value=\"GTF Volunteer\/ Board Member\/ Committee Member\" id=\"choice_9_45_8\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_45_8\" id=\"label_9_45_8\" class=\"gform-field-label gform-field-label--type-inline\">Voluntario de GTF \/ Miembro de la Junta \/ Miembro del Comit\u00e9<\/label>\n\t\t\t\t\t\t\t<\/fieldset><fieldset id=\"field_9_48\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">How did you hear about GTF services?*<\/legend>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_48.1\" type=\"checkbox\" value=\"GTF Website\" id=\"choice_9_48_1\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_48_1\" id=\"label_9_48_1\" class=\"gform-field-label gform-field-label--type-inline\">Sitio web de GTF<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_48.2\" type=\"checkbox\" value=\"IMPRINT Magazine\" id=\"choice_9_48_2\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_48_2\" id=\"label_9_48_2\" class=\"gform-field-label gform-field-label--type-inline\">Revista IMPRINT<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_48.3\" type=\"checkbox\" value=\"GTF Staff\" id=\"choice_9_48_3\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_48_3\" id=\"label_9_48_3\" class=\"gform-field-label gform-field-label--type-inline\">Personal de GTF<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_48.4\" type=\"checkbox\" value=\"GTF Volunteer\" id=\"choice_9_48_4\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_48_4\" id=\"label_9_48_4\" class=\"gform-field-label gform-field-label--type-inline\">Voluntario GTF<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_48.5\" type=\"checkbox\" value=\"Transplant Staff\" id=\"choice_9_48_5\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_48_5\" id=\"label_9_48_5\" class=\"gform-field-label gform-field-label--type-inline\">Personal de trasplante<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_48.6\" type=\"checkbox\" value=\"Other\" id=\"choice_9_48_6\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_48_6\" id=\"label_9_48_6\" class=\"gform-field-label gform-field-label--type-inline\">Otro<\/label>\n\t\t\t\t\t\t\t<\/fieldset><label class=\"gfield_label gform-field-label\" for=\"input_9_46\">Nombre de la persona de la que se enter\u00f3 sobre los servicios de GTF:<\/label><input name=\"input_46\" id=\"input_9_46\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\">\n                        <input type=\"button\" id=\"gform_previous_button_9_60\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"previous\" value=\"Anterior\"> <input type=\"button\" id=\"gform_next_button_9_60\" class=\"gform_next_button gform-theme-button button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"next\" value=\"pr\u00f3ximo\"> <button type=\"button\" id=\"gform_save_9_3_link\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"save-continue\" class=\"gform_save_link gform-theme-button gform-theme-button--secondary button\"> Guardar y continuar m\u00e1s tarde<\/button>\n                        <label class=\"gfield_label gform-field-label\" for=\"input_9_123\">Centro de trasplantes *<\/label><select name=\"input_123\" id=\"input_9_123\" class=\"large gfield_select\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"Augusta University Health\">Salud de la Universidad de Augusta<\/option><option value=\"Children's Healthcare of Atlanta\">Children&#039;s Healthcare of Atlanta<\/option><option value=\"Duke Health\">Duke Health<\/option><option value=\"Emory Healthcare\">Emory Healthcare<\/option><option value=\"Mayo Clinic (Jacksonville)\">Cl\u00ednica Mayo (Jacksonville)<\/option><option value=\"MUSC Health\">Salud MUSC<\/option><option value=\"Piedmont Healthcare\">Piedmont Healthcare<\/option><option value=\"UAB Medicine\">Medicina UAB<\/option><option value=\"Other\">Otro<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_124\">Otro centro de trasplantes<\/label><input name=\"input_124\" id=\"input_9_124\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_126\">I am&#8230;*<\/label><select name=\"input_126\" id=\"input_9_126\" class=\"large gfield_select\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"Currently being evaluated for transplant\">Actualmente en evaluaci\u00f3n para trasplante<\/option><option value=\"Listed for transplant\">Listado para trasplante<\/option><option value=\"Transplanted\">Trasplantado<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_127\">Fecha de trasplante<\/label>\n                            <input name=\"input_127\" id=\"input_9_127\" type=\"text\" value=\"\" class=\"datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon\" placeholder=\"mm\/dd\/yyyy\" aria-describedby=\"input_9_127_date_format\" aria-invalid=\"false\">\n                            MM slash DD slash YYYY\n                        <input type=\"hidden\" id=\"gforms_calendar_icon_input_9_127\" class=\"gform_hidden\" value=\"https:\/\/gatransplant.blackbaudwp.