{"id":12601,"date":"2024-05-28T09:39:04","date_gmt":"2024-05-28T09:39:04","guid":{"rendered":"https:\/\/ksa.mds.healthcare\/?page_id=12601"},"modified":"2024-05-28T10:52:53","modified_gmt":"2024-05-28T10:52:53","slug":"accreditation-application","status":"publish","type":"page","link":"https:\/\/ksa.mds.healthcare\/en\/accreditation-application\/","title":{"rendered":"Accreditation Application"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"12601\" class=\"elementor elementor-12601\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-50736146 elementor-section-height-min-height gradient-bg m-0 elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"50736146\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;video&quot;,&quot;background_video_link&quot;:&quot;https:\\\/\\\/vimeo.com\\\/919224261\\\/b45667d9d1?share=copy&quot;,&quot;background_play_on_mobile&quot;:&quot;yes&quot;,&quot;background_privacy_mode&quot;:&quot;yes&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-background-video-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"elementor-background-video-embed\" role=\"presentation\"><\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-3947f188\" data-id=\"3947f188\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-738d252d elementor-section-content-middle elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"738d252d\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-e7402b2\" data-id=\"e7402b2\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-e6c49a8 elementor-widget elementor-widget-banner-content\" data-id=\"e6c49a8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"banner-content.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\r\n        <div class=\"banner-content tg-content\">\r\n                            <h2 class=\"title\"><span>APPLY FOR ACCREDITATION SERVICES\n<\/span><\/h2>\r\n            \r\n                    <\/div>\r\n\r\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-de2280c elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"de2280c\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-1abb2f5\" data-id=\"1abb2f5\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-2f6319d elementor-section-content-middle elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"2f6319d\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-53c4f0c\" data-id=\"53c4f0c\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-caeb191 elementor-widget elementor-widget-banner-content\" data-id=\"caeb191\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"banner-content.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\r\n        <div class=\"banner-content tg-content\">\r\n                            <h2 class=\"title\"><span>This application is only for Healthcare Institutions that are seeking for Healthcare Accreditation\n\n\n<\/span><\/h2>\r\n            \r\n                            <p>After submission, We will send you a complete proposal based on the information you have filled out. \n\n<\/p>\r\n                    <\/div>\r\n\r\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-145a76a elementor-widget elementor-widget-ha-wpform happy-addon ha-wpform\" data-id=\"145a76a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"ha-wpform.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-12604\"><form id=\"wpforms-form-12604\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"12604\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/en\/wp-json\/wp\/v2\/pages\/12601\" data-token=\"ede15212ba54fef62cfda4a1a0eb8b11\" data-token-time=\"1782562654\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-12604-field_89-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"89\"><div id=\"wpforms-12604-field_89\" aria-errormessage=\"wpforms-12604-field_89-error\"><!-- Your form goes here -->\r\n    <!-- Other form fields go here -->\r\n    <input type=\"text\" name=\"packageName\" id=\"packageName\" value=\"\" readonly\/>\r\n\r\n<script>\r\n    document.addEventListener('DOMContentLoaded', function() {\r\n        var pageTitle = document.title;\r\n        console.log('Page Title:', pageTitle);\r\n\r\n        \/\/ Set the page name (package name) as the value of the readonly input field\r\n        document.getElementById('packageName').value = pageTitle;\r\n    });\r\n<\/script>\r\n\r\n\r\n\r\n<\/div><\/div><div id=\"wpforms-12604-field_3-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"3\"><label class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Name &amp; Address<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-12604-field_83-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"83\"><label class=\"wpforms-field-label\" for=\"wpforms-12604-field_83\">Hospital Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12604-field_83\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][83]\" aria-errormessage=\"wpforms-12604-field_83-error\" aria-describedby=\"wpforms-12604-field_83-description\" required><div id=\"wpforms-12604-field_83-description\" class=\"wpforms-field-description\">Write the name of your hospital\r\n<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-12604-field_141-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"141\"><label class=\"wpforms-field-label\" for=\"wpforms-12604-field_141\">Hospital Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12604-field_141\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][141]\" aria-errormessage=\"wpforms-12604-field_141-error\" aria-describedby=\"wpforms-12604-field_141-description\" required><div id=\"wpforms-12604-field_141-description\" class=\"wpforms-field-description\">Location of your