{"id":1084,"date":"2024-10-28T17:23:45","date_gmt":"2024-10-28T17:23:45","guid":{"rendered":"https:\/\/forms.westernu.edu\/students\/?page_id=1084"},"modified":"2024-10-28T17:47:37","modified_gmt":"2024-10-28T17:47:37","slug":"health-screening-approval-form-2","status":"publish","type":"page","link":"https:\/\/forms.westernu.edu\/students\/health-screening-approval-form-2\/","title":{"rendered":"Health Screening Approval Form"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_66' style='display:none'>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Community Heath Screening Approval Form<\/h3>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_66'  action='\/students\/wp-json\/wp\/v2\/pages\/1084' data-formid='66' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_66' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_66_49\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<span style=\"font-size: large\"><b>Health Screening Approval Form<\/b><\/span>\n<br>\n<br>\nThis form is required for all health screening events involving WesternU students. The process ensures that WesternU \nstudents are covered by the University\u2019s medical malpractice insurance. After completing the form contact Office of \nUniversity Student Affairs (USA) or COMP-Northwest Student Affairs to receive approval and the compliance paperwork. \n\u2022 Submit this form no less than FOUR weeks before your scheduled event.\n\u2022 Return the required documentation no more than ONE week following the event. <\/li><li id=\"field_66_112\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >\n\n\n    <title>Horizontal line <\/title>\n\n\n\n    <h1><b>Where is your campus<\/b><\/h1>\n    <hr width=\"100%\" size=\"2\">\n    \n\n\n<\/li><li id=\"field_66_237\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Campus<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_66_237'>\n\t\t\t<li class='gchoice gchoice_66_237_0'>\n\t\t\t\t<input name='input_237' type='radio' value='Pomona, California'  id='choice_66_237_0'    \/>\n\t\t\t\t<label for='choice_66_237_0' id='label_66_237_0' class='gform-field-label gform-field-label--type-inline'>Pomona, California<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_66_237_1'>\n\t\t\t\t<input name='input_237' type='radio' value='Lebanon, Oregon'  id='choice_66_237_1'    \/>\n\t\t\t\t<label for='choice_66_237_1' id='label_66_237_1' class='gform-field-label gform-field-label--type-inline'>Lebanon, Oregon<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_66_231\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br>\n<br><\/li><li id=\"field_66_236\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >\n\n\n    <title>Horizontal line <\/title>\n\n\n\n    <h1><b>WesternU Organizers<\/b><\/h1>\n    <hr width=\"100%\" size=\"2\">\n    \n\n\n<\/li><li id=\"field_66_4\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_4'>Club\/Class\/College Organizing the Event:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_66_4' type='text' value='' class='large'    placeholder='e.g. APhA and AAWD' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_66_97\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Student Organizer&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_66_97'>\n                            \n                            <span id='input_66_97_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_97.3' id='input_66_97_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_97_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_66_97_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_97.6' id='input_66_97_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_97_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_66_228\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_228'>Student Organizer&#039;s Program<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_228' id='input_66_228' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Select one of the following' >Select one of the following<\/option><option value='DO' >DO<\/option><option value='DMD' >DMD<\/option><option value='DNP' >DNP<\/option><option value='DPM' >DPM<\/option><option value='DPT' >DPT<\/option><option value='DVM' >DVM<\/option><option value='FNP' >FNP<\/option><option value='MSHS' >MSHS<\/option><option value='MSN' >MSN<\/option><option value='MSPA' >MSPA<\/option><option value='OD' >OD<\/option><option value='PharmD' >PharmD<\/option><option value='' ><\/option><option value='' ><\/option><option value='' ><\/option><\/select><\/div><\/li><li id=\"field_66_98\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_98'>Student Organizer&#039;s E-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_98' id='input_66_98' type='email' value='' class='large'   placeholder='@westernu.edu' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_66_131\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you organized a health screening before?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_66_131'>\n\t\t\t<li class='gchoice gchoice_66_131_0'>\n\t\t\t\t<input name='input_131' type='radio' value='Yes and I&#039;ve had the orientation with USA (Christy\/Jess)'  id='choice_66_131_0'    \/>\n\t\t\t\t<label for='choice_66_131_0' id='label_66_131_0' class='gform-field-label gform-field-label--type-inline'>Yes and I've had the orientation with USA (Christy\/Jess)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_66_131_1'>\n\t\t\t\t<input name='input_131' type='radio' value='No, this is my first'  id='choice_66_131_1'    \/>\n\t\t\t\t<label for='choice_66_131_1' id='label_66_131_1' class='gform-field-label gform-field-label--type-inline'>No, this is my first<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_66_132\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are there additional students\/organizers you&#039;d like notified upon approval?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_66_132'>\n\t\t\t<li class='gchoice gchoice_66_132_0'>\n\t\t\t\t<input name='input_132' type='radio' value='Yes'  id='choice_66_132_0'    \/>\n\t\t\t\t<label for='choice_66_132_0' id='label_66_132_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_66_132_1'>\n\t\t\t\t<input name='input_132' type='radio' value='No'  id='choice_66_132_1'    \/>\n\t\t\t\t<label for='choice_66_132_1' id='label_66_132_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_66_133\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_133'>Provide e-mail addresses here, separated by a semi-colon.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_133'>e.g. samplestudent@westernu.edu; sallystudent@westernu.edu<\/div><div class='ginput_container ginput_container_text'><input name='input_133' id='input_66_133' type='text' value='' class='large'  aria-describedby=\"gfield_description_66_133\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_66_115\" class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_115'>Expected Number of Student Volunteers<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_115' id='input_66_115' type='number' step='any'   value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_66_120\" class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_120'>Expected Number of hours worked per Student Volunteers<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_120' id='input_66_120' type='number' step='any'   value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_66_121\" class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_121'>Expected Number of hours worked per Faculty\/Preceptors Volunteers<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_121' id='input_66_121' type='number' step='any'   value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_66_232\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br>\n<br><\/li><li id=\"field_66_113\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >\n\n\n    <title>Horizontal line <\/title>\n\n\n\n    <h1><b>Event Information<\/b><\/h1>\n    <hr width=\"100%\" size=\"2\">\n    \n\n\n<\/li><li id=\"field_66_1\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_1'>Name of Event<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_1'>Example: Interprofessional Health Fair, October 11, 2025<\/div><div class='ginput_container ginput_container_text'><input name='input_1' id='input_66_1' type='text' value='' class='large'  aria-describedby=\"gfield_description_66_1\"  placeholder='Your answer' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_66_229\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Community Organizers Information<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_66_229'>\n                            \n                            <span id='input_66_229_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_229.3' id='input_66_229_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_229_3' class='gform-field-label gform-field-label--type-sub '>First name<\/label>\n                                                <\/span>\n                            <span id='input_66_229_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_229.4' id='input_66_229_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_66_229_4' class='gform-field-label gform-field-label--type-sub '>Last name<\/label>\n                                                <\/span>\n                            <span id='input_66_229_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_229.6' id='input_66_229_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_229_6' class='gform-field-label gform-field-label--type-sub '>E-mail<\/label>\n                                                <\/span>\n                            <span id='input_66_229_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_229.8' id='input_66_229_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_66_229_8' class='gform-field-label gform-field-label--type-sub '>Phone Number<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_66_61\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >My event is a:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_66_61'>\n\t\t\t<li class='gchoice gchoice_66_61_0'>\n\t\t\t\t<input name='input_61' type='radio' value='Single-Day Event'  id='choice_66_61_0'    \/>\n\t\t\t\t<label for='choice_66_61_0' id='label_66_61_0' class='gform-field-label gform-field-label--type-inline'>Single-Day Event<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_66_61_1'>\n\t\t\t\t<input name='input_61' type='radio' value='Multiple-Day Event'  id='choice_66_61_1'    \/>\n\t\t\t\t<label for='choice_66_61_1' id='label_66_61_1' class='gform-field-label gform-field-label--type-inline'>Multiple-Day Event<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_66_59\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_59'>Event Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_59' id='input_66_59' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_66_59_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_66_59_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_66_59' class='gform_hidden' value='https:\/\/forms.westernu.edu\/students\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_66_60\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_60'>End Date:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_60' id='input_66_60' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_66_60_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_66_60_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_66_60' class='gform_hidden' value='https:\/\/forms.westernu.edu\/students\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_66_20\" class=\"gfield gfield--type-time gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >What time does the event start?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"clear-multi\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_66_20'>\n                            <input type='number' name='input_20[]' id='input_66_20_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='true'   \/> <i>:<\/i>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_66_20_1'>Hours<\/label>\n                        <\/div>\n                        \n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_20[]' id='input_66_20_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_66_20_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_20[]' id='input_66_20_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_66_20_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/div><\/li><li id=\"field_66_21\" class=\"gfield gfield--type-time gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >What time does the event end?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"clear-multi\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_66_21'>\n                            <input type='number' name='input_21[]' id='input_66_21_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='true'   \/> <i>:<\/i>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_66_21_1'>Hours<\/label>\n                        <\/div>\n                        \n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_21[]' id='input_66_21_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_66_21_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_21[]' id='input_66_21_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_66_21_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/div><\/li><li id=\"field_66_114\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Where is the event located<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_66_114'>\n\t\t\t<li class='gchoice gchoice_66_114_0'>\n\t\t\t\t<input name='input_114' type='radio' value='Pomona, CA'  id='choice_66_114_0'    \/>\n\t\t\t\t<label for='choice_66_114_0' id='label_66_114_0' class='gform-field-label gform-field-label--type-inline'>Pomona, CA<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_66_114_1'>\n\t\t\t\t<input name='input_114' type='radio' value='Not in Pomona, CA'  id='choice_66_114_1'    \/>\n\t\t\t\t<label for='choice_66_114_1' id='label_66_114_1' class='gform-field-label gform-field-label--type-inline'>Not in Pomona, CA<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_66_108\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address of Event<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_66_108' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_66_108_1_container' >\n                                        <input type='text' name='input_108.1' id='input_66_108_1' value=''    aria-required='true'    \/>\n                                        <label for='input_66_108_1' id='input_66_108_1_label' class='gform-field-label gform-field-label--type-sub '>Building Name (e.g. Walmart) - put n\/a if not needed<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_66_108_2_container' >\n                                        <input type='text' name='input_108.2' id='input_66_108_2' value=''     aria-required='false'   \/>\n                                        <label for='input_66_108_2' id='input_66_108_2_label' class='gform-field-label gform-field-label--type-sub '>Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_66_108_3_container' >\n                                    <input type='text' name='input_108.3' id='input_66_108_3' value=''    aria-required='true'    \/>\n                                    <label for='input_66_108_3' id='input_66_108_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_66_108_4_container' >\n                                        <input type='text' name='input_108.4' id='input_66_108_4' value=''      aria-required='true'    \/>\n                                        <label for='input_66_108_4' id='input_66_108_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_66_108_5_container' >\n                                    <input type='text' name='input_108.5' id='input_66_108_5' value=''    aria-required='true'    \/>\n                                    <label for='input_66_108_5' id='input_66_108_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_108.6' id='input_66_108_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_66_233\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br>\n<br><\/li><li