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg\"><fieldset id=\"field_9_193\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">Organo*<\/legend>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_193.1\" type=\"checkbox\" value=\"Kidney\" id=\"choice_9_193_1\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_193_1\" id=\"label_9_193_1\" class=\"gform-field-label gform-field-label--type-inline\">Ri\u00f1\u00f3n<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_193.2\" type=\"checkbox\" value=\"Liver\" id=\"choice_9_193_2\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_193_2\" id=\"label_9_193_2\" class=\"gform-field-label gform-field-label--type-inline\">H\u00edgado<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_193.3\" type=\"checkbox\" value=\"Lung(s)\" id=\"choice_9_193_3\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_193_3\" id=\"label_9_193_3\" class=\"gform-field-label gform-field-label--type-inline\">Livianos)<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_193.4\" type=\"checkbox\" value=\"Pancreas\" id=\"choice_9_193_4\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_193_4\" id=\"label_9_193_4\" class=\"gform-field-label gform-field-label--type-inline\">P\u00e1ncreas<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_193.5\" type=\"checkbox\" value=\"Heart\" id=\"choice_9_193_5\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_193_5\" id=\"label_9_193_5\" class=\"gform-field-label gform-field-label--type-inline\">Coraz\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/fieldset><fieldset id=\"field_9_190\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">I am raising funds for:*<\/legend>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_190.1\" type=\"checkbox\" value=\"Prescription medications\" id=\"choice_9_190_1\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_190_1\" id=\"label_9_190_1\" class=\"gform-field-label gform-field-label--type-inline\">Medicamentos recetados<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_190.2\" type=\"checkbox\" value=\"Medical insurance premiums\" id=\"choice_9_190_2\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_190_2\" id=\"label_9_190_2\" class=\"gform-field-label gform-field-label--type-inline\">Primas de seguro m\u00e9dico<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_190.3\" type=\"checkbox\" value=\"Other transplant-related expenses\" id=\"choice_9_190_3\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_190_3\" id=\"label_9_190_3\" class=\"gform-field-label gform-field-label--type-inline\">Otros gastos relacionados con el trasplante<\/label>\n\t\t\t\t\t\t\t<\/fieldset><label class=\"gfield_label gform-field-label\" for=\"input_9_125\">Financial Coordinator\/Social Worker Name:*<\/label><input name=\"input_125\" id=\"input_9_125\" type=\"text\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\">\n                        <input type=\"button\" id=\"gform_previous_button_9_122\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"previous\" value=\"Anterior\"> <input type=\"button\" id=\"gform_next_button_9_122\" class=\"gform_next_button gform-theme-button button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"next\" value=\"pr\u00f3ximo\"> <button type=\"button\" id=\"gform_save_9_4_link\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"save-continue\" class=\"gform_save_link gform-theme-button gform-theme-button--secondary button\"> Guardar y continuar m\u00e1s tarde<\/button>\n                        <h3>Informaci\u00f3n del seguro<\/h3>Si tiene preguntas sobre su cobertura, comun\u00edquese con su compa\u00f1\u00eda de seguros o con el coordinador financiero \/ trabajador social del centro de trasplantes.<label class=\"gfield_label gform-field-label\" for=\"input_9_130\">Medical Insurance (Primary):*<\/label><input name=\"input_130\" id=\"input_9_130\" type=\"text\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_131\">Seguro m\u00e9dico (secundario):<\/label><input name=\"input_131\" id=\"input_9_131\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_132\">Tipo de cobertura:<\/label><select name=\"input_132\" id=\"input_9_132\" class=\"large gfield_select\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"Medicare\">Seguro m\u00e9dico del estado<\/option><option value=\"Medicare Advantage\">Medicare Advantage<\/option><option value=\"Medicare Supplement\">Suplemento de Medicare<\/option><option value=\"Katie Beckett\">Katie Beckett<\/option><option value=\"Medicaid\">Seguro de enfermedad<\/option><option value=\"Medicaid Spend-Down\">Reducci\u00f3n de gastos de Medicaid<\/option><option value=\"QMB Medicaid\">QMB Medicaid<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_133\">Tipo de Medicare<\/label><select name=\"input_133\" id=\"input_9_133\" class=\"large gfield_select\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"Medicare A\">Medicare A<\/option><option value=\"Medicare B\">Medicare B<\/option><option value=\"Medicare D\">Medicare D<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_134\">Informaci\u00f3n complementaria de Medicare<\/label><input name=\"input_134\" id=\"input_9_134\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_135\">\u00bfC\u00f3mo tienes esta cobertura?<\/label><select name=\"input_135\" id=\"input_9_135\" class=\"large gfield_select\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"ESRD\">ESRD<\/option><option value=\"My Employment\">Mi empleo<\/option><option value=\"Spouse's Employment\">Spouse&#8217;s Employment<\/option><option value=\"Private Policy\">Pol\u00edtica privada<\/option><option value=\"COBRA\">COBRA<\/option><option value=\"Retirement\">Jubilaci\u00f3n<\/option><option value=\"Disabled\">Discapacitado<\/option><option value=\"Other\">Otro<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_136\">Otra Cobertura<\/label><input name=\"input_136\" id=\"input_9_136\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\"><h3>\u00bfQu\u00e9 cubre su seguro para el trasplante?