{"id":5009,"date":"2026-07-23T13:37:51","date_gmt":"2026-07-23T20:37:51","guid":{"rendered":"https:\/\/uwm211.org\/?page_id=5009"},"modified":"2026-07-23T13:37:51","modified_gmt":"2026-07-23T20:37:51","slug":"211-nebraska-warmline-online-referral-form","status":"publish","type":"page","link":"https:\/\/uwm211.org\/fr\/211-nebraska-warmline-online-referral-form\/","title":{"rendered":"211 Nebraska Warmline Online Referral Form"},"content":{"rendered":"<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_9_container\" data-token=\"3ba9f0329d85a028610fc77a8820cc4d\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_6dz7k\" data-token=\"3ba9f0329d85a028610fc77a8820cc4d\">\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">211 Nebraska Warmline Referral Form<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"9\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_9\" id=\"frm_hide_fields_9\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"6dz7k\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_9\" name=\"frm_submit_entry_9\" value=\"b9421b0cea\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/fr\/wp-json\/wp\/v2\/pages\/5009\" \/><div id=\"frm_field_94_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<div  id=\"field_ijkmq_label\" class=\"frm_primary_label\">Name\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_ijkmq_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tName\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_94\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_94-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_ijkmq_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tFirst Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_ijkmq_first\" value=\"\" name=\"item_meta[94][first]\" autocomplete=\"given-name\" data-reqmsg=\"Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name est non valide\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_94_first_desc\">First Name<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_94-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_ijkmq_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tLast Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_ijkmq_last\" value=\"\" name=\"item_meta[94][last]\" autocomplete=\"family-name\" data-reqmsg=\"Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name est non valide\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_94_last_desc\">Last Name<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_95_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_ur634\" id=\"field_ur634_label\" class=\"frm_primary_label\">Phone\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_ur634\" name=\"item_meta[95]\" value=\"\"  data-reqmsg=\"Phone cannot be blank.\" aria-required=\"true\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_96_container\" class=\"frm_form_field form-field  frm_top_container frm6 frm_first\">\r\n\t<label for=\"field_l63jb\" id=\"field_l63jb_label\" class=\"frm_primary_label\">Gender\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_l63jb\" name=\"item_meta[96]\" value=\"\"  data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_97_container\" class=\"frm_form_field form-field  frm_top_container frm6\">\r\n\t<label for=\"field_ts40m\" id=\"field_ts40m_label\" class=\"frm_primary_label\">Age\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<div class=\"frm_with_box\"><input  