id=\"field_66_234\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br>\n<br><\/li><li id=\"field_66_50\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >\n\n\n    <title>Horizontal line <\/title>\n\n\n\n    <h1><b>Attendee Information<\/b><\/h1>\n    <hr width=\"100%\" size=\"2\">\n    \n\n\n<\/li><li id=\"field_66_125\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Types of Attendees<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_66_125'><li class='gchoice gchoice_66_125_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_125.1' type='checkbox'  value='Human'  id='choice_66_125_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_125_1' id='label_66_125_1' class='gform-field-label gform-field-label--type-inline'>Human<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_125_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_125.2' type='checkbox'  value='Animal'  id='choice_66_125_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_125_2' id='label_66_125_2' class='gform-field-label gform-field-label--type-inline'>Animal<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_125_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_125.3' type='checkbox'  value='Both (Human &amp; Animal)'  id='choice_66_125_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_125_3' id='label_66_125_3' class='gform-field-label gform-field-label--type-inline'>Both (Human &amp; Animal)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_66_84\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Expected Number of Attendees<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_66_84'>\n\t\t\t<li class='gchoice gchoice_66_84_0'>\n\t\t\t\t<input name='input_84' type='radio' value='Less than 5'  id='choice_66_84_0'    \/>\n\t\t\t\t<label for='choice_66_84_0' id='label_66_84_0' class='gform-field-label gform-field-label--type-inline'>Less than 5<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_66_84_1'>\n\t\t\t\t<input name='input_84' type='radio' value='5 - 25'  id='choice_66_84_1'    \/>\n\t\t\t\t<label for='choice_66_84_1' id='label_66_84_1' class='gform-field-label gform-field-label--type-inline'>5 - 25<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_66_84_2'>\n\t\t\t\t<input name='input_84' type='radio' value='25 - 50'  id='choice_66_84_2'    \/>\n\t\t\t\t<label for='choice_66_84_2' id='label_66_84_2' class='gform-field-label gform-field-label--type-inline'>25 - 50<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_66_84_3'>\n\t\t\t\t<input name='input_84' type='radio' value='50 - 100'  id='choice_66_84_3'    \/>\n\t\t\t\t<label for='choice_66_84_3' id='label_66_84_3' class='gform-field-label gform-field-label--type-inline'>50 - 100<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_66_84_4'>\n\t\t\t\t<input name='input_84' type='radio' value='100 - 150'  id='choice_66_84_4'    \/>\n\t\t\t\t<label for='choice_66_84_4' id='label_66_84_4' class='gform-field-label gform-field-label--type-inline'>100 - 150<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_66_84_5'>\n\t\t\t\t<input name='input_84' type='radio' value='150 - 200'  id='choice_66_84_5'    \/>\n\t\t\t\t<label for='choice_66_84_5' id='label_66_84_5' class='gform-field-label gform-field-label--type-inline'>150 - 200<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_66_84_6'>\n\t\t\t\t<input name='input_84' type='radio' value='200 - 250'  id='choice_66_84_6'    \/>\n\t\t\t\t<label for='choice_66_84_6' id='label_66_84_6' class='gform-field-label gform-field-label--type-inline'>200 - 250<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_66_84_7'>\n\t\t\t\t<input name='input_84' type='radio' value='250 - 300'  id='choice_66_84_7'    \/>\n\t\t\t\t<label for='choice_66_84_7' id='label_66_84_7' class='gform-field-label gform-field-label--type-inline'>250 - 300<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_66_84_8'>\n\t\t\t\t<input name='input_84' type='radio' value='300+'  id='choice_66_84_8'    \/>\n\t\t\t\t<label for='choice_66_84_8' id='label_66_84_8' class='gform-field-label gform-field-label--type-inline'>300+<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_66_82\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >What is the primary language(s) spoken by attendees?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_82'>Check all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_66_82'><li class='gchoice gchoice_66_82_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.1' type='checkbox'  value='English'  id='choice_66_82_1'   aria-describedby=\"gfield_description_66_82\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_66_82_1' id='label_66_82_1' class='gform-field-label gform-field-label--type-inline'>English<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_82_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.2' type='checkbox'  value='Spanish'  id='choice_66_82_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_82_2' id='label_66_82_2' class='gform-field-label gform-field-label--type-inline'>Spanish<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_82_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.3' type='checkbox'  value='Korean'  id='choice_66_82_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_82_3' id='label_66_82_3' class='gform-field-label gform-field-label--type-inline'>Korean<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_82_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.4' type='checkbox'  value='Mandarin Chinese'  id='choice_66_82_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_82_4' id='label_66_82_4' class='gform-field-label gform-field-label--type-inline'>Mandarin Chinese<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_82_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.5' type='checkbox'  value='Vietnamese'  id='choice_66_82_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_82_5' id='label_66_82_5' class='gform-field-label gform-field-label--type-inline'>Vietnamese<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_66_51\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >\n\n\n    <title>Horizontal line <\/title>\n\n\n\n    <h1><b>Faculty\/Preceptor Information<\/b><\/h1>\n    <hr width=\"100%\" size=\"2\">\n    \n\n\n<\/li><li id=\"field_66_135\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >The University has approved the screenings found on the Scope of Practice Guide linked below.  This guide will tell you what clinicians are required to oversee the activity and which students are allowed to participate.  \n\n<a href=\"https:\/\/www.westernu.edu\/media\/students\/scope-of-practice.pdf\">Sope of Practice Guide<\/a>\n<\/li><li id=\"field_66_127\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_127'>How many faculty\/preceptors will attend this event?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_127'>Must be a WesternU Faculty member or Preceptor and licensed in the State of California or Oregon. <\/div><div class='ginput_container ginput_container_select'><select name='input_127' id='input_66_127' class='large gfield_select'  aria-describedby=\"gfield_description_66_127\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='More than 10' >More than 10<\/option><\/select><\/div><\/li><li id=\"field_66_74\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br>\n<br><\/li><li id=\"field_66_128\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faculty\/Preceptor #1 | Name, Degree<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_66_128'>\n                            <span id='input_66_128_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' >\n                                                    <select name='input_128.2' id='input_66_128_2'    aria-required='false'   >\n                          <option value=''><\/option><option value='Dr.' >Dr.<\/option><option value='Prof.' >Prof.<\/option>\n                      <\/select>\n                                                    <label for='input_66_128_2' class='gform-field-label gform-field-label--type-sub '>Prefix<\/label>\n                                                  <\/span>\n                            <span id='input_66_128_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_128.3' id='input_66_128_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_128_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_66_128_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_128.6' id='input_66_128_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_128_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_66_128_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_128.8' id='input_66_128_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_66_128_8' class='gform-field-label gform-field-label--type-sub '>Degree (e.g. PharmD)<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_66_130\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_130'>Faculty\/Preceptor #1 | Employer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_130'>This is needed to verify affiliation with university if not a faculty member. If WesternU faculty, type WesternU.<\/div><div class='ginput_container ginput_container_text'><input name='input_130' id='input_66_130' type='text' value='' class='large'  aria-describedby=\"gfield_description_66_130\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_66_129\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_129'>Faculty\/Preceptor #1 | E-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_129' id='input_66_129' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_66_33\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faculty\/Preceptor #1 | Overseeing:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_33'>Check all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_66_33'><li class='gchoice gchoice_66_33_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.1' type='checkbox'  value='Autorefractor, Near Point of Convergence, &amp; Cover Test (OD Only)'  id='choice_66_33_1'   aria-describedby=\"gfield_description_66_33\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_1' id='label_66_33_1' class='gform-field-label gform-field-label--type-inline'>Autorefractor, Near Point of Convergence, &amp; Cover Test (OD Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.2' type='checkbox'  value='Basic First Aid (Distributing Bandages)'  id='choice_66_33_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_2' id='label_66_33_2' class='gform-field-label gform-field-label--type-inline'>Basic First Aid (Distributing Bandages)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.3' type='checkbox'  value='Blood Glucose'  id='choice_66_33_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_3' id='label_66_33_3' class='gform-field-label gform-field-label--type-inline'>Blood Glucose<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.4' type='checkbox'  value='Blood Pressure'  id='choice_66_33_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_4' id='label_66_33_4' class='gform-field-label gform-field-label--type-inline'>Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.5' type='checkbox'  value='Body Mass Index'  id='choice_66_33_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_5' id='label_66_33_5' class='gform-field-label gform-field-label--type-inline'>Body Mass Index<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.6' type='checkbox'  value='Bone Density'  id='choice_66_33_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_6' id='label_66_33_6' class='gform-field-label gform-field-label--type-inline'>Bone Density<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.7' type='checkbox'  value='Cholesterol Testing'  id='choice_66_33_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_7' id='label_66_33_7' class='gform-field-label gform-field-label--type-inline'>Cholesterol Testing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.8' type='checkbox'  value='Dental Screenings (DMD Only)'  id='choice_66_33_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_8' id='label_66_33_8' class='gform-field-label gform-field-label--type-inline'>Dental Screenings (DMD Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.9' type='checkbox'  value='Fall Prevention'  id='choice_66_33_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_9' id='label_66_33_9' class='gform-field-label gform-field-label--type-inline'>Fall Prevention<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.11' type='checkbox'  value='Flexibility\/Strength\/Balance'  id='choice_66_33_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_11' id='label_66_33_11' class='gform-field-label gform-field-label--type-inline'>Flexibility\/Strength\/Balance<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.12' type='checkbox'  value='Foot Screening'  id='choice_66_33_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_12' id='label_66_33_12' class='gform-field-label gform-field-label--type-inline'>Foot Screening<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.13' type='checkbox'  value='General Education'  id='choice_66_33_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_13' id='label_66_33_13' class='gform-field-label gform-field-label--type-inline'>General Education<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.14' type='checkbox'  value='Hip to Waist Ratio'  id='choice_66_33_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_14' id='label_66_33_14' class='gform-field-label gform-field-label--type-inline'>Hip to Waist Ratio<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.15' type='checkbox'  value='Kinesiology Tape Application (DPT Only)'  id='choice_66_33_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_15' id='label_66_33_15' class='gform-field-label gform-field-label--type-inline'>Kinesiology Tape Application (DPT Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.16' type='checkbox'  value='Medicare Part D - Education'  id='choice_66_33_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_16' id='label_66_33_16' class='gform-field-label gform-field-label--type-inline'>Medicare Part D - Education<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.17' type='checkbox'  value='Medication Review\/Counseling'  id='choice_66_33_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_17' id='label_66_33_17' class='gform-field-label gform-field-label--type-inline'>Medication Review\/Counseling<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.18' type='checkbox'  value='One-on-One Patient Education (medical advice)'  id='choice_66_33_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_18' id='label_66_33_18' class='gform-field-label gform-field-label--type-inline'>One-on-One Patient Education (medical advice)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.19' type='checkbox'  value='Osteopathic Manipulative Therapy (OMT) (DO Only)'  id='choice_66_33_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_19' id='label_66_33_19' class='gform-field-label gform-field-label--type-inline'>Osteopathic Manipulative Therapy (OMT) (DO Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.21' type='checkbox'  value='PAP, Breast exam (PCHAT)'  id='choice_66_33_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_21' id='label_66_33_21' class='gform-field-label gform-field-label--type-inline'>PAP, Breast exam (PCHAT)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.22' type='checkbox'  value='Pet Screenings, Vaccines, Microchipping (DVM Only)'  id='choice_66_33_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_22' id='label_66_33_22' class='gform-field-label gform-field-label--type-inline'>Pet Screenings, Vaccines, Microchipping (DVM Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.23' type='checkbox'  value='Physical Examinations'  id='choice_66_33_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_23' id='label_66_33_23' class='gform-field-label gform-field-label--type-inline'>Physical Examinations<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.24' type='checkbox'  value='Sports Physicals'  id='choice_66_33_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_24' id='label_66_33_24' class='gform-field-label gform-field-label--type-inline'>Sports Physicals<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.25' type='checkbox'  value='Symptom Survey, Distance Visual Acuity, Color Vision, &amp; Extraocular Muscle Assessment'  id='choice_66_33_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_25' id='label_66_33_25' class='gform-field-label gform-field-label--type-inline'>Symptom Survey, Distance Visual Acuity, Color Vision, &amp; Extraocular Muscle Assessment<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.26' type='checkbox'  value='Vaccines'  id='choice_66_33_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_26' id='label_66_33_26' class='gform-field-label gform-field-label--type-inline'>Vaccines<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_33_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.27' type='checkbox'  value='Other'  id='choice_66_33_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_33_27' id='label_66_33_27' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_66_178\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br>\n<br>\n<br>\n<br>\n<br><\/li><li id=\"field_66_174\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faculty\/Preceptor #2 | Name, Degree<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_66_174'>\n                            <span id='input_66_174_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' >\n                                                    <select name='input_174.2' id='input_66_174_2'    aria-required='false'   >\n                          <option value=''><\/option><option value='Dr.' >Dr.