{"id":62272,"date":"2025-08-10T13:13:38","date_gmt":"2025-08-10T17:13:38","guid":{"rendered":"https:\/\/gatransplant.blackbaudwp.com\/?page_id=62272"},"modified":"2025-08-10T13:15:58","modified_gmt":"2025-08-10T17:15:58","slug":"as-application","status":"publish","type":"page","link":"https:\/\/gatransplant.blackbaudwp.com\/es\/our-programs\/education-community-programs\/academic-scholarships\/as-application\/","title":{"rendered":"Solicitud de beca acad\u00e9mica"},"content":{"rendered":"<p><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                            \n\t\t\t\t\t\t\t&quot;*&quot; indicates required fields\n                        <form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_11' id='gform_11' class='compact' action='https:\/\/gatransplant.blackbaudwp.com\/es\/our-programs\/education-community-programs\/academic-scholarships\/as-application\/?fl_builder&#038;fl_builder_ui_iframe#gf_11' data-formid='11' novalidate data-trp-original-action=\"https:\/\/gatransplant.blackbaudwp.com\/our-programs\/education-community-programs\/academic-scholarships\/as-application\/?fl_builder&#038;fl_builder_ui_iframe#gf_11\">\n        \tStep 1 of 5 &#8211; General Information\n        \t\n                20%\n\t\t\t\t\t<fieldset id=\"field_11_1\"><legend class='gfield_label gform-field-label gfield_label_before_complex'>Scholarship Applicant&#039;s Name*<\/legend>\n                                                    <input type='text' name='input_1.3' id='input_11_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_11_1_3' class='gform-field-label gform-field-label--type-sub'>Primero<\/label>\n                                                    <input type='text' name='input_1.4' id='input_11_1_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_11_1_4' class='gform-field-label gform-field-label--type-sub'>Medio<\/label>\n                                                    <input type='text' name='input_1.6' id='input_11_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_11_1_6' class='gform-field-label gform-field-label--type-sub'>\u00daltimo<\/label>\n                        <\/fieldset><fieldset id=\"field_11_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_11_23_1' value=''    aria-required='true'    \/>\n                                        <label for='input_11_23_1' id='input_11_23_1_label' class='gform-field-label gform-field-label--type-sub'>Direcci\u00f3n<\/label>\n                                    <input type='text' name='input_23.3' id='input_11_23_3' value=''    aria-required='true'    \/>\n                                    <label for='input_11_23_3' id='input_11_23_3_label' class='gform-field-label gform-field-label--type-sub'>Ciudad<\/label>\n                                        <select name='input_23.4' id='input_11_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_11_23_4' id='input_11_23_4_label' class='gform-field-label gform-field-label--type-sub'>Estado<\/label>\n                                    <input type='text' name='input_23.5' id='input_11_23_5' value=''    aria-required='true'    \/>\n                                    <label for='input_11_23_5' id='input_11_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_11_23_6' value='United States' \/>\n                <\/fieldset><label class='gfield_label gform-field-label' for='input_11_155'>County*<\/label><input name='input_155' id='input_11_155' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><label class='gfield_label gform-field-label' for='input_11_26'>Correo electr\u00f3nico*<\/label>\n                            <input name='input_26' id='input_11_26' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <label class='gfield_label gform-field-label' for='input_11_24'>Primary Phone Number*<\/label><input name='input_24' id='input_11_24' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><label class='gfield_label gform-field-label' for='input_11_161'>Phone Type*<\/label><select name='input_161' id='input_11_161' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\"><option value='' selected='selected'><\/option><option value='Cell Phone'>Tel\u00e9fono m\u00f3vil<\/option><option value='Home Phone'>Tel\u00e9fono de casa<\/option><option value='Other'>Otro<\/option><\/select><label class='gfield_label gform-field-label' for='input_11_156'>G\u00e9nero*<\/label><select name='input_156' id='input_11_156' 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='I prefer not to answer'>Prefiero no contestar<\/option><\/select><label class='gfield_label gform-field-label' for='input_11_110'>Marital Status*<\/label><select name='input_110' id='input_11_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_11_29'>Fecha de nacimiento*<\/label>\n                            <input name='input_29' id='input_11_29' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_11_29_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            MM slash DD slash YYYY\n                        <input type='hidden' id='gforms_calendar_icon_input_11_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_11_31'>Social Security Number*<\/label><input name='input_31' id='input_11_31' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><label class='gfield_label gform-field-label' for='input_11_119'># in Household*<\/label><input name='input_119' id='input_11_119' type='number' step='any' min='1'  value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_119\" \/>Please enter a number greater than or equal to <strong>1<\/strong>.