{"id":751,"date":"2014-06-16T23:20:58","date_gmt":"2014-06-16T23:20:58","guid":{"rendered":"http:\/\/shwt.pushdesign.net\/gho\/?page_id=751"},"modified":"2022-07-26T19:04:08","modified_gmt":"2022-07-26T19:04:08","slug":"livewell-fit-reimbursement-form","status":"publish","type":"page","link":"https:\/\/soundhealthwellness.com\/kp\/sound-support\/livewell-fit\/livewell-fit-reimbursement-form\/","title":{"rendered":"LiveWell Fit Reimbursement Form"},"content":{"rendered":"<div class=\"forminator-ui forminator-custom-form forminator-custom-form-2879 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-2879\" data-uid=\"69d7e9045b7db\"><br\/><\/div><form\r\n\t\t\t\tid=\"forminator-module-2879\"\r\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-2879 forminator-design--default  forminator_ajax\"\r\n\t\t\t\tmethod=\"post\"\r\n\t\t\t\tdata-forminator-render=\"0\"\r\n\t\t\t\tdata-form-id=\"2879\"\r\n\t\t\t\t data-color-option=\"default\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\r\n\t\t\t\tdata-uid=\"69d7e9045b7db\"\r\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><p>Take a look at the current&nbsp;<a href=\"https:\/\/soundhealthwellness.com\/kp\/wp-content\/uploads\/sites\/2\/2026\/03\/LWF-Event-List-April-June-2026_Final.pdf\" target=\"_blank\" rel=\"noopener\">LiveWell Fit event list<\/a>&nbsp;to find an event in your area.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69d7e9045b7db\" id=\"forminator-field-text-1_69d7e9045b7db-label\" class=\"forminator-label\">Name of event <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" aria-describedby=\"forminator-field-text-1_69d7e9045b7db-description\" \/><span id=\"forminator-field-text-1_69d7e9045b7db-description\" class=\"forminator-description\">PLEASE NOTE THAT ONLY THOSE EVENTS LISTED ON THE TRUST WEBSITE ARE ELIGIBLE FOR REIMBURSEMENT<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69d7e9045b7db\" id=\"forminator-field-text-2_69d7e9045b7db-label\" class=\"forminator-label\">Event Location <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69d7e9045b7db\" id=\"forminator-field-text-3_69d7e9045b7db-label\" class=\"forminator-label\">Event Date <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_69d7e9045b7db\" id=\"forminator-field-text-4_69d7e9045b7db-label\" class=\"forminator-label\">Event Distance <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Complete this section with the employee&#039;s information:<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69d7e9045b7db\" id=\"forminator-field-text-5_69d7e9045b7db-label\" class=\"forminator-label\">Employee Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_69d7e9045b7db\" id=\"forminator-field-text-6_69d7e9045b7db-label\" class=\"forminator-label\">Last Four Digits Of Employee Social Security Number (xxxx) <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_69d7e9045b7db\" id=\"forminator-field-text-7_69d7e9045b7db-label\" class=\"forminator-label\">Employee Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-8\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-8_69d7e9045b7db\" id=\"forminator-field-text-8_69d7e9045b7db-label\" class=\"forminator-label\">City <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-8\" value=\"\" placeholder=\"\" id=\"forminator-field-text-8_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-9\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-9_69d7e9045b7db\" id=\"forminator-field-text-9_69d7e9045b7db-label\" class=\"forminator-label\">State <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-9\" value=\"\" placeholder=\"\" id=\"forminator-field-text-9_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-10\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-10_69d7e9045b7db\" id=\"forminator-field-text-10_69d7e9045b7db-label\" class=\"forminator-label\">Zip Code <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-10\" value=\"\" placeholder=\"\" id=\"forminator-field-text-10_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-11\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-11_69d7e9045b7db\" id=\"forminator-field-text-11_69d7e9045b7db-label\" class=\"forminator-label\">Employee Date of Birth <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-11\" value=\"\" placeholder=\"\" id=\"forminator-field-text-11_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Who is participating in the event? Complete all fields for each participating family member.<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-2-69d7e9045b7db-label\"><span id=\"forminator-radiogroup-radio-2-69d7e9045b7db-label\" class=\"forminator-label\">How many participants? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-69d7e9045b7db\" class=\"forminator-radio forminator-radio-inline\" title=\"1\"><input type=\"radio\" name=\"radio-2\" value=\"1\" id=\"forminator-field-radio-2-1-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">1<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-69d7e9045b7db\" class=\"forminator-radio forminator-radio-inline\" title=\"2\"><input type=\"radio\" name=\"radio-2\" value=\"2\" id=\"forminator-field-radio-2-2-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">2<\/span><\/label><label id=\"forminator-field-radio-2-label-3\" for=\"forminator-field-radio-2-3-69d7e9045b7db\" class=\"forminator-radio forminator-radio-inline\" title=\"3\"><input type=\"radio\" name=\"radio-2\" value=\"3\" id=\"forminator-field-radio-2-3-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-2-label-3\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">3<\/span><\/label><label id=\"forminator-field-radio-2-label-4\" for=\"forminator-field-radio-2-4-69d7e9045b7db\" class=\"forminator-radio forminator-radio-inline\" title=\"4\"><input type=\"radio\" name=\"radio-2\" value=\"4\" id=\"forminator-field-radio-2-4-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-2-label-4\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">4<\/span><\/label><label id=\"forminator-field-radio-2-label-5\" for=\"forminator-field-radio-2-5-69d7e9045b7db\" class=\"forminator-radio forminator-radio-inline\" title=\"5\"><input type=\"radio\" name=\"radio-2\" value=\"5\" id=\"forminator-field-radio-2-5-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-2-label-5\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">5<\/span><\/label><label id=\"forminator-field-radio-2-label-6\" for=\"forminator-field-radio-2-6-69d7e9045b7db\" class=\"forminator-radio forminator-radio-inline\" title=\"6\"><input type=\"radio\" name=\"radio-2\" value=\"6\" id=\"forminator-field-radio-2-6-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-2-label-6\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">6<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Participant 1<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-12\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-12_69d7e9045b7db\" id=\"forminator-field-text-12_69d7e9045b7db-label\" class=\"forminator-label\">Participant First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-12\" value=\"\" placeholder=\"\" id=\"forminator-field-text-12_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-13\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-13_69d7e9045b7db\" id=\"forminator-field-text-13_69d7e9045b7db-label\" class=\"forminator-label\">Participant Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-13\" value=\"\" placeholder=\"\" id=\"forminator-field-text-13_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-69d7e9045b7db-label\"><span id=\"forminator-radiogroup-radio-1-69d7e9045b7db-label\" class=\"forminator-label\">Relationship to Employee? (select one)<\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-69d7e9045b7db\" class=\"forminator-radio\" title=\"Employee\"><input type=\"radio\" name=\"radio-1\" value=\"Employee\" id=\"forminator-field-radio-1-1-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Employee<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-69d7e9045b7db\" class=\"forminator-radio\" title=\"Spouse\"><input type=\"radio\" name=\"radio-1\" value=\"Spouse\" id=\"forminator-field-radio-1-2-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Spouse<\/span><\/label><label id=\"forminator-field-radio-1-label-3\" for=\"forminator-field-radio-1-3-69d7e9045b7db\" class=\"forminator-radio\" title=\"Dependent\"><input type=\"radio\" name=\"radio-1\" value=\"Dependent\" id=\"forminator-field-radio-1-3-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-1-label-3\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Dependent<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-14\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-14_69d7e9045b7db\" id=\"forminator-field-text-14_69d7e9045b7db-label\" class=\"forminator-label\">Participant Phone Number<\/label><input type=\"text\" name=\"text-14\" value=\"\" placeholder=\"\" id=\"forminator-field-text-14_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-15\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-15_69d7e9045b7db\" id=\"forminator-field-text-15_69d7e9045b7db-label\" class=\"forminator-label\">Participant Email Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-15\" value=\"\" placeholder=\"\" id=\"forminator-field-text-15_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-2879__field--select-1_69d7e9045b7db\" id=\"forminator-form-2879__field--select-1_69d7e9045b7db-label\" class=\"forminator-label\">Participant T-Shirt Size<\/label><select  id=\"forminator-form-2879__field--select-1_69d7e9045b7db\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-1\" data-default-value=\"\" data-placeholder=\"***please select