{"id":5672,"date":"2024-03-20T11:30:04","date_gmt":"2024-03-20T11:30:04","guid":{"rendered":"https:\/\/server3.nilanktech.net\/test\/medicalstudentrotation\/?page_id=5672"},"modified":"2024-09-10T10:11:49","modified_gmt":"2024-09-10T10:11:49","slug":"package-form","status":"publish","type":"page","link":"https:\/\/medicalstudentrotation.com\/hands-on\/package-form\/","title":{"rendered":"Package Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"5672\" class=\"elementor elementor-5672\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section data-jarallax-video=\"\" data-speed=\"\" data-img-position=\"\" class=\"elementor-section elementor-top-section elementor-element elementor-element-0a6829c elementor-section-height-min-height elementor-section-items-stretch jarallax elementor-section-boxed elementor-section-height-default\" data-id=\"0a6829c\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;aos_animation_name&quot;:&quot;none&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-extended\">\n\t\t\t\t\t<div data-img-position=\"\" class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-18e6c14 elementor-hidden-tablet elementor-hidden-mobile\" data-id=\"18e6c14\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;aos_animation_name&quot;:&quot;none&quot;}\">\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<div data-img-position=\"\" class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-712ee6c has-shape-parent\" data-id=\"712ee6c\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;aos_animation_name&quot;:&quot;none&quot;}\">\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-17aabaf elementor-widget elementor-widget-heading\" data-id=\"17aabaf\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;aos_animation_name&quot;:&quot;none&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Packages Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-bd41c9b elementor-widget elementor-widget-vlt-shape\" data-id=\"bd41c9b\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;aos_animation_name&quot;:&quot;none&quot;}\" data-widget_type=\"vlt-shape.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\n\t\t<div class=\"vlt-shape vlt-shape--visible\">\n\n\t\t\t\n\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"2\" height=\"70\" src=\"https:\/\/medicalstudentrotation.com\/hands-on\/wp-content\/uploads\/2022\/10\/vertical-line-2x70-1.svg\" class=\"attachment-full size-full\" alt=\"\" loading=\"lazy\" \/>\n\t\t\t\n\t\t<\/div>\n\n\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<div data-img-position=\"\" class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-a966540 elementor-hidden-tablet elementor-hidden-mobile\" data-id=\"a966540\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;aos_animation_name&quot;:&quot;none&quot;}\">\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<div class=\"elementor-element elementor-element-4208cc4 e-flex e-con-boxed e-con e-parent\" data-id=\"4208cc4\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5549bb6 elementor-widget elementor-widget-spacer\" data-id=\"5549bb6\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;aos_animation_name&quot;:&quot;none&quot;}\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-56a0c87 e-flex e-con-boxed e-con e-parent\" data-id=\"56a0c87\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-10601f6 elementor-widget elementor-widget-shortcode\" data-id=\"10601f6\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;aos_animation_name&quot;:&quot;none&quot;}\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><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 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#112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/hands-on\/wp-json\/wp\/v2\/pages\/5672' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_1_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name (As on Passport)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><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_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_3\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_3\" ><label class='gfield_label gform-field-label' for='input_1_3'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_1_3' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_1_4\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_4\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_1_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_4_1_container' >\n                                        <input type='text' name='input_4.1' id='input_1_4_1' value=''    aria-required='true'    \/>\n                                        <label for='input_1_4_1' id='input_1_4_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_1_4_3_container' >\n                                    <input type='text' name='input_4.3' id='input_1_4_3' value=''    aria-required='true'    \/>\n                                    <label for='input_1_4_3' id='input_1_4_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_1_4_4_container' >\n                                        <input type='text' name='input_4.4' id='input_1_4_4' value=''      aria-required='true'    \/>\n                                        <label for='input_1_4_4' id='input_1_4_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_4_5_container' >\n                                    <input type='text' name='input_4.5' id='input_1_4_5' value=''    aria-required='true'    \/>\n                                    <label for='input_1_4_5' id='input_1_4_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_1_4_6_container' >\n                                        <select name='input_4.6' id='input_1_4_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_1_4_6' id='input_1_4_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_5\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\" ><label class='gfield_label gform-field-label' for='input_1_5'>WhatsApp Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_1_5' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_6\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Preferred Start Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_1_6' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_6_1_container'>\n                                            <input type='number' maxlength='2' name='input_6[]' id='input_1_6_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_6_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_6_2_container'>\n                                            <input type='number' maxlength='2' name='input_6[]' id='input_1_6_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_6_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_6_3_container'>\n                                            <input type='number' maxlength='4' name='input_6[]' id='input_1_6_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_6_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_1_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_9\" ><legend class='gfield_label gform-field-label' >Select Rotation Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_9'>\n\t\t\t<div class='gchoice gchoice_1_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Group A'  id='choice_1_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_9_0' id='label_1_9_0' class='gform-field-label gform-field-label--type-inline'>Group A<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Group B'  id='choice_1_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_9_1' id='label_1_9_1' class='gform-field-label gform-field-label--type-inline'>Group B<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_9_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Group C'  id='choice_1_9_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_9_2' id='label_1_9_2' class='gform-field-label gform-field-label--type-inline'>Group C<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_1_10\" ><legend class='gfield_label gform-field-label' >Group A<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_10'>\n\t\t\t<div class='gchoice gchoice_1_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Hands-ON Hospital-Based Rotations'  id='choice_1_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_10_0' id='label_1_10_0' class='gform-field-label gform-field-label--type-inline'>Hands-ON Hospital-Based Rotations<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_1_11\" ><legend class='gfield_label gform-field-label' >Group B<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_11'>\n\t\t\t<div class='gchoice gchoice_1_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Hands-On\/ Observerships\/ Externships'  id='choice_1_11_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_11_0' id='label_1_11_0' class='gform-field-label gform-field-label--type-inline'>Hands-On\/ Observerships\/ Externships<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_1_12\" ><legend class='gfield_label gform-field-label' >Group C<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_12'>\n\t\t\t<div class='gchoice gchoice_1_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Research Rotation'  id='choice_1_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_12_0' id='label_1_12_0' class='gform-field-label gform-field-label--type-inline'>Research Rotation<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Tele Medicine Rotation'  id='choice_1_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_12_1' id='label_1_12_1' class='gform-field-label gform-field-label--type-inline'>Tele Medicine Rotation<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_1_13\" ><legend class='gfield_label gform-field-label' >Group A City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_13'>\n\t\t\t<div class='gchoice gchoice_1_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Chicago'  id='choice_1_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_13_0' id='label_1_13_0' class='gform-field-label gform-field-label--type-inline'>Chicago<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Houston'  id='choice_1_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_13_1' id='label_1_13_1' class='gform-field-label gform-field-label--type-inline'>Houston<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='New York'  id='choice_1_13_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_13_2' id='label_1_13_2' class='gform-field-label gform-field-label--type-inline'>New York<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_13_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Dallas'  id='choice_1_13_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_13_3' id='label_1_13_3' class='gform-field-label gform-field-label--type-inline'>Dallas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_13_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='California'  id='choice_1_13_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_13_4' id='label_1_13_4' class='gform-field-label gform-field-label--type-inline'>California<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_1_15\" ><legend class='gfield_label gform-field-label' >Chicago<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_15'>\n\t\t\t<div class='gchoice gchoice_1_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Internal Medicine (IM1)'  id='choice_1_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_0' id='label_1_15_0' class='gform-field-label gform-field-label--type-inline'>Internal Medicine (IM1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Internal Medicine (IM2)'  id='choice_1_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_1' id='label_1_15_1' class='gform-field-label gform-field-label--type-inline'>Internal Medicine (IM2)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Internal Medicine (IM3)'  id='choice_1_15_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_2' id='label_1_15_2' class='gform-field-label gform-field-label--type-inline'>Internal Medicine (IM3)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Internal Medicine (IM4)'  id='choice_1_15_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_3' id='label_1_15_3' class='gform-field-label gform-field-label--type-inline'>Internal Medicine (IM4)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Nephrology (Neph 1)'  id='choice_1_15_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_4' id='label_1_15_4' class='gform-field-label gform-field-label--type-inline'>Nephrology (Neph 1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Nephrology (Neph 2)'  