type=\"text\" id=\"field_ts40m\" name=\"item_meta[97]\" value=\"\"  data-invmsg=\"Age is invalid\" class=\"frm-has-number-format\" aria-invalid=\"false\"   \/><\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_98_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<div  id=\"field_whgrt_label\" class=\"frm_primary_label\">Address\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_whgrt_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tAddress<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_98-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_whgrt_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress\t<\/label>\n\t\t<input type=\"text\" id=\"field_whgrt_line1\" value=\"\" name=\"item_meta[98][line1]\"  data-invmsg=\"Address est non valide\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_98-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_whgrt_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress\t<\/label>\n\t\t<input type=\"text\" id=\"field_whgrt_line2\" value=\"\" name=\"item_meta[98][line2]\"  data-invmsg=\"Address est non valide\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_98-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_whgrt_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_whgrt_city\" value=\"\" name=\"item_meta[98][city]\"  data-invmsg=\"Address est non valide\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_98-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_whgrt_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\t<\/label>\n\t\t<input type=\"text\" id=\"field_whgrt_state\" value=\"\" name=\"item_meta[98][state]\"  data-invmsg=\"Address est non valide\" aria-invalid=\"false\"   autocomplete=\"address-level1\" \/>\n\t<div class=\"frm_description\">State\/Province<\/div><\/div>\n<div id=\"frm_field_98-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_whgrt_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_whgrt_zip\" value=\"\" name=\"item_meta[98][zip]\"  data-invmsg=\"Address est non valide\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal<\/div><\/div>\n<div id=\"frm_field_98-country_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_whgrt_country\" class=\"frm_screen_reader frm_hidden\">\n\t\tCountry\t<\/label>\n\t\t\t<select name=\"item_meta[98][country]\" id=\"field_whgrt_country\"  data-invmsg=\"Address est non valide\" aria-invalid=\"false\"   autocomplete=\"country-name\">\n\t\t\t<option value=\"\" class=\"\">\n\t\t\t\t \t\t\t<\/option>\n\t\t\t<option  value=\"Afghanistan\" data-code=\"AF\">Afghanistan<\/option><option  value=\"Afrique du Sud\">Afrique du Sud<\/option><option  value=\"Albanie\">Albanie<\/option><option  value=\"Alg\u00e9rie\">Alg\u00e9rie<\/option><option  value=\"Allemagne\">Allemagne<\/option><option  value=\"Andorre\">Andorre<\/option><option  value=\"Angolie\">Angolie<\/option><option  value=\"Anguilla\" data-code=\"AI\">Anguilla<\/option><option  value=\"Antartique\">Antartique<\/option><option  value=\"Antigua and Barbuda\" data-code=\"AG\">Antigua and Barbuda<\/option><option  value=\"Arabie Saoudite\">Arabie Saoudite<\/option><option  value=\"Argentine\">Argentine<\/option><option  value=\"Arm\u00e9nie\">Arm\u00e9nie<\/option><option  value=\"Aruba\" data-code=\"AW\">Aruba<\/option><option  value=\"Australie\">Australie<\/option><option  value=\"Autriche\">Autriche<\/option><option  value=\"Azerbaijan\" data-code=\"AZ\">Azerbaijan<\/option><option  