{"id":7473,"date":"2021-03-25T11:16:29","date_gmt":"2021-03-25T16:16:29","guid":{"rendered":"https:\/\/uamscaregiving.org\/springdale\/?page_id=7473"},"modified":"2026-02-06T13:19:57","modified_gmt":"2026-02-06T19:19:57","slug":"heat","status":"publish","type":"page","link":"https:\/\/uamscaregiving.org\/springdale\/heat\/","title":{"rendered":"Healthy Eating and Tasting Program Voucher Application"},"content":{"rendered":"<p>Complete the form below if you, or someone you know in your county, would benefit from participation in the UAMS Schmieding Center&#8217;s <strong>Healthy Eating and Tasting Program<\/strong>.\u00a0 Successful applicants will receive a voucher to redeem at a local <strong>Harps\u2122 Food Store<\/strong> to purchase all ingredients necessary to prepare our meal of the month!\u00a0 In addition to covering the cost of all meal ingredients, the Schmieding Center will provide a live demonstration via Zoom of how the meal should be properly prepared.\u00a0 All prepared meals can feed up to 4 persons!<\/p>\n<p><strong>Take advantage of this limited-time offer today for yourself, or for someone you know!<\/strong><\/p>\n<p>If you have questions, call 479.751.3043 or email <a href=\"mailto:SCInfo@uams.edu\">SCInfo@uams.edu<\/a>.<\/p>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_141' style='display:none'><div id='gf_141' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_141'  action='\/springdale\/wp-json\/wp\/v2\/pages\/7473#gf_141' data-formid='141' novalidate>\n        <div id='gf_progressbar_wrapper_141' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>3<\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_33' style='width:33%;'><span>33%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_141_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_141' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_141_24\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_141_24\" ><strong><font color=\"red\">Please enter  <u>YOUR<\/u> information below. <\/font> <i> (The person who is completing this online application.)<\/i><\/strong>  <br><br>*** If you are applying for <i><u>someone else<\/u><\/i>, you will have opportunity on the next page to enter their information. *** <br><br><strong><font color=\"red\">IMPORTANT NOTE:<\/font><\/strong> <i>The voucher for a successful application will be mailed to the address provided on this page.<\/i><\/li><li id=\"field_141_3\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_141_3\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Enter your name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_141_3'>\n                            \n                            <span id='input_141_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_141_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_141_3_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_141_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_141_3_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_141_3_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><\/li><li id=\"field_141_18\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_141_18\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Enter your address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_141_18' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_141_18_1_container' >\n                                        <input type='text' name='input_18.1' id='input_141_18_1' value=''    aria-required='true'    \/>\n                                        <label for='input_141_18_1' id='input_141_18_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_141_18_3_container' >\n                                    <input type='text' name='input_18.3' id='input_141_18_3' value=''    aria-required='true'    \/>\n                                    <label for='input_141_18_3' id='input_141_18_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_141_18_4_container' >\n                                        <select name='input_18.4' id='input_141_18_4'     aria-required='true'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' selected='selected'>Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_141_18_4' id='input_141_18_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_141_18_5_container' >\n                                    <input type='text' name='input_18.5' id='input_141_18_5' value=''    aria-required='true'    \/>\n                                    <label for='input_141_18_5' id='input_141_18_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_18.6' id='input_141_18_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><\/li><li id=\"field_141_1\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_141_1\" ><label class='gfield_label gform-field-label' for='input_141_1'>Enter your email address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_1' id='input_141_1' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_141_2\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_141_2\" ><label class='gfield_label gform-field-label' for='input_141_2'>Enter your telephone number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_2' id='input_141_2' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_141_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_141_10\" ><label class='gfield_label gform-field-label' >This application to receive a Schmieding Center voucher to a local Harps\u2122 Food Store is for:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_141_10'>\n\t\t\t<li class='gchoice gchoice_141_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='Me' checked='checked' id='choice_141_10_0'    \/>\n\t\t\t\t<label for='choice_141_10_0' id='label_141_10_0' class='gform-field-label gform-field-label--type-inline'>Me<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_141_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='Someone else'  id='choice_141_10_1'    \/>\n\t\t\t\t<label for='choice_141_10_1' id='label_141_10_1' class='gform-field-label gform-field-label--type-inline'>Someone else<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_141_14' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_141\").val(\"2\");  jQuery(\"#gform_141\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_141\").val(\"2\");  jQuery(\"#gform_141\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_141_2' class='gform_page' data-js='page-field-id-14' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_141_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_141_15\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_141_15\" >This application is for the person named below to receive a Schmieding Center \/ Harps Food Store voucher to purchase recipe ingredients in the UAMS Center on Aging Healthy Eating and Tasting Program.