<\/option><option value='Prof.' >Prof.<\/option>\n                      <\/select>\n                                                    <label for='input_66_174_2' class='gform-field-label gform-field-label--type-sub '>Prefix<\/label>\n                                                  <\/span>\n                            <span id='input_66_174_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_174.3' id='input_66_174_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_174_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_66_174_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_174.6' id='input_66_174_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_174_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_66_174_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_174.8' id='input_66_174_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_66_174_8' class='gform-field-label gform-field-label--type-sub '>Degree (e.g. PharmD)<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_66_175\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_175'>Faculty\/Preceptor #2 | Employer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_175'>This is needed to verify affiliation with university if not a faculty member. If WesternU faculty, type WesternU.<\/div><div class='ginput_container ginput_container_text'><input name='input_175' id='input_66_175' type='text' value='' class='large'  aria-describedby=\"gfield_description_66_175\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_66_181\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_181'>Faculty\/Preceptor #2 | E-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_181' id='input_66_181' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_66_182\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faculty\/Preceptor #2 | Overseeing:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_182'>Check all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_66_182'><li class='gchoice gchoice_66_182_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.1' type='checkbox'  value='Autorefractor, Near Point of Convergence, &amp; Cover Test (OD Only)'  id='choice_66_182_1'   aria-describedby=\"gfield_description_66_182\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_1' id='label_66_182_1' class='gform-field-label gform-field-label--type-inline'>Autorefractor, Near Point of Convergence, &amp; Cover Test (OD Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.2' type='checkbox'  value='Basic First Aid (Distributing Bandages)'  id='choice_66_182_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_2' id='label_66_182_2' class='gform-field-label gform-field-label--type-inline'>Basic First Aid (Distributing Bandages)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.3' type='checkbox'  value='Blood Glucose'  id='choice_66_182_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_3' id='label_66_182_3' class='gform-field-label gform-field-label--type-inline'>Blood Glucose<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.4' type='checkbox'  value='Blood Pressure'  id='choice_66_182_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_4' id='label_66_182_4' class='gform-field-label gform-field-label--type-inline'>Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.5' type='checkbox'  value='Body Mass Index'  id='choice_66_182_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_5' id='label_66_182_5' class='gform-field-label gform-field-label--type-inline'>Body Mass Index<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.6' type='checkbox'  value='Bone Density'  id='choice_66_182_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_6' id='label_66_182_6' class='gform-field-label gform-field-label--type-inline'>Bone Density<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.7' type='checkbox'  value='Cholesterol Testing'  id='choice_66_182_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_7' id='label_66_182_7' class='gform-field-label gform-field-label--type-inline'>Cholesterol Testing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.8' type='checkbox'  value='Dental Screenings (DMD Only)'  id='choice_66_182_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_8' id='label_66_182_8' class='gform-field-label gform-field-label--type-inline'>Dental Screenings (DMD Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.9' type='checkbox'  value='Fall Prevention'  id='choice_66_182_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_9' id='label_66_182_9' class='gform-field-label gform-field-label--type-inline'>Fall Prevention<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.11' type='checkbox'  value='Flexibility\/Strength\/Balance'  id='choice_66_182_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_11' id='label_66_182_11' class='gform-field-label gform-field-label--type-inline'>Flexibility\/Strength\/Balance<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.12' type='checkbox'  value='Foot Screening'  id='choice_66_182_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_12' id='label_66_182_12' class='gform-field-label gform-field-label--type-inline'>Foot Screening<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.13' type='checkbox'  value='General Education'  id='choice_66_182_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_13' id='label_66_182_13' class='gform-field-label gform-field-label--type-inline'>General Education<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.14' type='checkbox'  value='Hip to Waist Ratio'  id='choice_66_182_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_14' id='label_66_182_14' class='gform-field-label gform-field-label--type-inline'>Hip to Waist Ratio<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.15' type='checkbox'  value='Kinesiology Tape Application (DPT Only)'  id='choice_66_182_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_15' id='label_66_182_15' class='gform-field-label gform-field-label--type-inline'>Kinesiology Tape Application (DPT Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.16' type='checkbox'  value='Medicare Part D - Education'  id='choice_66_182_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_16' id='label_66_182_16' class='gform-field-label gform-field-label--type-inline'>Medicare Part D - Education<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.17' type='checkbox'  value='Medication Review\/Counseling'  id='choice_66_182_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_17' id='label_66_182_17' class='gform-field-label gform-field-label--type-inline'>Medication Review\/Counseling<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.18' type='checkbox'  value='One-on-One Patient Education (medical advice)'  id='choice_66_182_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_18' id='label_66_182_18' class='gform-field-label gform-field-label--type-inline'>One-on-One Patient Education (medical advice)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.19' type='checkbox'  value='Osteopathic Manipulative Therapy (OMT) (DO Only)'  id='choice_66_182_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_19' id='label_66_182_19' class='gform-field-label gform-field-label--type-inline'>Osteopathic Manipulative Therapy (OMT) (DO Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.21' type='checkbox'  value='PAP, Breast exam (PCHAT)'  id='choice_66_182_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_21' id='label_66_182_21' class='gform-field-label gform-field-label--type-inline'>PAP, Breast exam (PCHAT)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.22' type='checkbox'  value='Pet Screenings, Vaccines, Microchipping (DVM Only)'  id='choice_66_182_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_22' id='label_66_182_22' class='gform-field-label gform-field-label--type-inline'>Pet Screenings, Vaccines, Microchipping (DVM Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.23' type='checkbox'  value='Physical Examinations'  id='choice_66_182_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_23' id='label_66_182_23' class='gform-field-label gform-field-label--type-inline'>Physical Examinations<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.24' type='checkbox'  value='Sports Physicals'  id='choice_66_182_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_24' id='label_66_182_24' class='gform-field-label gform-field-label--type-inline'>Sports Physicals<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.25' type='checkbox'  value='Symptom Survey, Distance Visual Acuity, Color Vision, &amp; Extraocular Muscle Assessment'  id='choice_66_182_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_25' id='label_66_182_25' class='gform-field-label gform-field-label--type-inline'>Symptom Survey, Distance Visual Acuity, Color Vision, &amp; Extraocular Muscle Assessment<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.26' type='checkbox'  value='Vaccines'  id='choice_66_182_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_26' id='label_66_182_26' class='gform-field-label gform-field-label--type-inline'>Vaccines<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_182_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.27' type='checkbox'  value='Other'  id='choice_66_182_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_182_27' id='label_66_182_27' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_66_183\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br>\n<br>\n<br>\n<br>\n<br><\/li><li id=\"field_66_179\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faculty\/Preceptor #3 | Name, Degree<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_66_179'>\n                            <span id='input_66_179_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' >\n                                                    <select name='input_179.2' id='input_66_179_2'    aria-required='false'   >\n                          <option value=''><\/option><option value='Dr.' >Dr.<\/option><option value='Prof.' >Prof.<\/option>\n                      <\/select>\n                                                    <label for='input_66_179_2' class='gform-field-label gform-field-label--type-sub '>Prefix<\/label>\n                                                  <\/span>\n                            <span id='input_66_179_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_179.3' id='input_66_179_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_179_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_66_179_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_179.6' id='input_66_179_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_179_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_66_179_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_179.8' id='input_66_179_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_66_179_8' class='gform-field-label gform-field-label--type-sub '>Degree (e.g. PharmD)<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_66_180\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_180'>Faculty\/Preceptor #3 | Employer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_180'>This is needed to verify affiliation with university if not a faculty member. If WesternU faculty, type WesternU.<\/div><div class='ginput_container ginput_container_text'><input name='input_180' id='input_66_180' type='text' value='' class='large'  aria-describedby=\"gfield_description_66_180\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_66_176\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_176'>Faculty\/Preceptor #3 | E-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_176' id='input_66_176' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_66_177\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faculty\/Preceptor #3 | Overseeing:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_177'>Check all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_66_177'><li class='gchoice gchoice_66_177_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.1' type='checkbox'  value='Autorefractor, Near Point of Convergence, &amp; Cover Test (OD Only)'  id='choice_66_177_1'   aria-describedby=\"gfield_description_66_177\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_1' id='label_66_177_1' class='gform-field-label gform-field-label--type-inline'>Autorefractor, Near Point of Convergence, &amp; Cover Test (OD Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.2' type='checkbox'  value='Basic First Aid (Distributing Bandages)'  id='choice_66_177_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_2' id='label_66_177_2' class='gform-field-label gform-field-label--type-inline'>Basic First Aid (Distributing Bandages)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.3' type='checkbox'  value='Blood Glucose'  id='choice_66_177_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_3' id='label_66_177_3' class='gform-field-label gform-field-label--type-inline'>Blood Glucose<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.4' type='checkbox'  value='Blood Pressure'  id='choice_66_177_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_4' id='label_66_177_4' class='gform-field-label gform-field-label--type-inline'>Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.5' type='checkbox'  value='Body Mass Index'  id='choice_66_177_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_5' id='label_66_177_5' class='gform-field-label gform-field-label--type-inline'>Body Mass Index<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.6' type='checkbox'  value='Bone Density'  id='choice_66_177_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_6' id='label_66_177_6' class='gform-field-label gform-field-label--type-inline'>Bone Density<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.7' type='checkbox'  value='Cholesterol Testing'  id='choice_66_177_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_7' id='label_66_177_7' class='gform-field-label gform-field-label--type-inline'>Cholesterol Testing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.8' type='checkbox'  value='Dental Screenings (DMD Only)'  id='choice_66_177_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_8' id='label_66_177_8' class='gform-field-label gform-field-label--type-inline'>Dental Screenings (DMD Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.9' type='checkbox'  value='Fall Prevention'  