English Español العربية 简体中文 繁體中文 Filipino Français हिन्दी 한국어 اردو Tiếng Việt
Loading Events

« All Events

  • This event has passed.

Collateral Damage: The Impact of Suicide on Congregations and Caregivers

April 13, 2016 @ 5:00 pm - 6:30 pm

Free

ABOUT THE PROGRAM

Suicide is a common cause of death which is often challenging to discuss because of stigma. A particular difficulty is the way suicide leaves painful questions within family members and caregivers of those lost to this grievous consequence of mental illness. This session will discuss this problem and how faith communities can come together to provide a healing space in the midst of pain and uncertainty.

Click here for event flyer.


1.5 CEUs will be offered for LCSW, LMFT, LPC, and Clinical Psychologist.

REGISTRATION IS REQUIRED FOR ALL ATTENDEES PRIOR TO THE EVENT. Check in will begin 15 minutes prior to the program beginning. Due to video filming, late attendees will be asked to view the presentation in the Green Room.


ABOUT THE SPEAKERS

Thomas Ellis2Thomas E. Ellis, PsyD, ABPP; and Director of Psychology at the Menninger Clinic and Professor of Psychiatry in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine

Thomas earned his bachelor’s degree at the University of Texas at Austin and his doctorate at Baylor University. He is a Fellow of the American Psychological Association (Clinical and Psychotherapy Divisions) and Diplomate of the American Board of Professional Psychology (Cognitive Behavior Therapy). He is a Founding Fellow of the Academy of Cognitive Therapy and Associate Fellow of the Albert Ellis Institute. His research and publications focus primarily on the problem of suicide, including cognitive characteristics of suicidal individuals and the effectiveness of suicide-specific therapeutic interventions. His books include Suicide Risk: Assessment and Response Guidelines (with W. Fremouw and M. dePerczel, 1990), Choosing to Live: How to Defeat Suicide through Cognitive Therapy (with C. Newman, 1996), and Cognition and Suicide: Theory, Research, and Practice (2006). He is the 2011 recipient of the Roger J. Tierney Award from the American Association of Suicidology, in recognition of distinguished contributions to the organization and the field of suicidology.

Lomax picture 2012 smaller imageJames W. Lomax, M.D., Professor, Psychiatry and Behavioral Sciences, Baylor College of Medicine

Dr. Lomax is a psychoanalyst whose clinical effort involves psychotherapeutic and psychoanalytic treatment of individuals with anxiety, mood, and personality disorders, as well as those with complicated grief, traumatic loss, and other adjustment reactions. He is interested in the interface between psychiatry (from a psychoanalytic perspective), religion, and spirituality. His interdisciplinary efforts involve the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine with the Institute for Spirituality and Health of The Texas Medical Center, the Department of Religious Studies, Rice University, the Hope and Healing Center and Institute at Saint Martin’s Episcopal Church, and many of the clinical entities of the Texas Medical Center. The purpose of these relationships is to deepen the exploration of phenomena, such as healing, grief, and response to loss from the different perspectives that each of the aforementioned disciplines brings to bear on similar situations.

Greg HanReverend Gregory Han

The Rev. Gregory Han is the Director of Interfaith Relations at Interfaith Ministries for Greater Houston, where, since June of 2014, he has led a four-person staff in building networks, strengthening relationships, and providing resources to increase and deepen understanding across religious traditions. Since moving to Houston in 1998, Rev. Han has been a hospital chaplain and served nearly eight years in two different Presbyterian congregations. For six years he was on the faculty of St. John’s School, where he taught courses in religion and ethics and also coordinated the school’s Chapel program. Rev. Han holds degrees from Georgetown University and Harvard Divinity School.

Ye Beverly DuYe Beverly Du, M.D., MPH

Beverly Du received her medical degree from Harvard Medical School and completed adult psychiatry residency at Columbia University. She has a strong interest in education, psychotherapy and personality disorders, including Borderline Personality Disorder. She currently serves as Medical Director of the Intensive Outpatient Program at Ben Taub Hospital, the Director of Psychotherapy Education for the Baylor Adult Psychiatry Residency, and the Associate Director of Medical Student Education  at the Baylor College of Medicine.

 

Father JozwiakFather Lawrence W. Jozwiak, J.C.L.

Fr. Lawrence W. Jozwiak, J.C.L., is a native Houstonian, received a Catholic education (1st grade through St. Pius X High School).  Went to the University of Houston for 1st two years and graduated from Texas A&M University in 1980 with a BBA in accounting.  Received his C.P.A. license and worked for an oil and gas company.  Entered St. Mary Seminary and was ordained a priest on May 23, 1987, receiving a Master’s Degree in Divinity from the University of St. Thomas in Houston. Received a graduate degree in Canon Law (J.C.L.) from The Catholic University of America in Washington, D.C. in 1991.  He is the Pastor / Rector of the Co-Cathedral of the Sacred Heart (since 2008), the Judicial Vicar for the Metropolitan Tribunal for the Archdiocese of Galveston-Houston (since 1997) and an adjunct professor of Canon Law at the Graduate School of Theology for the University of St. Thomas, located at St. Mary Seminary (since 2001).