<\/h3><label class=\"gfield_label gform-field-label\" for=\"input_9_139\">Deducible anual ($)<\/label><input name=\"input_139\" id=\"input_9_139\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_140\">Desembolso m\u00e1ximo anual ($)<\/label><input name=\"input_140\" id=\"input_9_140\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_141\">Beneficio m\u00e1ximo anual ($)<\/label><input name=\"input_141\" id=\"input_9_141\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_142\">Beneficio m\u00e1ximo de por vida ($)<\/label><input name=\"input_142\" id=\"input_9_142\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_143\">Copagos de inmunosupresores<\/label><input name=\"input_143\" id=\"input_9_143\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\" aria-describedby=\"gfield_description_9_143\">(Estimaci\u00f3n mensual $)<h3>Deducible anual de Medicare:<\/h3><label class=\"gfield_label gform-field-label\" for=\"input_9_144\">Parte A ($)<\/label><input name=\"input_144\" id=\"input_9_144\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_147\">Parte B ($)<\/label><input name=\"input_147\" id=\"input_9_147\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_148\">Parte D ($)<\/label><input name=\"input_148\" id=\"input_9_148\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_146\">Copagos de inmunosupresores (mensual $):<\/label><input name=\"input_146\" id=\"input_9_146\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><h3>\u00bfHabr\u00e1 ALG\u00daN cambio en la cobertura de su seguro despu\u00e9s de su trasplante?<\/h3><label class=\"gfield_label gform-field-label\" for=\"input_9_155\">Elija el tipo de cobertura<\/label><select name=\"input_155\" id=\"input_9_155\" class=\"large gfield_select\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"Eligible for\/accepting Medicare, Medicare benefits\">Elegible para \/ aceptar Medicare, beneficios de Medicare<\/option><option value=\"Medicare terminates 3 years post-transplant (kidney)\">Medicare termina 3 a\u00f1os despu\u00e9s del trasplante (ri\u00f1\u00f3n)<\/option><option value=\"COBRA benefits terminate on\">Los beneficios de COBRA terminan el<\/option><option value=\"Insurance is dependent on disability status\">El seguro depende del estado de discapacidad<\/option><option value=\"Other\">Otro<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_156\">Fecha<\/label>\n                            <input name=\"input_156\" id=\"input_9_156\" type=\"text\" value=\"\" class=\"datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon\" placeholder=\"mm\/dd\/yyyy\" aria-describedby=\"input_9_156_date_format\" aria-invalid=\"false\">\n                            MM slash DD slash YYYY\n                        <input type=\"hidden\" id=\"gforms_calendar_icon_input_9_156\" class=\"gform_hidden\" value=\"https:\/\/gatransplant.blackbaudwp.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg\"><label class=\"gfield_label gform-field-label\" for=\"input_9_154\">Otro:<\/label><input name=\"input_154\" id=\"input_9_154\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\">\n                        <input type=\"button\" id=\"gform_previous_button_9_157\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"previous\" value=\"Anterior\"> <input type=\"button\" id=\"gform_next_button_9_157\" class=\"gform_next_button gform-theme-button button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"next\" value=\"pr\u00f3ximo\"> <button type=\"button\" id=\"gform_save_9_5_link\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"save-continue\" class=\"gform_save_link gform-theme-button gform-theme-button--secondary button\"> Guardar y continuar m\u00e1s tarde<\/button>\n                        <label class=\"gfield_label gform-field-label\" for=\"input_9_194\">Has your transplant center required you to prepare a financial plan for your transplant?*<\/label><select name=\"input_194\" id=\"input_9_194\" class=\"large gfield_select\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">si<\/option><option value=\"No\">No<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_195\">Have you attended a GTF Fundraising Workshop?*<\/label><select name=\"input_195\" id=\"input_9_195\" class=\"medium gfield_select\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">si<\/option><option value=\"No\">No<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_159\">What have you done to plan for your transplant?*<\/label><textarea name=\"input_159\" id=\"input_9_159\" class=\"textarea medium\" aria-required=\"true\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea>\n                        <input type=\"button\" id=\"gform_previous_button_9_129\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"previous\" value=\"Anterior\"> <input type=\"button\" id=\"gform_next_button_9_129\" class=\"gform_next_button gform-theme-button button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"next\" value=\"pr\u00f3ximo\"> <button type=\"button\" id=\"gform_save_9_6_link\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"save-continue\" class=\"gform_save_link gform-theme-button gform-theme-button--secondary button\"> Guardar y continuar m\u00e1s tarde<\/button>\n                        <h3>Bienes:<\/h3><label class=\"gfield_label gform-field-label\" for=\"input_9_52\">Checking ($)*<\/label><input name=\"input_52\" id=\"input_9_52\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_55\">Savings ($)*<\/label><input name=\"input_55\" id=\"input_9_55\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_56\">Stocks &amp; Bonds ($)*<\/label><input name=\"input_56\" id=\"input_9_56\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_57\">Retirement Accounts ($)*<\/label><input name=\"input_57\" id=\"input_9_57\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><fieldset id=\"field_9_196\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">Autom\u00f3vil (s)<\/legend>YearMake&nbsp;<input aria-invalid=\"false\" aria-label=\"Year, Row 1\" data-aria-label-template=\"Year, Row {0}\" type=\"text\" name=\"input_196[]\" value=\"\"><input aria-invalid=\"false\" aria-label=\"Make, Row 1\" data-aria-label-template=\"Make, Row {0}\" type=\"text\" name=\"input_196[]\" value=\"\">   <button type=\"button\" class=\"add_list_item\" aria-label=\"Add another row\" onclick=\"gformAddListItem(this, 0)\">Add<\/button>   <button type=\"button\" class=\"delete_list_item\" aria-label=\"Remove row 1\" data-aria-label-template=\"Remove row {0}\" onclick=\"gformDeleteListItem(this, 0)\">Remove<\/button><\/fieldset><h3>Ingresos netos mensuales del hogar (utilice la descripci\u00f3n que se indica a continuaci\u00f3n)<\/h3><strong>Casa:<\/strong> Todas las personas que viven en su hogar (incluidos todos los ni\u00f1os, adultos o menores), miembros del hogar no relacionados, padres, nietos, hermanos, inquilinos, etc.