<\/li><li id=\"field_141_17\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_141_17\" >This application is for you to receive a Schmieding Center \/ Harps Food Store voucher to purchase recipe ingredients in the UAMS Center on Aging Healthy Eating and Tasting Program.<\/li><li id=\"field_141_11\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_141_11\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name of voucher recipient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_141_11'>\n                            \n                            <span id='input_141_11_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_11.3' id='input_141_11_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_141_11_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_141_11_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_11.6' id='input_141_11_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_141_11_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><\/li><li id=\"field_141_19\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_141_19\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Enter address of voucher recipient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='gfield_description' id='gfield_description_141_19'><i>To send a voucher to your address from the previous screen on behalf of the person named above, a valid address <strong><u>must<\/u><\/strong> be provided below <font color=\"red\">for delivery of the voucher or of purchased items to the voucher recipient<\/font>.  If you plan to shop for this person, the Schmieding Center will confirm their receipt of purchased items by calling the voucher recipient.<\/i><\/div>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_141_19' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_141_19_1_container' >\n                                        <input type='text' name='input_19.1' id='input_141_19_1' value=''    aria-required='true'    \/>\n                                        <label for='input_141_19_1' id='input_141_19_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_141_19_3_container' >\n                                    <input type='text' name='input_19.3' id='input_141_19_3' value=''    aria-required='true'    \/>\n                                    <label for='input_141_19_3' id='input_141_19_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_141_19_4_container' >\n                                        <select name='input_19.4' id='input_141_19_4'     aria-required='true'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' selected='selected'>Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_141_19_4' id='input_141_19_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_141_19_5_container' >\n                                    <input type='text' name='input_19.5' id='input_141_19_5' value=''    aria-required='true'    \/>\n                                    <label for='input_141_19_5' id='input_141_19_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_19.6' id='input_141_19_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><\/li><li id=\"field_141_12\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_141_12\" ><label class='gfield_label gform-field-label' for='input_141_12'>Email address of voucher recipient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='gfield_description' id='gfield_description_141_12'><i>If unavailable, you should enter your email address again here<\/i><\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_12' id='input_141_12' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_141_12\" \/>\n                        <\/div><\/li><li id=\"field_141_13\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_141_13\" ><label class='gfield_label gform-field-label' for='input_141_13'>Phone number of voucher recipient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='gfield_description' id='gfield_description_141_13'><i>A valid phone number <strong><u>must<\/u><\/strong> be provided below <font color=\"red\">for the voucher recipient<\/font>.  The Schmieding Center will contact the voucher recipient to confirm delivery of the voucher or of the purchased items.<\/i><\/div><div class='ginput_container ginput_container_phone'><input name='input_13' id='input_141_13' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_141_13\"  \/><\/div><\/li><li id=\"field_141_20\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_141_20\" ><i>Enter demographic information below<\/i><\/li><li id=\"field_141_6\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_141_6\" ><label class='gfield_label gform-field-label' for='input_141_6'>Residence County of voucher recipient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_141_6' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Benton' >Benton<\/option><option value='Washington' >Washington<\/option><option value='Madison' >Madison<\/option><option value='Baxter' >Baxter<\/option><option value='Boone' >Boone<\/option><option value='Carroll' >Carroll<\/option><option value='Izard' >Izard<\/option><option value='Marion' >Marion<\/option><option value='Newton' >Newton<\/option><option value='Searcy' >Searcy<\/option><option value='Stone' >Stone<\/option><option value='other' >other<\/option><\/select><\/div><\/li><li id=\"field_141_8\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_141_8\" ><label class='gfield_label gform-field-label' for='input_141_8'>Gender of voucher recipient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_8' id='input_141_8' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Male' >Male<\/option><option value='Female' >Female<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_141_7\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_141_7\" ><label class='gfield_label gform-field-label' for='input_141_7'>Race of voucher recipient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_141_7' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='African-American' >African-American<\/option><option value='American Indian' >American Indian<\/option><option value='Asian\/Pacific Islander' >Asian\/Pacific Islander<\/option><option value='Caucasian' >Caucasian<\/option><option value='Hispanic' >Hispanic<\/option><option value='Middle Eastern' >Middle Eastern<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_141_21' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_141\").val(\"1\");  jQuery(\"#gform_141\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_141\").val(\"1\");  jQuery(\"#gform_141\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_141_21' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_141\").val(\"3\");  jQuery(\"#gform_141\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_141\").val(\"3\");  jQuery(\"#gform_141\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_141_3' class='gform_page' data-js='page-field-id-21' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_141_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_141_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_141_22\" ><label class='gfield_label gform-field-label' >Question 1: Read the statement below and answer this question.  