size***\" data-search=\"false\" data-search-placeholder=\"***please select size***\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2879__field--select-1_69d7e9045b7db-label\"><option value=\"\"  >***please select size***<\/option><option value=\"Women&#039;s---Small\"  data-calculation=\"0\">Women's - Small<\/option><option value=\"Women&#039;s---Medium\"  data-calculation=\"0\">Women's - Medium<\/option><option value=\"Women&#039;s---Large\"  data-calculation=\"0\">Women's - Large<\/option><option value=\"Women&#039;s---X-Large\"  data-calculation=\"0\">Women's - X-Large<\/option><option value=\"Men&#039;s---Medium\"  data-calculation=\"0\">Men's - Medium<\/option><option value=\"Men&#039;s---Large\"  data-calculation=\"0\">Men's - Large<\/option><option value=\"Men&#039;s---X-Large\"  data-calculation=\"0\">Men's - X-Large<\/option><option value=\"Men&#039;s---X-X-Large\"  data-calculation=\"0\">Men's - X-X-Large<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-4\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Participant 2<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-16\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-16_69d7e9045b7db\" id=\"forminator-field-text-16_69d7e9045b7db-label\" class=\"forminator-label\">Participant First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-16\" value=\"\" placeholder=\"\" id=\"forminator-field-text-16_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-17\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-17_69d7e9045b7db\" id=\"forminator-field-text-17_69d7e9045b7db-label\" class=\"forminator-label\">Participant Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-17\" value=\"\" placeholder=\"\" id=\"forminator-field-text-17_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-3-69d7e9045b7db-label\"><span id=\"forminator-radiogroup-radio-3-69d7e9045b7db-label\" class=\"forminator-label\">Relationship to Employee? (select one)<\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-69d7e9045b7db\" class=\"forminator-radio\" title=\"Employee\"><input type=\"radio\" name=\"radio-3\" value=\"Employee\" id=\"forminator-field-radio-3-1-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-3-label-1\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Employee<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-69d7e9045b7db\" class=\"forminator-radio\" title=\"Spouse\"><input type=\"radio\" name=\"radio-3\" value=\"Spouse\" id=\"forminator-field-radio-3-2-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-3-label-2\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Spouse<\/span><\/label><label id=\"forminator-field-radio-3-label-3\" for=\"forminator-field-radio-3-3-69d7e9045b7db\" class=\"forminator-radio\" title=\"Dependent\"><input type=\"radio\" name=\"radio-3\" value=\"Dependent\" id=\"forminator-field-radio-3-3-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-3-label-3\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Dependent<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-18\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-18_69d7e9045b7db\" id=\"forminator-field-text-18_69d7e9045b7db-label\" class=\"forminator-label\">Participant Phone Number<\/label><input type=\"text\" name=\"text-18\" value=\"\" placeholder=\"\" id=\"forminator-field-text-18_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-19\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-19_69d7e9045b7db\" id=\"forminator-field-text-19_69d7e9045b7db-label\" class=\"forminator-label\">Participant Email Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-19\" value=\"\" placeholder=\"\" id=\"forminator-field-text-19_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-2879__field--select-2_69d7e9045b7db\" id=\"forminator-form-2879__field--select-2_69d7e9045b7db-label\" class=\"forminator-label\">Participant T-Shirt Size<\/label><select  id=\"forminator-form-2879__field--select-2_69d7e9045b7db\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-2\" data-default-value=\"\" data-placeholder=\"***please select size***\" data-search=\"false\" data-search-placeholder=\"***please select size***\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2879__field--select-2_69d7e9045b7db-label\"><option value=\"\"  >***please select size***<\/option><option value=\"Women&#039;s---Small\"  data-calculation=\"0\">Women's - Small<\/option><option value=\"Women&#039;s---Medium\"  data-calculation=\"0\">Women's - Medium<\/option><option value=\"Women&#039;s---Large\"  data-calculation=\"0\">Women's - Large<\/option><option value=\"Women&#039;s---X-Large\"  data-calculation=\"0\">Women's - X-Large<\/option><option value=\"Men&#039;s---Medium\"  data-calculation=\"0\">Men's - Medium<\/option><option value=\"Men&#039;s---Large\"  data-calculation=\"0\">Men's - Large<\/option><option value=\"Men&#039;s---X-Large\"  