{"id":827,"date":"2025-08-15T14:02:42","date_gmt":"2025-08-15T19:02:42","guid":{"rendered":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/?page_id=827"},"modified":"2026-03-05T12:37:24","modified_gmt":"2026-03-05T18:37:24","slug":"new-cooper-green-enrollment-form","status":"publish","type":"page","link":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/new-cooper-green-enrollment-form\/","title":{"rendered":"NEW Cooper Green Enrollment  and Re-Enrollment Form"},"content":{"rendered":"<script type=\"text\/javascript\">if(!gform){document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0});var 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),null==t&&(t=10),gform.hooks[o][n].push({tag:i,callable:r,priority:t})},doHook:function(o,n,r){if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[o][n]){var t,i=gform.hooks[o][n];i.sort(function(o,n){return o.priority-n.priority});for(var e=0;e<i.length;e++)\"function\"!=typeof(t=i[e].callable)&#038;&#038;(t=window[t]),\"action\"==o?t.apply(null,r):r[0]=t.apply(null,r)}if(\"filter\"==o)return r[0]},removeHook:function(o,n,r,t){if(null!=gform.hooks[o][n])for(var i=gform.hooks[o][n],e=i.length-1;0<=e;e--)null!=t&#038;&#038;t!=i[e].tag||null!=r&#038;&#038;r!=i[e].priority||i.splice(e,1)}}}<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme' id='gform_wrapper_221' style='display:none'><div id='gf_221' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_221' id='gform_221'  action='\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/827#gf_221' novalidate>\n        <div id='gf_progressbar_wrapper_221' class='gf_progressbar_wrapper'>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>5<\/span> - Start\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_green' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_green percentbar_0' style='width:0%;'><span>0%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform_body gform-body'><div id='gform_page_221_1' class='gform_page' >\n                                    <div class='gform_page_fields'><div id='gform_fields_221' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_221_43\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" >Before starting this form, we encourage you to gather the following documents, if you have them: <\/br>\n<ul>\n<li>Continuum ID Card<\/li>\n<li>Social Security Card<\/li>\n<li>Shelter Letter<\/li>\n<li>Health Insurance Card<\/li>\n<li>State Issued ID or Passport<\/li>\n<li>Food Stamp Award Letter<\/li>\n<li>Most Recent Income Statement (social security, disability, tax documents and\/or pay stub)<\/li>\n<\/ul>\n<\/div><fieldset id=\"field_221_9\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name' id='input_221_9'>\n                            \n                            <span id='input_221_9_3_container' class='name_first' >\n                                                    <input type='text' name='input_9.3' id='input_221_9_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_221_9_3' >First<\/label>\n                                                <\/span>\n                            <span id='input_221_9_4_container' class='name_middle' >\n                                                    <input type='text' name='input_9.4' id='input_221_9_4' value='' aria-label='Middle name'   aria-required='false'     \/>\n                                                    <label for='input_221_9_4' >Middle<\/label>\n                                                <\/span>\n                            <span id='input_221_9_6_container' class='name_last' >\n                                                    <input type='text' name='input_9.6' id='input_221_9_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_221_9_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_221_42\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Are you 18 years of age or older?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_221_42'>\n\t\t\t<div class='gchoice gchoice_221_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Yes'  id='choice_221_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_221_42_0' id='label_221_42_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_221_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='No'  id='choice_221_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_221_42_1' id='label_221_42_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_221_44\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Are you pregnant?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_221_44'>\n\t\t\t<div class='gchoice gchoice_221_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_221_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_221_44_0' id='label_221_44_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_221_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_221_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_221_44_1' id='label_221_44_1'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_221_44_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='NA'  id='choice_221_44_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_221_44_2' id='label_221_44_2'>NA<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_221_46\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Were you seen in the emergency department or admitted as in inpatient at any off the following locations in the past 30 days?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_221_46'>\n\t\t\t<div class='gchoice gchoice_221_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='UAB University Hospital'  id='choice_221_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_221_46_0' id='label_221_46_0'>UAB University Hospital<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_221_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='St. Vincent&#039;s Birmingham'  id='choice_221_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_221_46_1' id='label_221_46_1'>St. Vincent's Birmingham<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_221_46_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='St. Vincent&#039;s East'  id='choice_221_46_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_221_46_2' id='label_221_46_2'>St. Vincent's East<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_221_11\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_221_11' >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_11' id='input_221_11' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_221_11_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_221_11_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_221_11' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_221_12\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_221_12' >Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_12' id='input_221_12' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_221_1' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_221\").val(\"2\");  jQuery(\"#gform_221\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_221\").val(\"2\");  jQuery(\"#gform_221\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_221_2_link' class='gform_save_link button'  onclick='if(window[\"gf_submitting_221\"]){return false;}  if( !jQuery(\"#gform_221\")[0].checkValidity || jQuery(\"#gform_221\")[0].checkValidity()){window[\"gf_submitting_221\"]=true;} jQuery(\"#gform_save_221\").val(1); jQuery(\"#gform_221\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_221\"]){return false;} if( !jQuery(\"#gform_221\")[0].checkValidity || jQuery(\"#gform_221\")[0].checkValidity()){window[\"gf_submitting_221\"]=true;} jQuery(\"#gform_save_221\").val(1); jQuery(\"#gform_221\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later. Please note that field entries will save but uploaded docs will not.