{"id":89,"date":"2023-06-06T20:29:21","date_gmt":"2023-06-06T20:29:21","guid":{"rendered":"https:\/\/suhumpwd.com\/?page_id=89"},"modified":"2023-09-21T11:46:09","modified_gmt":"2023-09-21T11:46:09","slug":"pwd-registration-for-care-givers","status":"publish","type":"page","link":"https:\/\/suhumpwd.com\/index.php\/pwd-registration-for-care-givers\/","title":{"rendered":"PWD Registration for Care Givers"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"89\" class=\"elementor elementor-89\">\n\t\t\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-55e33f81 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"55e33f81\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-69343133\" data-id=\"69343133\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-d0d51dd elementor-widget elementor-widget-heading\" data-id=\"d0d51dd\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.13.3 - 28-05-2023 *\/\n.elementor-heading-title{padding:0;margin:0;line-height:1}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px}<\/style><h2 class=\"elementor-heading-title elementor-size-default\">PWD Registration for Care Givers<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-144d8231 elementor-widget elementor-widget-text-editor\" data-id=\"144d8231\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.13.3 - 28-05-2023 *\/\n.elementor-widget-text-editor.elementor-drop-cap-view-stacked .elementor-drop-cap{background-color:#69727d;color:#fff}.elementor-widget-text-editor.elementor-drop-cap-view-framed .elementor-drop-cap{color:#69727d;border:3px solid;background-color:transparent}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap{margin-top:8px}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap-letter{width:1em;height:1em}.elementor-widget-text-editor .elementor-drop-cap{float:left;text-align:center;line-height:1;font-size:50px}.elementor-widget-text-editor .elementor-drop-cap-letter{display:inline-block}<\/style>\t\t\t\t<!-- wp:paragraph -->\n\n<div class=\"um um-register um-121\">\n\n\t<div class=\"um-form\" data-mode=\"register\">\n\n\t\t<form method=\"post\" action=\"\">\n\n\t\t\t<div class=\"um-row _um_row_1 \" style=\"margin: 0 0 30px 0;\"><div class=\"um-col-1\"><div  id=\"um_field_121_regionofregistration\" class=\"um-field um-field-checkbox  um-field-regionofregistration um-field-checkbox um-field-type_checkbox\" data-key=\"regionofregistration\"><div class=\"um-field-label\"><label for=\"regionofregistration-121\">Region of Registration<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><label class=\"um-field-checkbox  um-field-half \"><input   type=\"checkbox\" name=\"regionofregistration[]\" value=\"Eastern Region\"  \/><span class=\"um-field-checkbox-state\"><i class=\"um-icon-android-checkbox-outline-blank\"><\/i><\/span><span class=\"um-field-checkbox-option\">Eastern Region<\/span><\/label><div class=\"um-clear\"><\/div><\/div><\/div><div  id=\"um_field_121_districtofregistration\" class=\"um-field um-field-checkbox  um-field-districtofregistration um-field-checkbox um-field-type_checkbox\" data-key=\"districtofregistration\"><div class=\"um-field-label\"><label for=\"districtofregistration-121\">District of Registration<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><label class=\"um-field-checkbox  um-field-half \"><input   type=\"checkbox\" name=\"districtofregistration[]\" value=\"Suhum Municipal Assembly\"  \/><span class=\"um-field-checkbox-state\"><i class=\"um-icon-android-checkbox-outline-blank\"><\/i><\/span><span class=\"um-field-checkbox-option\">Suhum Municipal Assembly<\/span><\/label><div class=\"um-clear\"><\/div><\/div><\/div><div  id=\"um_field_121_yearofapplication\" class=\"um-field um-field-number  um-field-yearofapplication um-field-number um-field-type_number\" data-key=\"yearofapplication\"><div class=\"um-field-label\"><div class=\"um-field-label-icon\"><i class=\"um-faicon-calendar\" aria-label=\"Year of Registration\"><\/i><\/div><label for=\"yearofapplication-121\">Year of Registration<\/label><span class=\"um-tip um-tip-w\" title=\"enter this year example 2023\"><i class=\"um-icon-help-circled\"><\/i><\/span><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  class=\"um-form-field valid not-required \" type=\"number\" name=\"yearofapplication-121\" id=\"yearofapplication-121\" value=\"\" placeholder=\"type this year number\" data-validate=\"numeric\" data-key=\"yearofapplication\"  min=\"2020\"  \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_firstnameofcaregiver\" class=\"um-field um-field-text  um-field-firstnameofcaregiver um-field-text um-field-type_text\" data-key=\"firstnameofcaregiver\"><div class=\"um-field-label\"><label for=\"firstnameofcaregiver-121\">First Name of Care Giver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"firstnameofcaregiver-121\" id=\"firstnameofcaregiver-121\" value=\"\" placeholder=\"First Name of Care Giver\" data-validate=\"\" data-key=\"firstnameofcaregiver\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_lastnameofcaregiver\" class=\"um-field um-field-text  um-field-lastnameofcaregiver um-field-text um-field-type_text\" data-key=\"lastnameofcaregiver\"><div class=\"um-field-label\"><label for=\"lastnameofcaregiver-121\">Last Name \/ Surname of Care Giver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"lastnameofcaregiver-121\" id=\"lastnameofcaregiver-121\" value=\"\" placeholder=\"enter your surname\" data-validate=\"\" data-key=\"lastnameofcaregiver\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_middlenameofcaregiver\" class=\"um-field um-field-text  um-field-middlenameofcaregiver um-field-text um-field-type_text\" data-key=\"middlenameofcaregiver\"><div class=\"um-field-label\"><label for=\"middlenameofcaregiver-121\">Middle Name of Care Giver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid not-required \" type=\"text\" name=\"middlenameofcaregiver-121\" id=\"middlenameofcaregiver-121\" value=\"\" placeholder=\"enter your midde name ( optional)\" data-validate=\"\" data-key=\"middlenameofcaregiver\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_user_login\" class=\"um-field um-field-text  um-field-user_login um-field-text um-field-type_text\" data-key=\"user_login\"><div class=\"um-field-label\"><label for=\"user_login-121\">Username of Care Giver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"user_login-121\" id=\"user_login-121\" value=\"\" placeholder=\"enter a