How would you describe your food circumstances over the past 12 months?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='gfield_description' id='gfield_description_141_22'><strong><font color=\"red\">\"We worried whether our food would run out before we got money to buy more.\"<\/font><\/strong><\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_141_22'>\n\t\t\t<li class='gchoice gchoice_141_22_0'>\n\t\t\t\t<input name='input_22' type='radio' value='Often true'  id='choice_141_22_0'    \/>\n\t\t\t\t<label for='choice_141_22_0' id='label_141_22_0' class='gform-field-label gform-field-label--type-inline'>Often true<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_141_22_1'>\n\t\t\t\t<input name='input_22' type='radio' value='Sometimes true'  id='choice_141_22_1'    \/>\n\t\t\t\t<label for='choice_141_22_1' id='label_141_22_1' class='gform-field-label gform-field-label--type-inline'>Sometimes true<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_141_22_2'>\n\t\t\t\t<input name='input_22' type='radio' value='Never true'  id='choice_141_22_2'    \/>\n\t\t\t\t<label for='choice_141_22_2' id='label_141_22_2' class='gform-field-label gform-field-label--type-inline'>Never true<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_141_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_141_25\" ><label class='gfield_label gform-field-label' >Question 1: Read the statement below and answer this question for the voucher recipient. How would you describe your food circumstances over the past 12 months?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='gfield_description' id='gfield_description_141_25'><strong><font color=\"red\">\"We worried whether our food would run out before we got money to buy more.\"<\/font><\/strong><\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_141_25'>\n\t\t\t<li class='gchoice gchoice_141_25_0'>\n\t\t\t\t<input name='input_25' type='radio' value='Often true'  id='choice_141_25_0'    \/>\n\t\t\t\t<label for='choice_141_25_0' id='label_141_25_0' class='gform-field-label gform-field-label--type-inline'>Often true<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_141_25_1'>\n\t\t\t\t<input name='input_25' type='radio' value='Sometimes true'  id='choice_141_25_1'    \/>\n\t\t\t\t<label for='choice_141_25_1' id='label_141_25_1' class='gform-field-label gform-field-label--type-inline'>Sometimes true<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_141_25_2'>\n\t\t\t\t<input name='input_25' type='radio' value='Never true'  id='choice_141_25_2'    \/>\n\t\t\t\t<label for='choice_141_25_2' id='label_141_25_2' class='gform-field-label gform-field-label--type-inline'>Never true<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_141_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_141_23\" ><label class='gfield_label gform-field-label' >Question 2: Read the statement below and answer this question.  How would you describe your food circumstances over the past 12 months?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='gfield_description' id='gfield_description_141_23'><strong><font color=\"red\">\"The food that we bought just didn't last, and we didn't have money to get more.\"<\/font><\/strong><\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_141_23'>\n\t\t\t<li class='gchoice gchoice_141_23_0'>\n\t\t\t\t<input name='input_23' type='radio' value='Often true'  id='choice_141_23_0'    \/>\n\t\t\t\t<label for='choice_141_23_0' id='label_141_23_0' class='gform-field-label gform-field-label--type-inline'>Often true<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_141_23_1'>\n\t\t\t\t<input name='input_23' type='radio' value='Sometimes true'  id='choice_141_23_1'    \/>\n\t\t\t\t<label for='choice_141_23_1' id='label_141_23_1' class='gform-field-label gform-field-label--type-inline'>Sometimes true<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_141_23_2'>\n\t\t\t\t<input name='input_23' type='radio' value='Never true'  id='choice_141_23_2'    \/>\n\t\t\t\t<label for='choice_141_23_2' id='label_141_23_2' class='gform-field-label gform-field-label--type-inline'>Never true<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_141_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_141_26\" ><label class='gfield_label gform-field-label' >Question 2: Read the statement below and answer this question for the voucher recipient. How would you describe your food circumstances over the past 12 months?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='gfield_description' id='gfield_description_141_26'><strong><font color=\"red\">\"The food that we bought just didn't last, and we didn't have money to get more.\"<\/font><\/strong><\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_141_26'>\n\t\t\t<li class='gchoice gchoice_141_26_0'>\n\t\t\t\t<input name='input_26' type='radio' value='Often true'  id='choice_141_26_0'    \/>\n\t\t\t\t<label for='choice_141_26_0' id='label_141_26_0' class='gform-field-label gform-field-label--type-inline'>Often true<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_141_26_1'>\n\t\t\t\t<input name='input_26' type='radio' value='Sometimes true'  id='choice_141_26_1'    \/>\n\t\t\t\t<label for='choice_141_26_1' id='label_141_26_1' class='gform-field-label gform-field-label--type-inline'>Sometimes true<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_141_26_2'>\n\t\t\t\t<input name='input_26' type='radio' value='Never true'  id='choice_141_26_2'    \/>\n\t\t\t\t<label for='choice_141_26_2' id='label_141_26_2' class='gform-field-label gform-field-label--type-inline'>Never true<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><\/ul><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_141' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='if(window[\"gf_submitting_141\"]){return false;}  if( !jQuery(\"#gform_141\")[0].checkValidity || jQuery(\"#gform_141\")[0].checkValidity()){window[\"gf_submitting_141\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_141\"]){return false;} if( !jQuery(\"#gform_141\")[0].checkValidity || jQuery(\"#gform_141\")[0].checkValidity()){window[\"gf_submitting_141\"]=true;}  jQuery(\"#gform_141\").trigger(\"submit\",[true]); 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