Sheikh Joe Bradford

Joe Bradford is an author, entrepreneur, and American scholar of Islamic studies. He holds a graduate degree in Islamic law from Medina University and has worked professionally in finance for the past 10 years. He’s the author of “Simple Zakat Guide” and the “Muslim Money Guide.” He currently teaches at Prairie View A&M University and runs his own advisory. He blogs at joebradford.net.

Register

Details

Date:
April 13, 2016
Time:
5:00 pm - 6:30 pm
Cost:
Free
Event Category:
Event Tags:
, , , , , , , , ,

Venue

Auditorium
717 Sage Road
Houston, TX 77056 United States
+ Google Map
Phone:
713.871.1004
Website:
hopeandhealingcenter.org
[o.length-1]
[o.length-1]
[gravityforms id=1]
<script type="text/javascript">var gform;gform||(document.addEventListener("gform_main_scripts_loaded",function(){gform.scriptsLoaded=!0}),window.addEventListener("DOMContentLoaded",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener("DOMContentLoaded",o):document.addEventListener("gform_main_scripts_loaded",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook("action",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook("filter",o,n,r,t)},doAction:function(o){gform.doHook("action",o,arguments)},applyFilters:function(o){return gform.doHook("filter",o,arguments)},removeAction:function(o,n){gform.removeHook("action",o,n)},removeFilter:function(o,n,r){gform.removeHook("filter",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+"_"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){"function"!=typeof(t=o.callable)&&(t=window[t]),"action"==n?t.apply(null,r):r[0]=t.apply(null,r)})),"filter"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});</script> <div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_1' > <div class='gform_heading'> <h3 class="gform_title">EMPOWER Online Training Registration</h3> <span class='gform_description'></span> </div><form method='post' enctype='multipart/form-data' id='gform_1' action='/event/collateral-damage-the-impact-of-suicide-on-congregations-and-caregivers/' novalidate> <div class='gform_body gform-body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><li id="field_1_1" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_1"><label class='gfield_label gfield_label_before_complex' >Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_1_1'> <span id='input_1_1_3_container' class='name_first' > <input type='text' name='input_1.3' id='input_1_1_3' value='' aria-required='true' /> <label for='input_1_1_3' >First</label> </span> <span id='input_1_1_6_container' class='name_last' > <input type='text' name='input_1.6' id='input_1_1_6' value='' aria-required='true' /> <label for='input_1_1_6' >Last</label> </span> </div></li><li id="field_1_2" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_2"><label class='gfield_label' for='input_1_2' >Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_email'> <input name='input_2' id='input_1_2' type='email' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></li><li id="field_1_3" class="gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_3"><label class='gfield_label' for='input_1_3' >Phone<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_1_3' type='tel' value='' class='medium' aria-required="true" aria-invalid="false" /></div></li><li id="field_1_4" class="gfield gfield--width-full gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_4"><label class='gfield_label' for='input_1_4' >Company / Organization<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_1_4' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></li><li id="field_1_7" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_7"><label class='gfield_label gfield_label_before_complex' >Password<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_complex ginput_container ginput_container_password' id='input_1_7_container'> <span id='input_1_7_1_container' class='ginput_left'> <span class='password_input_container'> <input type='password' name='input_7' id='input_1_7' value='' aria-required="true" aria-invalid="false" /> </span> <label for='input_1_7' >Enter Password</label> </span> <span id='input_1_7_2_container' class='ginput_right'> <span class='password_input_container'> <input type='password' name='input_7_2' id='input_1_7_2' value='' aria-required="true" aria-invalid="false" /> </span> <label for='input_1_7_2' >Confirm Password</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></li><li id="field_1_19" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_19"><h2 class="gsection_title"></h2></li><li id="field_1_16" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_16"><label class='gfield_label gfield_label_before_complex' >Home Address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label> <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_1_16' > <span class='ginput_full address_line_1 ginput_address_line_1' id='input_1_16_1_container' > <input type='text' name='input_16.1' id='input_1_16_1' value='' aria-required='true' /> <label for='input_1_16_1' id='input_1_16_1_label' >Street Address</label> </span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_1_16_2_container' > <input type='text' name='input_16.2' id='input_1_16_2' value='' aria-required='false' /> <label for='input_1_16_2' id='input_1_16_2_label' >Address Line 2</label> </span><span class='ginput_left address_city ginput_address_city' id='input_1_16_3_container' > <input type='text' name='input_16.3' id='input_1_16_3' value='' aria-required='true' /> <label for='input_1_16_3' id='input_1_16_3_label' >City</label> </span><span class='ginput_right address_state ginput_address_state' id='input_1_16_4_container' > <input type='text' name='input_16.4' id='input_1_16_4' value='' aria-required='true' /> <label for='input_1_16_4' id='input_1_16_4_label' >State / Province / Region</label> </span><span class='ginput_left address_zip ginput_address_zip' id='input_1_16_5_container' > <input type='text' name='input_16.5' id='input_1_16_5' value='' aria-required='true' /> <label for='input_1_16_5' id='input_1_16_5_label' >ZIP / Postal Code</label> </span><span class='ginput_right address_country ginput_address_country' id='input_1_16_6_container' > <select name='input_16.6' id='input_1_16_6' aria-required='true' ><option value='' ></option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Anguilla' >Anguilla</option><option