{"id":25831,"date":"2017-12-06T20:53:02","date_gmt":"2017-12-06T20:53:02","guid":{"rendered":"https:\/\/asburyseminary.edu\/?page_id=25831"},"modified":"2018-06-05T18:21:39","modified_gmt":"2018-06-05T18:21:39","slug":"shepherds-fund-application","status":"publish","type":"page","link":"https:\/\/asburyseminary.edu\/forms\/shepherds-fund-application\/","title":{"rendered":"Asbury Shepherd&#8217;s Fund Application"},"content":{"rendered":"<div style=\"padding:56.25% 0 0 0;position:relative;\"><iframe src=\"https:\/\/player.vimeo.com\/video\/253846477\" style=\"position:absolute;left:0;top:0;width:100%;height:100%;\" frameborder=\"0\" allowfullscreen><\/iframe><\/div>\n<p><script src=\"https:\/\/player.vimeo.com\/api\/player.js\"><\/script><\/p>\n<p><b>FOR RETIRED ASBURY SEMINARY ALUMNI AND THEIR SPOUSES<\/b><\/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_unknown gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_93' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_93'  action='\/wp-json\/wp\/v2\/pages\/25831' data-formid='93' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_93' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_93_2\" class=\"gfield gfield--type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_93_2\"><div class='ginput_container ginput_container_text'><input name='input_2' id='input_93_2' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='05\/08\/2024' \/><\/div><\/li><li id=\"field_93_3\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_93_3\"><label class='gfield_label gform-field-label' for='input_93_3'>Denomination<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_93_3' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_93_5\" 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_93_5\"><label class='gfield_label gform-field-label gfield_label_before_complex'>Full Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/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_93_5'>\n                            \n                            <span id='input_93_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto'>\n                                                    <input type='text' name='input_5.3' id='input_93_5_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_93_5_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_93_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto'>\n                                                    <input type='text' name='input_5.6' id='input_93_5_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_93_5_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_93_6\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_93_6\"><label class='gfield_label gform-field-label' for='input_93_6'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_6' id='input_93_6' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_93_6_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_93_6_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_93_6' class='gform_hidden' value='https:\/\/asburyseminary.edu\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_93_8\" 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_93_8\"><label class='gfield_label gform-field-label gfield_label_before_complex'>Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_93_8'>\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_93_8_1_container'>\n                                        <input type='text' name='input_8.1' id='input_93_8_1' value=''    aria-required='true'    \/>\n                                        <label for='input_93_8_1' id='input_93_8_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_93_8_2_container'>\n                                        <input type='text' name='input_8.2' id='input_93_8_2' value=''     aria-required='false'   \/>\n                                        <label for='input_93_8_2' id='input_93_8_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_93_8_3_container'>\n                                    <input type='text' name='input_8.3' id='input_93_8_3' value=''    aria-required='true'    \/>\n                                    <label for='input_93_8_3' id='input_93_8_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_93_8_4_container'>\n                                        <input type='text' name='input_8.4' id='input_93_8_4' value=''      aria-required='true'    \/>\n                                        <label for='input_93_8_4' id='input_93_8_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_93_8_5_container'>\n                                    <input type='text' name='input_8.5' id='input_93_8_5' value=''    aria-required='true'    \/>\n                                    <label for='input_93_8_5' id='input_93_8_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_93_8_6_container'>\n                                        <select name='input_8.6' id='input_93_8_6'   aria-required='true'><option value=''><\/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' selected='selected'>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_93_8_6' id='input_93_8_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><\/li><li id=\"field_93_9\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_93_9\"><label class='gfield_label gform-field-label' for='input_93_9'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_9' id='input_93_9' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_93_24\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_93_24\"><label class='gfield_label gform-field-label' for='input_93_24'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_24' id='input_93_24' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_93_10\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_93_10\"><label class='gfield_label gform-field-label' for='input_93_10'>SS#<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_93_10'>last 4 digits<\/div><div class='ginput_container ginput_container_text'><input name='input_10' id='input_93_10' type='text' value='' class='medium'  aria-describedby=\"gfield_description_93_10\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_93_11\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_93_11\"><label class='gfield_label gform-field-label' for='input_93_11'>Physician\u2019s name and phone number<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_93_11' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_93_12\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_93_12\"><label class='gfield_label gform-field-label' for='input_93_12'>Total Expected Medical Expense<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_93_12' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_93_13\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_93_13\"><label class='gfield_label gform-field-label' for='input_93_13'>Expense request for next 12 months<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_93_13' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_93_14\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_93_14\"><label class='gfield_label gform-field-label gfield_label_before_complex'>Connection with Asbury Seminary<\/label><div class='gfield_description' id='gfield_description_93_14'>Please indicate the following that apply<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_93_14'><li class='gchoice gchoice_93_14_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.1' type='checkbox'  value='Asbury Degree Received'  id='choice_93_14_1'   aria-describedby=\"gfield_description_93_14\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_93_14_1' id='label_93_14_1' class='gform-field-label gform-field-label--type-inline'>Asbury Degree Received<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_93_14_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.2' type='checkbox'  value='Spouse of Asbury Seminary graduate'  id='choice_93_14_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_14_2' id='label_93_14_2' class='gform-field-label gform-field-label--type-inline'>Spouse of Asbury Seminary graduate<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_93_14_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.3' type='checkbox'  value='Retired'  id='choice_93_14_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_14_3' id='label_93_14_3' class='gform-field-label gform-field-label--type-inline'>Retired<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_93_14_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.4' type='checkbox'  value='Disabled'  id='choice_93_14_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_14_4' id='label_93_14_4' class='gform-field-label gform-field-label--type-inline'>Disabled<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_93_14_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.5' type='checkbox'  value='Other'  id='choice_93_14_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_14_5' id='label_93_14_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_93_25\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_93_25\"><label class='gfield_label gform-field-label' for='input_93_25'>Spouse Details<\/label><div class='gfield_description' id='gfield_description_93_25'>Please provide your spouse's full name and graduation year.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_25' id='input_93_25' class='textarea medium'  aria-describedby=\"gfield_description_93_25\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_93_15\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_93_15\"><label class='gfield_label gform-field-label' for='input_93_15'>Degree Received<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_93_15' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_93_16\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_93_16\"><label class='gfield_label gform-field-label' for='input_93_16'>Years of Service in Ministry<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_93_16' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_93_17\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_93_17\"><label class='gfield_label gform-field-label' for='input_93_17'>Description<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_93_17'>Describe the medical situation you have encountered and the financial need you are experiencing as a result. \nInclude information regarding your capacity to meet that need.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_17' id='input_93_17' class='textarea medium'  aria-describedby=\"gfield_description_93_17\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_93_18\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_93_18\"><h2 class=\"gsection_title\">Denominational Leadership Contact<\/h2><div class='gsection_description' id='gfield_description_93_18'>Please provide contact information (Name, Phone # and email address) for your denominational leadership, to verify good standing in your denomination<\/div><\/li><li id=\"field_93_19\" 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_93_19\"><label class='gfield_label gform-field-label 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gform-grid-col gform-grid-col--size-auto'>\n                                                    <input type='text' name='input_19.6' id='input_93_19_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_93_19_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_93_20\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_93_20\"><label class='gfield_label gform-field-label' for='input_93_20'>Position\/Title<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_93_20' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_93_21\" class=\"gfield gfield--type-phone 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