username you can remember\" data-validate=\"unique_username\" data-key=\"user_login\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_user_password\" class=\"um-field um-field-password  um-field-user_password um-field-password um-field-type_password\" data-key=\"user_password\"><div class=\"um-field-label\"><label for=\"user_password-121\">Password of Care Giver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input class=\"um-form-field valid \" type=\"password\" name=\"user_password-121\" id=\"user_password-121\" value=\"\" placeholder=\"enter a password you can remember\" data-validate=\"\" data-key=\"user_password\" \/>\n\n\t\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_confirm_user_password\" class=\"um-field um-field-password  um-field-user_password um-field-password um-field-type_password\" data-key=\"confirm_user_password\"><div class=\"um-field-label\"><label for=\"confirm_user_password-121\">Confirm Password<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input class=\"um-form-field valid \" type=\"password\" name=\"confirm_user_password-121\" id=\"confirm_user_password-121\" value=\"\" placeholder=\"Confirm Password\" data-validate=\"\" data-key=\"confirm_user_password\" \/><\/div><\/div><div  id=\"um_field_121_sexofcaregiver\" class=\"um-field um-field-radio  um-field-sexofcaregiver um-field-radio um-field-type_radio\" data-key=\"sexofcaregiver\"><div class=\"um-field-label\"><label for=\"sexofcaregiver-121\">Sex of Care Giver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><label class=\"um-field-radio  um-field-half \"><input  type=\"radio\" name=\"sexofcaregiver[]\" value=\"Male\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Male<\/span><\/label><label class=\"um-field-radio  um-field-half  right \"><input  type=\"radio\" name=\"sexofcaregiver[]\" value=\"Female\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Female<\/span><\/label><div class=\"um-clear\"><\/div><div class=\"um-clear\"><\/div><\/div><\/div><div  id=\"um_field_121_ageofcaregiver\" class=\"um-field um-field-number  um-field-ageofcaregiver um-field-number um-field-type_number\" data-key=\"ageofcaregiver\"><div class=\"um-field-label\"><label for=\"ageofcaregiver-121\">Age of Care Giver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  class=\"um-form-field valid not-required \" type=\"number\" name=\"ageofcaregiver-121\" id=\"ageofcaregiver-121\" value=\"\" placeholder=\"how old are you?\" data-validate=\"\" data-key=\"ageofcaregiver\"  \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_birthdayofcaregiver\" class=\"um-field um-field-date  um-field-birthdayofcaregiver um-field-date um-field-type_date\" data-key=\"birthdayofcaregiver\"><div class=\"um-field-label\"><label for=\"birthdayofcaregiver-121\">Birthday of Care Giver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input   class=\"um-form-field valid not-required um-datepicker \" type=\"text\" name=\"birthdayofcaregiver-121\" id=\"birthdayofcaregiver-121\" value=\"\" placeholder=\"Click Here - 1. Select the year 2. Select the month 3. Select the day\" data-validate=\"\" data-key=\"birthdayofcaregiver\" data-range=\"years\" data-years=\"65\" data-years_x=\"past\" data-disabled_weekdays=\"\" data-date_min=\"1961,7,26\" data-date_max=\"2026,7,26\" data-format=\"d mmm yyyy\" data-value=\"\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_mobilenumberofcaregiver\" class=\"um-field um-field-number  um-field-mobilenumberofcaregiver um-field-number um-field-type_number\" data-key=\"mobilenumberofcaregiver\"><div class=\"um-field-label\"><label for=\"mobilenumberofcaregiver-121\">Mobile Number of Care Giver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  class=\"um-form-field valid \" type=\"number\" name=\"mobilenumberofcaregiver-121\" id=\"mobilenumberofcaregiver-121\" value=\"\" placeholder=\"enter your phone number example 0585675842\" data-validate=\"\" data-key=\"mobilenumberofcaregiver\"  \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_ghanacardnumberofcarereceiver\" class=\"um-field um-field-text  um-field-ghanacardnumberofcarereceiver um-field-text um-field-type_text\" data-key=\"ghanacardnumberofcarereceiver\"><div class=\"um-field-label\"><label for=\"ghanacardnumberofcarereceiver-121\">Ghana Card of Care Giver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid not-required \" type=\"text\" name=\"ghanacardnumberofcarereceiver-121\" id=\"ghanacardnumberofcarereceiver-121\" value=\"\" placeholder=\"Ghana card number example GHA-000000000-0\" data-validate=\"\" data-key=\"ghanacardnumberofcarereceiver\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_voterscardnumberofcaregiver\" class=\"um-field um-field-text  um-field-voterscardnumberofcaregiver um-field-text um-field-type_text\" data-key=\"voterscardnumberofcaregiver\"><div class=\"um-field-label\"><label for=\"voterscardnumberofcaregiver-121\">Voters Card Number of Care Giver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid not-required \" type=\"text\" name=\"voterscardnumberofcaregiver-121\" id=\"voterscardnumberofcaregiver-121\" value=\"\" placeholder=\"OPTIONAL ( enter your voters card number)\" data-validate=\"\" data-key=\"voterscardnumberofcaregiver\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_occupationofcaregiver\" class=\"um-field um-field-text  um-field-occupationofcaregiver um-field-text um-field-type_text\" data-key=\"occupationofcaregiver\"><div class=\"um-field-label\"><label for=\"occupationofcaregiver-121\">Occupation of Care Giver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid not-required \" type=\"text\" name=\"occupationofcaregiver-121\" id=\"occupationofcaregiver-121\" value=\"\" placeholder=\"example teacher, farmer, nurse, trader\" data-validate=\"\" data-key=\"occupationofcaregiver\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_communityofcaregiver\" class=\"um-field um-field-select  um-field-communityofcaregiver um-field-select um-field-type_select\" data-key=\"communityofcaregiver\"><div class=\"um-field-label\"><label for=\"communityofcaregiver-121\">Community of Care Giver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area  \"><select data-default=\"\"     name=\"communityofcaregiver\" id=\"communityofcaregiver\" data-validate=\"\" data-key=\"communityofcaregiver\" class=\"um-form-field valid um-s1 \" style=\"width: 100%\" data-placeholder=\"Click and select your community from the list\" ><option