<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_221_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_221_2' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_221_13\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Are You Currently Homeless<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_221_13'>\n\t\t\t<div class='gchoice gchoice_221_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Yes'  id='choice_221_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_221_13_0' id='label_221_13_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_221_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='No'  id='choice_221_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_221_13_1' id='label_221_13_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_221_21\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_above field_description_above gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_221_21' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_221_21_1_container' >\n                                        <label for='input_221_21_1' id='input_221_21_1_label' >Street Address<\/label>\n                                        <input type='text' name='input_21.1' id='input_221_21_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_221_21_2_container' >\n                                        <label for='input_221_21_2' id='input_221_21_2_label' >Address Line 2<\/label>\n                                        <input type='text' name='input_21.2' id='input_221_21_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_221_21_3_container' >\n                                    <label for='input_221_21_3' id='input_221_21_3_label' >City<\/label>\n                                    <input type='text' name='input_21.3' id='input_221_21_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_221_21_4_container' >\n                                        <label for='input_221_21_4' id='input_221_21_4_label' >State<\/label>\n                                        <select name='input_21.4' id='input_221_21_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_221_21_5_container' >\n                                    <label for='input_221_21_5' id='input_221_21_5_label' >ZIP Code<\/label>\n                                    <input type='text' name='input_21.5' id='input_221_21_5' value=''    aria-required='true'   \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_21.6' id='input_221_21_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_221_29\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Is this in Jefferson County?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_221_29'>\n\t\t\t<div class='gchoice gchoice_221_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_221_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_221_29_0' id='label_221_29_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_221_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_221_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_221_29_1' id='label_221_29_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_221_15\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_221_15' >Please upload a photo of your continuum ID card if you have one<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='8388608' \/><input name='input_15' id='input_221_15' type='file' class='large' aria-describedby=\"gfield_upload_rules_221_15\" onchange='javascript:gformValidateFileSize( this, 8388608 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_221_15'>Max. file size: 8 MB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_221_15'><\/div><\/div><\/div><div id=\"field_221_17\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_221_17' >Upload an image of your social security card, if you have one<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='8388608' \/><input name='input_17' id='input_221_17' type='file' class='large' aria-describedby=\"gfield_upload_rules_221_17\" onchange='javascript:gformValidateFileSize( this, 8388608 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_221_17'>Max. file size: 8 MB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_221_17'><\/div><\/div><\/div><div id=\"field_221_47\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_221_47' >If you cannot upload a photo of your social security card, please enter it below.<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_221_47' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_221_16\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_221_16' >Please upload a photo of your shelter letter  if you have one<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='8388608' \/><input name='input_16' id='input_221_16' type='file' class='large' aria-describedby=\"gfield_upload_rules_221_16\" onchange='javascript:gformValidateFileSize( this, 8388608 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_221_16'>Max. file size: 8 MB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_221_16'><\/div><\/div><\/div><div id=\"field_221_18\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" >If you are unable to upload these documents, please come to the Cooper Green enrollment department Monday Friday 7 a.m. \u2013 4 p.m.<\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_221_41' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_221\").val(\"1\");  jQuery(\"#gform_221\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_221\").val(\"1\");  jQuery(\"#gform_221\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_221_41' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_221\").val(\"3\");  jQuery(\"#gform_221\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_221\").val(\"3\");  jQuery(\"#gform_221\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_221_3_link' class='gform_save_link button'  onclick='if(window[\"gf_submitting_221\"]){return false;}  if( !jQuery(\"#gform_221\")[0].checkValidity || jQuery(\"#gform_221\")[0].checkValidity()){window[\"gf_submitting_221\"]=true;} jQuery(\"#gform_save_221\").val(1); jQuery(\"#gform_221\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_221\"]){return false;} if( !jQuery(\"#gform_221\")[0].checkValidity || jQuery(\"#gform_221\")[0].checkValidity()){window[\"gf_submitting_221\"]=true;} jQuery(\"#gform_save_221\").val(1); jQuery(\"#gform_221\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later. Please note that field entries will save but uploaded docs will not.