{"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\/vi\/our-programs\/education-community-programs\/academic-scholarships\/as-application\/","title":{"rendered":"\u0110\u01a1n xin h\u1ecdc b\u1ed5ng"},"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\/vi\/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'>\u0110\u1ea7u ti\u00ean<\/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'>\u1ede gi\u1eefa<\/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'>Cu\u1ed1i c\u00f9ng<\/label>\n                        <\/fieldset><fieldset id=\"field_11_23\"><legend class='gfield_label gform-field-label gfield_label_before_complex'>\u0110\u1ecba ch\u1ec9 g\u1eedi th\u01b0 *<\/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'>\u0110\u1ecba ch\u1ec9 \u0111\u01b0\u1eddng ph\u1ed1<\/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'>Tp.<\/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'>\u0110\u1eb7c khu Columbia<\/option><option value='Florida'>Florida<\/option><option value='Georgia' selected='selected'>Georgia<\/option><option value='Guam'>Guam<\/option><option value='Hawaii'>Hawaii<\/option><option value='Idaho'>Idaho<\/option><option value='Illinois'>Illinois<\/option><option value='Indiana'>Indiana<\/option><option value='Iowa'>Iowa<\/option><option value='Kansas'>Kansas<\/option><option value='Kentucky'>Kentucky<\/option><option value='Louisiana'>Louisiana<\/option><option value='Maine'>Maine<\/option><option value='Maryland'>Maryland<\/option><option value='Massachusetts'>Massachusetts<\/option><option value='Michigan'>Michigan<\/option><option value='Minnesota'>Minnesota<\/option><option value='Mississippi'>Mississippi<\/option><option value='Missouri'>Missouri<\/option><option value='Montana'>Montana<\/option><option value='Nebraska'>Nebraska<\/option><option value='Nevada'>Nevada<\/option><option value='New Hampshire'>M\u1edbi Hampshire<\/option><option value='New Jersey'>\u00c1o m\u1edbi<\/option><option value='New Mexico'>New Mexico<\/option><option value='New York'>Newyork<\/option><option value='North Carolina'>b\u1eafc Carolina<\/option><option value='North Dakota'>B\u1eafc Dakota<\/option><option value='Northern Mariana Islands'>Qu\u1ea7n \u0111\u1ea3o B\u1eafc Mariana<\/option><option value='Ohio'>Ohio<\/option><option value='Oklahoma'>Oklahoma<\/option><option value='Oregon'>Oregon<\/option><option value='Pennsylvania'>Pennsylvania<\/option><option value='Puerto Rico'>Puerto Rico<\/option><option value='Rhode Island'>\u0111\u1ea3o Rhode<\/option><option value='South Carolina'>ph\u00eda Nam Carolina<\/option><option value='South Dakota'>Nam Dakota<\/option><option value='Tennessee'>Tennessee<\/option><option value='Texas'>Texas<\/option><option value='Utah'>Utah<\/option><option value='U.S. Virgin Islands'>U.S. Virgin Islands<\/option><option value='Vermont'>Vermont<\/option><option value='Virginia'>Virginia<\/option><option value='Washington'>Washington<\/option><option value='West Virginia'>phia T\u00e2y Virginia<\/option><option value='Wisconsin'>Wisconsin<\/option><option value='Wyoming'>Wyoming<\/option><option value='Armed Forces Americas'>Qu\u00e2n \u0111\u1ed9i M\u1ef9<\/option><option value='Armed Forces Europe'>L\u1ef1c l\u01b0\u1ee3ng v\u0169 trang Ch\u00e2u \u00c2u<\/option><option value='Armed Forces Pacific'>L\u1ef1c l\u01b0\u1ee3ng v\u0169 trang Th\u00e1i B\u00ecnh D\u01b0\u01a1ng<\/option><\/select>\n                                        <label for='input_11_23_4' id='input_11_23_4_label' class='gform-field-label gform-field-label--type-sub'>Ti\u1ec3u bang<\/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'>M\u00e3 B\u01b0u Ch\u00ednh<\/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'>Qu\u1eadn *<\/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'>E-mail*<\/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'>S\u1ed1 \u0111i\u1ec7n tho\u1ea1i ch\u00ednh*<\/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'>Lo\u1ea1i \u0111i\u1ec7n tho\u1ea1i*<\/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'>\u0110i\u00ea\u0323n thoa\u0323i di \u0111\u00f4\u0323ng<\/option><option value='Home Phone'>\u0110i\u1ec7n tho\u1ea1i nh\u00e0<\/option><option value='Other'>Kh\u00e1c<\/option><\/select><label