value=\"\"><\/option><option value=\"Abenabo No.1\" >Abenabo No.1<\/option><option value=\"Abenabo No.2\" >Abenabo No.2<\/option><option value=\"Aboabo\" >Aboabo<\/option><option value=\"Abrodiamu\" >Abrodiamu<\/option><option value=\"Abrodiamu\" >Abrodiamu<\/option><option value=\"Adarkwa\" >Adarkwa<\/option><option value=\"Adentam\" >Adentam<\/option><option value=\"Adidiso\" >Adidiso<\/option><option value=\"Adogogye\" >Adogogye<\/option><option value=\"Afransidedewa\" >Afransidedewa<\/option><option value=\"Ahenbromu\" >Ahenbromu<\/option><option value=\"Ajate\" >Ajate<\/option><option value=\"Akorabo\" >Akorabo<\/option><option value=\"Akote\" >Akote<\/option><option value=\"Ali\" >Ali<\/option><option value=\"Amanshia\" >Amanshia<\/option><option value=\"Amede\" >Amede<\/option><option value=\"Amoakrom\" >Amoakrom<\/option><option value=\"Ampedwa\" >Ampedwa<\/option><option value=\"Anomankwanta\" >Anomankwanta<\/option><option value=\"Apete\" >Apete<\/option><option value=\"Aponapona\" >Aponapona<\/option><option value=\"Asiedu\" >Asiedu<\/option><option value=\"Asikafo Amantem\" >Asikafo Amantem<\/option><option value=\"Ateebu\" >Ateebu<\/option><option value=\"Autie Mary\" >Autie Mary<\/option><option value=\"Ayebromu\" >Ayebromu<\/option><option value=\"Ayekotse\" >Ayekotse<\/option><option value=\"Ayisaa\" >Ayisaa<\/option><option value=\"Ayisikrom\" >Ayisikrom<\/option><option value=\"Bana\" >Bana<\/option><option value=\"Betiase\" >Betiase<\/option><option value=\"Bosompa\" >Bosompa<\/option><option value=\"Brabiom\" >Brabiom<\/option><option value=\"Brong Densuso\" >Brong Densuso<\/option><option value=\"Cocoano\" >Cocoano<\/option><option value=\"Dabge\" >Dabge<\/option><option value=\"Dademantse\" >Dademantse<\/option><option value=\"Dawa\" >Dawa<\/option><option value=\"Dedewa No.1\" >Dedewa No.1<\/option><option value=\"Densuso\" >Densuso<\/option><option value=\"Doctor Mable\" >Doctor Mable<\/option><option value=\"Fieso\" >Fieso<\/option><option value=\"Fitanyano\" >Fitanyano<\/option><option value=\"Gariba Zongo\" >Gariba Zongo<\/option><option value=\"Gboayetse\" >Gboayetse<\/option><option value=\"Gorjiase\" >Gorjiase<\/option><option value=\"Jato\" >Jato<\/option><option value=\"Kofi Anim\" >Kofi Anim<\/option><option value=\"Kofiboafo\" >Kofiboafo<\/option><option value=\"Kofigya\" >Kofigya<\/option><option value=\"Kofikini\" >Kofikini<\/option><option value=\"Kokobibiem\" >Kokobibiem<\/option><option value=\"Kokotiesua\" >Kokotiesua<\/option><option value=\"Koponya\" >Koponya<\/option><option value=\"Koransang Bana\" >Koransang Bana<\/option><option value=\"Koransang Kese\" >Koransang Kese<\/option><option value=\"Koransang Ketewa\" >Koransang Ketewa<\/option><option value=\"Kradaso\" >Kradaso<\/option><option value=\"Krobom\" >Krobom<\/option><option value=\"Kromameng\" >Kromameng<\/option><option value=\"Kudovo\" >Kudovo<\/option><option value=\"Kudovo\" >Kudovo<\/option><option value=\"Kukua\" >Kukua<\/option><option value=\"Kwabena-Kumi\" >Kwabena-Kumi<\/option><option value=\"Kwahyia\" >Kwahyia<\/option><option value=\"Kwampo\" >Kwampo<\/option><option value=\"Kwanatey\" >Kwanatey<\/option><option value=\"Lenya\" >Lenya<\/option><option value=\"Mamedonya\" >Mamedonya<\/option><option value=\"Mamehyieso\" >Mamehyieso<\/option><option value=\"Mangoa\" >Mangoa<\/option><option value=\"Mempaaba\" >Mempaaba<\/option><option value=\"Metemano\" >Metemano<\/option><option value=\"My Name\" >My Name<\/option><option value=\"Nankese\" >Nankese<\/option><option value=\"Nartey Osei\" >Nartey Osei<\/option><option value=\"New Life\" >New Life<\/option><option value=\"Nkantinkwan\" >Nkantinkwan<\/option><option value=\"Nsuta-Wawase\" >Nsuta-Wawase<\/option><option value=\"Ntabea\" >Ntabea<\/option><option value=\"Ntabea\" >Ntabea<\/option><option value=\"Ntunkum\" >Ntunkum<\/option><option value=\"Numess\" >Numess<\/option><option value=\"Obeng-Down\" >Obeng-Down<\/option><option value=\"Obomofodensua\" >Obomofodensua<\/option><option value=\"Obretema\" >Obretema<\/option><option value=\"Obuodakaa\" >Obuodakaa<\/option><option value=\"Obuotunpan\" >Obuotunpan<\/option><option value=\"Odokote\" >Odokote<\/option><option value=\"Ojobi\" >Ojobi<\/option><option value=\"Okanta\" >Okanta<\/option><option value=\"Okonam\" >Okonam<\/option><option value=\"Okorase\" >Okorase<\/option><option value=\"Omenako\" >Omenako<\/option><option value=\"Otwe\" >Otwe<\/option><option value=\"Pobi\" >Pobi<\/option><option value=\"Praprabebida\" >Praprabebida<\/option><option value=\"Sakunya\" >Sakunya<\/option><option value=\"Samatare\" >Samatare<\/option><option value=\"Samatare\" >Samatare<\/option><option value=\"Sanse\" >Sanse<\/option><option value=\"Santramo\" >Santramo<\/option><option value=\"Santramor\" >Santramor<\/option><option value=\"Sawa\" >Sawa<\/option><option value=\"Sra\" >Sra<\/option><option value=\"Suhum 44\" >Suhum 44<\/option><option value=\"Sumie\" >Sumie<\/option><option value=\"Supresu\" >Supresu<\/option><option value=\"Tei Mensah\" >Tei Mensah<\/option><option value=\"Tenya\" >Tenya<\/option><option value=\"Teteh Nkwanta\" >Teteh Nkwanta<\/option><option value=\"Tetekasom\" >Tetekasom<\/option><option value=\"Tome\" >Tome<\/option><option value=\"Triao\" >Triao<\/option><option value=\"Trotor\" >Trotor<\/option><option value=\"Vokorno\" >Vokorno<\/option><option value=\"Volta House\" >Volta House<\/option><option value=\"Webeku\" >Webeku<\/option><option value=\"Whyese\" >Whyese<\/option><option value=\"Yaw Badu\" >Yaw Badu<\/option><option value=\"Yaw Badu Junction\" >Yaw Badu Junction<\/option><option value=\"Yaw Boadi\" >Yaw Boadi<\/option><option value=\"Zorh\" >Zorh<\/option><\/select><\/div><\/div><div  id=\"um_field_121_housenumberofcaregiver\" class=\"um-field um-field-text  um-field-housenumberofcaregiver um-field-text um-field-type_text\" data-key=\"housenumberofcaregiver\"><div class=\"um-field-label\"><label for=\"housenumberofcaregiver-121\">House Number of Care Giver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid not-required \" type=\"text\" name=\"housenumberofcaregiver-121\" id=\"housenumberofcaregiver-121\" value=\"\" placeholder=\"your house number \/ popular place around where you stay\" data-validate=\"\" data-key=\"housenumberofcaregiver\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_digitaladdressofcaregiver\" class=\"um-field um-field-text  