<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_221_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_221_3' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_221_20\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Do you have health insurance?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_221_20'>\n\t\t\t<div class='gchoice gchoice_221_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Yes'  id='choice_221_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_221_20_0' id='label_221_20_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_221_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='No'  id='choice_221_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_221_20_1' id='label_221_20_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_221_22\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_221_22' >Please upload a photo of the front of your insurance card  if you have one<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='8388608' \/><input name='input_22' id='input_221_22' type='file' class='large' aria-describedby=\"gfield_upload_rules_221_22\" onchange='javascript:gformValidateFileSize( this, 8388608 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_221_22'>Max. file size: 8 MB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_221_22'><\/div><\/div><\/div><div id=\"field_221_26\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_221_26' >Please upload a photo of the back of your insurance card  if you have one<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='8388608' \/><input name='input_26' id='input_221_26' type='file' class='large' aria-describedby=\"gfield_upload_rules_221_26\" onchange='javascript:gformValidateFileSize( this, 8388608 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_221_26'>Max. file size: 8 MB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_221_26'><\/div><\/div><\/div><div id=\"field_221_25\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_221_25' >Please upload an image of your social security number if you have one<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='8388608' \/><input name='input_25' id='input_221_25' type='file' class='large' aria-describedby=\"gfield_upload_rules_221_25\" onchange='javascript:gformValidateFileSize( this, 8388608 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_221_25'>Max. file size: 8 MB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_221_25'><\/div><\/div><\/div><div id=\"field_221_24\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_221_24' >Please upload a photo of the front of your state issued ID or passport  if you have one<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='8388608' \/><input name='input_24' id='input_221_24' type='file' class='large' aria-describedby=\"gfield_upload_rules_221_24\" onchange='javascript:gformValidateFileSize( this, 8388608 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_221_24'>Max. file size: 8 MB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_221_24'><\/div><\/div><\/div><div id=\"field_221_23\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_221_23' >Please upload a photo of your social security card  if you have one<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='8388608' \/><input name='input_23' id='input_221_23' type='file' class='large' aria-describedby=\"gfield_upload_rules_221_23\" onchange='javascript:gformValidateFileSize( this, 8388608 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_221_23'>Max. file size: 8 MB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_221_23'><\/div><\/div><\/div><div id=\"field_221_27\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" >If you are unable to upload these documents, please come to Cooper Green enrollment department Monday \u2013 Friday 7 a.m. \u2013 4 p.m.<\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_221_7' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_221\").val(\"2\");  jQuery(\"#gform_221\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_221\").val(\"2\");  jQuery(\"#gform_221\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_221_7' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_221\").val(\"4\");  jQuery(\"#gform_221\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_221\").val(\"4\");  jQuery(\"#gform_221\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_221_4_link' class='gform_save_link button'  onclick='if(window[\"gf_submitting_221\"]){return false;}  if( !jQuery(\"#gform_221\")[0].checkValidity || jQuery(\"#gform_221\")[0].checkValidity()){window[\"gf_submitting_221\"]=true;} jQuery(\"#gform_save_221\").val(1); jQuery(\"#gform_221\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_221\"]){return false;} if( !jQuery(\"#gform_221\")[0].checkValidity || jQuery(\"#gform_221\")[0].checkValidity()){window[\"gf_submitting_221\"]=true;} jQuery(\"#gform_save_221\").val(1); jQuery(\"#gform_221\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later. Please note that field entries will save but uploaded docs will not.<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_221_4' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_221_4' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_221_31\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Do you receive food stamps?