id='choice_66_177_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_9' id='label_66_177_9' class='gform-field-label gform-field-label--type-inline'>Fall Prevention<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.11' type='checkbox'  value='Flexibility\/Strength\/Balance'  id='choice_66_177_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_11' id='label_66_177_11' class='gform-field-label gform-field-label--type-inline'>Flexibility\/Strength\/Balance<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.12' type='checkbox'  value='Foot Screening'  id='choice_66_177_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_12' id='label_66_177_12' class='gform-field-label gform-field-label--type-inline'>Foot Screening<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.13' type='checkbox'  value='General Education'  id='choice_66_177_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_13' id='label_66_177_13' class='gform-field-label gform-field-label--type-inline'>General Education<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.14' type='checkbox'  value='Hip to Waist Ratio'  id='choice_66_177_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_14' id='label_66_177_14' class='gform-field-label gform-field-label--type-inline'>Hip to Waist Ratio<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.15' type='checkbox'  value='Kinesiology Tape Application (DPT Only)'  id='choice_66_177_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_15' id='label_66_177_15' class='gform-field-label gform-field-label--type-inline'>Kinesiology Tape Application (DPT Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.16' type='checkbox'  value='Medicare Part D - Education'  id='choice_66_177_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_16' id='label_66_177_16' class='gform-field-label gform-field-label--type-inline'>Medicare Part D - Education<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.17' type='checkbox'  value='Medication Review\/Counseling'  id='choice_66_177_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_17' id='label_66_177_17' class='gform-field-label gform-field-label--type-inline'>Medication Review\/Counseling<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.18' type='checkbox'  value='One-on-One Patient Education (medical advice)'  id='choice_66_177_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_18' id='label_66_177_18' class='gform-field-label gform-field-label--type-inline'>One-on-One Patient Education (medical advice)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.19' type='checkbox'  value='Osteopathic Manipulative Therapy (OMT) (DO Only)'  id='choice_66_177_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_19' id='label_66_177_19' class='gform-field-label gform-field-label--type-inline'>Osteopathic Manipulative Therapy (OMT) (DO Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.21' type='checkbox'  value='PAP, Breast exam (PCHAT)'  id='choice_66_177_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_21' id='label_66_177_21' class='gform-field-label gform-field-label--type-inline'>PAP, Breast exam (PCHAT)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.22' type='checkbox'  value='Pet Screenings, Vaccines, Microchipping (DVM Only)'  id='choice_66_177_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_22' id='label_66_177_22' class='gform-field-label gform-field-label--type-inline'>Pet Screenings, Vaccines, Microchipping (DVM Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.23' type='checkbox'  value='Physical Examinations'  id='choice_66_177_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_23' id='label_66_177_23' class='gform-field-label gform-field-label--type-inline'>Physical Examinations<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.24' type='checkbox'  value='Sports Physicals'  id='choice_66_177_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_24' id='label_66_177_24' class='gform-field-label gform-field-label--type-inline'>Sports Physicals<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.25' type='checkbox'  value='Symptom Survey, Distance Visual Acuity, Color Vision, &amp; Extraocular Muscle Assessment'  id='choice_66_177_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_25' id='label_66_177_25' class='gform-field-label gform-field-label--type-inline'>Symptom Survey, Distance Visual Acuity, Color Vision, &amp; Extraocular Muscle Assessment<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.26' type='checkbox'  value='Vaccines'  id='choice_66_177_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_26' id='label_66_177_26' class='gform-field-label gform-field-label--type-inline'>Vaccines<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_177_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.27' type='checkbox'  value='Other'  id='choice_66_177_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_177_27' id='label_66_177_27' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_66_190\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br>\n<br>\n<br>\n<br>\n<br><\/li><li id=\"field_66_185\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faculty\/Preceptor #4 | Name, Degree<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_66_185'>\n                            <span id='input_66_185_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' >\n                                                    <select name='input_185.2' id='input_66_185_2'    aria-required='false'   >\n                          <option value=''><\/option><option value='Dr.' >Dr.<\/option><option value='Prof.' >Prof.<\/option>\n                      <\/select>\n                                                    <label for='input_66_185_2' class='gform-field-label gform-field-label--type-sub '>Prefix<\/label>\n                                                  <\/span>\n                            <span id='input_66_185_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_185.3' id='input_66_185_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_185_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_66_185_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_185.6' id='input_66_185_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_185_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_66_185_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_185.8' id='input_66_185_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_66_185_8' class='gform-field-label gform-field-label--type-sub '>Degree (e.g. PharmD)<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_66_192\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_192'>Faculty\/Preceptor #4 | Employer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_192'>This is needed to verify affiliation with university if not a faculty member. If WesternU faculty, type WesternU.<\/div><div class='ginput_container ginput_container_text'><input name='input_192' id='input_66_192' type='text' value='' class='large'  aria-describedby=\"gfield_description_66_192\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_66_187\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_187'>Faculty\/Preceptor #4 | E-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_187' id='input_66_187' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_66_188\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faculty\/Preceptor #4 | Overseeing:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_188'>Check all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_66_188'><li class='gchoice gchoice_66_188_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.1' type='checkbox'  value='Autorefractor, Near Point of Convergence, &amp; Cover Test (OD Only)'  id='choice_66_188_1'   aria-describedby=\"gfield_description_66_188\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_1' id='label_66_188_1' class='gform-field-label gform-field-label--type-inline'>Autorefractor, Near Point of Convergence, &amp; Cover Test (OD Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.2' type='checkbox'  value='Basic First Aid (Distributing Bandages)'  id='choice_66_188_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_2' id='label_66_188_2' class='gform-field-label gform-field-label--type-inline'>Basic First Aid (Distributing Bandages)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.3' type='checkbox'  value='Blood Glucose'  id='choice_66_188_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_3' id='label_66_188_3' class='gform-field-label gform-field-label--type-inline'>Blood Glucose<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.4' type='checkbox'  value='Blood Pressure'  id='choice_66_188_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_4' id='label_66_188_4' class='gform-field-label gform-field-label--type-inline'>Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.5' type='checkbox'  value='Body Mass Index'  id='choice_66_188_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_5' id='label_66_188_5' class='gform-field-label gform-field-label--type-inline'>Body Mass Index<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.6' type='checkbox'  value='Bone Density'  id='choice_66_188_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_6' id='label_66_188_6' class='gform-field-label gform-field-label--type-inline'>Bone Density<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.7' type='checkbox'  value='Cholesterol Testing'  id='choice_66_188_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_7' id='label_66_188_7' class='gform-field-label gform-field-label--type-inline'>Cholesterol Testing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.8' type='checkbox'  value='Dental Screenings (DMD Only)'  id='choice_66_188_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_8' id='label_66_188_8' class='gform-field-label gform-field-label--type-inline'>Dental Screenings (DMD Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.9' type='checkbox'  value='Fall Prevention'  id='choice_66_188_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_9' id='label_66_188_9' class='gform-field-label gform-field-label--type-inline'>Fall Prevention<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.11' type='checkbox'  value='Flexibility\/Strength\/Balance'  id='choice_66_188_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_11' id='label_66_188_11' class='gform-field-label gform-field-label--type-inline'>Flexibility\/Strength\/Balance<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.12' type='checkbox'  value='Foot Screening'  id='choice_66_188_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_12' id='label_66_188_12' class='gform-field-label gform-field-label--type-inline'>Foot Screening<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.13' type='checkbox'  value='General Education'  id='choice_66_188_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_13' id='label_66_188_13' class='gform-field-label gform-field-label--type-inline'>General Education<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.14' type='checkbox'  value='Hip to Waist Ratio'  id='choice_66_188_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_14' id='label_66_188_14' class='gform-field-label gform-field-label--type-inline'>Hip to Waist Ratio<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.15' type='checkbox'  value='Kinesiology Tape Application (DPT Only)'  id='choice_66_188_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_15' id='label_66_188_15' class='gform-field-label gform-field-label--type-inline'>Kinesiology Tape Application (DPT Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.16' type='checkbox'  value='Medicare Part D - Education'  id='choice_66_188_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_16' id='label_66_188_16' class='gform-field-label gform-field-label--type-inline'>Medicare Part D - Education<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.17' type='checkbox'  value='Medication Review\/Counseling'  id='choice_66_188_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_17' id='label_66_188_17' class='gform-field-label gform-field-label--type-inline'>Medication Review\/Counseling<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.18' type='checkbox'  value='One-on-One Patient Education (medical advice)'  id='choice_66_188_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_18' id='label_66_188_18' class='gform-field-label gform-field-label--type-inline'>One-on-One Patient Education (medical advice)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.19' type='checkbox'  value='Osteopathic Manipulative Therapy (OMT) (DO Only)'  id='choice_66_188_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_19' id='label_66_188_19' class='gform-field-label gform-field-label--type-inline'>Osteopathic Manipulative Therapy (OMT) (DO Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.21' type='checkbox'  value='PAP, Breast exam (PCHAT)'  id='choice_66_188_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_21' id='label_66_188_21' class='gform-field-label gform-field-label--type-inline'>PAP, Breast exam (PCHAT)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.22' type='checkbox'  value='Pet Screenings, Vaccines, Microchipping (DVM Only)'  id='choice_66_188_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_22' id='label_66_188_22' class='gform-field-label gform-field-label--type-inline'>Pet Screenings, Vaccines, Microchipping (DVM Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.23' type='checkbox'  value='Physical Examination'  id='choice_66_188_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_23' id='label_66_188_23' class='gform-field-label gform-field-label--type-inline'>Physical Examination<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.24' type='checkbox'  value='Sports Physicals'  id='choice_66_188_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_24' id='label_66_188_24' class='gform-field-label gform-field-label--type-inline'>Sports Physicals<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.25' type='checkbox'  value='Symptom Survey, Distance Visual Acuity, Color Vision, &amp; Extraocular Muscle Assessment'  id='choice_66_188_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_25' id='label_66_188_25' class='gform-field-label gform-field-label--type-inline'>Symptom Survey, Distance Visual Acuity, Color Vision, &amp; Extraocular Muscle Assessment<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.26' type='checkbox'  value='Vaccines'  id='choice_66_188_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_26' id='label_66_188_26' class='gform-field-label gform-field-label--type-inline'>Vaccines<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_188_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.27' type='checkbox'  value='Other'  id='choice_66_188_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_188_27' id='label_66_188_27' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_66_184\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br>\n<br>\n<br>\n<br>\n<br><\/li><li id=\"field_66_191\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faculty\/Preceptor #5 | Name, Degree<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_66_191'>\n                            <span id='input_66_191_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' >\n                                                    <select name='input_191.2' id='input_66_191_2'    aria-required='false'   >\n                          <option value=''><\/option><option value='Dr.' >Dr.<\/option><option value='Prof.' >Prof.