hospital\r\n<\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-12604-field_149-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"149\"><label class=\"wpforms-field-label\" for=\"wpforms-12604-field_149\">Write the Name of Accreditation You Want to Apply  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-12604-field_149\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][149]\" required=\"required\"><option value=\"ACHSI\" >ACHSI<\/option><option value=\"ACI\" >ACI<\/option><option value=\"JCI\" >JCI<\/option><option value=\"National Accreditation\" >National Accreditation<\/option><option value=\"Other\" >Other<\/option><\/select><\/div><div id=\"wpforms-12604-field_150-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"150\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-12604-field_150\">Write the name of other accreditation you want to apply  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12604-field_150\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][150]\" aria-errormessage=\"wpforms-12604-field_150-error\" required><\/div><div id=\"wpforms-12604-field_147-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"147\"><label class=\"wpforms-field-label\" for=\"wpforms-12604-field_147\">Scope of Services  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12604-field_147\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][147]\" aria-errormessage=\"wpforms-12604-field_147-error\" aria-describedby=\"wpforms-12604-field_147-description\" required><div id=\"wpforms-12604-field_147-description\" class=\"wpforms-field-description\">Services provided (Categories e.g. Emergency, Outpatient,.........)& (Specialties e.g. Surgery, Medicine,.....) , Working days, working hours,........\r\n<\/div><\/div><div id=\"wpforms-12604-field_182-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"182\"><label class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Scope (copy)<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-12604-field_184-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"184\"><label class=\"wpforms-field-label\" for=\"wpforms-12604-field_184\">Top Five Diagnosis  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12604-field_184\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][184]\" aria-errormessage=\"wpforms-12604-field_184-error\" aria-describedby=\"wpforms-12604-field_184-description\" required><div id=\"wpforms-12604-field_184-description\" class=\"wpforms-field-description\">List of the most frequent diagnosis admitted to your hospital\r\n<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-12604-field_185-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"185\"><label class=\"wpforms-field-label\" for=\"wpforms-12604-field_185\">Top Five Procedures  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12604-field_185\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][185]\" aria-errormessage=\"wpforms-12604-field_185-error\" aria-describedby=\"wpforms-12604-field_185-description\" required><div id=\"wpforms-12604-field_185-description\" class=\"wpforms-field-description\">List of the most frequent procedures operated in your hospital\r\n<\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-12604-field_153-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"153\"><label class=\"wpforms-field-label\" for=\"wpforms-12604-field_153\">Contracted Services <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12604-field_153\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][153]\" aria-errormessage=\"wpforms-12604-field_153-error\" aria-describedby=\"wpforms-12604-field_153-description\" required><div id=\"wpforms-12604-field_153-description\" class=\"wpforms-field-description\">List of any outsources services provided\r\n<\/div><\/div><div id=\"wpforms-12604-field_152-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"152\"><label class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\"> Number<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-12604-field_154-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"154\"><label class=\"wpforms-field-label\" for=\"wpforms-12604-field_154\">Number of Hospital Active Beds  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12604-field_154\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][154]\" aria-errormessage=\"wpforms-12604-field_154-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-12604-field_155-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"155\"><label class=\"wpforms-field-label\" for=\"wpforms-12604-field_155\">Average Number of Daily Occupied Beds  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12604-field_155\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][155]\" aria-errormessage=\"wpforms-12604-field_155-error\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-12604-field_179-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"179\"><label class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\"> Number (copy)<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-12604-field_157-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"157\"><label class=\"wpforms-field-label\" for=\"wpforms-12604-field_157\">Average Number of Out Patient Visits \/ day  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12604-field_157\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][157]\" aria-errormessage=\"wpforms-12604-field_157-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-12604-field_158-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"158\"><label class=\"wpforms-field-label\" for=\"wpforms-12604-field_158\">Average Number of daily emergency visits  