um-field-digitaladdressofcaregiver um-field-text um-field-type_text\" data-key=\"digitaladdressofcaregiver\"><div class=\"um-field-label\"><label for=\"digitaladdressofcaregiver-121\">Digital Address of Care Giver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid not-required \" type=\"text\" name=\"digitaladdressofcaregiver-121\" id=\"digitaladdressofcaregiver-121\" value=\"\" placeholder=\"OPTIONAL - Enter your Ghana Post Digital Address\" data-validate=\"\" data-key=\"digitaladdressofcaregiver\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_caregivercarerecipientrelationship\" class=\"um-field um-field-radio  um-field-caregivercarerecipientrelationship um-field-radio um-field-type_radio\" data-key=\"caregivercarerecipientrelationship\"><div class=\"um-field-label\"><label for=\"caregivercarerecipientrelationship-121\">Relationship of Care Giver to Care Recipient<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><label class=\"um-field-radio  um-field-half \"><input  type=\"radio\" name=\"caregivercarerecipientrelationship[]\" value=\"Father\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Father<\/span><\/label><label class=\"um-field-radio  um-field-half  right \"><input  type=\"radio\" name=\"caregivercarerecipientrelationship[]\" value=\"Mother\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Mother<\/span><\/label><div class=\"um-clear\"><\/div><label class=\"um-field-radio  um-field-half \"><input  type=\"radio\" name=\"caregivercarerecipientrelationship[]\" value=\"Brother\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Brother<\/span><\/label><label class=\"um-field-radio  um-field-half  right \"><input  type=\"radio\" name=\"caregivercarerecipientrelationship[]\" value=\"Sister\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Sister<\/span><\/label><div class=\"um-clear\"><\/div><label class=\"um-field-radio  um-field-half \"><input  type=\"radio\" name=\"caregivercarerecipientrelationship[]\" value=\"Uncle\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Uncle<\/span><\/label><label class=\"um-field-radio  um-field-half  right \"><input  type=\"radio\" name=\"caregivercarerecipientrelationship[]\" value=\"Auntie\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Auntie<\/span><\/label><div class=\"um-clear\"><\/div><label class=\"um-field-radio  um-field-half \"><input  type=\"radio\" name=\"caregivercarerecipientrelationship[]\" value=\"Friend\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Friend<\/span><\/label><label class=\"um-field-radio  um-field-half  right \"><input  type=\"radio\" name=\"caregivercarerecipientrelationship[]\" value=\"Son\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Son<\/span><\/label><div class=\"um-clear\"><\/div><label class=\"um-field-radio  um-field-half \"><input  type=\"radio\" name=\"caregivercarerecipientrelationship[]\" value=\"Daughter\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Daughter<\/span><\/label><label class=\"um-field-radio  um-field-half  right \"><input  type=\"radio\" name=\"caregivercarerecipientrelationship[]\" value=\"Husband\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Husband<\/span><\/label><div class=\"um-clear\"><\/div><label class=\"um-field-radio  um-field-half \"><input  type=\"radio\" name=\"caregivercarerecipientrelationship[]\" value=\"Wife\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Wife<\/span><\/label><label class=\"um-field-radio  um-field-half  right \"><input  type=\"radio\" name=\"caregivercarerecipientrelationship[]\" value=\"other\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">other<\/span><\/label><div class=\"um-clear\"><\/div><div class=\"um-clear\"><\/div><\/div><\/div><div  id=\"um_field_121_caregivercarerecipientrelationship_other\" class=\"um-field um-field-text  um-is-conditional um-field-caregivercarerecipientrelationship_other um-field-text um-field-type_text\" data-key=\"caregivercarerecipientrelationship_other\" data-cond-0-action=\"show\" data-cond-0-field=\"caregivercarerecipientrelationship\" data-cond-0-operator=\"equals to\" data-cond-0-value=\"other\"><div class=\"um-field-label\"><label for=\"caregivercarerecipientrelationship_other-121\">Please type your relationship with the care recipient<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"caregivercarerecipientrelationship_other-121\" id=\"caregivercarerecipientrelationship_other-121\" value=\"\" placeholder=\"type here\" data-validate=\"\" data-key=\"caregivercarerecipientrelationship_other\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_hoursofcaregiving\" class=\"um-field um-field-text  um-field-hoursofcaregiving um-field-text um-field-type_text\" data-key=\"hoursofcaregiving\"><div class=\"um-field-label\"><label for=\"hoursofcaregiving-121\">Hours of Care Giving<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid not-required \" type=\"text\" name=\"hoursofcaregiving-121\" id=\"hoursofcaregiving-121\" value=\"\" placeholder=\"example 24\" data-validate=\"\" data-key=\"hoursofcaregiving\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_numberofyearsofcaregiving\" class=\"um-field um-field-text  um-field-numberofyearsofcaregiving um-field-text um-field-type_text\" data-key=\"numberofyearsofcaregiving\"><div class=\"um-field-label\"><label for=\"numberofyearsofcaregiving-121\">Number of Years of Care Giving<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid not-required \" type=\"text\" name=\"numberofyearsofcaregiving-121\" id=\"numberofyearsofcaregiving-121\" value=\"\" placeholder=\"example 3 years\" data-validate=\"\" data-key=\"numberofyearsofcaregiving\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_nameofcarerecipient\" class=\"um-field um-field-text  um-field-nameofcarerecipient um-field-text um-field-type_text\" data-key=\"nameofcarerecipient\"><div class=\"um-field-label\"><label for=\"nameofcarerecipient-121\">Name of Person Receiving Care<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"nameofcarerecipient-121\" id=\"nameofcarerecipient-121\" value=\"\" placeholder=\"Name of the person you take care of\" data-validate=\"\" data-key=\"nameofcarerecipient\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_sexofcarereceiver\" class=\"um-field um-field-radio  um-field-sexofcarereceiver um-field-radio um-field-type_radio\" data-key=\"sexofcarereceiver\"><div class=\"um-field-label\"><label for=\"sexofcarereceiver-121\">Sex of Care