value='Antarctica' >Antarctica</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Aruba' >Aruba</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Bouvet Island' >Bouvet Island</option><option value='Brazil' >Brazil</option><option value='British Indian Ocean Territory' >British Indian Ocean Territory</option><option value='Brunei Darussalam' >Brunei Darussalam</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Cayman Islands' >Cayman Islands</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Christmas Island' >Christmas Island</option><option value='Cocos Islands' >Cocos Islands</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the</option><option value='Congo, Republic of the' >Congo, Republic of the</option><option value='Cook Islands' >Cook Islands</option><option value='Costa Rica' >Costa Rica</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Curaçao' >Curaçao</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Côte d&#039;Ivoire' >Côte d&#039;Ivoire</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)</option><option value='Ethiopia' >Ethiopia</option><option value='Falkland Islands' >Falkland Islands</option><option value='Faroe Islands' >Faroe Islands</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='French Guiana' >French Guiana</option><option value='French Polynesia' >French Polynesia</option><option value='French Southern Territories' >French Southern Territories</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Gibraltar' >Gibraltar</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guadeloupe' >Guadeloupe</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guernsey' >Guernsey</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Heard and McDonald Islands' >Heard and McDonald Islands</option><option value='Holy See' >Holy See</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Isle of Man' >Isle of Man</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jersey' >Jersey</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macau' >Macau</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Martinique' >Martinique</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mayotte' >Mayotte</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Montserrat' >Montserrat</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Caledonia' >New Caledonia</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Niue' >Niue</option><option value='Norfolk Island' >Norfolk Island</option><option value='North Korea' >North Korea</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Norway' >Norway</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine, State of' >Palestine, State of</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Pitcairn' >Pitcairn</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Réunion' >Réunion</option><option value='Saint Barthélemy' >Saint Barthélemy</option><option value='Saint Helena' >Saint Helena</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Martin' >Saint Martin</option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia' >Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia' >South Georgia</option><option value='South Korea' >South Korea</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Timor-Leste' >Timor-Leste</option><option value='Togo' >Togo</option><option value='Tokelau' >Tokelau</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Turks and Caicos Islands' >Turks and Caicos Islands</option><option value='Tuvalu' >Tuvalu</option><option value='US Minor Outlying Islands' >US Minor Outlying Islands</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' selected='selected'>United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Wallis and Futuna' >Wallis and Futuna</option><option value='Western Sahara' >Western Sahara</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option><option value='Åland Islands' >Åland Islands</option></select> <label for='input_1_16_6' id='input_1_16_6_label' >Country</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></li><li id="field_1_17" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_17"><label class='gfield_label gfield_label_before_complex' >Work Address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label> <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_1_17' > <span class='ginput_full address_line_1 ginput_address_line_1' id='input_1_17_1_container' > <input type='text' name='input_17.1' id='input_1_17_1' value='' aria-required='true' /> <label for='input_1_17_1' id='input_1_17_1_label' >Street Address</label> </span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_1_17_2_container' > <input type='text' name='input_17.2' id='input_1_17_2' value='' aria-required='false' /> <label for='input_1_17_2' id='input_1_17_2_label' >Address Line 2</label> </span><span class='ginput_left address_city ginput_address_city' id='input_1_17_3_container' > <input type='text' name='input_17.3' id='input_1_17_3' value='' aria-required='true' /> <label for='input_1_17_3' id='input_1_17_3_label' >City</label> </span><span class='ginput_right address_state ginput_address_state' id='input_1_17_4_container' > <input type='text' name='input_17.4' id='input_1_17_4' value='' aria-required='true' /> <label for='input_1_17_4' id='input_1_17_4_label' >State / Province / Region</label> </span><span class='ginput_left address_zip ginput_address_zip' id='input_1_17_5_container' > <input type='text' name='input_17.5' id='input_1_17_5' value='' aria-required='true' /> <label for='input_1_17_5' id='input_1_17_5_label' >ZIP / Postal Code</label> </span><span class='ginput_right address_country ginput_address_country' id='input_1_17_6_container' > <select name='input_17.6' id='input_1_17_6' aria-required='true' ><option value='' ></option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Anguilla' >Anguilla</option><option value='Antarctica' >Antarctica</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Aruba' >Aruba</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Bouvet Island' >Bouvet Island</option><option value='Brazil' >Brazil</option><option value='British Indian Ocean Territory' >British Indian Ocean Territory</option><option value='Brunei Darussalam' >Brunei Darussalam</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Cayman Islands' >Cayman