class='gfield_label gform-field-label' for='input_11_156'>Gi\u1edbi t\u00ednh *<\/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'>Nam gi\u1edbi<\/option><option value='Female'>Gi\u1ed1ng c\u00e1i<\/option><option value='I prefer not to answer'>T\u00f4i kh\u00f4ng mu\u1ed1n tr\u1ea3 l\u1eddi<\/option><\/select><label class='gfield_label gform-field-label' for='input_11_110'>T\u00ecnh tr\u1ea1ng h\u00f4n nh\u00e2n*<\/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'>\u0110\u1ed9c th\u00e2n<\/option><option value='Married'>C\u01b0\u1edbi nhau<\/option><option value='Divorced'>\u0110\u00e3 ly h\u00f4n<\/option><option value='Widowed'>G\u00f3a v\u1ee3<\/option><option value='Partnered'>H\u1ee3p t\u00e1c<\/option><\/select><label class='gfield_label gform-field-label' for='input_11_29'>Ng\u00e0y sinh*<\/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'>S\u1ed1 an sinh x\u00e3 h\u1ed9i *<\/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'># trong h\u1ed9 gia \u0111\u00ecnh *<\/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\" \/>Vui l\u00f2ng nh\u1eadp m\u1ed9t s\u1ed1 l\u1edbn h\u01a1n ho\u1eb7c b\u1eb1ng <strong>1<\/strong>.<label class='gfield_label gform-field-label' for='input_11_120'># c\u1ee7a tr\u1ebb em trong gia \u0111\u00ecnh *<\/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 tu\u1ed5i tr\u1edf xu\u1ed1ng\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='K\u1ebf ti\u1ebfp'  \/> <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'> L\u01b0u v\u00e0 ti\u1ebfp t\u1ee5c sau<\/button>\n                        <fieldset id=\"field_11_122\"><legend class='gfield_label gform-field-label gfield_label_before_complex'>T\u00ean ng\u01b0\u1eddi nh\u1eadn c\u1ea5y gh\u00e9p *<\/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'>\u0110\u1ea7u ti\u00ean<\/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'>Cu\u1ed1i c\u00f9ng<\/label>\n                        <\/fieldset><label class='gfield_label gform-field-label' for='input_11_167'>M\u1ed1i quan h\u1ec7 v\u1edbi \u1ee9ng vi\u00ean*<\/label><select name='input_167' id='input_11_167' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\"><option value='Self'>B\u1ea3n th\u00e2n<\/option><option value='Dependent'>Ph\u1ee5 thu\u1ed9c<\/option><option value='Spouse\/Partner'>V\u1ee3 \/ ch\u1ed3ng \/ B\u1ea1n \u0111\u1eddi<\/option><option value='Living Donor'>Ng\u01b0\u1eddi hi\u1ebfn t\u1eb7ng c\u00f2n s\u1ed1ng<\/option><option value='Parent of Transplant Patient'>Ph\u1ee5 huynh c\u1ee7a b\u1ec7nh nh\u00e2n c\u1ea5y gh\u00e9p<\/option><option value='Sibling of a Transplant Patient'>Anh ch\u1ecb em c\u1ee7a b\u1ec7nh nh\u00e2n c\u1ea5y gh\u00e9p<\/option><\/select><label class='gfield_label gform-field-label' for='input_11_125'>Ng\u00e0y c\u1ea5y gh\u00e9p *<\/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'>\u0110\u00e0n organ*<\/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'>Th\u1eadn<\/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'>Tuy\u1ebfn t\u1ee5y<\/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'>Tim<\/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'>Gan<\/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'>(C\u00e1c) ph\u1ed5i<\/label>\n\t\t\t\t\t\t\t<\/fieldset><label class='gfield_label gform-field-label' for='input_11_163'>Trung t\u00e2m C\u1ea5y gh\u00e9p *<\/label><select name='input_163' id='input_11_163' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\"><option value='Augusta University'>\u0110\u1ea1i h\u1ecdc Augusta<\/option><option value='Children's healthcare'>Ch\u0103m s\u00f3c s\u1ee9c kh\u1ecfe tr\u1ebb em<\/option><option value='Duke Health'>Duke Health<\/option><option value='Emory Healthcare'>Emory Healthcare<\/option><option value='Mayo Clinic'>Ph\u00f2ng kh\u00e1m Mayo<\/option><option value='MUSC Health'>MUSC S\u1ee9c kh\u1ecfe<\/option><option value='Piedmont Healthcare'>Piedmont Healthcare<\/option><option value='UAB Medicine'>Thu\u1ed1c UAB<\/option><option value='Other'>Kh\u00e1c<\/option><\/select><label class='gfield_label gform-field-label' for='input_11_165'>Kh\u00e1c<\/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='Tr\u01b0\u1edbc'  \/> <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='K\u1ebf