<\/option>\n                      <\/select>\n                                                    <label for='input_66_191_2' class='gform-field-label gform-field-label--type-sub '>Prefix<\/label>\n                                                  <\/span>\n                            <span id='input_66_191_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_191.3' id='input_66_191_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_191_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_66_191_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_191.6' id='input_66_191_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_191_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_66_191_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_191.8' id='input_66_191_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_66_191_8' class='gform-field-label gform-field-label--type-sub '>Degree (e.g. PharmD)<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_66_186\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_186'>Faculty\/Preceptor #5 | Employer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_186'>This is needed to verify affiliation with university if not a faculty member. If WesternU faculty, type WesternU.<\/div><div class='ginput_container ginput_container_text'><input name='input_186' id='input_66_186' type='text' value='' class='large'  aria-describedby=\"gfield_description_66_186\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_66_193\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_193'>Faculty\/Preceptor #5 | E-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_193' id='input_66_193' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_66_194\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faculty\/Preceptor #5 | Overseeing:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_194'>Check all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_66_194'><li class='gchoice gchoice_66_194_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.1' type='checkbox'  value='Autorefractor, Near Point of Convergence, &amp; Cover Test (OD Only)'  id='choice_66_194_1'   aria-describedby=\"gfield_description_66_194\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_1' id='label_66_194_1' class='gform-field-label gform-field-label--type-inline'>Autorefractor, Near Point of Convergence, &amp; Cover Test (OD Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.2' type='checkbox'  value='Basic First Aid (Distributing Bandages)'  id='choice_66_194_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_2' id='label_66_194_2' class='gform-field-label gform-field-label--type-inline'>Basic First Aid (Distributing Bandages)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.3' type='checkbox'  value='Blood Glucose'  id='choice_66_194_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_3' id='label_66_194_3' class='gform-field-label gform-field-label--type-inline'>Blood Glucose<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.4' type='checkbox'  value='Blood Pressure'  id='choice_66_194_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_4' id='label_66_194_4' class='gform-field-label gform-field-label--type-inline'>Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.5' type='checkbox'  value='Body Mass Index'  id='choice_66_194_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_5' id='label_66_194_5' class='gform-field-label gform-field-label--type-inline'>Body Mass Index<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.6' type='checkbox'  value='Bone Density'  id='choice_66_194_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_6' id='label_66_194_6' class='gform-field-label gform-field-label--type-inline'>Bone Density<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.7' type='checkbox'  value='Cholesterol Testing'  id='choice_66_194_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_7' id='label_66_194_7' class='gform-field-label gform-field-label--type-inline'>Cholesterol Testing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.8' type='checkbox'  value='Dental Screenings (DMD Only)'  id='choice_66_194_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_8' id='label_66_194_8' class='gform-field-label gform-field-label--type-inline'>Dental Screenings (DMD Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.9' type='checkbox'  value='Fall Prevention'  id='choice_66_194_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_9' id='label_66_194_9' class='gform-field-label gform-field-label--type-inline'>Fall Prevention<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.11' type='checkbox'  value='Flexibility\/Strength\/Balance'  id='choice_66_194_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_11' id='label_66_194_11' class='gform-field-label gform-field-label--type-inline'>Flexibility\/Strength\/Balance<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.12' type='checkbox'  value='Foot Screening'  id='choice_66_194_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_12' id='label_66_194_12' class='gform-field-label gform-field-label--type-inline'>Foot Screening<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.13' type='checkbox'  value='General Education'  id='choice_66_194_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_13' id='label_66_194_13' class='gform-field-label gform-field-label--type-inline'>General Education<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.14' type='checkbox'  value='Hip to Waist Ratio'  id='choice_66_194_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_14' id='label_66_194_14' class='gform-field-label gform-field-label--type-inline'>Hip to Waist Ratio<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.15' type='checkbox'  value='Kinesiology Tape Application (DPT Only)'  id='choice_66_194_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_15' id='label_66_194_15' class='gform-field-label gform-field-label--type-inline'>Kinesiology Tape Application (DPT Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.16' type='checkbox'  value='Medicare Part D - Education'  id='choice_66_194_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_16' id='label_66_194_16' class='gform-field-label gform-field-label--type-inline'>Medicare Part D - Education<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.17' type='checkbox'  value='Medication Review\/Counseling'  id='choice_66_194_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_17' id='label_66_194_17' class='gform-field-label gform-field-label--type-inline'>Medication Review\/Counseling<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.18' type='checkbox'  value='One-on-One Patient Education (medical advice)'  id='choice_66_194_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_18' id='label_66_194_18' class='gform-field-label gform-field-label--type-inline'>One-on-One Patient Education (medical advice)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.19' type='checkbox'  value='Osteopathic Manipulative Therapy (OMT) (DO Only)'  id='choice_66_194_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_19' id='label_66_194_19' class='gform-field-label gform-field-label--type-inline'>Osteopathic Manipulative Therapy (OMT) (DO Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.21' type='checkbox'  value='PAP, Breast exam (PCHAT)'  id='choice_66_194_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_21' id='label_66_194_21' class='gform-field-label gform-field-label--type-inline'>PAP, Breast exam (PCHAT)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.22' type='checkbox'  value='Pet Screenings, Vaccines, Microchipping (DVM Only)'  id='choice_66_194_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_22' id='label_66_194_22' class='gform-field-label gform-field-label--type-inline'>Pet Screenings, Vaccines, Microchipping (DVM Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.23' type='checkbox'  value='Physical Examinations'  id='choice_66_194_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_23' id='label_66_194_23' class='gform-field-label gform-field-label--type-inline'>Physical Examinations<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.24' type='checkbox'  value='Sports Physicals'  id='choice_66_194_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_24' id='label_66_194_24' class='gform-field-label gform-field-label--type-inline'>Sports Physicals<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.25' type='checkbox'  value='Symptom Survey, Distance Visual Acuity, Color Vision, &amp; Extraocular Muscle Assessment'  id='choice_66_194_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_25' id='label_66_194_25' class='gform-field-label gform-field-label--type-inline'>Symptom Survey, Distance Visual Acuity, Color Vision, &amp; Extraocular Muscle Assessment<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.26' type='checkbox'  value='Vaccines'  id='choice_66_194_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_26' id='label_66_194_26' class='gform-field-label gform-field-label--type-inline'>Vaccines<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_194_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.27' type='checkbox'  value='Other'  id='choice_66_194_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_194_27' id='label_66_194_27' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_66_195\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br>\n<br>\n<br>\n<br>\n<br><\/li><li id=\"field_66_196\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faculty\/Preceptor #6 | Name, Degree<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_66_196'>\n                            <span id='input_66_196_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' >\n                                                    <select name='input_196.2' id='input_66_196_2'    aria-required='false'   >\n                          <option value=''><\/option><option value='Dr.' >Dr.<\/option><option value='Prof.' >Prof.<\/option>\n                      <\/select>\n                                                    <label for='input_66_196_2' class='gform-field-label gform-field-label--type-sub '>Prefix<\/label>\n                                                  <\/span>\n                            <span id='input_66_196_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_196.3' id='input_66_196_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_196_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_66_196_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_196.6' id='input_66_196_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_196_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_66_196_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_196.8' id='input_66_196_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_66_196_8' class='gform-field-label gform-field-label--type-sub '>Degree (e.g. PharmD)<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_66_197\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_197'>Faculty\/Preceptor #6 | Employer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_197'>This is needed to verify affiliation with university if not a faculty member. If WesternU faculty, type WesternU.<\/div><div class='ginput_container ginput_container_text'><input name='input_197' id='input_66_197' type='text' value='' class='large'  aria-describedby=\"gfield_description_66_197\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_66_198\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_198'>Faculty\/Preceptor #6 | E-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_198' id='input_66_198' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_66_204\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faculty\/Preceptor #6 | Overseeing:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_204'>Check all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_66_204'><li class='gchoice gchoice_66_204_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.1' type='checkbox'  value='Autorefractor, Near Point of Convergence, &amp; Cover Test (OD Only)'  id='choice_66_204_1'   aria-describedby=\"gfield_description_66_204\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_1' id='label_66_204_1' class='gform-field-label gform-field-label--type-inline'>Autorefractor, Near Point of Convergence, &amp; Cover Test (OD Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.2' type='checkbox'  value='Basic First Aid (Distributing Bandages)'  id='choice_66_204_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_2' id='label_66_204_2' class='gform-field-label gform-field-label--type-inline'>Basic First Aid (Distributing Bandages)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.3' type='checkbox'  value='Blood Glucose'  id='choice_66_204_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_3' id='label_66_204_3' class='gform-field-label gform-field-label--type-inline'>Blood Glucose<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.4' type='checkbox'  value='Blood Pressure'  id='choice_66_204_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_4' id='label_66_204_4' class='gform-field-label gform-field-label--type-inline'>Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.5' type='checkbox'  value='Body Mass Index'  id='choice_66_204_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_5' id='label_66_204_5' class='gform-field-label gform-field-label--type-inline'>Body Mass Index<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.6' type='checkbox'  value='Bone Density'  id='choice_66_204_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_6' id='label_66_204_6' class='gform-field-label gform-field-label--type-inline'>Bone Density<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.7' type='checkbox'  value='Cholesterol Testing'  id='choice_66_204_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_7' id='label_66_204_7' class='gform-field-label gform-field-label--type-inline'>Cholesterol Testing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.8' type='checkbox'  value='Dental Screenings (DMD Only)'  id='choice_66_204_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_8' id='label_66_204_8' class='gform-field-label gform-field-label--type-inline'>Dental Screenings (DMD Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.9' type='checkbox'  value='Fall Prevention'  id='choice_66_204_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_9' id='label_66_204_9' class='gform-field-label gform-field-label--type-inline'>Fall Prevention<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.11' type='checkbox'  value='Flexibility\/Strength\/Balance'  id='choice_66_204_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_11' id='label_66_204_11' class='gform-field-label gform-field-label--type-inline'>Flexibility\/Strength\/Balance<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.12' type='checkbox'  value='Foot Screening'  id='choice_66_204_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_12' id='label_66_204_12' class='gform-field-label gform-field-label--type-inline'>Foot Screening<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.13' type='checkbox'  value='General Education'  id='choice_66_204_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_13' id='label_66_204_13' class='gform-field-label gform-field-label--type-inline'>General Education<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.14' type='checkbox'  value='Hip to Waist Ratio'  id='choice_66_204_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_14' id='label_66_204_14' class='gform-field-label gform-field-label--type-inline'>Hip to Waist Ratio<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.15' type='checkbox'  value='Kinesiology Tape Application (DPT Only)'  id='choice_66_204_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_15' id='label_66_204_15' class='gform-field-label gform-field-label--type-inline'>Kinesiology Tape Application (DPT Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.16' type='checkbox'  value='Medicare Part D - Education'  id='choice_66_204_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_16' id='label_66_204_16' class='gform-field-label gform-field-label--type-inline'>Medicare Part D - Education<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.17' type='checkbox'  value='Medication Review\/Counseling'  id='choice_66_204_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_17' id='label_66_204_17' class='gform-field-label gform-field-label--type-inline'>Medication Review\/Counseling<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.18' type='checkbox'  value='One-on-One Patient Education (medical advice)'  id='choice_66_204_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_18' id='label_66_204_18' class='gform-field-label gform-field-label--type-inline'>One-on-One Patient Education (medical advice)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.19' type='checkbox'  value='Osteopathic Manipulative Therapy (OMT) (DO Only)'  id='choice_66_204_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_19' id='label_66_204_19' class='gform-field-label gform-field-label--type-inline'>Osteopathic Manipulative Therapy (OMT) (DO Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.21' type='checkbox'  value='PAP, Breast exam (PCHAT)'  id='choice_66_204_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_21' id='label_66_204_21' class='gform-field-label gform-field-label--type-inline'>PAP, Breast exam (PCHAT)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.22' type='checkbox'  value='Pet Screenings, Vaccines, Microchipping (DVM Only)'  id='choice_66_204_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_22' id='label_66_204_22' class='gform-field-label gform-field-label--type-inline'>Pet Screenings, Vaccines, Microchipping (DVM Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.23' type='checkbox'  value='Physical Examinations'  id='choice_66_204_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_23' id='label_66_204_23' class='gform-field-label gform-field-label--type-inline'>Physical Examinations<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.24' type='checkbox'  value='Sports Physicals'  id='choice_66_204_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_24' id='label_66_204_24' class='gform-field-label gform-field-label--type-inline'>Sports Physicals<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.25' type='checkbox'  value='Symptom Survey, Distance Visual Acuity, Color Vision, &amp; Extraocular Muscle Assessment'  id='choice_66_204_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_25' id='label_66_204_25' class='gform-field-label gform-field-label--type-inline'>Symptom Survey, Distance Visual Acuity, Color Vision, &amp; Extraocular Muscle Assessment<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.26' type='checkbox'  value='Vaccines'  id='choice_66_204_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_26' id='label_66_204_26' class='gform-field-label gform-field-label--type-inline'>Vaccines<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_204_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.27' type='checkbox'  value='Other'  id='choice_66_204_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_204_27' id='label_66_204_27' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_66_200\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br>\n<br>\n<br>\n<br>\n<br><\/li><li id=\"field_66_201\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faculty\/Preceptor #7 | Name, Degree<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_66_201'>\n                            <span id='input_66_201_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' >\n                                                    <select name='input_201.2' id='input_66_201_2'    aria-required='false'   >\n                          <option value=''><\/option><option value='Dr.' >Dr.<\/option><option value='Prof.' >Prof.<\/option>\n                      <\/select>\n                                                    <label for='input_66_201_2' class='gform-field-label gform-field-label--type-sub '>Prefix<\/label>\n                                                  <\/span>\n                            <span id='input_66_201_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_201.3' id='input_66_201_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_201_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_66_201_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_201.6' id='input_66_201_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_201_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_66_201_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_201.8' id='input_66_201_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_66_201_8' class='gform-field-label gform-field-label--type-sub '>Degree (e.g. PharmD)<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_66_202\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_202'>Faculty\/Preceptor #7 | Employer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_202'>This is needed to verify affiliation with university if not a faculty member. If WesternU faculty, type WesternU.<\/div><div class='ginput_container ginput_container_text'><input name='input_202' id='input_66_202' type='text' value='' class='large'  aria-describedby=\"gfield_description_66_202\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_66_203\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_203'>Faculty\/Preceptor #7 | E-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_203' id='input_66_203' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_66_199\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faculty\/Preceptor #7 | Overseeing:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_199'>Check all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_66_199'><li class='gchoice gchoice_66_199_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.1' type='checkbox'  value='Autorefractor, Near Point of Convergence, &amp; Cover Test (OD Only)'  id='choice_66_199_1'   aria-describedby=\"gfield_description_66_199\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_1' id='label_66_199_1' class='gform-field-label gform-field-label--type-inline'>Autorefractor, Near Point of Convergence, &amp; Cover Test (OD Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.2' type='checkbox'  value='Basic First Aid (Distributing Bandages)'  id='choice_66_199_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_2' id='label_66_199_2' class='gform-field-label gform-field-label--type-inline'>Basic First Aid (Distributing Bandages)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.3' type='checkbox'  value='Blood Glucose'  id='choice_66_199_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_3' id='label_66_199_3' class='gform-field-label gform-field-label--type-inline'>Blood Glucose<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.4' type='checkbox'  value='Blood Pressure'  id='choice_66_199_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_4' id='label_66_199_4' class='gform-field-label gform-field-label--type-inline'>Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.5' type='checkbox'  value='Body Mass Index'  id='choice_66_199_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_5' id='label_66_199_5' class='gform-field-label gform-field-label--type-inline'>Body Mass Index<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.6' type='checkbox'  value='Bone Density'  id='choice_66_199_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_6' id='label_66_199_6' class='gform-field-label gform-field-label--type-inline'>Bone Density<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.7' type='checkbox'  value='Cholesterol Testing'  id='choice_66_199_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_7' id='label_66_199_7' class='gform-field-label gform-field-label--type-inline'>Cholesterol Testing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.8' type='checkbox'  value='Dental Screenings (DMD Only)'  id='choice_66_199_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_8' id='label_66_199_8' class='gform-field-label gform-field-label--type-inline'>Dental Screenings (DMD Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.9' type='checkbox'  value='Fall Prevention'  id='choice_66_199_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_9' id='label_66_199_9' class='gform-field-label gform-field-label--type-inline'>Fall Prevention<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.11' type='checkbox'  value='Flexibility\/Strength\/Balance'  id='choice_66_199_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_11' id='label_66_199_11' class='gform-field-label gform-field-label--type-inline'>Flexibility\/Strength\/Balance<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.12' type='checkbox'  value='Foot Screening'  id='choice_66_199_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_12' id='label_66_199_12' class='gform-field-label gform-field-label--type-inline'>Foot Screening<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.13' type='checkbox'  value='General Education'  id='choice_66_199_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_13' id='label_66_199_13' class='gform-field-label gform-field-label--type-inline'>General Education<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.14' type='checkbox'  value='Hip to Waist Ratio'  id='choice_66_199_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_14' id='label_66_199_14' class='gform-field-label gform-field-label--type-inline'>Hip to Waist Ratio<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.15' type='checkbox'  value='Kinesiology Tape Application (DPT Only)'  id='choice_66_199_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_15' id='label_66_199_15' class='gform-field-label gform-field-label--type-inline'>Kinesiology Tape Application (DPT Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.16' type='checkbox'  value='Medicare Part D - Education'  id='choice_66_199_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_16' id='label_66_199_16' class='gform-field-label gform-field-label--type-inline'>Medicare Part D - Education<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.17' type='checkbox'  value='Medication Review\/Counseling'  id='choice_66_199_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_17' id='label_66_199_17' class='gform-field-label gform-field-label--type-inline'>Medication Review\/Counseling<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.18' type='checkbox'  value='One-on-One Patient Education (medical advice)'  id='choice_66_199_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_18' id='label_66_199_18' class='gform-field-label gform-field-label--type-inline'>One-on-One Patient Education (medical advice)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.19' type='checkbox'  value='Osteopathic Manipulative Therapy (OMT) (DO Only)'  id='choice_66_199_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_19' id='label_66_199_19' class='gform-field-label gform-field-label--type-inline'>Osteopathic Manipulative Therapy (OMT) (DO Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.21' type='checkbox'  value='PAP, Breast exam (PCHAT)'  id='choice_66_199_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_21' id='label_66_199_21' class='gform-field-label gform-field-label--type-inline'>PAP, Breast exam (PCHAT)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.22' type='checkbox'  value='Pet Screenings, Vaccines, Microchipping (DVM Only)'  id='choice_66_199_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_22' id='label_66_199_22' class='gform-field-label gform-field-label--type-inline'>Pet Screenings, Vaccines, Microchipping (DVM Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.23' type='checkbox'  value='Physical Examinations'  id='choice_66_199_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_23' id='label_66_199_23' class='gform-field-label gform-field-label--type-inline'>Physical Examinations<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.24' type='checkbox'  value='Sports Physicals'  id='choice_66_199_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_24' id='label_66_199_24' class='gform-field-label gform-field-label--type-inline'>Sports Physicals<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.25' type='checkbox'  value='Symptom Survey, Distance Visual Acuity, Color Vision, &amp; Extraocular Muscle Assessment'  id='choice_66_199_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_25' id='label_66_199_25' class='gform-field-label gform-field-label--type-inline'>Symptom Survey, Distance Visual Acuity, Color Vision, &amp; Extraocular Muscle Assessment<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.26' type='checkbox'  value='Vaccines'  id='choice_66_199_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_26' id='label_66_199_26' class='gform-field-label gform-field-label--type-inline'>Vaccines<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_199_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.27' type='checkbox'  value='Other'  id='choice_66_199_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_199_27' id='label_66_199_27' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_66_205\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br>\n<br>\n<br>\n<br>\n<br><\/li><li id=\"field_66_206\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faculty\/Preceptor #8 | Name, Degree<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_66_206'>\n                            <span id='input_66_206_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' >\n                                                    <select name='input_206.2' id='input_66_206_2'    aria-required='false'   >\n                          <option value=''><\/option><option value='Dr.' >Dr.<\/option><option value='Prof.' >Prof.<\/option>\n                      <\/select>\n                                                    <label for='input_66_206_2' class='gform-field-label gform-field-label--type-sub '>Prefix<\/label>\n                                                  <\/span>\n                            <span id='input_66_206_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_206.3' id='input_66_206_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_206_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_66_206_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_206.6' id='input_66_206_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_206_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_66_206_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_206.8' id='input_66_206_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_66_206_8' class='gform-field-label gform-field-label--type-sub '>Degree (e.g. PharmD)<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_66_207\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_207'>Faculty\/Preceptor #8 | Employer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_207'>This is needed to verify affiliation with university if not a faculty member. If WesternU faculty, type WesternU.