value=\"Bahamas\" data-code=\"BS\">Bahamas<\/option><option  value=\"Bahre\u00efn\">Bahre\u00efn<\/option><option  value=\"Barbade (la)\">Barbade (la)<\/option><option  value=\"Belgique\">Belgique<\/option><option  value=\"Belize\" data-code=\"BZ\">Belize<\/option><option  value=\"Bengladesh\">Bengladesh<\/option><option  value=\"Bermudes\">Bermudes<\/option><option  value=\"Bhoutan\">Bhoutan<\/option><option  value=\"Bi\u00e9lorussie\">Bi\u00e9lorussie<\/option><option  value=\"Bolivie\">Bolivie<\/option><option  value=\"Bonaire, Saint-Eustache et Saba\">Bonaire, Saint-Eustache et Saba<\/option><option  value=\"Bosnie-Herz\u00e9govine\">Bosnie-Herz\u00e9govine<\/option><option  value=\"Botswana\" data-code=\"BW\">Botswana<\/option><option  value=\"Brunei\" data-code=\"BN\">Brunei<\/option><option  value=\"Br\u00e9sil\">Br\u00e9sil<\/option><option  value=\"Bulgarie\">Bulgarie<\/option><option  value=\"Burkina Faso\" data-code=\"BF\">Burkina Faso<\/option><option  value=\"Burundi\" data-code=\"BI\">Burundi<\/option><option  value=\"B\u00e9nin\">B\u00e9nin<\/option><option  value=\"Cambodge\">Cambodge<\/option><option  value=\"Cameroun\">Cameroun<\/option><option  value=\"Canada\" data-code=\"CA\">Canada<\/option><option  value=\"Cap-Vert\">Cap-Vert<\/option><option  value=\"Chili\">Chili<\/option><option  value=\"Chine\">Chine<\/option><option  value=\"Chypre\">Chypre<\/option><option  value=\"Cit\u00e9 du Vatican\">Cit\u00e9 du Vatican<\/option><option  value=\"Colombie\">Colombie<\/option><option  value=\"Comores\">Comores<\/option><option  value=\"Congo\">Congo<\/option><option  value=\"Cor\u00e9e du Nord\">Cor\u00e9e du Nord<\/option><option  value=\"Cor\u00e9e du sud\">Cor\u00e9e du sud<\/option><option  value=\"Costa Rica\" data-code=\"CR\">Costa Rica<\/option><option  value=\"Croatie\">Croatie<\/option><option  value=\"Cuba\" data-code=\"CU\">Cuba<\/option><option  value=\"Cura\u00e7ao\">Cura\u00e7ao<\/option><option  value=\"C\u00f4te d\u2019Ivoire\">C\u00f4te d\u2019Ivoire<\/option><option  value=\"Danemark\">Danemark<\/option><option  value=\"Djibouti\" data-code=\"DJ\">Djibouti<\/option><option  value=\"Dominique\">Dominique<\/option><option  value=\"Espagne\">Espagne<\/option><option  value=\"Estonie\">Estonie<\/option><option  value=\"Fidji\">Fidji<\/option><option  value=\"Finlande\">Finlande<\/option><option  value=\"France\" data-code=\"FR\">France<\/option><option  value=\"Gabon\" data-code=\"GA\">Gabon<\/option><option  value=\"Gambie\">Gambie<\/option><option  value=\"Ghana\" data-code=\"GH\">Ghana<\/option><option  value=\"Gibraltar\" data-code=\"GI\">Gibraltar<\/option><option  value=\"Grenade\">Grenade<\/option><option  value=\"Groenland\">Groenland<\/option><option  value=\"Gr\u00e8ce\">Gr\u00e8ce<\/option><option  value=\"Guadeloupe\" data-code=\"GP\">Guadeloupe<\/option><option  value=\"Guam\" data-code=\"GU\">Guam<\/option><option  value=\"Guatemala\" data-code=\"GT\">Guatemala<\/option><option  value=\"Guernesey\">Guernesey<\/option><option  value=\"Guin\u00e9e\">Guin\u00e9e<\/option><option  value=\"Guin\u00e9e Bissau\">Guin\u00e9e Bissau<\/option><option  value=\"Guin\u00e9e \u00c9quatoriale\">Guin\u00e9e \u00c9quatoriale<\/option><option  value=\"Guyane\">Guyane<\/option><option  value=\"Guyane Fran\u00e7aise\">Guyane Fran\u00e7aise<\/option><option  value=\"G\u00e9orgie\">G\u00e9orgie<\/option><option  value=\"G\u00e9orgie du Sud et \u00eeles Sandwich du