Islands</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Christmas Island' >Christmas Island</option><option value='Cocos Islands' >Cocos Islands</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the</option><option value='Congo, Republic of the' >Congo, Republic of the</option><option value='Cook Islands' >Cook Islands</option><option value='Costa Rica' >Costa Rica</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Curaçao' >Curaçao</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Côte d&#039;Ivoire' >Côte d&#039;Ivoire</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)</option><option value='Ethiopia' >Ethiopia</option><option value='Falkland Islands' >Falkland Islands</option><option value='Faroe Islands' >Faroe Islands</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='French Guiana' >French Guiana</option><option value='French Polynesia' >French Polynesia</option><option value='French Southern Territories' >French Southern Territories</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Gibraltar' >Gibraltar</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guadeloupe' >Guadeloupe</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guernsey' >Guernsey</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Heard and McDonald Islands' >Heard and McDonald Islands</option><option value='Holy See' >Holy See</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Isle of Man' >Isle of Man</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jersey' >Jersey</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macau' >Macau</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Martinique' >Martinique</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mayotte' >Mayotte</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Montserrat' >Montserrat</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Caledonia' >New Caledonia</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Niue' >Niue</option><option value='Norfolk Island' >Norfolk Island</option><option value='North Korea' >North Korea</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Norway' >Norway</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine, State of' >Palestine, State of</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Pitcairn' >Pitcairn</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Réunion' >Réunion</option><option value='Saint Barthélemy' >Saint Barthélemy</option><option value='Saint Helena' >Saint Helena</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Martin' >Saint Martin</option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia' >Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia' >South Georgia</option><option value='South Korea' >South Korea</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Timor-Leste' >Timor-Leste</option><option value='Togo' >Togo</option><option value='Tokelau' >Tokelau</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Turks and Caicos Islands' >Turks and Caicos Islands</option><option value='Tuvalu' >Tuvalu</option><option value='US Minor Outlying Islands' >US Minor Outlying Islands</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' selected='selected'>United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Wallis and Futuna' >Wallis and Futuna</option><option value='Western Sahara' >Western Sahara</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option><option value='Åland Islands' >Åland Islands</option></select> <label for='input_1_17_6' id='input_1_17_6_label' >Country</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></li><li id="field_1_20" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_20"><h2 class="gsection_title"></h2></li><li id="field_1_14" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_14"><label class='gfield_label gfield_label_before_complex' >Are you of Hispanic/Latino/Spanish origin?<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_1_14'><li class='gchoice gchoice_1_14_1'> <input class='gfield-choice-input' name='input_14.1' type='checkbox' value='Yes' id='choice_1_14_1' /> <label for='choice_1_14_1' id='label_1_14_1'>Yes</label> </li><li class='gchoice gchoice_1_14_2'> <input class='gfield-choice-input' name='input_14.2' type='checkbox' value='No' id='choice_1_14_2' /> <label for='choice_1_14_2' id='label_1_14_2'>No</label> </li></ul></div></li><li id="field_1_15" class="gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_15"><label class='gfield_label gfield_label_before_complex' >How would you best describe yourself?</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_15'><li class='gchoice gchoice_1_15_1'> <input class='gfield-choice-input' name='input_15.1' type='checkbox' value='American Indian or Alaska Native' id='choice_1_15_1' /> <label for='choice_1_15_1' id='label_1_15_1'>American Indian or Alaska Native</label> </li><li class='gchoice gchoice_1_15_2'> <input class='gfield-choice-input' name='input_15.2' type='checkbox' value='Asian' id='choice_1_15_2' /> <label for='choice_1_15_2' id='label_1_15_2'>Asian</label> </li><li class='gchoice gchoice_1_15_3'> <input class='gfield-choice-input' name='input_15.3' type='checkbox' value='Black or African American' id='choice_1_15_3' /> <label for='choice_1_15_3' id='label_1_15_3'>Black or African American</label> </li><li class='gchoice gchoice_1_15_4'> <input class='gfield-choice-input' name='input_15.4' type='checkbox' value='Native Hawaiian or Other Pacific Islander' id='choice_1_15_4' /> <label for='choice_1_15_4' id='label_1_15_4'>Native Hawaiian or Other Pacific Islander</label> </li><li class='gchoice gchoice_1_15_5'> <input class='gfield-choice-input' name='input_15.5' type='checkbox' value='White' id='choice_1_15_5' /> <label for='choice_1_15_5' id='label_1_15_5'>White</label> </li><li class='gchoice gchoice_1_15_6'> <input class='gfield-choice-input' name='input_15.6' type='checkbox' value='Other' id='choice_1_15_6' /> <label for='choice_1_15_6' id='label_1_15_6'>Other</label> </li></ul></div></li><li id="field_1_21" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_21"><h2 class="gsection_title"></h2></li><li id="field_1_18" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_18"><label class='gfield_label gfield_label_before_complex' >Terms &amp; Conditions<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_consent'><input name='input_18.1' id='input_1_18_1' type='checkbox' value='1' aria-describedby="gfield_consent_description_1_18 gfield_description_1_18" aria-required="true" aria-invalid="false" /> <label class="gfield_consent_label" for='input_1_18_1' >I understand and acknowledge that by checking the box below, I am legally agreeing to all of the statements listed below.