<\/div><div class='ginput_container ginput_container_text'><input name='input_207' id='input_66_207' type='text' value='' class='large'  aria-describedby=\"gfield_description_66_207\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_66_208\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_208'>Faculty\/Preceptor #8 | E-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_208' id='input_66_208' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_66_209\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faculty\/Preceptor #8 | Overseeing:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_209'>Check all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_66_209'><li class='gchoice gchoice_66_209_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.1' type='checkbox'  value='Autorefractor, Near Point of Convergence, &amp; Cover Test (OD Only)'  id='choice_66_209_1'   aria-describedby=\"gfield_description_66_209\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_1' id='label_66_209_1' class='gform-field-label gform-field-label--type-inline'>Autorefractor, Near Point of Convergence, &amp; Cover Test (OD Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.2' type='checkbox'  value='Basic First Aid (Distributing Bandages)'  id='choice_66_209_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_2' id='label_66_209_2' class='gform-field-label gform-field-label--type-inline'>Basic First Aid (Distributing Bandages)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.3' type='checkbox'  value='Blood Glucose'  id='choice_66_209_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_3' id='label_66_209_3' class='gform-field-label gform-field-label--type-inline'>Blood Glucose<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.4' type='checkbox'  value='Blood Pressure'  id='choice_66_209_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_4' id='label_66_209_4' class='gform-field-label gform-field-label--type-inline'>Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.5' type='checkbox'  value='Body Mass Index'  id='choice_66_209_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_5' id='label_66_209_5' class='gform-field-label gform-field-label--type-inline'>Body Mass Index<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.6' type='checkbox'  value='Bone Density'  id='choice_66_209_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_6' id='label_66_209_6' class='gform-field-label gform-field-label--type-inline'>Bone Density<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.7' type='checkbox'  value='Cholesterol Testing'  id='choice_66_209_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_7' id='label_66_209_7' class='gform-field-label gform-field-label--type-inline'>Cholesterol Testing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.8' type='checkbox'  value='Dental Screenings (DMD Only)'  id='choice_66_209_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_8' id='label_66_209_8' class='gform-field-label gform-field-label--type-inline'>Dental Screenings (DMD Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.9' type='checkbox'  value='Fall Prevention'  id='choice_66_209_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_9' id='label_66_209_9' class='gform-field-label gform-field-label--type-inline'>Fall Prevention<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.11' type='checkbox'  value='Flexibility\/Strength\/Balance'  id='choice_66_209_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_11' id='label_66_209_11' class='gform-field-label gform-field-label--type-inline'>Flexibility\/Strength\/Balance<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.12' type='checkbox'  value='Foot Screening'  id='choice_66_209_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_12' id='label_66_209_12' class='gform-field-label gform-field-label--type-inline'>Foot Screening<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.13' type='checkbox'  value='General Education'  id='choice_66_209_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_13' id='label_66_209_13' class='gform-field-label gform-field-label--type-inline'>General Education<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.14' type='checkbox'  value='Hip to Waist Ratio'  id='choice_66_209_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_14' id='label_66_209_14' class='gform-field-label gform-field-label--type-inline'>Hip to Waist Ratio<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.15' type='checkbox'  value='Kinesiology Tape Application (DPT Only)'  id='choice_66_209_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_15' id='label_66_209_15' class='gform-field-label gform-field-label--type-inline'>Kinesiology Tape Application (DPT Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.16' type='checkbox'  value='Medicare Part D - Education'  id='choice_66_209_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_16' id='label_66_209_16' class='gform-field-label gform-field-label--type-inline'>Medicare Part D - Education<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.17' type='checkbox'  value='Medication Review\/Counseling'  id='choice_66_209_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_17' id='label_66_209_17' class='gform-field-label gform-field-label--type-inline'>Medication Review\/Counseling<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.18' type='checkbox'  value='One-on-One Patient Education (medical advice)'  id='choice_66_209_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_18' id='label_66_209_18' class='gform-field-label gform-field-label--type-inline'>One-on-One Patient Education (medical advice)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.19' type='checkbox'  value='Osteopathic Manipulative Therapy (OMT) (DO Only)'  id='choice_66_209_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_19' id='label_66_209_19' class='gform-field-label gform-field-label--type-inline'>Osteopathic Manipulative Therapy (OMT) (DO Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.21' type='checkbox'  value='PAP, Breast exam (PCHAT)'  id='choice_66_209_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_21' id='label_66_209_21' class='gform-field-label gform-field-label--type-inline'>PAP, Breast exam (PCHAT)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.22' type='checkbox'  value='Pet Screenings, Vaccines, Microchipping (DVM Only)'  id='choice_66_209_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_22' id='label_66_209_22' class='gform-field-label gform-field-label--type-inline'>Pet Screenings, Vaccines, Microchipping (DVM Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.23' type='checkbox'  value='Physical Examinations'  id='choice_66_209_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_23' id='label_66_209_23' class='gform-field-label gform-field-label--type-inline'>Physical Examinations<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.24' type='checkbox'  value='Sports Physicals'  id='choice_66_209_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_24' id='label_66_209_24' class='gform-field-label gform-field-label--type-inline'>Sports Physicals<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.25' type='checkbox'  value='Symptom Survey, Distance Visual Acuity, Color Vision, &amp; Extraocular Muscle Assessment'  id='choice_66_209_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_25' id='label_66_209_25' class='gform-field-label gform-field-label--type-inline'>Symptom Survey, Distance Visual Acuity, Color Vision, &amp; Extraocular Muscle Assessment<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.26' type='checkbox'  value='Vaccines'  id='choice_66_209_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_26' id='label_66_209_26' class='gform-field-label gform-field-label--type-inline'>Vaccines<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_209_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.27' type='checkbox'  value='Other'  id='choice_66_209_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_209_27' id='label_66_209_27' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_66_210\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br>\n<br>\n<br>\n<br>\n<br><\/li><li id=\"field_66_214\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faculty\/Preceptor #9 | Name, Degree<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_66_214'>\n                            <span id='input_66_214_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' >\n                                                    <select name='input_214.2' id='input_66_214_2'    aria-required='false'   >\n                          <option value=''><\/option><option value='Dr.' >Dr.<\/option><option value='Prof.' >Prof.<\/option>\n                      <\/select>\n                                                    <label for='input_66_214_2' class='gform-field-label gform-field-label--type-sub '>Prefix<\/label>\n                                                  <\/span>\n                            <span id='input_66_214_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_214.3' id='input_66_214_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_214_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_66_214_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_214.6' id='input_66_214_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_214_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_66_214_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_214.8' id='input_66_214_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_66_214_8' class='gform-field-label gform-field-label--type-sub '>Degree (e.g. PharmD)<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_66_216\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_216'>Faculty\/Preceptor #9 | Employer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_216'>This is needed to verify affiliation with university if not a faculty member. If WesternU faculty, type WesternU.<\/div><div class='ginput_container ginput_container_text'><input name='input_216' id='input_66_216' type='text' value='' class='large'  aria-describedby=\"gfield_description_66_216\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_66_218\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_218'>Faculty\/Preceptor #9 | E-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_218' id='input_66_218' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_66_220\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faculty\/Preceptor #9 | Overseeing:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_220'>Check all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_66_220'><li class='gchoice gchoice_66_220_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.1' type='checkbox'  value='Autorefractor, Near Point of Convergence, &amp; Cover Test (OD Only)'  id='choice_66_220_1'   aria-describedby=\"gfield_description_66_220\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_1' id='label_66_220_1' class='gform-field-label gform-field-label--type-inline'>Autorefractor, Near Point of Convergence, &amp; Cover Test (OD Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.2' type='checkbox'  value='Basic First Aid (Distributing Bandages)'  id='choice_66_220_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_2' id='label_66_220_2' class='gform-field-label gform-field-label--type-inline'>Basic First Aid (Distributing Bandages)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.3' type='checkbox'  value='Blood Glucose'  id='choice_66_220_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_3' id='label_66_220_3' class='gform-field-label gform-field-label--type-inline'>Blood Glucose<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.4' type='checkbox'  value='Blood Pressure'  id='choice_66_220_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_4' id='label_66_220_4' class='gform-field-label gform-field-label--type-inline'>Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.5' type='checkbox'  value='Body Mass Index'  id='choice_66_220_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_5' id='label_66_220_5' class='gform-field-label gform-field-label--type-inline'>Body Mass Index<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.6' type='checkbox'  value='Bone Density'  id='choice_66_220_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_6' id='label_66_220_6' class='gform-field-label gform-field-label--type-inline'>Bone Density<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.7' type='checkbox'  value='Cholesterol Testing'  id='choice_66_220_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_7' id='label_66_220_7' class='gform-field-label gform-field-label--type-inline'>Cholesterol Testing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.8' type='checkbox'  value='Dental Screenings (DMD Only)'  id='choice_66_220_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_8' id='label_66_220_8' class='gform-field-label gform-field-label--type-inline'>Dental Screenings (DMD Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.9' type='checkbox'  value='Fall Prevention'  id='choice_66_220_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_9' id='label_66_220_9' class='gform-field-label gform-field-label--type-inline'>Fall Prevention<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.11' type='checkbox'  value='Flexibility\/Strength\/Balance'  id='choice_66_220_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_11' id='label_66_220_11' class='gform-field-label gform-field-label--type-inline'>Flexibility\/Strength\/Balance<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.12' type='checkbox'  value='Foot Screening'  id='choice_66_220_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_12' id='label_66_220_12' class='gform-field-label gform-field-label--type-inline'>Foot Screening<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.13' type='checkbox'  value='General Education'  id='choice_66_220_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_13' id='label_66_220_13' class='gform-field-label gform-field-label--type-inline'>General Education<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.14' type='checkbox'  value='Hip to Waist Ratio'  id='choice_66_220_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_14' id='label_66_220_14' class='gform-field-label gform-field-label--type-inline'>Hip to Waist Ratio<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.15' type='checkbox'  value='Kinesiology Tape Application (DPT Only)'  id='choice_66_220_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_15' id='label_66_220_15' class='gform-field-label gform-field-label--type-inline'>Kinesiology Tape Application (DPT Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.16' type='checkbox'  value='Medicare Part D - Education'  id='choice_66_220_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_16' id='label_66_220_16' class='gform-field-label gform-field-label--type-inline'>Medicare Part D - Education<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.17' type='checkbox'  value='Medication Review\/Counseling'  id='choice_66_220_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_17' id='label_66_220_17' class='gform-field-label gform-field-label--type-inline'>Medication Review\/Counseling<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.18' type='checkbox'  value='One-on-One Patient Education (medical advice)'  id='choice_66_220_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_18' id='label_66_220_18' class='gform-field-label gform-field-label--type-inline'>One-on-One Patient Education (medical advice)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.19' type='checkbox'  value='Osteopathic Manipulative Therapy (OMT) (DO Only)'  id='choice_66_220_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_19' id='label_66_220_19' class='gform-field-label gform-field-label--type-inline'>Osteopathic Manipulative Therapy (OMT) (DO Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.21' type='checkbox'  value='PAP, Breast exam (PCHAT)'  id='choice_66_220_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_21' id='label_66_220_21' class='gform-field-label gform-field-label--type-inline'>PAP, Breast exam (PCHAT)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.22' type='checkbox'  value='Pet Screenings, Vaccines, Microchipping (DVM Only)'  id='choice_66_220_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_22' id='label_66_220_22' class='gform-field-label gform-field-label--type-inline'>Pet Screenings, Vaccines, Microchipping (DVM Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.23' type='checkbox'  value='Physical Examinations'  id='choice_66_220_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_23' id='label_66_220_23' class='gform-field-label gform-field-label--type-inline'>Physical Examinations<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.24' type='checkbox'  value='Sports Physicals'  id='choice_66_220_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_24' id='label_66_220_24' class='gform-field-label gform-field-label--type-inline'>Sports Physicals<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.25' type='checkbox'  value='Symptom Survey, Distance Visual Acuity, Color Vision, &amp; Extraocular Muscle Assessment'  id='choice_66_220_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_25' id='label_66_220_25' class='gform-field-label gform-field-label--type-inline'>Symptom Survey, Distance Visual Acuity, Color Vision, &amp; Extraocular Muscle Assessment<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.26' type='checkbox'  value='Vaccines'  id='choice_66_220_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_26' id='label_66_220_26' class='gform-field-label gform-field-label--type-inline'>Vaccines<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_220_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.27' type='checkbox'  value='Other'  id='choice_66_220_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_220_27' id='label_66_220_27' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_66_211\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br>\n<br>\n<br>\n<br>\n<br><\/li><li id=\"field_66_213\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faculty\/Preceptor #10 | Name, Degree<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_66_213'>\n                            <span id='input_66_213_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' >\n                                                    <select name='input_213.2' id='input_66_213_2'    aria-required='false'   >\n                          <option value=''><\/option><option value='Dr.' >Dr.