data-calculation=\"0\">Men's - X-Large<\/option><option value=\"Men&#039;s---X-X-Large\"  data-calculation=\"0\">Men's - X-X-Large<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-5\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Participant 3<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-20\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-20_69d7e9045b7db\" id=\"forminator-field-text-20_69d7e9045b7db-label\" class=\"forminator-label\">Participant First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-20\" value=\"\" placeholder=\"\" id=\"forminator-field-text-20_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-21\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-21_69d7e9045b7db\" id=\"forminator-field-text-21_69d7e9045b7db-label\" class=\"forminator-label\">Participant Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-21\" value=\"\" placeholder=\"\" id=\"forminator-field-text-21_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-4\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-4-69d7e9045b7db-label\"><span id=\"forminator-radiogroup-radio-4-69d7e9045b7db-label\" class=\"forminator-label\">Relationship to Employee? (select one)<\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-69d7e9045b7db\" class=\"forminator-radio\" title=\"Employee\"><input type=\"radio\" name=\"radio-4\" value=\"Employee\" id=\"forminator-field-radio-4-1-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-4-label-1\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Employee<\/span><\/label><label id=\"forminator-field-radio-4-label-2\" for=\"forminator-field-radio-4-2-69d7e9045b7db\" class=\"forminator-radio\" title=\"Spouse\"><input type=\"radio\" name=\"radio-4\" value=\"Spouse\" id=\"forminator-field-radio-4-2-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-4-label-2\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Spouse<\/span><\/label><label id=\"forminator-field-radio-4-label-3\" for=\"forminator-field-radio-4-3-69d7e9045b7db\" class=\"forminator-radio\" title=\"Dependent\"><input type=\"radio\" name=\"radio-4\" value=\"Dependent\" id=\"forminator-field-radio-4-3-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-4-label-3\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Dependent<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-22\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-22_69d7e9045b7db\" id=\"forminator-field-text-22_69d7e9045b7db-label\" class=\"forminator-label\">Participant Phone Number<\/label><input type=\"text\" name=\"text-22\" value=\"\" placeholder=\"\" id=\"forminator-field-text-22_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-23\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-23_69d7e9045b7db\" id=\"forminator-field-text-23_69d7e9045b7db-label\" class=\"forminator-label\">Participant Email Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-23\" value=\"\" placeholder=\"\" id=\"forminator-field-text-23_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-3\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-2879__field--select-3_69d7e9045b7db\" id=\"forminator-form-2879__field--select-3_69d7e9045b7db-label\" class=\"forminator-label\">Participant T-Shirt Size<\/label><select  id=\"forminator-form-2879__field--select-3_69d7e9045b7db\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-3\" data-default-value=\"\" data-placeholder=\"***please select size***\" data-search=\"false\" data-search-placeholder=\"***please select size***\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2879__field--select-3_69d7e9045b7db-label\"><option value=\"\"  >***please select size***<\/option><option value=\"Women&#039;s---Small\"  data-calculation=\"0\">Women's - Small<\/option><option value=\"Women&#039;s---Medium\"  data-calculation=\"0\">Women's - Medium<\/option><option value=\"Women&#039;s---Large\"  data-calculation=\"0\">Women's - Large<\/option><option value=\"Women&#039;s---X-Large\"  data-calculation=\"0\">Women's - X-Large<\/option><option value=\"Men&#039;s---Medium\"  data-calculation=\"0\">Men's - Medium<\/option><option value=\"Men&#039;s---Large\"  data-calculation=\"0\">Men's - Large<\/option><option value=\"Men&#039;s---X-Large\"  data-calculation=\"0\">Men's - X-Large<\/option><option value=\"Men&#039;s---X-X-Large\"  data-calculation=\"0\">Men's - X-X-Large<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-6\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Participant 4<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-24\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-24_69d7e9045b7db\" id=\"forminator-field-text-24_69d7e9045b7db-label\" class=\"forminator-label\">Participant