<br><br>\n<strong>Ingresos:<\/strong> Total amount for wages or salary income, self-employment income, interests, dividends and rental income, Social Security Retirement and Social Security Disability income, Supplemental Security Income, child support, public assistance, TANF, food stamps, family&#8217;s financial help, income from working children, parents, siblings, etc. who reside in your household. <br><br>\n<strong>Gastos:<\/strong> General household expenses per month &#8211; rent\/mortgage, food, average utilities, phone charges &#8211; basic phone, cell phone, credit card payments &#8211; monthly amount, not total balances owed.\n<label class=\"gfield_label gform-field-label\" for=\"input_9_62\">Wages (net $)*<\/label><input name=\"input_62\" id=\"input_9_62\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_63\">Spouse&#8217;s Income ($)<\/label><input name=\"input_63\" id=\"input_9_63\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_69\">Family Member&#8217;s Income ($)<\/label><input name=\"input_69\" id=\"input_9_69\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_68\">Seguridad social ($)<\/label><input name=\"input_68\" id=\"input_9_68\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_67\">Discapacidad adicional ($)<\/label><input name=\"input_67\" id=\"input_9_67\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_66\">Pensi\u00f3n ($)<\/label><input name=\"input_66\" id=\"input_9_66\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_71\">Ingresos de jubilaci\u00f3n ($)<\/label><input name=\"input_71\" id=\"input_9_71\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_70\">Pensi\u00f3n de veteranos ($)<\/label><input name=\"input_70\" id=\"input_9_70\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_65\">TANF ($)<\/label><input name=\"input_65\" id=\"input_9_65\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_64\">Cupones para alimentos ($)<\/label><input name=\"input_64\" id=\"input_9_64\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_75\">Ingresos por alquiler ($)<\/label><input name=\"input_75\" id=\"input_9_75\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_74\">Dividendos ($)<\/label><input name=\"input_74\" id=\"input_9_74\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_76\">Otro ($)<\/label><input name=\"input_76\" id=\"input_9_76\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_77\">Ingresos mensuales totales<\/label><input name=\"input_77\" id=\"input_9_77\" type=\"text\" step=\"any\" value=\"\" class=\"large gform-text-input-reset\" readonly=\"readonly\" aria-invalid=\"false\"><h3>Gastos dom\u00e9sticos mensuales:<\/h3><label class=\"gfield_label gform-field-label\" for=\"input_9_73\">Rent or Mortgage ($)*<\/label><input name=\"input_73\" id=\"input_9_73\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_91\">Food ($)*<\/label><input name=\"input_91\" id=\"input_9_91\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_90\">Home Phone and Internet ($)*<\/label><input name=\"input_90\" id=\"input_9_90\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_89\">Gas and Electric ($)*<\/label><input name=\"input_89\" id=\"input_9_89\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_88\">Cell Phone ($)*<\/label><input name=\"input_88\" id=\"input_9_88\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_87\">Water ($)*<\/label><input name=\"input_87\" id=\"input_9_87\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_86\">Transporte p\u00fablico ($)<\/label><input name=\"input_86\" id=\"input_9_86\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_85\">Pago autom\u00e1tico ($)<\/label><input name=\"input_85\" id=\"input_9_85\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_72\">Gasolina ($)<\/label><input name=\"input_72\" id=\"input_9_72\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_84\">Honorarios m\u00e9dicos ($)<\/label><input name=\"input_84\" id=\"input_9_84\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_83\">Pagos hospitalarios ($)<\/label><input name=\"input_83\" id=\"input_9_83\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_82\">Medicamentos recetados ($)<\/label><input name=\"input_82\" id=\"input_9_82\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_81\">Dental ($)<\/label><input name=\"input_81\" id=\"input_9_81\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_80\">Seguro m\u00e9dico ($)<\/label><input name=\"input_80\" id=\"input_9_80\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_94\">Seguro de vida ($)<\/label><input name=\"input_94\" id=\"input_9_94\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_93\">Seguro de autom\u00f3vil ($)<\/label><input name=\"input_93\" id=\"input_9_93\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_92\">Tarjetas bancarias ($)<\/label><input