<\/option><option value='Prof.' >Prof.<\/option>\n                      <\/select>\n                                                    <label for='input_66_213_2' class='gform-field-label gform-field-label--type-sub '>Prefix<\/label>\n                                                  <\/span>\n                            <span id='input_66_213_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_213.3' id='input_66_213_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_213_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_66_213_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_213.6' id='input_66_213_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_66_213_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_66_213_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_213.8' id='input_66_213_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_66_213_8' class='gform-field-label gform-field-label--type-sub '>Degree (e.g. PharmD)<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_66_215\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_215'>Faculty\/Preceptor #10 | Employer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_215'>This is needed to verify affiliation with university if not a faculty member. If WesternU faculty, type WesternU.<\/div><div class='ginput_container ginput_container_text'><input name='input_215' id='input_66_215' type='text' value='' class='large'  aria-describedby=\"gfield_description_66_215\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_66_217\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_217'>Faculty\/Preceptor #10 | E-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_217' id='input_66_217' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_66_219\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faculty\/Preceptor #10 | Overseeing:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_219'>Check all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_66_219'><li class='gchoice gchoice_66_219_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.1' type='checkbox'  value='Autorefractor, Near Point of Convergence, &amp; Cover Test (OD Only)'  id='choice_66_219_1'   aria-describedby=\"gfield_description_66_219\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_1' id='label_66_219_1' class='gform-field-label gform-field-label--type-inline'>Autorefractor, Near Point of Convergence, &amp; Cover Test (OD Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.2' type='checkbox'  value='Basic First Aid (Distributing Bandages)'  id='choice_66_219_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_2' id='label_66_219_2' class='gform-field-label gform-field-label--type-inline'>Basic First Aid (Distributing Bandages)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.3' type='checkbox'  value='Blood Glucose'  id='choice_66_219_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_3' id='label_66_219_3' class='gform-field-label gform-field-label--type-inline'>Blood Glucose<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.4' type='checkbox'  value='Blood Pressure'  id='choice_66_219_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_4' id='label_66_219_4' class='gform-field-label gform-field-label--type-inline'>Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.5' type='checkbox'  value='Body Mass Index'  id='choice_66_219_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_5' id='label_66_219_5' class='gform-field-label gform-field-label--type-inline'>Body Mass Index<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.6' type='checkbox'  value='Bone Density'  id='choice_66_219_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_6' id='label_66_219_6' class='gform-field-label gform-field-label--type-inline'>Bone Density<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.7' type='checkbox'  value='Cholesterol Testing'  id='choice_66_219_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_7' id='label_66_219_7' class='gform-field-label gform-field-label--type-inline'>Cholesterol Testing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.8' type='checkbox'  value='Dental Screenings (DMD Only)'  id='choice_66_219_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_8' id='label_66_219_8' class='gform-field-label gform-field-label--type-inline'>Dental Screenings (DMD Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.9' type='checkbox'  value='Fall Prevention'  id='choice_66_219_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_9' id='label_66_219_9' class='gform-field-label gform-field-label--type-inline'>Fall Prevention<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.11' type='checkbox'  value='Flexibility\/Strength\/Balance'  id='choice_66_219_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_11' id='label_66_219_11' class='gform-field-label gform-field-label--type-inline'>Flexibility\/Strength\/Balance<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.12' type='checkbox'  value='Foot Screening'  id='choice_66_219_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_12' id='label_66_219_12' class='gform-field-label gform-field-label--type-inline'>Foot Screening<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.13' type='checkbox'  value='General Education'  id='choice_66_219_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_13' id='label_66_219_13' class='gform-field-label gform-field-label--type-inline'>General Education<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.14' type='checkbox'  value='Hip to Waist Ratio'  id='choice_66_219_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_14' id='label_66_219_14' class='gform-field-label gform-field-label--type-inline'>Hip to Waist Ratio<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.15' type='checkbox'  value='Kinesiology Tape Application (DPT Only)'  id='choice_66_219_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_15' id='label_66_219_15' class='gform-field-label gform-field-label--type-inline'>Kinesiology Tape Application (DPT Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.16' type='checkbox'  value='Medicare Part D - Education'  id='choice_66_219_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_16' id='label_66_219_16' class='gform-field-label gform-field-label--type-inline'>Medicare Part D - Education<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.17' type='checkbox'  value='Medication Review\/Counseling'  id='choice_66_219_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_17' id='label_66_219_17' class='gform-field-label gform-field-label--type-inline'>Medication Review\/Counseling<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.18' type='checkbox'  value='One-on-One Patient Education (medical advice)'  id='choice_66_219_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_18' id='label_66_219_18' class='gform-field-label gform-field-label--type-inline'>One-on-One Patient Education (medical advice)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.19' type='checkbox'  value='Osteopathic Manipulative Therapy (OMT) (DO Only)'  id='choice_66_219_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_19' id='label_66_219_19' class='gform-field-label gform-field-label--type-inline'>Osteopathic Manipulative Therapy (OMT) (DO Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.21' type='checkbox'  value='PAP, Breast exam (PCHAT)'  id='choice_66_219_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_21' id='label_66_219_21' class='gform-field-label gform-field-label--type-inline'>PAP, Breast exam (PCHAT)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.22' type='checkbox'  value='Pet Screenings, Vaccines, Microchipping (DVM Only)'  id='choice_66_219_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_22' id='label_66_219_22' class='gform-field-label gform-field-label--type-inline'>Pet Screenings, Vaccines, Microchipping (DVM Only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.23' type='checkbox'  value='Physical Examinations'  id='choice_66_219_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_23' id='label_66_219_23' class='gform-field-label gform-field-label--type-inline'>Physical Examinations<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.24' type='checkbox'  value='Sports Physicals'  id='choice_66_219_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_24' id='label_66_219_24' class='gform-field-label gform-field-label--type-inline'>Sports Physicals<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.25' type='checkbox'  value='Symptom Survey, Distance Visual Acuity, Color Vision, &amp; Extraocular Muscle Assessment'  id='choice_66_219_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_25' id='label_66_219_25' class='gform-field-label gform-field-label--type-inline'>Symptom Survey, Distance Visual Acuity, Color Vision, &amp; Extraocular Muscle Assessment<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.26' type='checkbox'  value='Vaccines'  id='choice_66_219_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_26' id='label_66_219_26' class='gform-field-label gform-field-label--type-inline'>Vaccines<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_66_219_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.27' type='checkbox'  value='Other'  id='choice_66_219_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_66_219_27' id='label_66_219_27' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_66_212\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br>\n<br>\n<br>\n<br>\n<br><\/li><li id=\"field_66_221\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_221'>More than 10?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_221'>Please include the necessary information in the block below. <\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_221' id='input_66_221' class='textarea large'  aria-describedby=\"gfield_description_66_221\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_66_52\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >\n\n\n    <title>Horizontal line <\/title>\n\n\n\n    <h1><b>Vaccines<\/b><\/h1>\n    <hr width=\"100%\" size=\"2\">\n    \n\n\n<\/li><li id=\"field_66_235\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br>\n<span style=\"font-size: large\"><b>Vaccines<\/b><\/span>\nYou indicated you are providing vaccines as a services. Please let us know the following:\n<br>\n<br><\/li><li id=\"field_66_222\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_222'>Name of person providing on-site EpiPen:<\/label><div class='ginput_container ginput_container_text'><input name='input_222' id='input_66_222' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_66_224\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_224'>Who is supplying the vaccines?<\/label><div class='gfield_description' id='gfield_description_66_224'>E.g. San Bernardino County, LA County, WesternU Pharmacy, etc. <\/div><div class='ginput_container ginput_container_text'><input name='input_224' id='input_66_224' type='text' value='' class='large'  aria-describedby=\"gfield_description_66_224\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_66_225\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_225'>Name of clinician responsible for entering in to ciarweb.org (a WesternU requirement).<\/label><div class='gfield_description' id='gfield_description_66_225'>Clinician must have a California Immunization Registry (CAIR) login. <\/div><div class='ginput_container ginput_container_text'><input name='input_225' id='input_66_225' type='text' value='' class='large'  aria-describedby=\"gfield_description_66_225\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_66_227\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_227'>PharmD Students<\/label><div class='gfield_description' id='gfield_description_66_227'>List names of PharmD students assisting with vaccines.  If you don't know your student volunteers names yet leave blank and e-mail to studentaffairs@westernu.edu along with their APhA certificates. <\/div><div class='ginput_container ginput_container_text'><input name='input_227' id='input_66_227' type='text' value='' class='large'  aria-describedby=\"gfield_description_66_227\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_66_226\" class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_66_226'>APhA Certificates<\/label><div class='gfield_description' id='gfield_description_66_226'>PharmD students assisting with vaccines must provide proof of their APhA certificate before participating.  You may upload their certificates here (merge all into one .pdf) or e-mail them to studentaffairs@westernu.edu<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='131072000' \/><input name='input_226' id='input_66_226' type='file' class='large' aria-describedby=\"gfield_upload_rules_66_226 gfield_description_66_226\" onchange='javascript:gformValidateFileSize( this, 131072000 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_66_226'>Max. file size: 125 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_66_226'><\/div> <\/div><\/li><li id=\"field_66_223\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br>\n<span style=\"font-size: large\"><b>Contract<\/b><\/span>\n<br>\n<br><\/li><li id=\"field_66_101\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >Certificate of Liability Insurance (COI)*: If the Community Organizer (CO) is asking for a COI, ask \nthem to contact University Student Affairs (studentaffairs@westernu.edu) directly. \nContract\/Agreement*: All contracts must be reviewed by University Legal and signed by a designated \nsignatory. If the CO requires a contract, please send it to: studentaffairs@westernu.edu. \n*COI requests may delay approval by 2 weeks and a contract by 4-6 weeks.\n<\/li><li id=\"field_66_41\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Is the community organizer asking for a signed contract?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_66_41'>If yes, it must be reviewed by our legal department and signed by a designated signatory. <\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_66_41'>\n\t\t\t<li class='gchoice gchoice_66_41_0'>\n\t\t\t\t<input name='input_41' type='radio' value='No. A contract is not necessary'  id='choice_66_41_0'    \/>\n\t\t\t\t<label for='choice_66_41_0' id='label_66_41_0' class='gform-field-label gform-field-label--type-inline'>No. A contract is not necessary<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_66_41_1'>\n\t\t\t\t<input name='input_41' type='radio' value='Yes. I will upload my .pdf contract now'  id='choice_66_41_1'    \/>\n\t\t\t\t<label for='choice_66_41_1' id='label_66_41_1' class='gform-field-label gform-field-label--type-inline'>Yes. I will upload my .pdf contract now<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_66_41_2'>\n\t\t\t\t<input name='input_41' type='radio' value='Yes. I will e-mail contract to studentaffairs@westernu.edu'  id='choice_66_41_2'    \/>\n\t\t\t\t<label for='choice_66_41_2' id='label_66_41_2' class='gform-field-label gform-field-label--type-inline'>Yes. 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