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12604-field_158\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][158]\" aria-errormessage=\"wpforms-12604-field_158-error\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-12604-field_160-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"160\"><fieldset><legend class=\"wpforms-field-label\">Has your hospital been accredited by any other accreditation organization<\/legend><ul id=\"wpforms-12604-field_160\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-12604-field_160_1\" name=\"wpforms[fields][160]\" value=\"Yes\" aria-errormessage=\"wpforms-12604-field_160_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12604-field_160_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-12604-field_160_2\" name=\"wpforms[fields][160]\" value=\"No\" aria-errormessage=\"wpforms-12604-field_160_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12604-field_160_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-12604-field_162-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"162\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-12604-field_162\">Write the Name of Accreditation Body <\/label><select id=\"wpforms-12604-field_162\" class=\"wpforms-field-large\" name=\"wpforms[fields][162]\"><option value=\"ACHSI\" >ACHSI<\/option><option value=\"ACI\" >ACI<\/option><option value=\"JCI\" >JCI<\/option><option value=\"National Accreditation\" >National Accreditation<\/option><option value=\"Other\" >Other<\/option><\/select><\/div><div id=\"wpforms-12604-field_163-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"163\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-12604-field_163\">Write the Name of other Accreditation Body *<\/label><input type=\"text\" id=\"wpforms-12604-field_163\" class=\"wpforms-field-large\" name=\"wpforms[fields][163]\" aria-errormessage=\"wpforms-12604-field_163-error\" ><\/div><div id=\"wpforms-12604-field_172-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"172\"><fieldset><legend class=\"wpforms-field-label\">Hospital Director Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-12604-field_172\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][172][first]\" aria-errormessage=\"wpforms-12604-field_172-error\" required><label for=\"wpforms-12604-field_172\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-12604-field_172-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][172][last]\" aria-errormessage=\"wpforms-12604-field_172-last-error\" required><label for=\"wpforms-12604-field_172-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-12604-field_7-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"7\"><label class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Email &amp; Check In\/Out<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-12604-field_173-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"173\"><label class=\"wpforms-field-label\" for=\"wpforms-12604-field_173\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-12604-field_173\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][173]\" spellcheck=\"false\" aria-errormessage=\"wpforms-12604-field_173-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-12604-field_142-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"142\"><label class=\"wpforms-field-label\" for=\"wpforms-12604-field_142\">Phone Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-12604-field_142\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][142]\" aria-errormessage=\"wpforms-12604-field_142-error\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-12604-field_178-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"178\"><fieldset><legend class=\"wpforms-field-label\">Accreditation Coordinator Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-12604-field_178\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][178][first]\" aria-errormessage=\"wpforms-12604-field_178-error\" required><label for=\"wpforms-12604-field_178\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-12604-field_178-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][178][last]\" aria-errormessage=\"wpforms-12604-field_178-last-error\" required><label for=\"wpforms-12604-field_178-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-12604-field_175-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"175\"><label class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Email &amp; Check In\/Out (copy)<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-12604-field_176-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"176\"><label class=\"wpforms-field-label\" for=\"wpforms-12604-field_176\">Email  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-12604-field_176\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][176]\" spellcheck=\"false\" aria-errormessage=\"wpforms-12604-field_176-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-12604-field_177-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"177\"><label class=\"wpforms-field-label\" for=\"wpforms-12604-field_177\">Phone Number  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-12604-field_177\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][177]\" aria-errormessage=\"wpforms-12604-field_177-error\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-12604-field_2-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-12604-field_2\">Additional Information (Optional)<\/label><textarea id=\"wpforms-12604-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" aria-errormessage=\"wpforms-12604-field_2-error\" ><\/textarea><\/div><\/div><!-- .wpforms-field-container --><div 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