ti\u1ebfp'  \/> <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'> L\u01b0u v\u00e0 ti\u1ebfp t\u1ee5c sau<\/button>\n                        <label class='gfield_label gform-field-label' for='input_11_114'>Cu\u1ed9c \u0111ua (t\u00f9y ch\u1ecdn)<\/label><select name='input_114' id='input_11_114' class='large gfield_select'     aria-invalid=\"false\"><option value='African American'>Ng\u01b0\u1eddi M\u1ef9 g\u1ed1c Phi<\/option><option value='Asian-American'>Ng\u01b0\u1eddi M\u1ef9 g\u1ed1c \u00c1<\/option><option value='Asian-Pacific Islander'>Ch\u00e2u \u00c1 \/ Th\u00e1i B\u00ecnh D\u01b0\u01a1ng<\/option><option value='Black'>\u0110en<\/option><option value='Hispanic'>Ng\u01b0\u1eddi T\u00e2y Ban Nha<\/option><option value='Native American'>Ng\u01b0\u1eddi M\u1ef9 b\u1ea3n x\u1ee9<\/option><option value='White, Non-Hispanic'>Da tr\u1eafng, kh\u00f4ng ph\u1ea3i g\u1ed1c T\u00e2y Ban Nha<\/option><option value='Other'>Kh\u00e1c<\/option><\/select><label class='gfield_label gform-field-label' for='input_11_115'>Ch\u1ee7ng t\u1ed9c kh\u00e1c<\/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'>Tr\u00ecnh \u0111\u1ed9 h\u1ecdc v\u1ea5n (t\u00f9y ch\u1ecdn)<\/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'>\u0110i h\u1ecdc trung h\u1ecdc<\/option><option value='High School Graduate'>T\u1ed1t nghi\u1ec7p trung h\u1ecdc<\/option><option value='Technical Certificate\/Diploma'>Ch\u1ee9ng ch\u1ec9 k\u1ef9 thu\u1eadt \/ V\u0103n b\u1eb1ng<\/option><option value='Currently Enrolled in College'>Hi\u1ec7n \u0111\u00e3 \u0111\u0103ng k\u00fd v\u00e0o tr\u01b0\u1eddng cao \u0111\u1eb3ng<\/option><option value='Attended College'>H\u1ecdc \u0111\u1ea1i h\u1ecdc<\/option><option value='Associates Degree'>M\u1ee9c \u0111\u1ed9<\/option><option value='Bachelors Degree'>B\u1eb1ng c\u1eed nh\u00e2n<\/option><option value='Post-Graduate Degree'>Ch\u1ee9ng ch\u1ec9 sau t\u1ed1t nghi\u1ec7p<\/option><\/select><label class='gfield_label gform-field-label' for='input_11_22'># trong n\u0103m<\/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'>T\u00ecnh tr\u1ea1ng c\u00f4ng vi\u1ec7c (vui l\u00f2ng ch\u1ecdn)<\/label><select name='input_117' id='input_11_117' class='large gfield_select'     aria-invalid=\"false\"><option value='Currently Employed'>Hi\u1ec7n \u0111ang l\u00e0m vi\u1ec7c<\/option><option value='Medically Disabled'>Khuy\u1ebft t\u1eadt v\u1ec1 m\u1eb7t y t\u1ebf<\/option><option value='Retired'>V\u1ec1 h\u01b0u<\/option><option value='Unemployed'>Th\u1ea5t nghi\u1ec7p<\/option><\/select><label class='gfield_label gform-field-label' for='input_11_39'>T\u00ean nh\u00e0 tuy\u1ec3n d\u1ee5ng<\/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'>K\u1ec3 t\u1eeb (Ng\u00e0y)<\/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'>Vi\u1ec7c l\u00e0m to\u00e0n th\u1eddi gian<\/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'>V\u1ee3 \/ ch\u1ed3ng \u0111ang \u0111i l\u00e0m<\/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'>Vi\u1ec7c l\u00e0m b\u00e1n th\u1eddi gian<\/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'>Thu nh\u1eadp c\u1ee7a (c\u00e1c) ph\u1ee5 huynh<\/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'>L\u01b0\u01a1ng h\u01b0u<\/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'>Ngh\u1ec9 h\u01b0u 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'>Kh\u00e1c<\/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'>B\u1ea3o hi\u1ec3m<\/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'>B\u1ea3o hi\u1ec3m c\u1ee7a cha m\u1eb9<\/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'>Medicare<\/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'>Medicaid<\/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 gi\u1ea3m chi ti\u00eau<\/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'>Kh\u00e1c<\/label>\n\t\t\t\t\t\t\t<\/fieldset><label class='gfield_label gform-field-label' for='input_11_166'>Nh\u00e0 cung c\u1ea5p d\u1ecbch v\u1ee5 b\u1ea3o hi\u1ec3m<\/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'>Kaiser<\/option><option value='Aetna'>Aetna<\/option><option value='Other'>Kh\u00e1c<\/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'>Trang web 