Sud\">G\u00e9orgie du Sud et \u00eeles Sandwich du Sud<\/option><option  value=\"Ha\u00efti\">Ha\u00efti<\/option><option  value=\"Honduras\" data-code=\"HN\">Honduras<\/option><option  value=\"Hong Kong\" data-code=\"HK\">Hong Kong<\/option><option  value=\"Hongrie\">Hongrie<\/option><option  value=\"Iles Falkland (Malouines)\">Iles Falkland (Malouines)<\/option><option  value=\"Inde\">Inde<\/option><option  value=\"Indon\u00e9sie\">Indon\u00e9sie<\/option><option  value=\"Iran\" data-code=\"IR\">Iran<\/option><option  value=\"Iraq\" data-code=\"IQ\">Iraq<\/option><option  value=\"Irlande\">Irlande<\/option><option  value=\"Islande\">Islande<\/option><option  value=\"Isra\u00ebl\">Isra\u00ebl<\/option><option  value=\"Italie\">Italie<\/option><option  value=\"Jama\u00efque\">Jama\u00efque<\/option><option  value=\"Japon\">Japon<\/option><option  value=\"Jersey\" data-code=\"JE\">Jersey<\/option><option  value=\"Jordanie\">Jordanie<\/option><option  value=\"Kazakhstan\" data-code=\"KZ\">Kazakhstan<\/option><option  value=\"Kenia\">Kenia<\/option><option  value=\"Kirghizistan\">Kirghizistan<\/option><option  value=\"Kiribati\" data-code=\"KI\">Kiribati<\/option><option  value=\"Kosovo\" data-code=\"XK\">Kosovo<\/option><option  value=\"Koweit\">Koweit<\/option><option  value=\"La R\u00e9union\">La R\u00e9union<\/option><option  value=\"Laos\" data-code=\"LA\">Laos<\/option><option  value=\"Lesotho\" data-code=\"LS\">Lesotho<\/option><option  value=\"Lettonie\">Lettonie<\/option><option  value=\"Liban\">Liban<\/option><option  value=\"Libye\">Libye<\/option><option  value=\"Lib\u00e9ria\">Lib\u00e9ria<\/option><option  value=\"Liechtenstein\" data-code=\"LI\">Liechtenstein<\/option><option  value=\"Lituanie\">Lituanie<\/option><option  value=\"Luxembourg\" data-code=\"LU\">Luxembourg<\/option><option  value=\"Macao\" data-code=\"MO\">Macao<\/option><option  value=\"Mac\u00e9doine\">Mac\u00e9doine<\/option><option  value=\"Madagascar\" data-code=\"MG\">Madagascar<\/option><option  value=\"Malaisie\">Malaisie<\/option><option  value=\"Malawi\" data-code=\"MW\">Malawi<\/option><option  value=\"Maldives\" data-code=\"MV\">Maldives<\/option><option  value=\"Mali\" data-code=\"ML\">Mali<\/option><option  value=\"Malte\">Malte<\/option><option  value=\"Maroc\">Maroc<\/option><option  value=\"Martinique\" data-code=\"MQ\">Martinique<\/option><option  value=\"Mauritanie\">Mauritanie<\/option><option  value=\"Mayotte\" data-code=\"YT\">Mayotte<\/option><option  value=\"Mexique\">Mexique<\/option><option  value=\"Micron\u00e9sie\">Micron\u00e9sie<\/option><option  value=\"Moldavie\">Moldavie<\/option><option  value=\"Monaco\" data-code=\"MC\">Monaco<\/option><option  value=\"Mongolie\">Mongolie<\/option><option  value=\"Montserrat\" data-code=\"MS\">Montserrat<\/option><option  value=\"Mont\u00e9n\u00e9gro\">Mont\u00e9n\u00e9gro<\/option><option  value=\"Mozambique\" data-code=\"MZ\">Mozambique<\/option><option  value=\"Myanmar\" data-code=\"MM\">Myanmar<\/option><option  value=\"Namibie\">Namibie<\/option><option  value=\"Nauru\" data-code=\"NR\">Nauru<\/option><option  value=\"Nepal\" data-code=\"NP\">Nepal<\/option><option  value=\"Nicaragua\" data-code=\"NI\">Nicaragua<\/option><option  value=\"Niger\" data-code=\"NE\">Niger<\/option><option  value=\"Nig\u00e9ria\">Nig\u00e9ria<\/option><option  value=\"Niue\" data-code=\"NU\">Niue<\/option><option  value=\"Norv\u00e8ge\">Norv\u00e8ge<\/option><option  