name=\"input_92\" id=\"input_9_92\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\" aria-describedby=\"gfield_description_9_92\">pagos mensuales<label class=\"gfield_label gform-field-label\" for=\"input_9_97\">Otro<\/label><input name=\"input_97\" id=\"input_9_97\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_96\">Gastos mensuales totales<\/label><input name=\"input_96\" id=\"input_9_96\" type=\"text\" step=\"any\" value=\"\" class=\"large gform-text-input-reset\" readonly=\"readonly\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_98\">Si no est\u00e1 pagando el alquiler o la hipoteca, explique:<\/label><textarea name=\"input_98\" id=\"input_9_98\" class=\"textarea medium\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea><label class=\"gfield_label gform-field-label\" for=\"input_9_99\">Si sus gastos mensuales son m\u00e1s que sus ingresos mensuales, explique c\u00f3mo paga sus facturas cada mes:<\/label><textarea name=\"input_99\" id=\"input_9_99\" class=\"textarea medium\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea>\n                        <input type=\"button\" id=\"gform_previous_button_9_100\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"previous\" value=\"Anterior\"> <input type=\"button\" id=\"gform_next_button_9_100\" class=\"gform_next_button gform-theme-button button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"next\" value=\"pr\u00f3ximo\"> <button type=\"button\" id=\"gform_save_9_7_link\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"save-continue\" class=\"gform_save_link gform-theme-button gform-theme-button--secondary button\"> Guardar y continuar m\u00e1s tarde<\/button>\n                        <b>CUENTA EMPAREJADA<\/b>\n<ul>\n<li>Los fondos recaudados dentro de un (1) a\u00f1o de aceptaci\u00f3n en el Programa se igualan hasta un m\u00e1ximo de $10,000.<\/li>\n<li>Debe ser aceptado en el Programa antes del trasplante.<\/li>\n<li>Los fondos se limitan a $1,000 para los costos de medicamentos sin receta.<\/li>\n<li>Las primas del seguro m\u00e9dico no est\u00e1n sujetas al l\u00edmite de $1,000.<\/li>\n<\/ul>\nGTF cobra una tarifa administrativa de 3% por cada dep\u00f3sito realizado en la cuenta.\n\n<b>CUENTA INIGUALABLE<\/b>\n<ul>\n<li>Elegible para aplicar antes o despu\u00e9s del trasplante.<\/li>\n<li>Hay fondos disponibles para gastos razonables previos y posteriores al trasplante.<\/li>\n<li>L\u00edmites ampliados sobre los costos relacionados con el trasplante de medicamentos sin receta.<\/li>\n<li>GTF cobra una tarifa administrativa de 3% por cada dep\u00f3sito realizado en la cuenta.<\/li>\n<\/ul><label class=\"gfield_label gform-field-label\" for=\"input_9_164\">Please choose ONE type of account.*<\/label><select name=\"input_164\" id=\"input_9_164\" class=\"large gfield_select\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"Matched Account\">Cuenta emparejada<\/option><option value=\"Unmatched Account\">Cuenta incomparable<\/option><\/select>\n                        <input type=\"button\" id=\"gform_previous_button_9_166\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"previous\" value=\"Anterior\"> <input type=\"button\" id=\"gform_next_button_9_166\" class=\"gform_next_button gform-theme-button button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"next\" value=\"pr\u00f3ximo\"> <button type=\"button\" id=\"gform_save_9_8_link\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"save-continue\" class=\"gform_save_link gform-theme-button gform-theme-button--secondary button\"> Guardar y continuar m\u00e1s tarde<\/button>\n                        <fieldset id=\"field_9_168\"><legend class=\"gfield_label gform-field-label\">Please choose one PHARMACY OPTION:*<\/legend>\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_168\" type=\"radio\" value=\"I CHOOSE TO use the direct billing process for my post-transplant prescription medications. Prescription medications are supplied by a GTF-approved pharmacy.  This process will allow the GTF-approved pharmacy to bill my insurance, Medicare or Medicaid for the cost of my post-transplant prescription medications. The balance or co-pay will then be directly taken from my TFP account.  This process will allow me to have my fundraising account directly billed so that I do not have to pay upfront for my prescription medications.  It is my responsibility to notify my transplant center that I have chosen this option at the time of transplant.  It is my responsibility to monitor this billing process by contacting the pharmacy directly as needed.\" id=\"choice_9_168_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_9_168_0\" id=\"label_9_168_0\" class=\"gform-field-label gform-field-label--type-inline\">ELIJO utilizar el proceso de facturaci\u00f3n directa para mis medicamentos recetados posteriores al trasplante. Los medicamentos recetados son suministrados por una farmacia aprobada por GTF. Este proceso permitir\u00e1 a la farmacia aprobada por GTF facturar a mi seguro, Medicare o Medicaid el costo de mis medicamentos recetados posteriores al trasplante. El saldo o copago se deducir\u00e1 directamente de mi cuenta de TFP. Este proceso me permitir\u00e1 hacer que mi cuenta de recaudaci\u00f3n de fondos se facture directamente para no tener que pagar por adelantado mis medicamentos recetados. Es mi responsabilidad notificar a mi centro de trasplantes que he elegido esta opci\u00f3n en el momento del trasplante. Es mi responsabilidad controlar este proceso de facturaci\u00f3n poni\u00e9ndome en contacto directamente con la farmacia seg\u00fan sea necesario.