<label class='gfield_label gform-field-label' for='input_11_120'># of children in household*<\/label><input name='input_120' id='input_11_120' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_11_120\" \/>18 a\u00f1os o menos\n                         <input type='button' id='gform_next_button_11_121' 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_11_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                        <fieldset id=\"field_11_122\"><legend class='gfield_label gform-field-label gfield_label_before_complex'>Name of Transplant Recipient*<\/legend>\n                                                    <input type='text' name='input_122.3' id='input_11_122_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_11_122_3' class='gform-field-label gform-field-label--type-sub'>Primero<\/label>\n                                                    <input type='text' name='input_122.6' id='input_11_122_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_11_122_6' class='gform-field-label gform-field-label--type-sub'>\u00daltimo<\/label>\n                        <\/fieldset><label class='gfield_label gform-field-label' for='input_11_167'>Relationship to Applicant*<\/label><select name='input_167' id='input_11_167' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\"><option value='Self'>Yo<\/option><option value='Dependent'>Dependiente<\/option><option value='Spouse\/Partner'>C\u00f3nyuge \/ pareja<\/option><option value='Living Donor'>Donante vivo<\/option><option value='Parent of Transplant Patient'>Padre del paciente trasplantado<\/option><option value='Sibling of a Transplant Patient'>Hermano de un paciente trasplantado<\/option><\/select><label class='gfield_label gform-field-label' for='input_11_125'>Date of Transplant*<\/label>\n                            <input name='input_125' id='input_11_125' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_11_125_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            MM slash DD slash YYYY\n                        <input type='hidden' id='gforms_calendar_icon_input_11_125' class='gform_hidden' value='https:\/\/gatransplant.blackbaudwp.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><fieldset id=\"field_11_162\"><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_162.1' type='checkbox'  value='Kidney'  id='choice_11_162_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_162_1' id='label_11_162_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_162.2' type='checkbox'  value='Pancreas'  id='choice_11_162_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_162_2' id='label_11_162_2' 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_162.3' type='checkbox'  value='Heart'  id='choice_11_162_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_162_3' id='label_11_162_3' class='gform-field-label gform-field-label--type-inline'>Coraz\u00f3n<\/label>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_162.4' type='checkbox'  value='Liver'  id='choice_11_162_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_162_4' id='label_11_162_4' 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_162.5' type='checkbox'  value='Lung(s)'  id='choice_11_162_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_162_5' id='label_11_162_5' class='gform-field-label gform-field-label--type-inline'>Livianos)<\/label>\n\t\t\t\t\t\t\t<\/fieldset><label class='gfield_label gform-field-label' for='input_11_163'>Centro de trasplantes *<\/label><select name='input_163' id='input_11_163' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\"><option value='Augusta University'>Universidad de Augusta<\/option><option value='Children's healthcare'>Children&#8217;s Healthcare<\/option><option value='Duke Health'>Duke Health<\/option><option value='Emory Healthcare'>Emory Healthcare<\/option><option value='Mayo Clinic'>Mayo Clinic<\/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_11_165'>Otro<\/label><input name='input_165' id='input_11_165' type='text' value='' class='large'      aria-invalid=\"false\"   \/>\n                        <input type='button' id='gform_previous_button_11_10' 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_11_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_11_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_11_114'>Carrera (opcional)<\/label><select name='input_114' id='input_11_114' class='large gfield_select'     aria-invalid=\"false\"><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_11_115'>Otra Raza<\/label><input name='input_115' id='input_11_115' type='text' value='' class='large'      aria-invalid=\"false\"   \/><label class='gfield_label gform-field-label' for='input_11_116'>Nivel de educaci\u00f3n (opcional)<\/label><select name='input_116' id='input_11_116' class='large gfield_select'     aria-invalid=\"false\"><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_11_22'># de a\u00f1os<\/label><input name='input_22' id='input_11_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/><label class='gfield_label gform-field-label' for='input_11_117'>Estado de trabajo (elija)<\/label><select name='input_117' id='input_11_117' class='large gfield_select'     aria-invalid=\"false\"><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_11_39'>Nombre del empleador<\/label><input name='input_39' id='input_11_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/><label class='gfield_label gform-field-label' for='input_11_40'>Desde (fecha)<\/label>\n                            <input name='input_40' id='input_11_40' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_11_40_date_format\" aria-invalid=\"false\" \/>\n                            MM slash DD slash YYYY\n                        <input type='hidden' id='gforms_calendar_icon_input_11_40' class='gform_hidden' value='https:\/\/gatransplant.blackbaudwp.