Receiver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><label class=\"um-field-radio  um-field-half \"><input  type=\"radio\" name=\"sexofcarereceiver[]\" value=\"Male\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Male<\/span><\/label><label class=\"um-field-radio  um-field-half  right \"><input  type=\"radio\" name=\"sexofcarereceiver[]\" value=\"Female\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Female<\/span><\/label><div class=\"um-clear\"><\/div><div class=\"um-clear\"><\/div><\/div><\/div><div  id=\"um_field_121_ageofcarereceiver\" class=\"um-field um-field-number  um-field-ageofcarereceiver um-field-number um-field-type_number\" data-key=\"ageofcarereceiver\"><div class=\"um-field-label\"><label for=\"ageofcarereceiver-121\">Age of Care Receiver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  class=\"um-form-field valid \" type=\"number\" name=\"ageofcarereceiver-121\" id=\"ageofcarereceiver-121\" value=\"\" placeholder=\"what is the age of the person you take care of?\" data-validate=\"\" data-key=\"ageofcarereceiver\"  \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_birthdayofcarereceiver\" class=\"um-field um-field-date  um-field-birthdayofcarereceiver um-field-date um-field-type_date\" data-key=\"birthdayofcarereceiver\"><div class=\"um-field-label\"><label for=\"birthdayofcarereceiver-121\">Birthday of Care Receiver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input   class=\"um-form-field valid not-required um-datepicker \" type=\"text\" name=\"birthdayofcarereceiver-121\" id=\"birthdayofcarereceiver-121\" value=\"\" placeholder=\"Click Here - 1. Select the year 2. Select the month 3. Select the day\" data-validate=\"\" data-key=\"birthdayofcarereceiver\" data-range=\"years\" data-years=\"65\" data-years_x=\"past\" data-disabled_weekdays=\"\" data-date_min=\"1961,7,26\" data-date_max=\"2026,7,26\" data-format=\"d mmm yyyy\" data-value=\"\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_phonenumberofcarereceiver\" class=\"um-field um-field-number  um-field-phonenumberofcarereceiver um-field-number um-field-type_number\" data-key=\"phonenumberofcarereceiver\"><div class=\"um-field-label\"><label for=\"phonenumberofcarereceiver-121\">Phone Number of Care Receiver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  class=\"um-form-field valid \" type=\"number\" name=\"phonenumberofcarereceiver-121\" id=\"phonenumberofcarereceiver-121\" value=\"\" placeholder=\"phone number of the person you are taking care of\" data-validate=\"\" data-key=\"phonenumberofcarereceiver\"  \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_housenumberofcarereceiver\" class=\"um-field um-field-text  um-field-housenumberofcarereceiver um-field-text um-field-type_text\" data-key=\"housenumberofcarereceiver\"><div class=\"um-field-label\"><label for=\"housenumberofcarereceiver-121\">House Number of Care Receiver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid not-required \" type=\"text\" name=\"housenumberofcarereceiver-121\" id=\"housenumberofcarereceiver-121\" value=\"\" placeholder=\"what is the area or house number of the person you take care of?\" data-validate=\"\" data-key=\"housenumberofcarereceiver\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_typeofdisabilityofcarereceiver\" class=\"um-field um-field-select  um-field-typeofdisabilityofcarereceiver um-field-select um-field-type_select\" data-key=\"typeofdisabilityofcarereceiver\"><div class=\"um-field-label\"><label for=\"typeofdisabilityofcarereceiver-121\">Type of Disability of Care Receiver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area  \"><select data-default=\"\"     name=\"typeofdisabilityofcarereceiver\" id=\"typeofdisabilityofcarereceiver\" data-validate=\"\" data-key=\"typeofdisabilityofcarereceiver\" class=\"um-form-field valid um-s1 \" style=\"width: 100%\" data-placeholder=\"Click Here to select the type(s) of disability\" ><option value=\"\"><\/option><option value=\"Persons with physical disabilities\" >Persons with physical disabilities<\/option><option value=\"Deaf persons\" >Deaf persons<\/option><option value=\"Person who are non-verbal\" >Person who are non-verbal<\/option><option value=\"Persons with communication disabilities including speech and language disabilities\" >Persons with communication disabilities including speech and language disabilities<\/option><option value=\"Persons who are hard of hearing\" >Persons who are hard of hearing<\/option><option value=\"Persons with visual disabilities\" >Persons with visual disabilities<\/option><option value=\"Persons with multiple disabilities such as deafblind\" >Persons with multiple disabilities such as deafblind<\/option><option value=\"Persons with psychological disabilities\" >Persons with psychological disabilities<\/option><option value=\"Persons with cerebral palsy\" >Persons with cerebral palsy<\/option><option value=\"Persons with bipolar conditions\" >Persons with bipolar conditions<\/option><option value=\"Persons with attention deficit disorders\" >Persons with attention deficit disorders<\/option><option value=\"Persons with schizophrenia\" >Persons with schizophrenia<\/option><option value=\"Persons with developmental and neurological disabilities\" >Persons with developmental and neurological disabilities<\/option><option value=\"Persons with autism\" >Persons with autism<\/option><option value=\"Persons with Down Syndrome\" >Persons with Down Syndrome<\/option><option value=\"Persons with Turner Syndrome\" >Persons with Turner Syndrome<\/option><option value=\"Persons with spinal injury\" >Persons with spinal injury<\/option><option value=\"Persons with autoimmune conditions\" >Persons with autoimmune conditions<\/option><option value=\"Persons with osteogenesis imperfecta\" >Persons with osteogenesis imperfecta<\/option><option value=\"Persons with albinism\" >Persons with albinism<\/option><option value=\"Persons with intellectual disabilities\" >Persons with intellectual disabilities<\/option><option value=\"Persons with epilepsy\" >Persons with epilepsy<\/option><option value=\"Persons with leprosy\" >Persons with leprosy<\/option><option value=\"Little persons\" >Little persons<\/option><option value=\"Persons with hunchback\" >Persons with hunchback<\/option><option value=\"Burns survivors\" >Burns survivors<\/option><option value=\"Other disabilities ( click here to type disability if not found in the above