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'>T\u1ea1p ch\u00ed IMPRINT ho\u1eb7c Brochure<\/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'>Nh\u00e2n vi\u00ean 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'>T\u00ecnh nguy\u1ec7n vi\u00ean 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'>Nh\u00e2n vi\u00ean Trung t\u00e2m C\u1ea5y gh\u00e9p<\/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'>Kh\u00e1c<\/label>\n\t\t\t\t\t\t\t<\/fieldset><label class='gfield_label gform-field-label' for='input_11_46'>T\u00ean c\u1ee7a ng\u01b0\u1eddi b\u1ea1n \u0111\u00e3 nghe v\u1ec1 c\u00e1c d\u1ecbch v\u1ee5 GTF t\u1eeb:<\/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='Tr\u01b0\u1edbc'  \/> <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='K\u1ebf ti\u1ebfp'  \/> <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'> L\u01b0u v\u00e0 ti\u1ebfp t\u1ee5c sau<\/button>\n                        <fieldset id=\"field_11_131\"><legend class='gfield_label gform-field-label gfield_label_before_complex'>X\u00e1c minh tr\u01b0\u1eddng h\u1ecdc *<\/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>Li\u1ec7t k\u00ea t\u1ea5t c\u1ea3 c\u00e1c tr\u01b0\u1eddng trung h\u1ecdc, tr\u01b0\u1eddng k\u1ef9 thu\u1eadt v\u00e0 cao \u0111\u1eb3ng m\u00e0 b\u1ea1n \u0111\u00e3 theo h\u1ecdc:<\/fieldset><label class='gfield_label gform-field-label' for='input_11_132'>\u0110i\u1ec3m 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'>SAT (ph\u1ea7n \u0111\u1ecdc v\u00e0 to\u00e1n)<\/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'>T\u00ean t\u1ed5 ch\u1ee9c b\u1ea1n d\u1ef1 \u0111\u1ecbnh theo h\u1ecdc: *<\/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'>B\u1ea1n \u0111ang theo \u0111u\u1ed5i b\u1eb1ng c\u1ea5p ho\u1eb7c ch\u1ee9ng ch\u1ec9 n\u00e0o: *<\/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'>L\u00fd do ch\u1ecdn c\u01a1 s\u1edf n\u00e0y: *<\/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'>L\u00fd do ch\u1ecdn ngh\u1ec1 n\u00e0y: *<\/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'>\u0110\u00fang<\/option><option value='No'>Kh\u00f4ng<\/option><\/select><label class='gfield_label gform-field-label' for='input_11_140'>Kh\u1ed1i*<\/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'>Ng\u00e0y b\u1eaft \u0111\u1ea7u d\u1ef1 ki\u1ebfn *<\/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'>Ng\u00e0y ho\u00e0n th\u00e0nh d\u1ef1 ki\u1ebfn*<\/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>Chi ph\u00ed d\u1ef1 ki\u1ebfn m\u1ed7i n\u0103m<\/h3><label class='gfield_label gform-field-label' for='input_11_145'>H\u1ecdc ph\u00ed*<\/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'>Nh\u00e0 \u1edf \/ B\u1eefa \u0103n *<\/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'>S\u00e1ch*<\/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'>Du l\u1ecbch*<\/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'>To\u00e0n b\u1ed9<\/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'>H\u1ecdc b\u1ed5ng ho\u1eb7c tr\u1ee3 c\u1ea5p - Li\u1ec7t k\u00ea t\u1ea5t c\u1ea3 h\u1ecdc b\u1ed5ng \/ tr\u1ee3 c\u1ea5p m\u00e0 b\u1ea1n \u0111\u00e3 \u0111\u01b0\u1ee3c trao, bao g\u1ed3m c\u1ea3 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'>B\u1ea1n hi\u1ec7n c\u00f3 kho\u1ea3n vay sinh vi\u00ean kh\u00f4ng? *<\/label><select name='input_169' id='input_11_169' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\"><option value='yes'>\u0110\u00fang<\/option><option value='no'>Kh\u00f4ng<\/option><\/select><label class='gfield_label gform-field-label' for='input_11_152'>S\u1ed1 ti\u1ec1n g\u1ea7n \u0111\u00fang ($)<\/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'>Li\u1ec7t k\u00ea nh\u1eefng ng\u01b0\u1eddi kh\u00e1c trong gia \u0111\u00ecnh b\u1ea1n hi\u1ec7n \u0111ang \u0111i h\u1ecdc<\/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'>D\u01b0\u1edbi $50.000<\/option><option value='$50,000 to $100,000'>$50,000 \u0111\u1ebfn $100,000<\/option><option value='$100,000 to $150,000'>$100,000 \u0111\u1ebfn $150,000<\/option><option value='$150,000 to $200,000'>$150,000 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GED certificate, if applicable. 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