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><fieldset id=\"field_11_42\"><legend class='gfield_label gform-field-label gfield_label_before_complex'>Current Source of Income*<\/legend>\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_11_42_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_42_1' id='label_11_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_11_42_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_42_2' id='label_11_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_11_42_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_42_3' id='label_11_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_11_42_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_42_4' id='label_11_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_11_42_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_42_5' id='label_11_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='SS Retirement'  id='choice_11_42_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_42_6' id='label_11_42_6' class='gform-field-label gform-field-label--type-inline'>Jubilaci\u00f3n SS<\/label>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.7' type='checkbox'  value='SSDI'  id='choice_11_42_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_42_7' id='label_11_42_7' class='gform-field-label gform-field-label--type-inline'>SSDI<\/label>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.8' type='checkbox'  value='SSI'  id='choice_11_42_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_42_8' id='label_11_42_8' class='gform-field-label gform-field-label--type-inline'>SSI<\/label>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.9' type='checkbox'  value='Other'  id='choice_11_42_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_42_9' id='label_11_42_9' class='gform-field-label gform-field-label--type-inline'>Otro<\/label>\n\t\t\t\t\t\t\t<\/fieldset><fieldset id=\"field_11_43\"><legend class='gfield_label gform-field-label gfield_label_before_complex'>Current Source of Healthcare Coverage*<\/legend>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.1' type='checkbox'  value='Insurance'  id='choice_11_43_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_43_1' id='label_11_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='Parent&#039;s Insurance'  id='choice_11_43_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_43_2' id='label_11_43_2' class='gform-field-label gform-field-label--type-inline'>Parent&#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_11_43_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_43_3' id='label_11_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_11_43_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_43_4' id='label_11_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_11_43_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_43_5' id='label_11_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_11_43_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_43_6' id='label_11_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_11_43_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_43_7' id='label_11_43_7' class='gform-field-label gform-field-label--type-inline'>COBRA<\/label>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.8' type='checkbox'  value='Other'  id='choice_11_43_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_43_8' id='label_11_43_8' 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_11_166'>Proveedor de seguros<\/label><select name='input_166' id='input_11_166' class='medium gfield_select'     aria-invalid=\"false\"><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_11_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_11_48_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_48_1' id='label_11_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 or Brochure'  id='choice_11_48_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_48_2' id='label_11_48_2' class='gform-field-label gform-field-label--type-inline'>Revista o folleto de 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_11_48_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_48_3' id='label_11_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_11_48_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_48_4' id='label_11_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 Center Staff'  id='choice_11_48_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_48_5' id='label_11_48_5' class='gform-field-label gform-field-label--type-inline'>Personal del centro de trasplantes<\/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_11_48_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_48_6' id='label_11_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_11_46'>Nombre de la persona de la que se enter\u00f3 sobre los servicios de GTF:<\/label><input name='input_46' id='input_11_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/>\n                        <input type='button' id='gform_previous_button_11_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_11_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_11_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                        <fieldset id=\"field_11_131\"><legend class='gfield_label gform-field-label gfield_label_before_complex'>School Verification*<\/legend>School NameCity\/StateDate AttendedDate GraduatedGPA&nbsp;<input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_11_131\" aria-label='School Name, Row 1' data-aria-label-template='School Name, Row {0}' type='text' name='input_131[]' value=''   \/><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_11_131\" aria-label='City\/State, Row 1' data-aria-label-template='City\/State, Row {0}' type='text' name='input_131[]' value=''   \/><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_11_131\" aria-label='Date Attended, Row 1' data-aria-label-template='Date Attended, Row {0}' type='text' name='input_131[]' value=''   \/><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_11_131\" aria-label='Date Graduated, Row 1' data-aria-label-template='Date Graduated, Row {0}' type='text' name='input_131[]' value=''   \/><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_11_131\" aria-label='GPA, Row 1' data-aria-label-template='GPA, Row {0}' type='text' name='input_131[]' value=''   \/>   <button type=\"button\"  class='add_list_item' aria-label='Add another row' onclick='gformAddListItem(this, 4)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 4)'>Remove<\/button>Enumere todas las escuelas secundarias, escuelas t\u00e9cnicas y universidades a las que ha asistido:<\/fieldset><label class='gfield_label gform-field-label' for='input_11_132'>Puntuaciones ACT<\/label><input name='input_132' id='input_11_132' type='text' value='' class='large'      aria-invalid=\"false\"   \/><label class='gfield_label gform-field-label' for='input_11_133'>Puntuaciones del SAT (secciones de lectura y matem\u00e1ticas)<\/label><input name='input_133' id='input_11_133' type='text' value='' class='large'      aria-invalid=\"false\"   \/><label class='gfield_label gform-field-label' for='input_11_134'>List school and community activities, special awards, honors, advanced placement classes and leadership positions held:*<\/label><textarea name='input_134' id='input_11_134' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><label class='gfield_label gform-field-label' for='input_11_135'>Name of institution you plan to attend:*<\/label><input name='input_135' id='input_11_135' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><label class='gfield_label gform-field-label' for='input_11_137'>What degree or certificate are you pursuing:*<\/label><input name='input_137' id='input_11_137' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><label class='gfield_label gform-field-label' for='input_11_136'>Reason for selecting this institution:*<\/label><input name='input_136' id='input_11_136' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><label class='gfield_label gform-field-label' for='input_11_138'>Reason for selecting this career:*<\/label><textarea name='input_138' id='input_11_138' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><label class='gfield_label gform-field-label' for='input_11_168'>Have you been accepted into this school\/program?*<\/label><select name='input_168' id='input_11_168' 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_11_140'>Grade Level*<\/label><input name='input_140' id='input_11_140' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><label class='gfield_label gform-field-label' for='input_11_141'>Expected starting date*<\/label>\n                            <input name='input_141' id='input_11_141' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_11_141_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            MM slash DD slash YYYY\n                        <input type='hidden' id='gforms_calendar_icon_input_11_141' 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_11_142'>Expected completion date*<\/label>\n                            <input name='input_142' id='input_11_142' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_11_142_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            MM slash DD slash YYYY\n                        <input type='hidden' id='gforms_calendar_icon_input_11_142' class='gform_hidden' value='https:\/\/gatransplant.blackbaudwp.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><h3>Costo proyectado por a\u00f1o<\/h3><label class='gfield_label gform-field-label' for='input_11_145'>Tuition\/Fees*<\/label><input name='input_145' id='input_11_145' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><label class='gfield_label gform-field-label' for='input_11_146'>Housing\/Meals*<\/label><input name='input_146' id='input_11_146' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><label class='gfield_label gform-field-label' for='input_11_147'>Books*<\/label><input name='input_147' id='input_11_147' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><label class='gfield_label gform-field-label' for='input_11_148'>Travel*<\/label><input name='input_148' id='input_11_148' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><label class='gfield_label gform-field-label' for='input_11_149'>Total<\/label><input name='input_149' id='input_11_149' type='text' step='any'   value='' class='large gform-text-input-reset'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><fieldset id=\"field_11_150\"><legend class='gfield_label gform-field-label gfield_label_before_complex'>Scholarships or Grants &#8211; List all scholarships\/grants  that you have been awarded, including HOPE<\/legend>Name ScholarshipAnnual AmountScholarship Duration&nbsp;<input aria-invalid='false'   aria-label='Name Scholarship, Row 1' data-aria-label-template='Name Scholarship, Row {0}' type='text' name='input_150[]' value=''   \/><input aria-invalid='false'   aria-label='Annual Amount, Row 1' data-aria-label-template='Annual Amount, Row {0}' type='text' name='input_150[]' value=''   \/><input aria-invalid='false'   aria-label='Scholarship Duration, Row 1' data-aria-label-template='Scholarship Duration, Row {0}' type='text' name='input_150[]' 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><label class='gfield_label gform-field-label' for='input_11_169'>Do you currently have a student loan?