{"id":4814,"date":"2022-09-16T12:09:28","date_gmt":"2022-09-16T16:09:28","guid":{"rendered":"https:\/\/can.girlguides.ca\/?page_id=4814"},"modified":"2026-07-28T10:07:31","modified_gmt":"2026-07-28T14:07:31","slug":"nl-the-sharron-callahan-member-assistance-fund-application-for-girl-members","status":"publish","type":"page","link":"https:\/\/can.girlguides.ca\/index.php\/nl-the-sharron-callahan-member-assistance-fund-application-for-girl-members\/","title":{"rendered":"NL &#8211; The Sharron Callahan Member Assistance application for girl members"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_577' ><form method='post' enctype='multipart\/form-data'  id='gform_577'  action='\/index.php\/wp-json\/wp\/v2\/pages\/4814' data-formid='577' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_577' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_577_18\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Girl(s) for whom assistance is being requested:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">First name<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Last name<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Unit (e.g. 1st Anytown Sparks)<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_18_cell1 gform-grid-col' data-label='First name'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_577_18\" aria-label='First name, Row 1' data-aria-label-template='First name, Row {0}' type='text' name='input_18[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_18_cell2 gform-grid-col' data-label='Last name'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_577_18\" aria-label='Last name, Row 1' data-aria-label-template='Last name, Row {0}' type='text' name='input_18[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_18_cell3 gform-grid-col' data-label='Unit (e.g. 1st Anytown Sparks)'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_577_18\" aria-label='Unit (e.g. 1st Anytown Sparks), Row 1' data-aria-label-template='Unit (e.g. 1st Anytown Sparks), Row {0}' type='text' name='input_18[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_577_18'>To add a girl, click the + symbol<\/div><\/fieldset><fieldset id=\"field_577_17\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Parent or Caregiver<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_577_17'>\n                            \n                            <span id='input_577_17_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_17.3' id='input_577_17_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_577_17_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_577_17_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_17.6' id='input_577_17_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_577_17_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_577_3\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_577_3_container'>\n                                <span id='input_577_3_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_3' id='input_577_3' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_577_3' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_577_3_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_3_2' id='input_577_3_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_577_3_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_577_7\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_577_7'><span class='gform-field-label__text'>Amount requested for uniform (50% up to maximum of $25 per girl)<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_7' id='input_577_7' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_description_577_7\" \/><\/div><div class='gfield_description' id='gfield_description_577_7'>Approved uniform assistance will be sent to the district concerned. Your district will advise you on placing the order for uniform pieces needed.  Assistance for camp registration fees will be sent to the unit or council concerned.<\/div><\/div><fieldset id=\"field_577_19\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Specify:<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_577_19'><div class='gchoice gchoice_577_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='Shirt'  id='choice_577_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_577_19_1' id='label_577_19_1' class='gform-field-label gform-field-label--type-inline'>Shirt<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_577_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='Scarf'  id='choice_577_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_577_19_2' id='label_577_19_2' class='gform-field-label gform-field-label--type-inline'>Scarf<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_577_19_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.3' type='checkbox'  value='Badge Sash'  id='choice_577_19_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_577_19_3' id='label_577_19_3' class='gform-field-label gform-field-label--type-inline'>Badge Sash<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_577_15\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_577_15'><span class='gform-field-label__text'>Amount requested for Canadian camp registration fee such as a unit or district camp (up to 50%, to a maximum of $150):<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_15' id='input_577_15' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_577_22\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_577_22'><span class='gform-field-label__text'>Details of the camp<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_577_22' class='textarea large'  aria-describedby=\"gfield_description_577_22\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_577_22'>Please provide all known details about the camp such as the name of the camp, the planned date, total registration fee being charged, etc.<\/div><\/div><div id=\"field_577_8\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_577_8'><span class='gform-field-label__text'>Please indicate why financial assistance is requested at this time.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_8' id='input_577_8' class='textarea large'  aria-describedby=\"gfield_description_577_8\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_577_8'>Examples of need for financial assistance include family size, single parent, or any circumstance that affects your ability to pay these expenses. <\/div><\/div><fieldset id=\"field_577_9\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Agreement<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_9.1' id='input_577_9_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_577_9\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_577_9_1' ><span class='gform-field-label__text'>I agree<\/span><\/label><input type='hidden' name='input_9.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_9.3' value='143' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_577_9'><div class='gfield_consent_description_text' tabindex='0'>I understand that the Newfoundland and Labrador Council through the Sharron Callahan Member Assistance provides financial assistance to members who are not otherwise able to pay for membership fees or uniform.  