{"id":675,"date":"2024-02-15T14:19:23","date_gmt":"2024-02-15T19:19:23","guid":{"rendered":"https:\/\/impactstlc.org\/?page_id=675"},"modified":"2024-02-15T18:55:39","modified_gmt":"2024-02-15T23:55:39","slug":"introducing-impacts-tlc-social-club","status":"publish","type":"page","link":"https:\/\/impactstlc.org\/?page_id=675","title":{"rendered":"Social Club Registration"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-907681f8-21ff-41e4-bd0d-80561a96b8f5\" id=\"wpforms-671\"><form id=\"wpforms-form-671\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"671\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F675\" data-token=\"b82c67a462822a634e449e0fa50ed51a\" data-token-time=\"1777039775\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-671-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\" for=\"wpforms-671-field_0\">Participant Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-671-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" required><label for=\"wpforms-671-field_0\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-671-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" required><label for=\"wpforms-671-field_0-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-671-field_15-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-671-field_15\">Address <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-671-field_15\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][15][address1]\" required><label for=\"wpforms-671-field_15\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-671-field_15-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][15][address2]\" ><label for=\"wpforms-671-field_15-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-671-field_15-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][15][city]\" required><label for=\"wpforms-671-field_15-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-671-field_15-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][15][state]\" required><option class=\"placeholder\" value=\"\" selected disabled>&#8212; Select state &#8212;<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-671-field_15-state\" class=\"wpforms-field-sublabel after\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-671-field_15-postal\" class=\"wpforms-field-address-postal wpforms-field-required wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][15][postal]\" required><label for=\"wpforms-671-field_15-postal\" class=\"wpforms-field-sublabel after\">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-671-field_3-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"3\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-671-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-671-field_1\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-671-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-671-field_4-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-671-field_4\">Mobile Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-671-field_4\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][4]\" aria-label=\"Mobile Phone\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-671-field_5-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-671-field_5\">Date of Birth <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-671-field_5\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][5][date]\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-671-field_9-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-671-field_9\">T-shirt Size (unisex) <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-671-field_9\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-671-field_9_1\" name=\"wpforms[fields][9][]\" value=\"XS\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-671-field_9_1\">XS<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-671-field_9_2\" name=\"wpforms[fields][9][]\" value=\"S\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-671-field_9_2\">S<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-671-field_9_3\" name=\"wpforms[fields][9][]\" value=\"M\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-671-field_9_3\">M<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-671-field_9_4\" name=\"wpforms[fields][9][]\" value=\"L\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-671-field_9_4\">L<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-671-field_9_5\" name=\"wpforms[fields][9][]\" value=\"XL\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-671-field_9_5\">XL<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-671-field_9_6\" name=\"wpforms[fields][9][]\" value=\"XXL\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-671-field_9_6\">XXL<\/label><\/li><\/ul><\/div><div id=\"wpforms-671-field_11-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-671-field_11\">Parent\/Caregiver Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-671-field_11\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][11][first]\" required><label for=\"wpforms-671-field_11\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-671-field_11-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][11][last]\" required><label for=\"wpforms-671-field_11-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-671-field_12-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"12\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-671-field_17-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-671-field_17\">Parent\/Caregiver Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-671-field_17\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][17]\" aria-label=\"Parent\/Caregiver Phone\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-671-field_18-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-671-field_18\">Parent\/Caregiver Email  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-671-field_18\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][18]\" spellcheck=\"false\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-671-field_22-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-671-field_22\">Emergency Contact Name <\/label><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-671-field_22\" class=\"wpforms-field-name-first\" name=\"wpforms[fields][22][first]\" ><label for=\"wpforms-671-field_22\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-671-field_22-last\" class=\"wpforms-field-name-last\" name=\"wpforms[fields][22][last]\" ><label for=\"wpforms-671-field_22-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-671-field_19-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"19\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-671-field_20-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-671-field_20\">Emergency Contact Phone<\/label><input type=\"tel\" id=\"wpforms-671-field_20\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][20]\" aria-label=\"Emergency Contact Phone\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-671-field_21-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-671-field_21\">Emergency Contact Email<\/label><input type=\"email\" id=\"wpforms-671-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\" spellcheck=\"false\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-671-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-671-field_23\">Diagnosis  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-671-field_23\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][23]\" required><\/div><div id=\"wpforms-671-field_24-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-671-field_24\">Concerning behaviors, i.e., aggression, self-injury, previous 1:1 required? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-671-field_24\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][24]\" required><\/div><div id=\"wpforms-671-field_29-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"29\"><div id=\"wpforms-671-field_29\" class=\"wpforms-field-medium wpforms-field-row\"><p>Payment Information<\/p>\n<p>Welcome to Impact&#8217;s TLC Social Club Registration. $20 nonrefundable registration fee is due within 48 hours of registering. Payment can be dropped off at any Impact location.<br \/>\nCredit card payments can be taken over the phone by contacting mary@impactacademyschool.org or beth@impactacademyschool.org. A service fee will apply for all credit card payments.<br \/>\n$300 session fee is due on March 6, 2024<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"671\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/impactstlc.org\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F675\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-671\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/impactstlc.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"neve_meta_sidebar":"","neve_meta_container":"","neve_meta_enable_content_width":"","neve_meta_content_width":0,"neve_meta_title_alignment":"","neve_meta_author_avatar":"","neve_post_elements_order":"","neve_meta_disable_header":"","neve_meta_disable_footer":"","neve_meta_disable_title":"","footnotes":""},"class_list":["post-675","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/impactstlc.org\/index.php?rest_route=\/wp\/v2\/pages\/675","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/impactstlc.org\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/impactstlc.org\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/impactstlc.org\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/impactstlc.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=675"}],"version-history":[{"count":4,"href":"https:\/\/impactstlc.org\/index.php?rest_route=\/wp\/v2\/pages\/675\/revisions"}],"predecessor-version":[{"id":686,"href":"https:\/\/impactstlc.org\/index.php?rest_route=\/wp\/v2\/pages\/675\/revisions\/686"}],"wp:attachment":[{"href":"https:\/\/impactstlc.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=675"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}