</label><input type='hidden' name='input_18.2' value='I understand and acknowledge that by checking the box below, I am legally agreeing to all of the statements listed below.' class='gform_hidden' /><input type='hidden' name='input_18.3' value='6' class='gform_hidden' /></div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_1_18'>By registering for this Gateway to Hope (GTH) training, the user acknowledges and agrees to all terms and conditions stated herein. All copyrights, trademarks, content, business methods, graphics, designs and documents posted on this website, as well as the look and feel of this website ("Intellectual Property") are the property of the Hope and Healing Center & Institute.<br /> <br /> The user may download one copy of the materials on any single computer and print a copy of the materials solely for use in learning about or utilizing Gateway to Hope's training materials and resources. The user may not otherwise copy, print, reproduce, distribute, transmit, upload, download, store, use, or change the materials. All such materials are copyrighted by the Hope and Healing Center & Institute.</div></li><li id="field_1_13" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_13"><h2 class="gsection_title"></h2></li><li id="field_1_9" class="gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible" data-js-reload="field_1_9"><label class='gfield_label gfield_label_before_complex' >Newsletter Optin</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_9'><li class='gchoice gchoice_1_9_1'> <input class='gfield-choice-input' name='input_9.1' type='checkbox' value='Please sign me up for updates, insights, resources, and more.' checked='checked' id='choice_1_9_1' /> <label for='choice_1_9_1' id='label_1_9_1'>Please sign me up for updates, insights, resources, and more.</label> </li></ul></div></li><li id="field_1_22" class="gfield gform_validation_container field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_22"><label class='gfield_label' for='input_1_22' >Name</label><div class='ginput_container'><input name='input_22' id='input_1_22' type='text' value='' autocomplete='new-password'/></div><div class='gfield_description' id='gfield_description_1_22'>This field is for validation purposes and should be left unchanged.</div></li></ul></div> <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Submit' onclick='if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} jQuery("#gform_1").trigger("submit",[true]); }' /> <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='1' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_1' value='WyJ7XCIxOC4xXCI6XCI4ZWVjNjNkZDZhMDFjYjE5MjEyMzliY2M5YWNkNmNlMVwiLFwiMTguMlwiOlwiOTA2YWZlM2IyN2U5ZDFjYTQ4NmFkOGM4YmE3YWZlMzlcIixcIjE4LjNcIjpcImY4MGQwNTNlMzUwZjU5ZDM3M2M2YzJlZTc5ODViMzY2XCJ9IiwiZjI0MDg4NjhmY2IxNWYxMTZhN2QxYmJjNTk4YzAwNWYiXQ==' /> <input type='hidden' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' /> <input type='hidden' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' /> <input type='hidden' name='gform_field_values' value='' /> </div> <input type="hidden" id="ct_checkjs_42e77b63637ab381e8be5f8318cc28a2" name="ct_checkjs" value="0" /><script type="text/javascript" >setTimeout(function(){var ct_input_name = "ct_checkjs_42e77b63637ab381e8be5f8318cc28a2";if (document.getElementById(ct_input_name) !== null) {var ct_input_value = document.getElementById(ct_input_name).value;document.getElementById(ct_input_name).value = document.getElementById(ct_input_name).value.replace(ct_input_value, 'daff13625f026def51775140059231ba46d5adca1056f439641605167e8402c2');}}, 1000);</script></form> </div>
[gravityforms id=4]
Oops! You need to be logged in to use this form.
[gravityforms id=1]
<div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_1' > <div class='gform_heading'> <h3 class="gform_title">EMPOWER Online Training Registration</h3> <span class='gform_description'></span> </div><form method='post' enctype='multipart/form-data' id='gform_1' action='/event/collateral-damage-the-impact-of-suicide-on-congregations-and-caregivers/' novalidate> <div class='gform_body gform-body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><li id="field_1_1" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_1"><label class='gfield_label gfield_label_before_complex' >Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_1_1'> <span id='input_1_1_3_container' class='name_first' > <input type='text' name='input_1.3' id='input_1_1_3' value='' aria-required='true' /> <label for='input_1_1_3' >First</label> </span> <span id='input_1_1_6_container' class='name_last' > <input type='text' name='input_1.6' id='input_1_1_6' value='' aria-required='true' /> <label for='input_1_1_6' >Last</label> </span> </div></li><li id="field_1_2" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_2"><label class='gfield_label' for='input_1_2' >Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_email'> <input name='input_2' id='input_1_2' type='email' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></li><li id="field_1_3" class="gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_3"><label class='gfield_label' for='input_1_3' >Phone<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_1_3' type='tel' value='' class='medium' aria-required="true" aria-invalid="false" /></div></li><li id="field_1_4" class="gfield gfield--width-full gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_4"><label class='gfield_label' for='input_1_4' >Company / Organization<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_1_4' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></li><li id="field_1_7" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_7"><label class='gfield_label gfield_label_before_complex' >Password<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_complex ginput_container ginput_container_password' id='input_1_7_container'> <span id='input_1_7_1_container' class='ginput_left'> <span class='password_input_container'> <input