id='choice_1_15_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_5' id='label_1_15_5' class='gform-field-label gform-field-label--type-inline'>Nephrology (Neph 2)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Pulmonary & Critical Care (PCC 1)'  id='choice_1_15_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_6' id='label_1_15_6' class='gform-field-label gform-field-label--type-inline'>Pulmonary & Critical Care (PCC 1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Neurology (Neuro 1)'  id='choice_1_15_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_7' id='label_1_15_7' class='gform-field-label gform-field-label--type-inline'>Neurology (Neuro 1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Neurology (Neuro 2)'  id='choice_1_15_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_8' id='label_1_15_8' class='gform-field-label gform-field-label--type-inline'>Neurology (Neuro 2)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Infectious Disease (I\/D 1)'  id='choice_1_15_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_9' id='label_1_15_9' class='gform-field-label gform-field-label--type-inline'>Infectious Disease (I\/D 1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Infectious Disease (I\/D 2)'  id='choice_1_15_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_10' id='label_1_15_10' class='gform-field-label gform-field-label--type-inline'>Infectious Disease (I\/D 2)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Heme\/Oncology (Hem-Onc 1)'  id='choice_1_15_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_11' id='label_1_15_11' class='gform-field-label gform-field-label--type-inline'>Heme\/Oncology (Hem-Onc 1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Heme\/Oncology (Hem-Onc 2)'  id='choice_1_15_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_12' id='label_1_15_12' class='gform-field-label gform-field-label--type-inline'>Heme\/Oncology (Hem-Onc 2)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_13'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Cardiology (Cardio 1)'  id='choice_1_15_13' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_13' id='label_1_15_13' class='gform-field-label gform-field-label--type-inline'>Cardiology (Cardio 1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_14'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Cardiology (Cardio 2)'  id='choice_1_15_14' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_14' id='label_1_15_14' class='gform-field-label gform-field-label--type-inline'>Cardiology (Cardio 2)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_15'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Family Medicine (FM 1)'  id='choice_1_15_15' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_15' id='label_1_15_15' class='gform-field-label gform-field-label--type-inline'>Family Medicine (FM 1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_16'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Family Medicine (FM 2)'  id='choice_1_15_16' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_16' id='label_1_15_16' class='gform-field-label gform-field-label--type-inline'>Family Medicine (FM 2)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_17'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Psychiatry (Psych 1)'  id='choice_1_15_17' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_17' id='label_1_15_17' class='gform-field-label gform-field-label--type-inline'>Psychiatry (Psych 1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_18'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Psychiatry (Psych 2)'  id='choice_1_15_18' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_18' id='label_1_15_18' class='gform-field-label gform-field-label--type-inline'>Psychiatry (Psych 2)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_19'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Pediatrics (Peds 1)'  id='choice_1_15_19' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_19' id='label_1_15_19' class='gform-field-label gform-field-label--type-inline'>Pediatrics (Peds 1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_20'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Pediatrics (Peds 2)'  id='choice_1_15_20' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_20' id='label_1_15_20' class='gform-field-label gform-field-label--type-inline'>Pediatrics (Peds 2)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_21'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='General Surgery'  id='choice_1_15_21' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_21' id='label_1_15_21' class='gform-field-label gform-field-label--type-inline'>General Surgery<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_22'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='OB\/ GYN'  id='choice_1_15_22' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_22' id='label_1_15_22' class='gform-field-label gform-field-label--type-inline'>OB\/ GYN<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_23'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Emergency Room (ER 1)'  id='choice_1_15_23' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_23' id='label_1_15_23' class='gform-field-label gform-field-label--type-inline'>Emergency Room (ER 1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_24'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Emergency Room (ER 2)'  id='choice_1_15_24' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_24' id='label_1_15_24' class='gform-field-label gform-field-label--type-inline'>Emergency Room (ER 2)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_25'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Anesthesia'  id='choice_1_15_25' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_25' id='label_1_15_25' class='gform-field-label gform-field-label--type-inline'>Anesthesia<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_26'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Radiology (Radio 1)'  id='choice_1_15_26' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_26' id='label_1_15_26' class='gform-field-label gform-field-label--type-inline'>Radiology (Radio 1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_27'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Radiology (Radio 2)'  id='choice_1_15_27' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_27' id='label_1_15_27' class='gform-field-label gform-field-label--type-inline'>Radiology (Radio 2)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_28'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Radiology (Radio 3)'  id='choice_1_15_28' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_28' id='label_1_15_28' class='gform-field-label gform-field-label--type-inline'>Radiology (Radio 3)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_1_16\" ><legend class='gfield_label gform-field-label' >Houston<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_16'>\n\t\t\t<div class='gchoice gchoice_1_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Internal Medicine'  id='choice_1_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_16_0' id='label_1_16_0' class='gform-field-label gform-field-label--type-inline'>Internal Medicine<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Internal Medicine + Pediatrics'  id='choice_1_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_16_1' id='label_1_16_1' class='gform-field-label gform-field-label--type-inline'>Internal Medicine + Pediatrics<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_16_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Nephrology'  id='choice_1_16_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_16_2' id='label_1_16_2' class='gform-field-label gform-field-label--type-inline'>Nephrology<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_16_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Pulmonary & Critical Care'  id='choice_1_16_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_16_3' id='label_1_16_3' class='gform-field-label gform-field-label--type-inline'>Pulmonary & Critical Care<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_16_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Cardiology'  id='choice_1_16_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_16_4' id='label_1_16_4' class='gform-field-label gform-field-label--type-inline'>Cardiology<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_16_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Infectious Disease'  id='choice_1_16_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_16_5' id='label_1_16_5' class='gform-field-label gform-field-label--type-inline'>Infectious Disease<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_16_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Hematology\/ Oncology'  id='choice_1_16_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_16_6' id='label_1_16_6' class='gform-field-label gform-field-label--type-inline'>Hematology\/ Oncology<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_16_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Pathology'  id='choice_1_16_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_16_7' id='label_1_16_7' class='gform-field-label gform-field-label--type-inline'>Pathology<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_16_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Surgery - Vascular'  id='choice_1_16_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_16_8' id='label_1_16_8' class='gform-field-label gform-field-label--type-inline'>Surgery - Vascular<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_16_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Radiology - Radiation Oncology'  id='choice_1_16_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_16_9' id='label_1_16_9' class='gform-field-label gform-field-label--type-inline'>Radiology - Radiation Oncology<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_1_17\" ><legend class='gfield_label gform-field-label' >New York<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_17'>\n\t\t\t<div class='gchoice gchoice_1_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Internal Medicine'  id='choice_1_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_17_0' id='label_1_17_0' class='gform-field-label gform-field-label--type-inline'>Internal Medicine<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Nephrology'  id='choice_1_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_17_1' id='label_1_17_1' class='gform-field-label gform-field-label--type-inline'>Nephrology<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_1_14\" ><legend class='gfield_label gform-field-label' >Group B City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_14'>\n\t\t\t<div class='gchoice gchoice_1_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Chicago'  id='choice_1_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_14_0' id='label_1_14_0' class='gform-field-label gform-field-label--type-inline'>Chicago<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Houston'  id='choice_1_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_14_1' id='label_1_14_1' class='gform-field-label gform-field-label--type-inline'>Houston<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_14_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='New York'  id='choice_1_14_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_14_2' id='label_1_14_2' class='gform-field-label gform-field-label--type-inline'>New York<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_14_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Dallas'  id='choice_1_14_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_14_3' id='label_1_14_3' class='gform-field-label gform-field-label--type-inline'>Dallas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_14_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='California'  id='choice_1_14_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_14_4' id='label_1_14_4' class='gform-field-label gform-field-label--type-inline'>California<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_1_18\" ><legend class='gfield_label gform-field-label' >Chicago<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_18'>\n\t\t\t<div class='gchoice gchoice_1_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Internal Medicine @ Comm Munster'  id='choice_1_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_18_0' id='label_1_18_0' class='gform-field-label gform-field-label--type-inline'>Internal