Online Inquiry
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<ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">CHILDREN'S BUREAU Formulario de Consulta para Cuidado de Crianza/Adopción</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="FH_Name_First_A" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">First Name/Nombre</label><input name="CST_3" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Name_Last_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name/Apellido</label><input name="CST_4" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="FH_EMail" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Email Address/Correo Electronico</label><input name="CST_6" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Phone_Home"> <i class="fa fa-font"></i><label class="er_fld_label">Main Phone//Numero de Teléfono</label><input name="CST_8" type="text" value="" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="FH_Address_Street_1" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address/Dirección</label><input name="CST_12" type="text" class="er_fld_width75"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="FH_Address_City" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label required">City/Ciudad</label><input name="CST_13" type="text" class="er_fld_required"></li><li class="er_fld_type_dropdown" draggable="false" map_to="FH_Address_State" style="width: 25%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">State/Estado</label><select name="CST_27" class="er_fld_width50 er_fld_required"><option value="Alabama">Alabama</option><option value="Alaska">Alaska</option><option value="Arizona">Arizona</option><option value="Arkansas">Arkansas</option><option value="California" selected="">California</option><option value="Colorado">Colorado</option><option value="Connecticut">Connecticut</option><option value="Delaware">Delaware</option><option value="Florida">Florida</option><option value="Georgia">Georgia</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="Ohio">Ohio</option><option value="Oklahoma">Oklahoma</option><option value="Oregon">Oregon</option><option value="Pennsylvania">Pennsylvania</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="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></select></li><li class="er_fld_type_text" draggable="false" map_to="FH_Address_Zip" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Zip/Código Postal</label><input name="CST_15" type="text" class="er_fld_width50"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Nota: Para ser un padre adoptivo o de crianza temporal con Children's Bureau, debe residir en el sur de California.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;" map_to="FH_Language"><i class="fa fa-caret-down"></i><label class="er_fld_label required">¿Cuál es su idioma de preferencia?</label><select name="CST_16" class="er_fld_width50 er_fld_required"><option value="- No especificado -">- No especificado -</option><option value="English">English</option><option value="Spanish" selected="">Spanish</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;" map_to="FH_ReferralSource"><i class="fa fa-caret-down"></i><label class="er_fld_label required">¿Cómo se enteró de Children's Bureau?</label><select name="CST_21" class="er_fld_required er_fld_width100"><option value="- No especificado -" selected="">- No especificado -</option><option value="Google">Google</option><option value="Bing">Bing</option><option value="Building Sign (Anuncio del Edificio)">Building Sign (Anuncio del Edificio)</option><option value="DCFS (Departamento de Servicios Sociales)">DCFS (Departamento de Servicios Sociales)</option><option value="Email Newsletter (Boletín electrónico)">Email Newsletter (Boletín electrónico)</option><option value="Eventbrite">Eventbrite</option><option value="Facebook">Facebook</option><option value="Foster Parent/Resource Parent (Padre adoptivo/padre de recurso)">Foster Parent/Resource Parent (Padre adoptivo/padre de recurso)</option><option value="FosterAll">FosterAll</option><option value="FosterMore">FosterMore</option><option value="Instagram">Instagram</option><option value="Newspaper/Magazine (Periódico/revista)">Newspaper/Magazine (Periódico/revista)</option><option value="Other Agency (Otra agencia)">Other Agency (Otra agencia)</option><option value="Outdoor Ads/Billboard (Anuncios al aire libre/anuncio publicitarios)">Outdoor Ads/Billboard (Anuncios al aire libre/anuncio publicitarios)</option><option value="Postcard/Flyer (tarjeta Postal/Folleto)">Postcard/Flyer (tarjeta Postal/Folleto)</option><option value="Staff/Employee/Board Member (El Personal/Empleado/Miembro de la mesa Derectiva)">Staff/Employee/Board Member (El Personal/Empleado/Miembro de la mesa Derectiva)</option><option value="Television/Radio">Television/Radio</option><option value="Twitter">Twitter</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 100%;" draggable="false" map_to="FH_Interest"><i class="fa fa-check-square-o"></i><label class="er_fld_label">¿está interesado en:</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_30" value="Foster Care/Cuidado de Crianza">Foster Care/Cuidado de Crianza</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_30" value="Fost-Adopt/Cuidado de Crianza-Adopción">Fost-Adopt/Cuidado de Crianza-Adopción</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_30" value="Other:">Other:<input class="cst_Other" name="CST_30_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_selected" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Si está interesado en asistir a una orientación virtual (a través de Zoom) para obtener más información, marque una de las fechas a continuación (horario de 5:30 a 6:30 p.m. PST):</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="mayo 16, 2024">mayo 16, 2024</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="junio 20, 2024">junio 20, 2024</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="julio 18, 2024">julio 18, 2024</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_28" value="Other:">Other:<input class="cst_Other" name="CST_28_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">*campo requerido</div></li></ul>
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