list)\" >Other disabilities ( click here to type disability if not found in the above list)<\/option><\/select><\/div><\/div><div  id=\"um_field_121_otherdisabilities\" class=\"um-field um-field-text  um-is-conditional um-field-otherdisabilities um-field-text um-field-type_text\" data-key=\"otherdisabilities\" data-cond-0-action=\"show\" data-cond-0-field=\"typeofdisabilityofcarereceiver\" data-cond-0-operator=\"equals to\" data-cond-0-value=\"Other disabilities ( click here to type disability if not found in the above list)\"><div class=\"um-field-label\"><label for=\"otherdisabilities-121\">Other Disability<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid not-required \" type=\"text\" name=\"otherdisabilities-121\" id=\"otherdisabilities-121\" value=\"\" placeholder=\"type your disability here\" data-validate=\"\" data-key=\"otherdisabilities\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_register_profile_photo\" class=\"um-field um-field-image  um-field-register_profile_photo um-field-image um-field-type_image\" data-key=\"register_profile_photo\" data-mode=\"register\" data-upload-label=\"Click Here to Upload Picture of Yourself\"><input type=\"hidden\" name=\"register_profile_photo-121\" id=\"register_profile_photo-121\" value=\"\" \/><div class=\"um-field-label\"><div class=\"um-field-label-icon\"><i class=\"um-faicon-camera\" aria-label=\"Care Giver Profile Picture\"><\/i><\/div><label for=\"register_profile_photo-121\">Care Giver Profile Picture<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\" style=\"text-align: center;\"><div class=\"um-single-image-preview crop\" data-crop=\"square\" data-key=\"register_profile_photo\"><a href=\"javascript:void(0);\" class=\"cancel\"><i class=\"um-icon-close\"><\/i><\/a><img decoding=\"async\" src=\"\" alt=\"\" \/><div class=\"um-clear\"><\/div><\/div><a href=\"javascript:void(0);\" data-modal=\"um_upload_single\" data-modal-size=\"normal\" data-modal-copy=\"1\" class=\"um-button um-btn-auto-width\">Click Here to Upload Picture of Yourself<\/a><\/div><div class=\"um-modal-hidden-content\"><div class=\"um-modal-header\"> Care Giver Profile Picture<\/div><div class=\"um-modal-body\"><div class=\"um-single-image-preview crop\"  data-crop=\"square\" data-ratio=\"1\" data-min_width=\"190\" data-min_height=\"190\" data-coord=\"\"><a href=\"javascript:void(0);\" class=\"cancel\"><i class=\"um-icon-close\"><\/i><\/a><img decoding=\"async\" src=\"\" alt=\"\" \/><div class=\"um-clear\"><\/div><\/div><div class=\"um-clear\"><\/div><div class=\"um-single-image-upload\" data-user_id=\"\" data-nonce=\"87433b8822\" data-timestamp=\"1785061914\"  data-set_id=\"121\" data-set_mode=\"register\" data-type=\"image\" data-key=\"register_profile_photo\" data-max_size=\"999999999\" data-max_size_error=\"This image is too large!\" data-min_size_error=\"This image is too small!\" data-extension_error=\"Sorry this is not a valid image.\"  data-allowed_types=\"png,jpeg,jpg,gif\" data-upload_text=\"Upload your photo here\" data-max_files_error=\"You can only upload one image\" data-upload_help_text=\"\">Click Here to Upload Picture of Yourself<\/div><div class=\"um-modal-footer\">\n\t\t\t\t\t\t\t\t\t<div class=\"um-modal-right\">\n\t\t\t\t\t\t\t\t\t\t<a href=\"javascript:void(0);\" class=\"um-modal-btn um-finish-upload image disabled\" data-key=\"register_profile_photo\" data-change=\"Change photo\" data-processing=\"Processing...\">Apply<\/a>\n\t\t\t\t\t\t\t\t\t\t<a href=\"javascript:void(0);\" class=\"um-modal-btn alt\" data-action=\"um_remove_modal\"> Cancel<\/a>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"um-clear\"><\/div>\n\t\t\t\t\t\t\t\t<\/div><\/div><\/div><\/div><div  id=\"um_field_121_carereceiverpicture\" class=\"um-field um-field-image  um-field-carereceiverpicture um-field-image um-field-type_image\" data-key=\"carereceiverpicture\" data-mode=\"register\" data-upload-label=\"Click here to Upload a Picture of the Care Receiver\"><input type=\"hidden\" name=\"carereceiverpicture-121\" id=\"carereceiverpicture-121\" value=\"\" \/><div class=\"um-field-label\"><label for=\"carereceiverpicture-121\">Upload a Picture of the Care Receiver<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\" style=\"text-align: center;\"><div class=\"um-single-image-preview \" data-crop=\"0\" data-key=\"carereceiverpicture\"><a href=\"javascript:void(0);\" class=\"cancel\"><i class=\"um-icon-close\"><\/i><\/a><img decoding=\"async\" src=\"\" alt=\"\" \/><div class=\"um-clear\"><\/div><\/div><a href=\"javascript:void(0);\" data-modal=\"um_upload_single\" data-modal-size=\"normal\" data-modal-copy=\"1\" class=\"um-button um-btn-auto-width\">Click here to Upload a Picture of the Care Receiver<\/a><\/div><div class=\"um-modal-hidden-content\"><div class=\"um-modal-header\"> Upload a Picture of the Care Receiver<\/div><div class=\"um-modal-body\"><div class=\"um-single-image-preview \"  data-crop=\"0\" data-ratio=\"1\" data-min_width=\"\" data-min_height=\"\" data-coord=\"\"><a href=\"javascript:void(0);\" class=\"cancel\"><i class=\"um-icon-close\"><\/i><\/a><img decoding=\"async\" src=\"\" alt=\"\" \/><div class=\"um-clear\"><\/div><\/div><div class=\"um-clear\"><\/div><div class=\"um-single-image-upload\" data-user_id=\"\" data-nonce=\"87433b8822\" data-timestamp=\"1785061914\"  data-set_id=\"121\" data-set_mode=\"register\" data-type=\"image\" data-key=\"carereceiverpicture\" data-max_size=\"999999999\" data-max_size_error=\"This image is too large!\" data-min_size_error=\"This image is too small!\" data-extension_error=\"Sorry this is not a valid image.\"  data-allowed_types=\"png,jpeg,jpg\" data-upload_text=\"Drag &amp; Drop Photo\" data-max_files_error=\"You can only upload one image\" data-upload_help_text=\"\">Click here to Upload a Picture of the Care Receiver<\/div><div class=\"um-modal-footer\">\n\t\t\t\t\t\t\t\t\t<div class=\"um-modal-right\">\n\t\t\t\t\t\t\t\t\t\t<a href=\"javascript:void(0);\" class=\"um-modal-btn um-finish-upload image disabled\" data-key=\"carereceiverpicture\" data-change=\"Change photo\" data-processing=\"Processing...