value=\"Nouvelle Z\u00e9lande\">Nouvelle Z\u00e9lande<\/option><option  value=\"Nouvelle-Cal\u00e9donie\">Nouvelle-Cal\u00e9donie<\/option><option  value=\"Oman\" data-code=\"OM\">Oman<\/option><option  value=\"Ouganda\">Ouganda<\/option><option  value=\"Ouzb\u00e9kistan\">Ouzb\u00e9kistan<\/option><option  value=\"Pakistan\" data-code=\"PK\">Pakistan<\/option><option  value=\"Palau\" data-code=\"PW\">Palau<\/option><option  value=\"Palestine\">Palestine<\/option><option  value=\"Panama\" data-code=\"PA\">Panama<\/option><option  value=\"Papouasie-Nouvelle-Guin\u00e9e\">Papouasie-Nouvelle-Guin\u00e9e<\/option><option  value=\"Paraguay\" data-code=\"PY\">Paraguay<\/option><option  value=\"Pays-Bas\">Pays-Bas<\/option><option  value=\"Philippines\" data-code=\"PH\">Philippines<\/option><option  value=\"Pitcairn\" data-code=\"PN\">Pitcairn<\/option><option  value=\"Pologne\">Pologne<\/option><option  value=\"Polyn\u00e9sie Fran\u00e7aise\">Polyn\u00e9sie Fran\u00e7aise<\/option><option  value=\"Portugal\" data-code=\"PT\">Portugal<\/option><option  value=\"Puerto Rico\" data-code=\"PR\">Puerto Rico<\/option><option  value=\"P\u00e9rou\">P\u00e9rou<\/option><option  value=\"Qatar\" data-code=\"QA\">Qatar<\/option><option  value=\"Roumanie\">Roumanie<\/option><option  value=\"Rouwanda\">Rouwanda<\/option><option  value=\"Royaume-Uni\">Royaume-Uni<\/option><option  value=\"Russie\">Russie<\/option><option  value=\"R\u00e9publique Dominicaine\">R\u00e9publique Dominicaine<\/option><option  value=\"R\u00e9publique Tch\u00e8que\">R\u00e9publique Tch\u00e8que<\/option><option  value=\"R\u00e9publique centrafricaine\">R\u00e9publique centrafricaine<\/option><option  value=\"Sahara occidental\">Sahara occidental<\/option><option  value=\"Saint Barthelemy\" data-code=\"BL\">Saint Barthelemy<\/option><option  value=\"Saint Vincent et les Grenadines\">Saint Vincent et les Grenadines<\/option><option  value=\"Saint-Christophe-et-Ni\u00e9v\u00e8s\">Saint-Christophe-et-Ni\u00e9v\u00e8s<\/option><option  value=\"Saint-Martin (partie fran\u00e7aise)\">Saint-Martin (partie fran\u00e7aise)<\/option><option  value=\"Saint-Pierre-et-Miquelon\">Saint-Pierre-et-Miquelon<\/option><option  value=\"Saint-Si\u00e8ge\">Saint-Si\u00e8ge<\/option><option  value=\"Sainte-H\u00e9l\u00e8ne, Ascension et Tristan de Cunha\">Sainte-H\u00e9l\u00e8ne, Ascension et Tristan de Cunha<\/option><option  value=\"Sainte-Lucie\">Sainte-Lucie<\/option><option  value=\"Salvador (le)\">Salvador (le)<\/option><option  value=\"Samoa\" data-code=\"WS\">Samoa<\/option><option  value=\"San Marino\" data-code=\"SM\">San Marino<\/option><option  value=\"Sao Tome and Principe\" data-code=\"ST\">Sao Tome and Principe<\/option><option  value=\"Senegal\" data-code=\"SN\">Senegal<\/option><option  value=\"Serbie\">Serbie<\/option><option  value=\"Seychelles\" data-code=\"SC\">Seychelles<\/option><option  value=\"Sierra Leone\" data-code=\"SL\">Sierra Leone<\/option><option  value=\"Singapour\">Singapour<\/option><option  value=\"Sint Maarten (partie hollandaise)\">Sint Maarten (partie hollandaise)<\/option><option  value=\"Slovaquie\">Slovaquie<\/option><option  value=\"Slov\u00e9nie\">Slov\u00e9nie<\/option><option  value=\"Somalie\">Somalie<\/option><option  value=\"Soudan\">Soudan<\/option><option  value=\"Soudan du Sud\">Soudan du Sud<\/option><option  value=\"Sri Lanka\" data-code=\"LK\">Sri Lanka<\/option><option  