I also understand that the full amount requested may not be available if there are many requests.  If funding is not approved, I understand that I am responsible for payment of these amounts.  I also understand that all members are expected to participate in the sale of Girl Guide cookies.<\/div><\/div><\/fieldset><fieldset id=\"field_577_20\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Signature of Parent\/Caregiver<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_signature\"><input type='hidden' value='' name='input_20' id='input_577_20_signature_filename' class='gfield_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_577_20_Container' class='gfield_signature_container' style='height:90px; width:300px; ' ><input type='hidden' id='input_577_20_data' name='input_577_20_data' class='gfield_signature_data' \/><canvas id=\"input_577_20\" width=\"300\" height=\"90\" style=\"border-style: Dashed; border-width: 2px; border-color: #757575; background-color:#FFFFFF; cursor: url(\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;\" tabindex=\"0\" aria-label=\"Signature pad\" ><\/canvas><input type='text' id='input_577_20_textinput' name='input_577_20_textinput' class='gfield_signature_text_input' style='text-indent:10px;display:none;width:300px;height:90px;border-style:Dashed;border-width:2px;border-color:#757575;background-color:#FFFFFF;font-family:&quot;Snell Roundhand&quot;, &quot;Segoe Script&quot;, cursive;font-size:2em;padding:0 12px;box-sizing:border-box;color:#000;' placeholder='Type your signature' autocomplete='off' aria-label='Type your signature' \/><style type='text\/css'>\n                #input_577_20_textinput::placeholder {\n                    font-size: 1.5rem;\n                    font-family: Arial;\n                    opacity: 0.8;\n                }\n            <\/style><\/div><div id='input_577_20_toolbar' class='gfield_signature_toolbar' dir='ltr' style='margin:5px 0;position:relative;height:35px;width:300px;max-width:100%;display:flex;align-items:center;'><div id='input_577_20_status' class='gfield_signature_status gform-visually-hidden' role='status' aria-live='polite' aria-atomic='true' style='position:absolute;width:1px;height:1px;padding:0;margin:-1px;overflow:hidden;clip:rect(0,0,0,0);white-space:nowrap;border:0;'><\/div><input type='hidden' id='input_577_20_font_select' class='gfield_signature_font_select' value='script' \/><div id='input_577_20_font_dropdown' class='gfield_signature_font_dropdown'><span class='gform-common-icon gform-common-icon--chevron-down gfield_signature_font_dropdown_icon'><\/span><button type='button' id='input_577_20_font_select_button' class='gfield_signature_font_select_button gform-theme__disable' tabindex='0' aria-haspopup='listbox' aria-expanded='false' aria-label='Font Options' style='width:100%;box-sizing:border-box;overflow:hidden;text-overflow:ellipsis;white-space:nowrap;font-family:\"Snell Roundhand\", \"Segoe Script\", cursive;color:#000'>Your Name<\/button><ul id='input_577_20_font_select_list' class='gfield_signature_font_select_list' role='listbox' tabindex='-1' style='display:none;position:absolute;top:100%;left:0;right:0;margin:0;padding:0;list-style:none;background:#fff;border:1px solid #ccc;z-index:10;max-height:200px;overflow-y:auto;box-sizing:border-box;'><li class='gfield_signature_font_option' role='option' data-value='script' tabindex='0' style='font-family:&quot;Snell Roundhand&quot;, &quot;Segoe Script&quot;, cursive; color:#000' aria-label='Your Name, Script style'>Your Name<\/li><li class='gfield_signature_font_option' role='option' data-value='handwritten' tabindex='0' style='font-family:&quot;Bradley Hand&quot;, &quot;Comic Sans MS&quot;, cursive; color:#000' aria-label='Your Name, Handwritten style'>Your Name<\/li><li class='gfield_signature_font_option' role='option' data-value='print' tabindex='0' style='font-family:&quot;Noteworthy&quot;, &quot;Segoe Print&quot;, cursive; color:#000' aria-label='Your Name, Print style'>Your Name<\/li><\/ul><\/div><div class='gfield_signature_toolbar_icons' style='margin-left:auto;display:flex;align-items:center;'><button type='button' id='input_577_20_textbutton' class='gform-common-icon gform-common-icon--text-field gfield_signature_text_button gform-theme-no-framework' tabindex='0' style='background:none;border:0;padding:0;margin:0;appearance:none;-webkit-appearance:none;cursor:pointer;' alt='Text Signature' aria-label='Text Signature'><\/button><button type='button' id='input_577_20_drawbutton' class='gform-common-icon gform-common-icon--pencil gfield_signature_draw_button gform-theme-no-framework' tabindex='0' style='display:none;background:none;border:0;padding:0;margin:0;appearance:none;-webkit-appearance:none;cursor:pointer;' alt='Draw Signature' aria-label='Draw Signature'><\/button><button type='button' id='input_577_20_resetbutton' class='gform-common-icon gform-common-icon--arrow-path gfield_signature_reset_button gform-theme-no-framework' tabindex='0' style='background:none;border:0;padding:0;margin:0;appearance:none;-webkit-appearance:none;cursor:pointer;' alt='Clear Signature' aria-label='Clear Signature'><\/button><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_577_21\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_577_21'><span class='gform-field-label__text'>Date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_577_21'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_21'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_577_21' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_577_21' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_577_21' aria-label='Date: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_577_10\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><em>Privacy Statement<\/em><\/p>\n<p><em>We protect and respect your privacy.&nbsp; Your personal information is used to communicate within our organization.&nbsp; We do not provide or sell this information outside our organization.&nbsp; For further information, see our Privacy Policy at <a href=\"http:\/\/www.girlguides.ca\/\">www.girlguides.ca<\/a><\/em><\/p><\/div><div id=\"field_577_12\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc 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100%;\n}\n<\/style>\n<\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_577' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_577' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_577' id='gform_theme_577' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_577' id='gform_style_settings_577' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_577' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='577' \/>\n            \n            <input type='hidden' class='gform_hidden' 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name='gform_source_page_number_577' id='gform_source_page_number_577' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        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