\">Apply<\/a>\n\t\t\t\t\t\t\t\t\t\t<a href=\"javascript:void(0);\" class=\"um-modal-btn alt\" data-action=\"um_remove_modal\"> Cancel<\/a>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"um-clear\"><\/div>\n\t\t\t\t\t\t\t\t<\/div><\/div><\/div><\/div><div  id=\"um_field_121_pastfundbeneficiary\" class=\"um-field um-field-radio  um-field-pastfundbeneficiary um-field-radio um-field-type_radio\" data-key=\"pastfundbeneficiary\"><div class=\"um-field-label\"><label for=\"pastfundbeneficiary-121\">Past Fund Beneficiary<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><label class=\"um-field-radio  um-field-half \"><input  type=\"radio\" name=\"pastfundbeneficiary[]\" value=\"Yes\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Yes<\/span><\/label><label class=\"um-field-radio  um-field-half  right \"><input  type=\"radio\" name=\"pastfundbeneficiary[]\" value=\"No\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">No<\/span><\/label><div class=\"um-clear\"><\/div><div class=\"um-clear\"><\/div><\/div><\/div><div  id=\"um_field_121_pastfundbeneficiarydate\" class=\"um-field um-field-text  um-is-conditional um-field-pastfundbeneficiarydate um-field-text um-field-type_text\" data-key=\"pastfundbeneficiarydate\" data-cond-0-action=\"show\" data-cond-0-field=\"pastfundbeneficiary\" data-cond-0-operator=\"equals to\" data-cond-0-value=\"Yes\"><div class=\"um-field-label\"><label for=\"pastfundbeneficiarydate-121\">Past Fund Beneficiary Date<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"pastfundbeneficiarydate-121\" id=\"pastfundbeneficiarydate-121\" value=\"\" placeholder=\"Enter the YEAR you last received the fund\" data-validate=\"\" data-key=\"pastfundbeneficiarydate\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_pastfundbeneficiarytype\" class=\"um-field um-field-radio  um-is-conditional um-field-pastfundbeneficiarytype um-field-radio um-field-type_radio\" data-key=\"pastfundbeneficiarytype\" data-cond-0-action=\"show\" data-cond-0-field=\"pastfundbeneficiarydate\" data-cond-0-operator=\"not empty\" data-cond-0-value=\"\"><div class=\"um-field-label\"><label for=\"pastfundbeneficiarytype-121\">What Support did you receive in the past?<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><label class=\"um-field-radio  um-field-half \"><input  type=\"radio\" name=\"pastfundbeneficiarytype[]\" value=\"Income Generation\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Income Generation<\/span><\/label><label class=\"um-field-radio  um-field-half  right \"><input  type=\"radio\" name=\"pastfundbeneficiarytype[]\" value=\"Education\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Education<\/span><\/label><div class=\"um-clear\"><\/div><label class=\"um-field-radio  um-field-half \"><input  type=\"radio\" name=\"pastfundbeneficiarytype[]\" value=\"Health\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Health<\/span><\/label><div class=\"um-clear\"><\/div><\/div><\/div><div  id=\"um_field_121_pastfundbeneficiaryspecifics\" class=\"um-field um-field-text  um-is-conditional um-field-pastfundbeneficiaryspecifics um-field-text um-field-type_text\" data-key=\"pastfundbeneficiaryspecifics\" data-cond-0-action=\"show\" data-cond-0-field=\"pastfundbeneficiarytype\" data-cond-0-operator=\"not empty\" data-cond-0-value=\"\"><div class=\"um-field-label\"><label for=\"pastfundbeneficiaryspecifics-121\">Past Fund Beneficiary Type Specifics<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid not-required \" type=\"text\" name=\"pastfundbeneficiaryspecifics-121\" id=\"pastfundbeneficiaryspecifics-121\" value=\"\" placeholder=\"What particular support was it, example, fridge, medical device\" data-validate=\"\" data-key=\"pastfundbeneficiaryspecifics\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_dacfapplication\" class=\"um-field um-field-radio  um-field-dacfapplication um-field-radio um-field-type_radio\" data-key=\"dacfapplication\"><div class=\"um-field-label\"><label for=\"dacfapplication-121\">Do you wish to apply for support from the District Assembly Common Fund ( DACF) for the care receiver?<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><label class=\"um-field-radio  um-field-half \"><input  type=\"radio\" name=\"dacfapplication[]\" value=\"Yes\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Yes<\/span><\/label><label class=\"um-field-radio  um-field-half  right \"><input  type=\"radio\" name=\"dacfapplication[]\" value=\"No\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">No<\/span><\/label><div class=\"um-clear\"><\/div><div class=\"um-clear\"><\/div><\/div><\/div><div  id=\"um_field_121_purposeoffundcaregivers\" class=\"um-field um-field-radio  um-is-conditional um-field-purposeoffundcaregivers um-field-radio um-field-type_radio\" data-key=\"purposeoffundcaregivers\" data-cond-0-action=\"show\" data-cond-0-field=\"dacfapplication\" data-cond-0-operator=\"equals to\" data-cond-0-value=\"Yes\"><div class=\"um-field-label\"><label for=\"purposeoffundcaregivers-121\">Purpose of Applying for the Fund ( Care Givers)<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><label class=\"um-field-radio  um-field-half \"><input  type=\"radio\" name=\"purposeoffundcaregivers[]\" value=\"Basic Needs\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Basic Needs<\/span><\/label><label class=\"um-field-radio  um-field-half  right \"><input  type=\"radio\" name=\"purposeoffundcaregivers[]\" value=\"Utility Bills\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Utility Bills<\/span><\/label><div class=\"um-clear\"><\/div><label class=\"um-field-radio  um-field-half \"><input  type=\"radio\" name=\"purposeoffundcaregivers[]\" value=\"House Rent\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">House Rent<\/span><\/label><label class=\"um-field-radio  um-field-half  right \"><input  type=\"radio\" name=\"purposeoffundcaregivers[]\" value=\"Others ( click here to type)\"  \/><span class=\"um-field-radio-state\"><i class=\"um-icon-android-radio-button-off\"><\/i><\/span><span class=\"um-field-radio-option\">Others ( click here to type)<\/span><\/label><div class=\"um-clear\"><\/div><div class=\"um-clear\"><\/div><\/div><\/div><div  id=\"um_field_121_otherpurposeforfundapplicationcaregivers\" class=\"um-field um-field-text  um-is-conditional um-field-otherpurposeforfundapplicationcaregivers um-field-text um-field-type_text\" data-key=\"otherpurposeforfundapplicationcaregivers\" data-cond-0-action=\"show\" data-cond-0-field=\"purposeoffundcaregivers\" data-cond-0-operator=\"equals to\" data-cond-0-value=\"Others ( click here to type)\"><div class=\"um-field-label\"><label for=\"otherpurposeforfundapplicationcaregivers-121\">Other Purpose for applying for the fund (Care Givers)<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid not-required \" type=\"text\" name=\"otherpurposeforfundapplicationcaregivers-121\" id=\"otherpurposeforfundapplicationcaregivers-121\" value=\"\" placeholder=\"\" data-validate=\"\" data-key=\"otherpurposeforfundapplicationcaregivers\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_amount_requested\" class=\"um-field um-field-number  um-is-conditional um-field-amount_requested um-field-number um-field-type_number\" data-key=\"amount_requested\" data-cond-0-action=\"show\" data-cond-0-field=\"dacfapplication\" data-cond-0-operator=\"equals to\" data-cond-0-value=\"Yes\"><div class=\"um-field-label\"><label for=\"amount_requested-121\">What is the total amount of money required for the the purpose you applied for the fund ?