type='password' name='input_7' id='input_1_7' value='' aria-required="true" aria-invalid="false" /> </span> <label for='input_1_7' >Enter Password</label> </span> <span id='input_1_7_2_container' class='ginput_right'> <span class='password_input_container'> <input type='password' name='input_7_2' id='input_1_7_2' value='' aria-required="true" aria-invalid="false" /> </span> <label for='input_1_7_2' >Confirm Password</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></li><li id="field_1_19" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_19"><h2 class="gsection_title"></h2></li><li id="field_1_16" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_16"><label class='gfield_label gfield_label_before_complex' >Home Address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label> <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_1_16' > <span class='ginput_full address_line_1 ginput_address_line_1' id='input_1_16_1_container' > <input type='text' name='input_16.1' id='input_1_16_1' value='' aria-required='true' /> <label for='input_1_16_1' id='input_1_16_1_label' >Street Address</label> </span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_1_16_2_container' > <input type='text' name='input_16.2' id='input_1_16_2' value='' aria-required='false' /> <label for='input_1_16_2' id='input_1_16_2_label' >Address Line 2</label> </span><span class='ginput_left address_city ginput_address_city' id='input_1_16_3_container' > <input type='text' name='input_16.3' id='input_1_16_3' value='' aria-required='true' /> <label for='input_1_16_3' id='input_1_16_3_label' >City</label> </span><span class='ginput_right address_state ginput_address_state' id='input_1_16_4_container' > <input type='text' name='input_16.4' id='input_1_16_4' value='' aria-required='true' /> <label for='input_1_16_4' id='input_1_16_4_label' >State / Province / Region</label> </span><span class='ginput_left address_zip ginput_address_zip' id='input_1_16_5_container' > <input type='text' name='input_16.5' id='input_1_16_5' value='' aria-required='true' /> <label for='input_1_16_5' id='input_1_16_5_label' >ZIP / Postal Code</label> </span><span class='ginput_right address_country ginput_address_country' id='input_1_16_6_container' > <select name='input_16.6' id='input_1_16_6' aria-required='true' ><option value='' ></option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Anguilla' >Anguilla</option><option value='Antarctica' >Antarctica</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Aruba' >Aruba</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Bouvet Island' >Bouvet Island</option><option value='Brazil' >Brazil</option><option value='British Indian Ocean Territory' >British Indian Ocean Territory</option><option value='Brunei Darussalam' >Brunei Darussalam</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Cayman Islands' >Cayman Islands</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Christmas Island' >Christmas Island</option><option value='Cocos Islands' >Cocos Islands</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the</option><option value='Congo, Republic of the' >Congo, Republic of the</option><option value='Cook Islands' >Cook Islands</option><option value='Costa Rica' >Costa Rica</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Curaçao' >Curaçao</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Côte d&#039;Ivoire' >Côte d&#039;Ivoire</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)</option><option value='Ethiopia' >Ethiopia</option><option value='Falkland Islands' >Falkland Islands</option><option value='Faroe Islands' >Faroe Islands</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='French Guiana' >French Guiana</option><option value='French Polynesia' >French Polynesia</option><option value='French Southern Territories' >French Southern Territories</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Gibraltar' >Gibraltar</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guadeloupe' >Guadeloupe</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guernsey' >Guernsey</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Heard and McDonald Islands' >Heard and McDonald Islands</option><option value='Holy See' >Holy See</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Isle of Man' >Isle of Man</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jersey' >Jersey</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macau' >Macau</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Martinique' >Martinique</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mayotte' >Mayotte</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Montserrat' >Montserrat</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Caledonia' >New Caledonia</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Niue' >Niue</option><option value='Norfolk Island' >Norfolk Island</option><option value='North Korea' >North Korea</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Norway' >Norway</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine, State of' >Palestine, State of</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Pitcairn' >Pitcairn</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Réunion' >Réunion</option><option value='Saint Barthélemy' >Saint Barthélemy</option><option value='Saint Helena' >Saint Helena</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Martin' >Saint Martin</option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia' >Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia' >South Georgia</option><option value='South Korea' >South Korea</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Timor-Leste' >Timor-Leste</option><option value='Togo' >Togo</option><option value='Tokelau' >Tokelau</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Turks and Caicos Islands' >Turks and Caicos Islands</option><option value='Tuvalu' >Tuvalu</option><option value='US Minor Outlying Islands' >US Minor Outlying Islands</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' selected='selected'>United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Wallis and Futuna' >Wallis and Futuna</option><option value='Western Sahara' >Western Sahara</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option><option value='Åland Islands' >Åland Islands</option></select> <label