First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-24\" value=\"\" placeholder=\"\" id=\"forminator-field-text-24_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-25\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-25_69d7e9045b7db\" id=\"forminator-field-text-25_69d7e9045b7db-label\" class=\"forminator-label\">Participant Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-25\" value=\"\" placeholder=\"\" id=\"forminator-field-text-25_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-5\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-5-69d7e9045b7db-label\"><span id=\"forminator-radiogroup-radio-5-69d7e9045b7db-label\" class=\"forminator-label\">Relationship to Employee? (select one)<\/span><label id=\"forminator-field-radio-5-label-1\" for=\"forminator-field-radio-5-1-69d7e9045b7db\" class=\"forminator-radio\" title=\"Employee\"><input type=\"radio\" name=\"radio-5\" value=\"Employee\" id=\"forminator-field-radio-5-1-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-5-label-1\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Employee<\/span><\/label><label id=\"forminator-field-radio-5-label-2\" for=\"forminator-field-radio-5-2-69d7e9045b7db\" class=\"forminator-radio\" title=\"Spouse\"><input type=\"radio\" name=\"radio-5\" value=\"Spouse\" id=\"forminator-field-radio-5-2-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-5-label-2\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Spouse<\/span><\/label><label id=\"forminator-field-radio-5-label-3\" for=\"forminator-field-radio-5-3-69d7e9045b7db\" class=\"forminator-radio\" title=\"Dependent\"><input type=\"radio\" name=\"radio-5\" value=\"Dependent\" id=\"forminator-field-radio-5-3-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-5-label-3\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Dependent<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-26\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-26_69d7e9045b7db\" id=\"forminator-field-text-26_69d7e9045b7db-label\" class=\"forminator-label\">Participant Phone Number<\/label><input type=\"text\" name=\"text-26\" value=\"\" placeholder=\"\" id=\"forminator-field-text-26_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-27\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-27_69d7e9045b7db\" id=\"forminator-field-text-27_69d7e9045b7db-label\" class=\"forminator-label\">Participant Email Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-27\" value=\"\" placeholder=\"\" id=\"forminator-field-text-27_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-4\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-2879__field--select-4_69d7e9045b7db\" id=\"forminator-form-2879__field--select-4_69d7e9045b7db-label\" class=\"forminator-label\">Participant T-Shirt Size<\/label><select  id=\"forminator-form-2879__field--select-4_69d7e9045b7db\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-4\" data-default-value=\"\" data-placeholder=\"***please select size***\" data-search=\"false\" data-search-placeholder=\"***please select size***\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2879__field--select-4_69d7e9045b7db-label\"><option value=\"\"  >***please select size***<\/option><option value=\"Women&#039;s---Small\"  data-calculation=\"0\">Women's - Small<\/option><option value=\"Women&#039;s---Medium\"  data-calculation=\"0\">Women's - Medium<\/option><option value=\"Women&#039;s---Large\"  data-calculation=\"0\">Women's - Large<\/option><option value=\"Women&#039;s---X-Large\"  data-calculation=\"0\">Women's - X-Large<\/option><option value=\"Men&#039;s---Medium\"  data-calculation=\"0\">Men's - Medium<\/option><option value=\"Men&#039;s---Large\"  data-calculation=\"0\">Men's - Large<\/option><option value=\"Men&#039;s---X-Large\"  data-calculation=\"0\">Men's - X-Large<\/option><option value=\"Men&#039;s---X-X-Large\"  data-calculation=\"0\">Men's - X-X-Large<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-7\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Participant 5<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-28\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-28_69d7e9045b7db\" id=\"forminator-field-text-28_69d7e9045b7db-label\" class=\"forminator-label\">Participant First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-28\" value=\"\" placeholder=\"\" id=\"forminator-field-text-28_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-29\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-29_69d7e9045b7db\" id=\"forminator-field-text-29_69d7e9045b7db-label\" class=\"forminator-label\">Participant Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-29\" value=\"\" placeholder=\"\" id=\"forminator-field-text-29_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-6\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-6-69d7e9045b7db-label\"><span id=\"forminator-radiogroup-radio-6-69d7e9045b7db-label\" class=\"forminator-label\">Relationship to Employee? (select one)<\/span><label