<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  class=\"um-form-field valid \" type=\"number\" name=\"amount_requested-121\" id=\"amount_requested-121\" value=\"\" placeholder=\"example 700\" data-validate=\"\" data-key=\"amount_requested\"  \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_121_applicationattachments\" class=\"um-field um-field-file  um-is-conditional um-field-applicationattachments um-field-file um-field-type_file\" data-key=\"applicationattachments\" data-cond-0-action=\"show\" data-cond-0-field=\"dacfapplication\" data-cond-0-operator=\"equals to\" data-cond-0-value=\"Yes\" data-mode=\"register\" data-upload-label=\"Click here to upload your supporting documents\"><input type=\"hidden\" name=\"applicationattachments-121\" id=\"applicationattachments-121\" value=\"\" \/><div class=\"um-field-label\"><label for=\"applicationattachments-121\">Please attach supporting documents ( school fees bills, medical bills, etc. )<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\" style=\"text-align: center;\"><div class=\"um-single-file-preview\" data-key=\"applicationattachments\"><\/div><a href=\"#\" data-modal=\"um_upload_single\" data-modal-size=\"normal\" data-modal-copy=\"1\" class=\"um-button um-btn-auto-width\">Click here to upload your supporting documents<\/a><\/div><div class=\"um-modal-hidden-content\"><div class=\"um-modal-header\"> Please attach supporting documents ( school fees bills, medical bills, etc. )<\/div><div class=\"um-modal-body\"><div class=\"um-single-file-preview\">\n\t\t\t\t\t\t\t\t\t\t<a href=\"javascript:void(0);\" class=\"cancel\"><i class=\"um-icon-close\"><\/i><\/a>\n\t\t\t\t\t\t\t\t\t\t<div class=\"um-single-fileinfo\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"\" target=\"_blank\">\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"icon\"><i><\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"filename\"><\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div><div class=\"um-single-file-upload\" data-user_id=\"\" data-timestamp=\"1785061914\" data-nonce=\"87433b8822\"  data-set_id=\"121\" data-set_mode=\"register\" data-type=\"file\" data-key=\"applicationattachments\" data-max_size=\"999999999\" data-max_size_error=\"This file is too large!\" data-min_size_error=\"This file is too small!\" data-extension_error=\"Sorry this is not a valid file.\"  data-allowed_types=\"pdf,txt,csv,doc,docx,xls,xlsx,mp3,jpg,jpeg,png\" data-upload_text=\"Drag &amp; Drop File\" data-max_files_error=\"You can only upload one file\" data-upload_help_text=\"\">Click here to upload your supporting documents<\/div><div class=\"um-modal-footer\">\n\t\t\t\t\t\t\t\t\t<div class=\"um-modal-right\">\n\t\t\t\t\t\t\t\t\t\t<a href=\"javascript:void(0);\" class=\"um-modal-btn um-finish-upload file disabled\" data-key=\"applicationattachments\" data-change=\"Change file\" data-processing=\"Processing...\"> Save<\/a>\n\t\t\t\t\t\t\t\t\t\t<a href=\"javascript:void(0);\" class=\"um-modal-btn alt\" data-action=\"um_remove_modal\"> Cancel<\/a>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"um-clear\"><\/div>\n\t\t\t\t\t\t\t\t<\/div><\/div><\/div><\/div><div  id=\"um_field_121_signature\" class=\"um-field um-field-text  um-is-conditional um-field-signature um-field-text um-field-type_text\" data-key=\"signature\" data-cond-0-action=\"show\" data-cond-0-field=\"dacfapplication\" data-cond-0-operator=\"equals to\" data-cond-0-value=\"Yes\"><div class=\"um-field-label\"><label for=\"signature-121\">Signature ( I certify that all answers are true to the best of my knowledge )<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"signature-121\" id=\"signature-121\" value=\"\" placeholder=\"type your full name here instead of your signature\" data-validate=\"\" data-key=\"signature\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><\/div><\/div>\t\t<input type=\"hidden\" name=\"form_id\" id=\"form_id_121\" value=\"121\" \/>\n\t\n\t<p class=\"um_request_name\">\n\t\t<label for=\"um_request_121\">Only fill in if you are not human<\/label>\n\t\t<input type=\"hidden\" name=\"um_request\" id=\"um_request_121\" class=\"input\" value=\"\" size=\"25\" autocomplete=\"off\" \/>\n\t<\/p>\n\n\t<input type=\"hidden\" id=\"_wpnonce\" name=\"_wpnonce\" value=\"b7c7af09b6\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/89\" \/>\n\t<div class=\"um-col-alt\">\n\n\t\t\n\t\t\t<div class=\"um-center\">\n\t\t\t\t<input type=\"submit\" value=\"Register\" class=\"um-button\" id=\"um-submit-btn\" \/>\n\t\t\t<\/div>\n\n\t\t\n\t\t<div class=\"um-clear\"><\/div>\n\n\t<\/div>\n\n\t\n\t\t<\/form>\n\n\t<\/div>\n\n<\/div>\n<style>\n\t\t\t.um-121.um {\n\t\t\tmax-width: 450px;\n\t\t}\n\t\t<\/style>\n\n<!-- \/wp:paragraph -->\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>PWD Registration for Care Givers<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-89","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/suhumpwd.com\/index.php\/wp-json\/wp\/v2\/pages\/89","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/suhumpwd.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/suhumpwd.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/suhumpwd.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/suhumpwd.com\/index.php\/wp-json\/wp\/v2\/comments?post=89"}],"version-history":[{"count":8,"href":"https:\/\/suhumpwd.com\/index.php\/wp-json\/wp\/v2\/pages\/89\/revisions"}],"predecessor-version":[{"id":268,"href":"https:\/\/suhumpwd.com\/index.php\/wp-json\/wp\/v2\/pages\/89\/revisions\/268"}],"wp:attachment":[{"href":"https:\/\/suhumpwd.com\/index.php\/wp-json\/wp\/v2\/media?parent=89"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}