for='input_1_16_6' id='input_1_16_6_label' >Country</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></li><li id="field_1_17" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_17"><label class='gfield_label gfield_label_before_complex' >Work Address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label> <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_1_17' > <span class='ginput_full address_line_1 ginput_address_line_1' id='input_1_17_1_container' > <input type='text' name='input_17.1' id='input_1_17_1' value='' aria-required='true' /> <label for='input_1_17_1' id='input_1_17_1_label' >Street Address</label> </span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_1_17_2_container' > <input type='text' name='input_17.2' id='input_1_17_2' value='' aria-required='false' /> <label for='input_1_17_2' id='input_1_17_2_label' >Address Line 2</label> </span><span class='ginput_left address_city ginput_address_city' id='input_1_17_3_container' > <input type='text' name='input_17.3' id='input_1_17_3' value='' aria-required='true' /> <label for='input_1_17_3' id='input_1_17_3_label' >City</label> </span><span class='ginput_right address_state ginput_address_state' id='input_1_17_4_container' > <input type='text' name='input_17.4' id='input_1_17_4' value='' aria-required='true' /> <label for='input_1_17_4' id='input_1_17_4_label' >State / Province / Region</label> </span><span class='ginput_left address_zip ginput_address_zip' id='input_1_17_5_container' > <input type='text' name='input_17.5' id='input_1_17_5' value='' aria-required='true' /> <label for='input_1_17_5' id='input_1_17_5_label' >ZIP / Postal Code</label> </span><span class='ginput_right address_country ginput_address_country' id='input_1_17_6_container' > <select name='input_17.6' id='input_1_17_6' aria-required='true' ><option value='' ></option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Anguilla' >Anguilla</option><option value='Antarctica' >Antarctica</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Aruba' >Aruba</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Bouvet Island' >Bouvet Island</option><option value='Brazil' >Brazil</option><option value='British Indian Ocean Territory' >British Indian Ocean Territory</option><option value='Brunei Darussalam' >Brunei Darussalam</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Cayman Islands' >Cayman Islands</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Christmas Island' >Christmas Island</option><option value='Cocos Islands' >Cocos Islands</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the</option><option value='Congo, Republic of the' >Congo, Republic of the</option><option value='Cook Islands' >Cook Islands</option><option value='Costa Rica' >Costa Rica</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Curaçao' >Curaçao</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Côte d&#039;Ivoire' >Côte d&#039;Ivoire</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)</option><option value='Ethiopia' >Ethiopia</option><option value='Falkland Islands' >Falkland Islands</option><option value='Faroe Islands' >Faroe Islands</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='French Guiana' >French Guiana</option><option value='French Polynesia' >French Polynesia</option><option value='French Southern Territories' >French Southern Territories</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Gibraltar' >Gibraltar</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guadeloupe' >Guadeloupe</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guernsey' >Guernsey</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Heard and McDonald Islands' >Heard and McDonald Islands</option><option value='Holy See' >Holy See</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Isle of Man' >Isle of Man</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jersey' >Jersey</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macau' >Macau</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Martinique' >Martinique</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mayotte' >Mayotte</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Montserrat' >Montserrat</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Caledonia' >New Caledonia</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Niue' >Niue</option><option value='Norfolk Island' >Norfolk Island</option><option value='North Korea' >North Korea</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Norway' >Norway</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine, State of' >Palestine, State of</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Pitcairn' >Pitcairn</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Réunion' >Réunion</option><option value='Saint Barthélemy' >Saint Barthélemy</option><option value='Saint Helena' >Saint Helena</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Martin' >Saint Martin</option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia' >Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia' >South Georgia</option><option value='South Korea' >South Korea</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Timor-Leste' >Timor-Leste</option><option value='Togo' >Togo</option><option value='Tokelau' >Tokelau</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Turks and Caicos Islands' >Turks and Caicos Islands</option><option value='Tuvalu' >Tuvalu</option><option value='US Minor Outlying Islands' >US Minor Outlying Islands</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' selected='selected'>United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Wallis and Futuna' >Wallis and Futuna</option><option value='Western Sahara' >Western Sahara</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option><option value='Åland Islands' >Åland Islands</option></select> <label for='input_1_17_6' id='input_1_17_6_label' >Country</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></li><li id="field_1_20" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_20"><h2 class="gsection_title"></h2></li><li id="field_1_14" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_14"><label class='gfield_label gfield_label_before_complex' >Are you of Hispanic/Latino/Spanish origin?