<\/label>\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_168\" type=\"radio\" value=\"I DO NOT CHOOSE to participate in Direct Billing with any of the Georgia Transplant Foundation\" s=\"\" partner=\"\" pharmacies=\"\" at=\"\" this=\"\" time.=\"\" i=\"\" understand=\"\" that=\"\" choice=\"\" means=\"\" will=\"\" have=\"\" to=\"\" pay=\"\" for=\"\" my=\"\" prescriptions=\"\" out=\"\" of=\"\" pocket=\"\" time=\"\" refill=\"\" and=\"\" be=\"\" reimbursed=\"\" from=\"\" tfp=\"\" account=\"\" a=\"\" later=\"\" time.'=\"\" id=\"choice_9_168_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_9_168_1\" id=\"label_9_168_1\" class=\"gform-field-label gform-field-label--type-inline\">I DO NOT CHOOSE to participate in Direct Billing with any of the Georgia Transplant Foundation&#8217;s partner pharmacies at this time. I understand that this choice means that I will have to pay for my prescriptions out of pocket at time of refill and be reimbursed from my TFP account at a later time.<\/label>\n\t\t\t<\/fieldset>\n                        <input type=\"button\" id=\"gform_previous_button_9_161\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"previous\" value=\"Anterior\"> <input type=\"button\" id=\"gform_next_button_9_161\" class=\"gform_next_button gform-theme-button button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"next\" value=\"pr\u00f3ximo\"> <button type=\"button\" id=\"gform_save_9_9_link\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"save-continue\" class=\"gform_save_link gform-theme-button gform-theme-button--secondary button\"> Guardar y continuar m\u00e1s tarde<\/button>\n                        <h3>OBLIGATORIO: Adem\u00e1s de usted mismo, identifique qui\u00e9n est\u00e1 autorizado para manejar sus asuntos financieros. Esta persona puede ser un c\u00f3nyuge, pariente o amigo, pero ser\u00e1 la \u00fanica persona con la que GTF hablar\u00e1 sobre su cuenta de recaudaci\u00f3n de fondos.<\/h3><fieldset id=\"field_9_170\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">Nombre*<\/legend>\n                                                    <select name=\"input_170.2\" id=\"input_9_170_2\" aria-required=\"false\">\n                          <option value=\"\"><\/option><option value=\"Dr.\">Dr.<\/option><option value=\"Miss\">Pierda<\/option><option value=\"Mr.\">se\u00f1or.<\/option><option value=\"Mrs.\">Se\u00f1ora.<\/option><option value=\"Ms.\">Em.<\/option><option value=\"Prof.\">Profe.<\/option><option value=\"Rev.\">Rvdo.<\/option>\n                      <\/select>\n                                                    <label for=\"input_9_170_2\" class=\"gform-field-label gform-field-label--type-sub\">Prefijo<\/label>\n                                                    <input type=\"text\" name=\"input_170.3\" id=\"input_9_170_3\" value=\"\" aria-required=\"true\">\n                                                    <label for=\"input_9_170_3\" class=\"gform-field-label gform-field-label--type-sub\">Primero<\/label>\n                                                    <input type=\"text\" name=\"input_170.4\" id=\"input_9_170_4\" value=\"\" aria-required=\"false\">\n                                                    <label for=\"input_9_170_4\" class=\"gform-field-label gform-field-label--type-sub\">Medio<\/label>\n                                                    <input type=\"text\" name=\"input_170.6\" id=\"input_9_170_6\" value=\"\" aria-required=\"true\">\n                                                    <label for=\"input_9_170_6\" class=\"gform-field-label gform-field-label--type-sub\">\u00daltimo<\/label>\n                        <\/fieldset><fieldset id=\"field_9_171\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">Direcci\u00f3n*<\/legend>    \n                                        <input type=\"text\" name=\"input_171.1\" id=\"input_9_171_1\" value=\"\" aria-required=\"true\">\n                                        <label for=\"input_9_171_1\" id=\"input_9_171_1_label\" class=\"gform-field-label gform-field-label--type-sub\">Direcci\u00f3n<\/label>\n                                    <input type=\"text\" name=\"input_171.3\" id=\"input_9_171_3\" value=\"\" aria-required=\"true\">\n                                    <label for=\"input_9_171_3\" id=\"input_9_171_3_label\" class=\"gform-field-label gform-field-label--type-sub\">Ciudad<\/label>\n                                        <select name=\"input_171.4\" id=\"input_9_171_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\">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\">Distrito de Columbia<\/option><option value=\"Florida\">Florida<\/option><option value=\"Georgia\" selected=\"selected\">Georgia<\/option><option value=\"Guam\">Guam<\/option><option value=\"Hawaii\">Hawai<\/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\">Luisiana<\/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\">Misisip\u00ed<\/option><option value=\"Missouri\">Misuri<\/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\">Nuevo Mexico<\/option><option value=\"New York\">Nueva York<\/option><option value=\"North Carolina\">Carolina del Norte<\/option><option value=\"North Dakota\">Dakota del Norte<\/option><option value=\"Northern Mariana Islands\">Northern Mariana Islands<\/option><option value=\"Ohio\">Ohio<\/option><option value=\"Oklahoma\">Oklahoma<\/option><option value=\"Oregon\">Oreg\u00f3n<\/option><option value=\"Pennsylvania\">Pensilvania<\/option><option value=\"Puerto Rico\">Puerto Rico<\/option><option value=\"Rhode Island\">Rhode Island<\/option><option value=\"South Carolina\">Carolina del Sur<\/option><option value=\"South Dakota\">Dakota del Sur<\/option><option