value=\"Suisse\">Suisse<\/option><option  value=\"Surinam\">Surinam<\/option><option  value=\"Su\u00e8de\">Su\u00e8de<\/option><option  value=\"Svalbard et Jan Mayen\">Svalbard et Jan Mayen<\/option><option  value=\"Swaziland\" data-code=\"SZ\">Swaziland<\/option><option  value=\"Syrie\">Syrie<\/option><option  value=\"Tadjikistan\">Tadjikistan<\/option><option  value=\"Taiwan\" data-code=\"TW\">Taiwan<\/option><option  value=\"Tanzanie\">Tanzanie<\/option><option  value=\"Tchad\">Tchad<\/option><option  value=\"Terres australes et antarctiques fran\u00e7aises\">Terres australes et antarctiques fran\u00e7aises<\/option><option  value=\"Territoire britannique de l\u2019oc\u00e9an Indien\">Territoire britannique de l\u2019oc\u00e9an Indien<\/option><option  value=\"Tha\u00eflande\">Tha\u00eflande<\/option><option  value=\"Timor oriental\">Timor oriental<\/option><option  value=\"Timor-Oriental\">Timor-Oriental<\/option><option  value=\"Togo\" data-code=\"TG\">Togo<\/option><option  value=\"Tok\u00e9laou\">Tok\u00e9laou<\/option><option  value=\"Tonga\" data-code=\"TO\">Tonga<\/option><option  value=\"Trinit\u00e9-et-Tobago\">Trinit\u00e9-et-Tobago<\/option><option  value=\"Tunisie\">Tunisie<\/option><option  value=\"Turkm\u00e9nistan\">Turkm\u00e9nistan<\/option><option  value=\"Turquie\">Turquie<\/option><option  value=\"Tuvalu\" data-code=\"TV\">Tuvalu<\/option><option  value=\"Ukraine\" data-code=\"UA\">Ukraine<\/option><option  value=\"Uruguay\" data-code=\"UY\">Uruguay<\/option><option  value=\"Vanuatu\" data-code=\"VU\">Vanuatu<\/option><option  value=\"Vietnam\" data-code=\"VN\">Vietnam<\/option><option  value=\"V\u00e9n\u00e9zu\u00e9la\">V\u00e9n\u00e9zu\u00e9la<\/option><option  value=\"Wallis et Futuna\">Wallis et Futuna<\/option><option  value=\"Y\u00e9men\">Y\u00e9men<\/option><option  value=\"Zambie\">Zambie<\/option><option  value=\"Zimbabwe\" data-code=\"ZW\">Zimbabwe<\/option><option  value=\"\u00c9gypte\">\u00c9gypte<\/option><option  value=\"\u00c9mirats Arabes Unis\">\u00c9mirats Arabes Unis<\/option><option  value=\"\u00c9quateur\">\u00c9quateur<\/option><option  value=\"\u00c9rythr\u00e9e (l\u2019)\">\u00c9rythr\u00e9e (l\u2019)<\/option><option  value=\"\u00c9tats-Unis\">\u00c9tats-Unis<\/option><option  value=\"\u00c9thiopie\">\u00c9thiopie<\/option><option  value=\"\u00cele Bouvet\">\u00cele Bouvet<\/option><option  value=\"\u00cele Christmas\">\u00cele Christmas<\/option><option  value=\"\u00cele Maurice\">\u00cele Maurice<\/option><option  value=\"\u00cele Norfolk\">\u00cele Norfolk<\/option><option  value=\"\u00cele de Man\">\u00cele de Man<\/option><option  value=\"\u00celes Ca\u00efmans\">\u00celes Ca\u00efmans<\/option><option  value=\"\u00celes Cocos\">\u00celes Cocos<\/option><option  value=\"\u00celes Cook\">\u00celes Cook<\/option><option  value=\"\u00celes Falkland\">\u00celes Falkland<\/option><option  value=\"\u00celes F\u00e9ro\u00e9\">\u00celes F\u00e9ro\u00e9<\/option><option  value=\"\u00celes Heard-et-MacDonald\">\u00celes Heard-et-MacDonald<\/option><option  value=\"\u00celes Mariannes du Nord\">\u00celes Mariannes du Nord<\/option><option  value=\"\u00celes Marshall\">\u00celes Marshall<\/option><option  value=\"\u00celes Salomon\">\u00celes Salomon<\/option><option  value=\"\u00celes Samoa Am\u00e9ricaines\">\u00celes Samoa Am\u00e9ricaines<\/option><option  value=\"\u00celes Turques et Ca\u00efques\">\u00celes Turques et Ca\u00efques<\/option><option  