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_221_31'>\n\t\t\t<div class='gchoice gchoice_221_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_221_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_221_31_0' id='label_221_31_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_221_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_221_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_221_31_1' id='label_221_31_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_221_32\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_221_32' >Please upload a photo of your award letter  if you have one<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='8388608' \/><input name='input_32' id='input_221_32' type='file' class='large' aria-describedby=\"gfield_upload_rules_221_32\" onchange='javascript:gformValidateFileSize( this, 8388608 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_221_32'>Max. file size: 8 MB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_221_32'><\/div><\/div><\/div><div id=\"field_221_34\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_221_34' >Please upload a photo of the front of your state issued ID or passport  if you have one<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='8388608' \/><input name='input_34' id='input_221_34' type='file' class='large' aria-describedby=\"gfield_upload_rules_221_34\" onchange='javascript:gformValidateFileSize( this, 8388608 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_221_34'>Max. file size: 8 MB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_221_34'><\/div><\/div><\/div><div id=\"field_221_33\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_221_33' >Please upload a photo of your social security card<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='8388608' \/><input name='input_33' id='input_221_33' type='file' class='large' aria-describedby=\"gfield_upload_rules_221_33\" onchange='javascript:gformValidateFileSize( this, 8388608 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_221_33'>Max. file size: 8 MB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_221_33'><\/div><\/div><\/div><div id=\"field_221_35\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" >If you are unable to upload these documents, please come to Cooper Green enrollment department Monday \u2013 Friday 7 a.m. \u2013 4 p.m.<\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_221_8' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_221\").val(\"3\");  jQuery(\"#gform_221\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_221\").val(\"3\");  jQuery(\"#gform_221\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_221_8' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_221\").val(\"5\");  jQuery(\"#gform_221\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_221\").val(\"5\");  jQuery(\"#gform_221\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_221_5_link' class='gform_save_link button'  onclick='if(window[\"gf_submitting_221\"]){return false;}  if( !jQuery(\"#gform_221\")[0].checkValidity || jQuery(\"#gform_221\")[0].checkValidity()){window[\"gf_submitting_221\"]=true;} jQuery(\"#gform_save_221\").val(1); jQuery(\"#gform_221\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_221\"]){return false;} if( !jQuery(\"#gform_221\")[0].checkValidity || jQuery(\"#gform_221\")[0].checkValidity()){window[\"gf_submitting_221\"]=true;} jQuery(\"#gform_save_221\").val(1); jQuery(\"#gform_221\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later. Please note that field entries will save but uploaded docs will not.<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_221_5' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_221_5' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_221_36\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Do you have income?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_221_36'>\n\t\t\t<div class='gchoice gchoice_221_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Yes'  id='choice_221_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_221_36_0' id='label_221_36_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_221_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='No'  id='choice_221_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_221_36_1' id='label_221_36_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_221_45\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Do you have a minor child in custody?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_221_45'>\n\t\t\t<div class='gchoice gchoice_221_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='Yes'  id='choice_221_45_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_221_45_0' id='label_221_45_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_221_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='No'  id='choice_221_45_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_221_45_1' id='label_221_45_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_221_37\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_221_37' >Please upload a photo of your most recent income statement (social security, disability, tax documents and\/ or pay stub)  if you have one<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='8388608' \/><input name='input_37' id='input_221_37' type='file' class='large' aria-describedby=\"gfield_upload_rules_221_37\" onchange='javascript:gformValidateFileSize( this, 8388608 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_221_37'>Max. file size: 8 MB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_221_37'><\/div><\/div><\/div><div id=\"field_221_39\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_221_39' >Please upload a photo of the front of your state issued ID or passport  if you have one<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='8388608' \/><input name='input_39' id='input_221_39' type='file' class='large' aria-describedby=\"gfield_upload_rules_221_39\" onchange='javascript:gformValidateFileSize( this, 8388608 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_221_39'>Max. file size: 8 MB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_221_39'><\/div><\/div><\/div><div id=\"field_221_38\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_221_38' >Please upload a photo of your social security card  if you have one<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='8388608' \/><input name='input_38' id='input_221_38' type='file' class='large' aria-describedby=\"gfield_upload_rules_221_38\" onchange='javascript:gformValidateFileSize( this, 8388608 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_221_38'>Max. file size: 8 MB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_221_38'><\/div><\/div><\/div><div id=\"field_221_40\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" >If you are unable to upload these documents, please come to the Cooper Green enrollment department Monday Friday 7 a.m. \u2013 4 p.m.<\/div><\/div><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_221' class='gform_previous_button button' value='Previous'  onclick='if(window[\"gf_submitting_221\"]){return false;}  if( !jQuery(\"#gform_221\")[0].checkValidity || jQuery(\"#gform_221\")[0].checkValidity()){window[\"gf_submitting_221\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_221\"]){return false;} if( !jQuery(\"#gform_221\")[0].checkValidity || jQuery(\"#gform_221\")[0].checkValidity()){window[\"gf_submitting_221\"]=true;}  jQuery(\"#gform_221\").trigger(\"submit\",[true]); }' \/> <input type='submit' id='gform_submit_button_221' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_221\"]){return false;}  if( 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