id=\"forminator-field-radio-6-label-1\" for=\"forminator-field-radio-6-1-69d7e9045b7db\" class=\"forminator-radio\" title=\"Employee\"><input type=\"radio\" name=\"radio-6\" value=\"Employee\" id=\"forminator-field-radio-6-1-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-6-label-1\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Employee<\/span><\/label><label id=\"forminator-field-radio-6-label-2\" for=\"forminator-field-radio-6-2-69d7e9045b7db\" class=\"forminator-radio\" title=\"Spouse\"><input type=\"radio\" name=\"radio-6\" value=\"Spouse\" id=\"forminator-field-radio-6-2-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-6-label-2\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Spouse<\/span><\/label><label id=\"forminator-field-radio-6-label-3\" for=\"forminator-field-radio-6-3-69d7e9045b7db\" class=\"forminator-radio\" title=\"Dependent\"><input type=\"radio\" name=\"radio-6\" value=\"Dependent\" id=\"forminator-field-radio-6-3-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-6-label-3\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Dependent<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-30\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-30_69d7e9045b7db\" id=\"forminator-field-text-30_69d7e9045b7db-label\" class=\"forminator-label\">Participant Phone Number<\/label><input type=\"text\" name=\"text-30\" value=\"\" placeholder=\"\" id=\"forminator-field-text-30_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-31\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-31_69d7e9045b7db\" id=\"forminator-field-text-31_69d7e9045b7db-label\" class=\"forminator-label\">Participant Email Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-31\" value=\"\" placeholder=\"\" id=\"forminator-field-text-31_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-5\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-2879__field--select-5_69d7e9045b7db\" id=\"forminator-form-2879__field--select-5_69d7e9045b7db-label\" class=\"forminator-label\">Participant T-Shirt Size<\/label><select  id=\"forminator-form-2879__field--select-5_69d7e9045b7db\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-5\" data-default-value=\"\" data-placeholder=\"***please select size***\" data-search=\"false\" data-search-placeholder=\"***please select size***\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2879__field--select-5_69d7e9045b7db-label\"><option value=\"\"  >***please select size***<\/option><option value=\"Women&#039;s---Small\"  data-calculation=\"0\">Women's - Small<\/option><option value=\"Women&#039;s---Medium\"  data-calculation=\"0\">Women's - Medium<\/option><option value=\"Women&#039;s---Large\"  data-calculation=\"0\">Women's - Large<\/option><option value=\"Women&#039;s---X-Large\"  data-calculation=\"0\">Women's - X-Large<\/option><option value=\"Men&#039;s---Medium\"  data-calculation=\"0\">Men's - Medium<\/option><option value=\"Men&#039;s---Large\"  data-calculation=\"0\">Men's - Large<\/option><option value=\"Men&#039;s---X-Large\"  data-calculation=\"0\">Men's - X-Large<\/option><option value=\"Men&#039;s---X-X-Large\"  data-calculation=\"0\">Men's - X-X-Large<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-8\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Participant 6<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-32\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-32_69d7e9045b7db\" id=\"forminator-field-text-32_69d7e9045b7db-label\" class=\"forminator-label\">Participant First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-32\" value=\"\" placeholder=\"\" id=\"forminator-field-text-32_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-33\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-33_69d7e9045b7db\" id=\"forminator-field-text-33_69d7e9045b7db-label\" class=\"forminator-label\">Participant Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-33\" value=\"\" placeholder=\"\" id=\"forminator-field-text-33_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-7\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-7-69d7e9045b7db-label\"><span id=\"forminator-radiogroup-radio-7-69d7e9045b7db-label\" class=\"forminator-label\">Relationship to Employee? (select one)<\/span><label id=\"forminator-field-radio-7-label-1\" for=\"forminator-field-radio-7-1-69d7e9045b7db\" class=\"forminator-radio\" title=\"Employee\"><input type=\"radio\" name=\"radio-7\" value=\"Employee\" id=\"forminator-field-radio-7-1-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-7-label-1\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Employee<\/span><\/label><label id=\"forminator-field-radio-7-label-2\" for=\"forminator-field-radio-7-2-69d7e9045b7db\" class=\"forminator-radio\" title=\"Spouse\"><input