value=\"\u00celes Vierges britanniques\">\u00celes Vierges britanniques<\/option><option  value=\"\u00celes Vierges des \u00c9tats-Unis\">\u00celes Vierges des \u00c9tats-Unis<\/option><option  value=\"\u00celes mineures am\u00e9ricaines\">\u00celes mineures am\u00e9ricaines<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">Country<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_99_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_r387r\" id=\"field_r387r_label\" class=\"frm_primary_label\">Please Provide a Brief Description of Need\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[99]\" id=\"field_r387r\" rows=\"5\"  data-reqmsg=\"Please Provide a Brief Description of Need cannot be blank.\" aria-required=\"true\" data-invmsg=\"Please Provide a Brief Description of Need is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_100_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n\t<div  id=\"field_76m98_label\" class=\"frm_primary_label\">Who is Filling Out this Form?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_76m98_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_100-0\">\t\t\t<label  for=\"field_76m98-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[100][]\" id=\"field_76m98-0\" value=\"Myself\"  data-invmsg=\"Who is Filling Out this Form? is invalid\"   \/> Myself<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_100-1\">\t\t\t<label  for=\"field_76m98-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[100][]\" id=\"field_76m98-1\" value=\"Other (Family, Friend, Community Worker, etc.)\"  data-invmsg=\"Who is Filling Out this Form? is invalid\"   \/> Other (Family, Friend, Community Worker, etc.)<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_93_container\" class=\"frm_form_field form-field  frm12 frm_first\">\r\n\t<div class=\"frm_submit frm_flex\">\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"  >Submit<\/button>\r\n\r\n\r\n\r\n<\/div>\r\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_101_container\">\n\t\t\t<label for=\"field_o3xde\" >\n\t\t\t\tSi vous \u00eates un humain, ne remplissez pas ce champ.\t\t\t<\/label>\n\t\t\t<input  id=\"field_o3xde\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[101]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"Me57AtOcHfCtcii7VXqpCCps+sGtX8h5UKl7ToRQS1s98opAQsZIrGSQKk1taDqS\" \/><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":10,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"page_tag":[],"class_list":["post-5009","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/uwm211.org\/fr\/wp-json\/wp\/v2\/pages\/5009","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/uwm211.org\/fr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/uwm211.org\/fr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/uwm211.org\/fr\/wp-json\/wp\/v2\/users\/10"}],"replies":[{"embeddable":true,"href":"https:\/\/uwm211.org\/fr\/wp-json\/wp\/v2\/comments?post=5009"}],"version-history":[{"count":1,"href":"https:\/\/uwm211.org\/fr\/wp-json\/wp\/v2\/pages\/5009\/revisions"}],"predecessor-version":[{"id":5010,"href":"https:\/\/uwm211.org\/fr\/wp-json\/wp\/v2\/pages\/5009\/revisions\/5010"}],"wp:attachment":[{"href":"https:\/\/uwm211.org\/fr\/wp-json\/wp\/v2\/media?parent=5009"}],"wp:term":[{"taxonomy":"page_tag","embeddable":true,"href":"https:\/\/uwm211.org\/fr\/wp-json\/wp\/v2\/page_tag?post=5009"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}