Medicine @ Comm Munster<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Family Medicine @ Comm Munster'  id='choice_1_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_18_1' id='label_1_18_1' class='gform-field-label gform-field-label--type-inline'>Family Medicine @ Comm Munster<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_18_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Pediatrics (Peds 1)'  id='choice_1_18_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_18_2' id='label_1_18_2' class='gform-field-label gform-field-label--type-inline'>Pediatrics (Peds 1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_18_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Pediatrics (Peds 2)'  id='choice_1_18_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_18_3' id='label_1_18_3' class='gform-field-label gform-field-label--type-inline'>Pediatrics (Peds 2)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_18_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Neurology'  id='choice_1_18_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_18_4' id='label_1_18_4' class='gform-field-label gform-field-label--type-inline'>Neurology<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_18_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Clinical Research (CR 1)'  id='choice_1_18_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_18_5' id='label_1_18_5' class='gform-field-label gform-field-label--type-inline'>Clinical Research (CR 1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_18_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Clinical Research (CR 2)'  id='choice_1_18_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_18_6' id='label_1_18_6' class='gform-field-label gform-field-label--type-inline'>Clinical Research (CR 2)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_18_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Infectious Disease I\/D'  id='choice_1_18_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_18_7' id='label_1_18_7' class='gform-field-label gform-field-label--type-inline'>Infectious Disease I\/D<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_1_19\" ><legend class='gfield_label gform-field-label' >Houston<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_19'>\n\t\t\t<div class='gchoice gchoice_1_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Internal Medicine (IM 1)'  id='choice_1_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_0' id='label_1_19_0' class='gform-field-label gform-field-label--type-inline'>Internal Medicine (IM 1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Internal Medicine (IM 2)'  id='choice_1_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_1' id='label_1_19_1' class='gform-field-label gform-field-label--type-inline'>Internal Medicine (IM 2)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_19_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Internal Medicine (IM 3)'  id='choice_1_19_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_2' id='label_1_19_2' class='gform-field-label gform-field-label--type-inline'>Internal Medicine (IM 3)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_19_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Psychiatry'  id='choice_1_19_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_3' id='label_1_19_3' class='gform-field-label gform-field-label--type-inline'>Psychiatry<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_19_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Anesthesia - Pain (Anesth 1)'  id='choice_1_19_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_4' id='label_1_19_4' class='gform-field-label gform-field-label--type-inline'>Anesthesia - Pain (Anesth 1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_19_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Anesthesia - Pain (Anesth 2)'  id='choice_1_19_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_5' id='label_1_19_5' class='gform-field-label gform-field-label--type-inline'>Anesthesia - Pain (Anesth 2)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_19_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Pediatrics'  id='choice_1_19_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_6' id='label_1_19_6' class='gform-field-label gform-field-label--type-inline'>Pediatrics<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_19_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Nephrology'  id='choice_1_19_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_7' id='label_1_19_7' class='gform-field-label gform-field-label--type-inline'>Nephrology<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_1_20\" ><legend class='gfield_label gform-field-label' >New York<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_20'>\n\t\t\t<div class='gchoice gchoice_1_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Internal Medicine'  id='choice_1_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_20_0' id='label_1_20_0' class='gform-field-label gform-field-label--type-inline'>Internal Medicine<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Nephrology'  id='choice_1_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_20_1' id='label_1_20_1' class='gform-field-label gform-field-label--type-inline'>Nephrology<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_1_21\" ><legend class='gfield_label gform-field-label' >Research Rotation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_21'>\n\t\t\t<div class='gchoice gchoice_1_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Northwestern Memorial University Medical Center (Research 1)'  id='choice_1_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_21_0' id='label_1_21_0' class='gform-field-label gform-field-label--type-inline'>Northwestern Memorial University Medical Center (Research 1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='University of Oklahoma Medical Center (Research 2)'  id='choice_1_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_21_1' id='label_1_21_1' class='gform-field-label gform-field-label--type-inline'>University of Oklahoma Medical Center (Research 2)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_22\" class=\"gfield gfield--type-radio 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