*<\/label><select name='input_169' id='input_11_169' 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_11_152'>Cantidad aproximada ($)<\/label><input name='input_152' id='input_11_152' type='text' value='' class='large'      aria-invalid=\"false\"   \/><fieldset id=\"field_11_153\"><legend class='gfield_label gform-field-label gfield_label_before_complex'>Enumere a otras personas de su hogar que est\u00e1n actualmente en la escuela<\/legend>NameRelationshipSchool (Elem, HS,College)Expected Date of CompletionTuition&nbsp;<input aria-invalid='false'   aria-label='Name, Row 1' data-aria-label-template='Name, Row {0}' type='text' name='input_153[]' value=''   \/><input aria-invalid='false'   aria-label='Relationship, Row 1' data-aria-label-template='Relationship, Row {0}' type='text' name='input_153[]' value=''   \/><input aria-invalid='false'   aria-label='School (Elem, HS,College), Row 1' data-aria-label-template='School (Elem, HS,College), Row {0}' type='text' name='input_153[]' value=''   \/><input aria-invalid='false'   aria-label='Expected Date of Completion, Row 1' data-aria-label-template='Expected Date of Completion, Row {0}' type='text' name='input_153[]' value=''   \/><input aria-invalid='false'   aria-label='Tuition, Row 1' data-aria-label-template='Tuition, Row {0}' type='text' name='input_153[]' 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><label class='gfield_label gform-field-label' for='input_11_154'>Total Household Income Per Year*<\/label><select name='input_154' id='input_11_154' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\"><option value='Less than $50,000'>Menos de $50,000<\/option><option value='$50,000 to $100,000'>$50,000 a $100,000<\/option><option value='$100,000 to $150,000'>$100,000 a $150,000<\/option><option value='$150,000 to $200,000'>$150,000 a $200,000<\/option><option value='$200,000 to $250,000'>$200,000 a $250,000<\/option><option value='Greater than $250,000'>Mayor que $250,000<\/option><\/select>\n                        <input type='button' id='gform_previous_button_11_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_11_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_11_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                        <fieldset id=\"field_11_101\"><legend class='gfield_label gform-field-label gfield_label_before_complex'>Consent*<\/legend><input name='input_101.1' id='input_11_101_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_11_101\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label for='input_11_101_1'>Estoy de acuerdo con lo siguiente:<\/label><input type='hidden' name='input_101.2' value='I agree to the following:' class='gform_hidden' \/><input type='hidden' name='input_101.3' value='9' class='gform_hidden' \/>Declaro que la informaci\u00f3n reportada es verdadera, correcta y completa.<\/fieldset><label class='gfield_label gform-field-label' for='input_11_102'>Date*<\/label>\n                            <input name='input_102' id='input_11_102' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_11_102_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            MM slash DD slash YYYY\n                        <input type='hidden' id='gforms_calendar_icon_input_11_102' 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_11_157'>School Transcripts*<\/label><input type='hidden' name='MAX_FILE_SIZE' value='16777216' \/><input name='input_157' id='input_11_157' type='file' class='medium' aria-describedby=\"gfield_upload_rules_11_157 gfield_description_11_157\" onchange='javascript:gformValidateFileSize( this, 16777216 );'  \/>Max. file size: 16 MB.Upload your official high school transcript (grades 9-12, or Fall semester) OR college\/technical school transcript for all courses. GED certificate, if applicable. If your last schooling was more than 5 years ago, current admission testing is acceptable in place of high school transcripts.<label class='gfield_label gform-field-label' for='input_11_158'>Acceptance Letter*<\/label><input type='hidden' name='MAX_FILE_SIZE' value='16777216' \/><input name='input_158' id='input_11_158' type='file' class='medium' aria-describedby=\"gfield_upload_rules_11_158 gfield_description_11_158\" onchange='javascript:gformValidateFileSize( this, 16777216 );'  \/>Max. file size: 16 MB.Upload a copy of the acceptance letter to your current institution.<label class='gfield_label gform-field-label' for='input_11_159'>Student&#039;s Personal Statement*<\/label><input type='hidden' name='MAX_FILE_SIZE' value='16777216' \/><input name='input_159' id='input_11_159' type='file' class='medium' aria-describedby=\"gfield_upload_rules_11_159 gfield_description_11_159\" onchange='javascript:gformValidateFileSize( this, 16777216 );'  \/>Max. file size: 16 MB.Maximum of three (3) pages. Describe yourself and how transplantation has affected your life. Tell us something about you that would help us to know you better. You might relate some event that changed your life or beliefs, or an issue about which you have strong feelings. Please tell us about your life goals as they relate to your field of study.<label class='gfield_label gform-field-label' for='gform_browse_button_11_160'>Two (2) Letters of Recommendation*<\/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_11_160' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_11_160 gfield_description_11_160\">Select files<\/button>\n\t\t\t\t\t\t\t\t\tMax. file size: 16 MB, Max. files: 3.<ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_11_160'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. -->Al menos uno de ellos debe ser de una fuente acad\u00e9mica. 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