<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_1_14'><li class='gchoice gchoice_1_14_1'> <input class='gfield-choice-input' name='input_14.1' type='checkbox' value='Yes' id='choice_1_14_1' /> <label for='choice_1_14_1' id='label_1_14_1'>Yes</label> </li><li class='gchoice gchoice_1_14_2'> <input class='gfield-choice-input' name='input_14.2' type='checkbox' value='No' id='choice_1_14_2' /> <label for='choice_1_14_2' id='label_1_14_2'>No</label> </li></ul></div></li><li id="field_1_15" class="gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_15"><label class='gfield_label gfield_label_before_complex' >How would you best describe yourself?</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_15'><li class='gchoice gchoice_1_15_1'> <input class='gfield-choice-input' name='input_15.1' type='checkbox' value='American Indian or Alaska Native' id='choice_1_15_1' /> <label for='choice_1_15_1' id='label_1_15_1'>American Indian or Alaska Native</label> </li><li class='gchoice gchoice_1_15_2'> <input class='gfield-choice-input' name='input_15.2' type='checkbox' value='Asian' id='choice_1_15_2' /> <label for='choice_1_15_2' id='label_1_15_2'>Asian</label> </li><li class='gchoice gchoice_1_15_3'> <input class='gfield-choice-input' name='input_15.3' type='checkbox' value='Black or African American' id='choice_1_15_3' /> <label for='choice_1_15_3' id='label_1_15_3'>Black or African American</label> </li><li class='gchoice gchoice_1_15_4'> <input class='gfield-choice-input' name='input_15.4' type='checkbox' value='Native Hawaiian or Other Pacific Islander' id='choice_1_15_4' /> <label for='choice_1_15_4' id='label_1_15_4'>Native Hawaiian or Other Pacific Islander</label> </li><li class='gchoice gchoice_1_15_5'> <input class='gfield-choice-input' name='input_15.5' type='checkbox' value='White' id='choice_1_15_5' /> <label for='choice_1_15_5' id='label_1_15_5'>White</label> </li><li class='gchoice gchoice_1_15_6'> <input class='gfield-choice-input' name='input_15.6' type='checkbox' value='Other' id='choice_1_15_6' /> <label for='choice_1_15_6' id='label_1_15_6'>Other</label> </li></ul></div></li><li id="field_1_21" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_21"><h2 class="gsection_title"></h2></li><li id="field_1_18" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_18"><label class='gfield_label gfield_label_before_complex' >Terms &amp; Conditions<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_consent'><input name='input_18.1' id='input_1_18_1' type='checkbox' value='1' aria-describedby="gfield_consent_description_1_18 gfield_description_1_18" aria-required="true" aria-invalid="false" /> <label class="gfield_consent_label" for='input_1_18_1' >I understand and acknowledge that by checking the box below, I am legally agreeing to all of the statements listed below.</label><input type='hidden' name='input_18.2' value='I understand and acknowledge that by checking the box below, I am legally agreeing to all of the statements listed below.' class='gform_hidden' /><input type='hidden' name='input_18.3' value='6' class='gform_hidden' /></div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_1_18'>By registering for this Gateway to Hope (GTH) training, the user acknowledges and agrees to all terms and conditions stated herein. All copyrights, trademarks, content, business methods, graphics, designs and documents posted on this website, as well as the look and feel of this website ("Intellectual Property") are the property of the Hope and Healing Center & Institute.<br /> <br /> The user may download one copy of the materials on any single computer and print a copy of the materials solely for use in learning about or utilizing Gateway to Hope's training materials and resources. The user may not otherwise copy, print, reproduce, distribute, transmit, upload, download, store, use, or change the materials. All such materials are copyrighted by the Hope and Healing Center & Institute.</div></li><li id="field_1_13" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_13"><h2 class="gsection_title"></h2></li><li id="field_1_9" class="gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible" data-js-reload="field_1_9"><label class='gfield_label gfield_label_before_complex' >Newsletter Optin</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_9'><li class='gchoice gchoice_1_9_1'> <input class='gfield-choice-input' name='input_9.1' type='checkbox' value='Please sign me up for updates, insights, resources, and more.' checked='checked' id='choice_1_9_1' /> <label for='choice_1_9_1' id='label_1_9_1'>Please sign me up for updates, insights, resources, and more.</label> </li></ul></div></li><li id="field_1_22" class="gfield gform_validation_container field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_22"><label class='gfield_label' for='input_1_22' >Comments</label><div class='ginput_container'><input name='input_22' id='input_1_22' type='text' value='' autocomplete='new-password'/></div><div class='gfield_description' id='gfield_description_1_22'>This field is for validation purposes and should be left unchanged.</div></li></ul></div> <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Submit' onclick='if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} jQuery("#gform_1").trigger("submit",[true]); }' /> <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='1' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_1' value='WyJ7XCIxOC4xXCI6XCI4ZWVjNjNkZDZhMDFjYjE5MjEyMzliY2M5YWNkNmNlMVwiLFwiMTguMlwiOlwiOTA2YWZlM2IyN2U5ZDFjYTQ4NmFkOGM4YmE3YWZlMzlcIixcIjE4LjNcIjpcImY4MGQwNTNlMzUwZjU5ZDM3M2M2YzJlZTc5ODViMzY2XCJ9IiwiZjI0MDg4NjhmY2IxNWYxMTZhN2QxYmJjNTk4YzAwNWYiXQ==' /> <input type='hidden' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' /> <input type='hidden' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' /> <input type='hidden' name='gform_field_values' value='' /> </div> <input type="hidden" id="ct_checkjs_884d247c6f65a96a7da4d1105d584ddd" name="ct_checkjs" value="0" /><script type="text/javascript" >setTimeout(function(){var ct_input_name = "ct_checkjs_884d247c6f65a96a7da4d1105d584ddd";if (document.getElementById(ct_input_name) !== null) {var ct_input_value = document.getElementById(ct_input_name).value;document.getElementById(ct_input_name).value = document.getElementById(ct_input_name).value.replace(ct_input_value, 'daff13625f026def51775140059231ba46d5adca1056f439641605167e8402c2');}}, 1000);</script></form> </div>