type=\"radio\" name=\"radio-7\" value=\"Spouse\" id=\"forminator-field-radio-7-2-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-7-label-2\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Spouse<\/span><\/label><label id=\"forminator-field-radio-7-label-3\" for=\"forminator-field-radio-7-3-69d7e9045b7db\" class=\"forminator-radio\" title=\"Dependent\"><input type=\"radio\" name=\"radio-7\" value=\"Dependent\" id=\"forminator-field-radio-7-3-69d7e9045b7db\" aria-labelledby=\"forminator-field-radio-7-label-3\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Dependent<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-34\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-34_69d7e9045b7db\" id=\"forminator-field-text-34_69d7e9045b7db-label\" class=\"forminator-label\">Participant Phone Number<\/label><input type=\"text\" name=\"text-34\" value=\"\" placeholder=\"\" id=\"forminator-field-text-34_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-35\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-35_69d7e9045b7db\" id=\"forminator-field-text-35_69d7e9045b7db-label\" class=\"forminator-label\">Participant Email Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-35\" value=\"\" placeholder=\"\" id=\"forminator-field-text-35_69d7e9045b7db\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-6\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-2879__field--select-6_69d7e9045b7db\" id=\"forminator-form-2879__field--select-6_69d7e9045b7db-label\" class=\"forminator-label\">Participant T-Shirt Size<\/label><select  id=\"forminator-form-2879__field--select-6_69d7e9045b7db\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-6\" data-default-value=\"\" data-placeholder=\"***please select size***\" data-search=\"false\" data-search-placeholder=\"***please select size***\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2879__field--select-6_69d7e9045b7db-label\"><option value=\"\"  >***please select size***<\/option><option value=\"Women&#039;s---Small\"  data-calculation=\"0\">Women's - Small<\/option><option value=\"Women&#039;s---Medium\"  data-calculation=\"0\">Women's - Medium<\/option><option value=\"Women&#039;s---Large\"  data-calculation=\"0\">Women's - Large<\/option><option value=\"Women&#039;s---X-Large\"  data-calculation=\"0\">Women's - X-Large<\/option><option value=\"Men&#039;s---Medium\"  data-calculation=\"0\">Men's - Medium<\/option><option value=\"Men&#039;s---Large\"  data-calculation=\"0\">Men's - Large<\/option><option value=\"Men&#039;s---X-Large\"  data-calculation=\"0\">Men's - X-Large<\/option><option value=\"Men&#039;s---X-X-Large\"  data-calculation=\"0\">Men's - X-X-Large<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\" style=\"margin: 0;\"><div id=\"captcha-1\" class=\"forminator-field-captcha  forminator-col-12 \"><div class=\"forminator-captcha-left forminator-g-recaptcha recaptcha-invisible\" data-theme=\"light\" data-badge=\"bottomright\" data-sitekey=\"6LcNgnEqAAAAAEXz0OoH2dvQ4OLQLN8y0D-HXhbX\" data-size=\"invisible\"><\/div> <\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Submit<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"c07ec1a7f7\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/kp\/wp-json\/wp\/v2\/pages\/751\" \/><input type=\"hidden\" name=\"form_id\" value=\"2879\"><input type=\"hidden\" name=\"page_id\" value=\"751\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/soundhealthwellness.com\/kp\/sound-support\/livewell-fit\/livewell-fit-reimbursement-form\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":2766,"parent":32,"menu_order":0,"comment_status":"open","ping_status":"closed","template":"page-one-sidebar.php","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-751","page","type-page","status-publish","has-post-thumbnail","hentry"],"acf":[],"jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/soundhealthwellness.com\/kp\/wp-json\/wp\/v2\/pages\/751","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/soundhealthwellness.com\/kp\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/soundhealthwellness.com\/kp\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/soundhealthwellness.com\/kp\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/soundhealthwellness.com\/kp\/wp-json\/wp\/v2\/comments?post=751"}],"version-history":[{"count":1,"href":"https:\/\/soundhealthwellness.com\/kp\/wp-json\/wp\/v2\/pages\/751\/revisions"}],"predecessor-version":[{"id":2936,"href":"https:\/\/soundhealthwellness.com\/kp\/wp-json\/wp\/v2\/pages\/751\/revisions\/2936"}],"up":[{"embeddable":true,"href":"https:\/\/soundhealthwellness.com\/kp\/wp-json\/wp\/v2\/pages\/32"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/soundhealthwellness.com\/kp\/wp-json\/wp\/v2\/media\/2766"}],"wp:attachment":[{"href":"https:\/\/soundhealthwellness.com\/kp\/wp-json\/wp\/v2\/media?parent=751"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}