value=\"Tennessee\">Tennesse<\/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\">Virginia del Oeste<\/option><option value=\"Wisconsin\">Wisconsin<\/option><option value=\"Wyoming\">Wyoming<\/option><option value=\"Armed Forces Americas\">Fuerzas Armadas Am\u00e9ricas<\/option><option value=\"Armed Forces Europe\">Fuerzas Armadas de Europa<\/option><option value=\"Armed Forces Pacific\">Fuerzas Armadas del Pac\u00edfico<\/option><\/select>\n                                        <label for=\"input_9_171_4\" id=\"input_9_171_4_label\" class=\"gform-field-label gform-field-label--type-sub\">Estado<\/label>\n                                    <input type=\"text\" name=\"input_171.5\" id=\"input_9_171_5\" value=\"\" aria-required=\"true\">\n                                    <label for=\"input_9_171_5\" id=\"input_9_171_5_label\" class=\"gform-field-label gform-field-label--type-sub\">C\u00f3digo postal<\/label>\n                                <input type=\"hidden\" class=\"gform_hidden\" name=\"input_171.6\" id=\"input_9_171_6\" value=\"United States\">\n                <\/fieldset><label class=\"gfield_label gform-field-label\" for=\"input_9_172\">Primary Phone Number*<\/label><input name=\"input_172\" id=\"input_9_172\" type=\"tel\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_175\">Correo electr\u00f3nico*<\/label>\n                            <input name=\"input_175\" id=\"input_9_175\" type=\"email\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\">\n                        <label class=\"gfield_label gform-field-label\" for=\"input_9_176\">Relationship to Client*<\/label><input name=\"input_176\" id=\"input_9_176\" type=\"text\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><fieldset id=\"field_9_177\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">Consent*<\/legend><input name=\"input_177.1\" id=\"input_9_177_1\" type=\"checkbox\" value=\"1\" aria-describedby=\"gfield_consent_description_9_177\" aria-required=\"true\" aria-invalid=\"false\"> <label for=\"input_9_177_1\">Estoy de acuerdo con lo siguiente:<\/label><input type=\"hidden\" name=\"input_177.2\" value=\"I agree to the following:\" class=\"gform_hidden\"><input type=\"hidden\" name=\"input_177.3\" value=\"7\" class=\"gform_hidden\">Entiendo que si se aprueba mi solicitud de una cuenta EMPAREJADA \/ NO COINCIDIDA, GTF cobra una tarifa administrativa de 3% por cada dep\u00f3sito realizado en mi cuenta.<\/fieldset><fieldset id=\"field_9_179\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">Consent*<\/legend><input name=\"input_179.1\" id=\"input_9_179_1\" type=\"checkbox\" value=\"1\" aria-describedby=\"gfield_consent_description_9_179\" aria-required=\"true\" aria-invalid=\"false\"> <label for=\"input_9_179_1\">Estoy de acuerdo con lo siguiente:<\/label><input type=\"hidden\" name=\"input_179.2\" value=\"I agree to the following:\" class=\"gform_hidden\"><input type=\"hidden\" name=\"input_179.3\" value=\"7\" class=\"gform_hidden\">Entiendo que si se aprueba mi solicitud para una cuenta de recaudaci\u00f3n de fondos de TFP, se me reembolsar\u00e1 y se me igualar\u00e1 DESPU\u00c9S de recibir mi trasplante, una vez que comience a comprar \/ pagar mis medicamentos recetados posteriores al trasplante y \/ o los gastos relacionados con el postrasplante aprobados y primas de seguro m\u00e9dico.<\/fieldset><fieldset id=\"field_9_178\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">Consent*<\/legend><input name=\"input_178.1\" id=\"input_9_178_1\" type=\"checkbox\" value=\"1\" aria-describedby=\"gfield_consent_description_9_178\" aria-required=\"true\" aria-invalid=\"false\"> <label for=\"input_9_178_1\">Estoy de acuerdo con lo siguiente:<\/label><input type=\"hidden\" name=\"input_178.2\" value=\"I agree to the following:\" class=\"gform_hidden\"><input type=\"hidden\" name=\"input_178.3\" value=\"7\" class=\"gform_hidden\">Entiendo que si se aprueba mi solicitud para una cuenta TFP igualada, se me reembolsar\u00e1 y se me asignar\u00e1 lo siguiente:<br>\n&#8211; Prescription medications necessitated by my transplant.<br>\n&#8211; Medical insurance premiums.<br>\n&#8211; A combined total of $1,000 for any of the following categories:<br>\n&#8212; Medical bills and co-pays related to my transplant, and\/or<br>\n&#8212; Travel and lodging expenses during my transplant for one (1) caregiver and\/or<br>\n&#8212; Travel and lodging expenses for my follow-up medical care<\/fieldset><h3>Documentos de respaldo<\/h3><label class=\"gfield_label gform-field-label\" for=\"gform_browse_button_9_185\">Proof of Georgia Residency*<\/label>\n\t\t\t\t\t\t\t\t\t\t\tDrop files here or \n\t\t\t\t\t\t\t\t\t\t\t<button type=\"button\" id=\"gform_browse_button_9_185\" class=\"button gform_button_select_files gform-theme-button gform-theme-button--control\" aria-describedby=\"gfield_upload_rules_9_185 gfield_description_9_185\">Select files<\/button>\n\t\t\t\t\t\t\t\t\tMax. file size: 16 MB.<ul class=\"validation_message--hidden-on-empty gform-ul-reset\" id=\"gform_multifile_messages_9_185\"><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. -->Proof of Georgia residency during the last six (6) months prior to the application date (this can be one of the following: a copy of your driver&#8217;s license issued at least six months prior; a six month old document with your current address, such as a bank statement or utility bill).\nIf you are applying for an unmatched account and do not reside in Georgia, you must provide proof that you are being transplanted at a hospital in Georgia.