{"id":279,"date":"2023-08-02T13:58:10","date_gmt":"2023-08-02T13:58:10","guid":{"rendered":"https:\/\/ebridgeacademy.com\/?page_id=279"},"modified":"2023-08-02T14:05:16","modified_gmt":"2023-08-02T14:05:16","slug":"district-referral","status":"publish","type":"page","link":"https:\/\/ebridgeacademy.com\/?page_id=279","title":{"rendered":"District Referral"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"279\" class=\"elementor elementor-279\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-a0a972d elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"a0a972d\" data-element_type=\"section\" data-e-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-7f3058c\" data-id=\"7f3058c\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-3c614db elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"3c614db\" data-element_type=\"section\" data-e-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-02d1434\" data-id=\"02d1434\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-aba5629 elementor-widget elementor-widget-wpforms\" data-id=\"aba5629\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-217\"><form id=\"wpforms-form-217\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"217\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F279\" data-token=\"a758d0a080579fb0e7f474b12d2ecd32\" data-token-time=\"1784106955\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-217-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-217-field_2\">School District <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-217-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" aria-errormessage=\"wpforms-217-field_2-error\" required><\/div><div id=\"wpforms-217-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-217-field_3\">District Rep. Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-217-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-217-field_3-error\" required><\/div><div id=\"wpforms-217-field_5-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-217-field_5\">Student Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-217-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" spellcheck=\"false\" aria-errormessage=\"wpforms-217-field_5-error\" required><\/div><div id=\"wpforms-217-field_6-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"6\"><fieldset><legend class=\"wpforms-field-label\">Student Full Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-217-field_6\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][6][first]\" aria-errormessage=\"wpforms-217-field_6-error\" required><label for=\"wpforms-217-field_6\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-fifth\"><input type=\"text\" id=\"wpforms-217-field_6-middle\" class=\"wpforms-field-name-middle\" name=\"wpforms[fields][6][middle]\" aria-errormessage=\"wpforms-217-field_6-middle-error\" ><label for=\"wpforms-217-field_6-middle\" class=\"wpforms-field-sublabel after\">Middle<\/label><\/div><div class=\"wpforms-field-row-block wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-217-field_6-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][6][last]\" aria-errormessage=\"wpforms-217-field_6-last-error\" required><label for=\"wpforms-217-field_6-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-217-field_7-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-217-field_7\">Student Grade <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-217-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" required=\"required\"><option value=\"K\"  class=\"choice-1 depth-1\"  >K<\/option><option value=\"1\"  class=\"choice-2 depth-1\"  >1<\/option><option value=\"2\"  class=\"choice-4 depth-1\"  >2<\/option><option value=\"3\"  class=\"choice-5 depth-1\"  >3<\/option><option value=\"4\"  class=\"choice-6 depth-1\"  >4<\/option><option value=\"5\"  class=\"choice-7 depth-1\"  >5<\/option><option value=\"6\"  class=\"choice-8 depth-1\"  >6<\/option><option value=\"7\"  class=\"choice-9 depth-1\"  >7<\/option><option value=\"8\"  class=\"choice-10 depth-1\"  >8<\/option><option value=\"9\"  class=\"choice-11 depth-1\"  >9<\/option><option value=\"10\"  class=\"choice-12 depth-1\"  >10<\/option><option value=\"11\"  class=\"choice-13 depth-1\"  >11<\/option><option value=\"12\"  class=\"choice-14 depth-1\"  >12<\/option><\/select><\/div><div id=\"wpforms-217-field_8-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-217-field_8\">Education Type <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-217-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" required=\"required\"><option value=\"Regular Ed.\"  class=\"choice-1 depth-1\"  >Regular Ed.<\/option><option value=\"Special Ed.\"  class=\"choice-2 depth-1\"  >Special Ed.<\/option><\/select><\/div><div id=\"wpforms-217-field_19-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-217-field_19\">Race <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-217-field_19\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][19]\" required=\"required\"><option value=\"African American\"  class=\"choice-1 depth-1\"  >African American<\/option><option value=\"American Indian or Alaska Native\"  class=\"choice-2 depth-1\"  >American Indian or Alaska Native<\/option><option value=\"Asian\"  class=\"choice-3 depth-1\"  >Asian<\/option><option value=\"Hispanic\/Latino\"  class=\"choice-7 depth-1\"  >Hispanic\/Latino<\/option><option value=\"Multiple\"  class=\"choice-6 depth-1\"  >Multiple<\/option><option value=\"Non-Hispanic\/Latino\"  class=\"choice-5 depth-1\"  >Non-Hispanic\/Latino<\/option><option value=\"Pacific Islander\"  class=\"choice-10 depth-1\"  >Pacific Islander<\/option><option value=\"Unknown\"  class=\"choice-9 depth-1\"  >Unknown<\/option><option value=\"White\"  class=\"choice-8 depth-1\"  >White<\/option><\/select><\/div><div id=\"wpforms-217-field_18-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-217-field_18\">Ethnicity <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-217-field_18\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][18]\" required=\"required\"><option value=\"African American\"  class=\"choice-1 depth-1\"  >African American<\/option><option value=\"Asian\"  class=\"choice-2 depth-1\"  >Asian<\/option><option value=\"Asian \/ Pacific Islander\"  class=\"choice-3 depth-1\"  >Asian \/ Pacific Islander<\/option><option value=\"Bi-racial\"  class=\"choice-4 depth-1\"  >Bi-racial<\/option><option value=\"Black\"  class=\"choice-5 depth-1\"  >Black<\/option><option value=\"Caucasian\"  class=\"choice-6 depth-1\"  >Caucasian<\/option><option value=\"Hispanic\"  class=\"choice-7 depth-1\"  >Hispanic<\/option><option value=\"Latino\"  class=\"choice-8 depth-1\"  >Latino<\/option><option value=\"Native American\"  class=\"choice-11 depth-1\"  >Native American<\/option><option value=\"Other\"  class=\"choice-10 depth-1\"  >Other<\/option><option value=\"Unknown\"  class=\"choice-13 depth-1\"  >Unknown<\/option><option value=\"Vietnamese\"  class=\"choice-12 depth-1\"  >Vietnamese<\/option><\/select><\/div><div id=\"wpforms-217-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-217-field_16\">Student PA State ID # <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-217-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" aria-errormessage=\"wpforms-217-field_16-error\" aria-describedby=\"wpforms-217-field_16-description\" required><div id=\"wpforms-217-field_16-description\" class=\"wpforms-field-description\">Pennsylvania Issued Student State ID<\/div><\/div><div id=\"wpforms-217-field_9-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"9\"><fieldset><legend class=\"wpforms-field-label\">504 Plan <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-217-field_9\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-217-field_9_1\" name=\"wpforms[fields][9]\" value=\"YES\" aria-errormessage=\"wpforms-217-field_9_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-217-field_9_1\">YES<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-217-field_9_2\" name=\"wpforms[fields][9]\" value=\"NO\" aria-errormessage=\"wpforms-217-field_9_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-217-field_9_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-217-field_10-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"10\"><fieldset><legend class=\"wpforms-field-label\">Parent \/ Guardian Full Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-217-field_10\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][10][first]\" aria-errormessage=\"wpforms-217-field_10-error\" required><label for=\"wpforms-217-field_10\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-217-field_10-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][10][last]\" aria-errormessage=\"wpforms-217-field_10-last-error\" required><label for=\"wpforms-217-field_10-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-217-field_11-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-217-field_11\">Parent \/ Guardian Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-217-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" spellcheck=\"false\" aria-errormessage=\"wpforms-217-field_11-error\" required><\/div><div id=\"wpforms-217-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-217-field_12\">Parent \/ Guardian Phone Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-217-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-217-field_12-error\" required><\/div><div id=\"wpforms-217-field_13-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-217-field_13\">Parent \/ Guardian Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-217-field_13\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][13]\" aria-errormessage=\"wpforms-217-field_13-error\" required><\/textarea><\/div><div id=\"wpforms-217-field_14-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-217-field_14\">Student Classes <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-217-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-217-field_14-error\" required><\/textarea><\/div><div id=\"wpforms-217-field_15-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-217-field_15\">Special Instructions<\/label><textarea id=\"wpforms-217-field_15\" class=\"wpforms-field-medium\" name=\"wpforms[fields][15]\" aria-errormessage=\"wpforms-217-field_15-error\" ><\/textarea><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"217\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/ebridgeacademy.com\/index.php?rest_route=\/wp\/v2\/pages\/279\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-217\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/ebridgeacademy.com\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\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<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":420,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-279","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/ebridgeacademy.com\/index.php?rest_route=\/wp\/v2\/pages\/279","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/ebridgeacademy.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/ebridgeacademy.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/ebridgeacademy.com\/index.php?rest_route=\/wp\/v2\/users\/420"}],"replies":[{"embeddable":true,"href":"https:\/\/ebridgeacademy.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=279"}],"version-history":[{"count":4,"href":"https:\/\/ebridgeacademy.com\/index.php?rest_route=\/wp\/v2\/pages\/279\/revisions"}],"predecessor-version":[{"id":284,"href":"https:\/\/ebridgeacademy.com\/index.php?rest_route=\/wp\/v2\/pages\/279\/revisions\/284"}],"wp:attachment":[{"href":"https:\/\/ebridgeacademy.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=279"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}