<label class=\"gfield_label gform-field-label\" for=\"gform_browse_button_9_197\">Proof of Household Income*<\/label>\n\t\t\t\t\t\t\t\t\t\t\tDrop files here or \n\t\t\t\t\t\t\t\t\t\t\t<button type=\"button\" id=\"gform_browse_button_9_197\" class=\"button gform_button_select_files gform-theme-button gform-theme-button--control\" aria-describedby=\"gfield_upload_rules_9_197 gfield_description_9_197\">Select files<\/button>\n\t\t\t\t\t\t\t\t\tMax. file size: 16 MB.<ul class=\"validation_message--hidden-on-empty gform-ul-reset\" id=\"gform_multifile_messages_9_197\"><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. -->This can be one of the following: a Social Security Income statement; your most recent pay stub; or a copy of your most recent Federal Income Tax Return.<label class=\"gfield_label gform-field-label\" for=\"input_9_198\">Tel\u00e9fono<\/label><input name=\"input_198\" id=\"input_9_198\" type=\"text\" value=\"\" autocomplete=\"new-password\">Este campo tiene fines de validaci\u00f3n y no debe modificarse.\n        <input type=\"submit\" id=\"gform_previous_button_9\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"previous\" value=\"Anterior\"> <input type=\"submit\" id=\"gform_submit_button_9\" class=\"gform_button button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"submit\" value=\"Enviar\"> <button type=\"button\" id=\"gform_save_9_footer_link\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"save-continue\" class=\"gform_save_link gform-theme-button gform-theme-button--secondary button\"> Guardar y continuar m\u00e1s tarde<\/button><input type=\"hidden\" name=\"gform_ajax\" value=\"form_id=9&amp;title=&amp;description=1&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=e5787c5c10fd9527b52110afb4e34a12\">\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"gform_submission_method\" data-js=\"gform_submission_method_9\" value=\"iframe\">\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"gform_theme\" data-js=\"gform_theme_9\" id=\"gform_theme_9\" value=\"gravity-theme\">\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"gform_style_settings\" data-js=\"gform_style_settings_9\" id=\"gform_style_settings_9\" value=\"[]\">\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"is_submit_9\" value=\"1\">\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"gform_submit\" value=\"9\">\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"gform_save\" id=\"gform_save_9\" value=\"\">\n                             <input type=\"hidden\" class=\"gform_hidden\" name=\"gform_resume_token\" id=\"gform_resume_token_9\" value=\"\">\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"gform_unique_id\" value=\"\">\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"state_9\" value=\"WyJ7XCIxNzcuMVwiOlwiY2RjYzI0NWYxNjZmNjAzYzc4ODMwZTA3Nzg4OTBhNzlcIixcIjE3Ny4yXCI6XCJjNmZkNDRhOTdmMjVhYjUwODM3NzAyMTI0MDE3Y2QzNFwiLFwiMTc3LjNcIjpcImEyM2JlNDAxODk5YzFhMmVhMzRjMjA2ZWI3YTczNGZjXCIsXCIxNzkuMVwiOlwiY2RjYzI0NWYxNjZmNjAzYzc4ODMwZTA3Nzg4OTBhNzlcIixcIjE3OS4yXCI6XCJjNmZkNDRhOTdmMjVhYjUwODM3NzAyMTI0MDE3Y2QzNFwiLFwiMTc5LjNcIjpcImEyM2JlNDAxODk5YzFhMmVhMzRjMjA2ZWI3YTczNGZjXCIsXCIxNzguMVwiOlwiY2RjYzI0NWYxNjZmNjAzYzc4ODMwZTA3Nzg4OTBhNzlcIixcIjE3OC4yXCI6XCJjNmZkNDRhOTdmMjVhYjUwODM3NzAyMTI0MDE3Y2QzNFwiLFwiMTc4LjNcIjpcImEyM2JlNDAxODk5YzFhMmVhMzRjMjA2ZWI3YTczNGZjXCJ9IiwiYWFiMTZkYTE4OTI4YWQ1NTAwYjUyMmQwNmZmYmMwNmIiXQ==\">\n            <input type=\"hidden\" autocomplete=\"off\" class=\"gform_hidden\" name=\"gform_target_page_number_9\" id=\"gform_target_page_number_9\" value=\"2\">\n            <input type=\"hidden\" autocomplete=\"off\" class=\"gform_hidden\" name=\"gform_source_page_number_9\" id=\"gform_source_page_number_9\" value=\"1\">\n            <input type=\"hidden\" name=\"gform_field_values\" value=\"\">\n            <input type=\"hidden\" name=\"gform_uploaded_files\" id=\"gform_uploaded_files_9\" value=\"\">\n                        <input type=\"hidden\" name=\"trp-form-language\" value=\"es\"\/><\/form>\n\t\t                <iframe style=\"display:none;width:0px;height:0px;\" src=\"about:blank\" name=\"gform_ajax_frame_9\" id=\"gform_ajax_frame_9\" title=\"Este iframe contiene la l\u00f3gica necesaria para manejar Gravity Forms con tecnolog\u00eda Ajax.\"><\/iframe>","protected":false},"excerpt":{"rendered":"<p>Transplant Fundraising Program Application You must complete this application to the best of your ability and provide all supporting documents in order to be reviewed for assistance.&nbsp;&nbsp;Please note: you can&hellip;<\/p>","protected":false},"author":43,"featured_media":0,"parent":6841,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-62225","page","type-page","status-publish","hentry"],"acf":[],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/gatransplant.blackbaudwp.com\/es\/wp-json\/wp\/v2\/pages\/62225","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/gatransplant.blackbaudwp.com\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/gatransplant.blackbaudwp.com\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/gatransplant.blackbaudwp.com\/es\/wp-json\/wp\/v2\/users\/43"}],"replies":[{"embeddable":true,"href":"https:\/\/gatransplant.blackbaudwp.com\/es\/wp-json\/wp\/v2\/comments?post=62225"}],"version-history":[{"count":4,"href":"https:\/\/gatransplant.blackbaudwp.com\/es\/wp-json\/wp\/v2\/pages\/62225\/revisions"}],"predecessor-version":[{"id":62263,"href":"https:\/\/gatransplant.blackbaudwp.com\/es\/wp-json\/wp\/v2\/pages\/62225\/revisions\/62263"}],"up":[{"embeddable":true,"href":"https:\/\/gatransplant.blackbaudwp.com\/es\/wp-json\/wp\/v2\/pages\/6841"}],"wp:attachment":[{"href":"https:\/\/gatransplant.blackbaudwp.com\/es\/wp-json\/wp\/v2\/media?parent=62225"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}