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1</head><body><!-- HEADER --><header id="cc_header" class="cc_header"><div id="google_translate_element"></div><div class="cc_navfluid container-fluid"><div class="cc_nav_container w-100"><nav class="cc_navbar navbar navbar-expand-xl navbar-light d-xl-flex d-none align-items-center justify-content-between float-left w-100"><div class="collapse justify-content-between navbar-collapse cc_navwrap w-100" id="navbarNav"><div class="d-flex logo_sec"><a class="cc_logo_main pull-left main_logo" href="/"><img alt="Site Logo" src="/files/images/capcalogo.png" class="img-fluid"></a></div><div class="menu_wrap"><div class="top_content"><div class="resource_btn d-inline-block"><a href="/resources" class="res_link"> Resources </a></div><div class="search-form d-inline-block"><input class="form-control search_now searchvalue" name="search" type="search" placeholder="Search here..." value=""><button class="btn search_items" type="button"><i class="fa fa-search" aria-hidden="true"></i></button></div></div><ul class="cc_nav_right_secondary navbar-nav nav"><li class="nav-item menu_toggle"><button class="cc_navtoggle_secondary open" type="button"><span>Menu </span><i class="pb-menu-close" aria-hidden="true"></i></button></li><li class="nav-item nav-donate-btn j_btn"><a class="nav-link shop_now" href="/how-do-i/apply#employment">Join Our Team</a></li><ul class="pb_navlink_secondary"> <li class=" nav-item"> <a href="https://capcainc.org/who-we-are" class="nav-link" > TEAM HIGHLIGHTS </a> <li class=" nav-item"> <a href="https://capcainc.org/what-we-do" class="nav-link" > Programs &amp; Services </a> <li class=" nav-item"> <a href="https://capcainc.org/engagement-opportunities" class="nav-link" > VOLUNTEER </a> <li class="nav-item nav-donate-btn"><a class="nav-link shop_now" href="https://capcainc.org/posts/supply-drive">Donate</a></li></ul><div class="mob_only"><a class="nav-link shop_now" href="/how-do-i/apply#employment">Join Our Team</a></div></div></div><button class="cc_navtoggle_secondary" type="button"><span>Menu</span><i class="pb-menu-open" aria-hidden="true"></i></button></nav></div></div></header><!-- HEADER --> <section id="team" class="team-area"><div class="container page_inner"><div class="row innerrow"><div class="col-lg-3 col-md-4 inner_tabs"><ul class="nav nav-tabs tabs-left sideways"><li><a href="#board" data-toggle="tab" class="active">Board Member Application</a></li><li><a href="#employment" data-toggle="tab">Employment Application</a></li><li><a href="#volunteer" data-toggle="tab">Volunteer Application</a></li></ul></div><div class="col-lg-9 col-md-8"><div class="tab-content"><div class="tab-pane active" id="board"><div class="container"><div class="row form_row"><div class="col-lg-12"><h4>Board Member Application</h4></div><div class="col-lg-10 career_form"><div class="stepwizard"><div class="stepwizard-row setup-panel"><div class="stepwizard-step col-xs-3"> <a href="#step-1" class="btn btn-success btn-circle cust_but_1">1</a></div><div class="stepwizard-step col-xs-3"> <a href="#step-2" class="btn btn-default btn-circle cust_but_2" disabled="disabled">2</a></div><div class="stepwizard-step col-xs-3"> <a href="#step-3" class="btn btn-default btn-circle cust_but_3" disabled="disabled">3</a></div><div class="stepwizard-step col-xs-3"> <a href="#step-4" class="btn btn-default btn-circle cust_but_4" disabled="disabled">4</a></div></div></div><form method="POST" action="https://capcainc.org/form/handle/b9c56f9b27c2a9c183d45042d20de82b" accept-charset="UTF-8" enctype="multipart/form-data"><input name="_token" type="hidden" value="8vlpbN59Bo9Ud3jieIWu9iwffAeqTKdg7uGkIgzd"><div class="panel panel-primary setup-content" id="step-1"><div class="panel-body"><div class="row"><div class="form-group col-md-12"><label class="control-label">Referral Source</label><div data-field="referral_source" data-field_name="referral_source" data-provides="anomaly.field_type.select"> <label class=" custom-radio" style="display: block;"> <input type="radio" value="Advertisement" name="referral_source" > <span class=""></span> Advertisement </label> <label class=" custom-radio" style="display: block;"> <input type="radio" value="Staff" name="referral_source" > <span class=""></span> Staff </label> <label class=" custom-radio" style="display: block;"> <input type="radio" value="Board Member" name="referral_source" > <span class=""></span> Board Member </label> <label class=" custom-radio" style="display: block;"> <input type="radio" value="Website" name="referral_source" > <span class=""></span> Website </label> <label class=" custom-radio" style="display: block;"> <input type="radio" value="Other" name="referral_source" > <span class=""></span> Other </label> </div></div><div class="form-group col-md-12"><label class="control-label">Other</label><input value="" name="other" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Other" class="form-control" data-field="other" data-field_name="other" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6"><label class="control-label">First Name <span>*</span></label><input value="" name="first_name" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="First Name" class="form-control" data-field="first_name" data-field_name="first_name" data-provides="anomaly.field_type.text" required="required" required ></div><div class="form-group col-md-6"><label class="control-label">Last Name</label><input value="" name="last_name" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Last Name" class="form-control" data-field="last_name" data-field_name="last_name" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6"><label class="control-label">Street Address <span>*</span></label><input value="" name="street_address" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Street Address" class="form-control" data-field="street_address" data-field_name="street_address" data-provides="anomaly.field_type.text" required="required" ></div><div class="form-group col-md-6"><label class="control-label">Address Line 2</label><input value="" name="address_line_2" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Address Line 2" class="form-control" data-field="address_line_2" data-field_name="address_line_2" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6"><label class="control-label">City</label><input value="" name="city" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="City" class="form-control" data-field="city" data-field_name="city" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6"><label class="control-label">State / Province / Region</label><input value="" name="state_province_region" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="State" class="form-control" data-field="state_province_region" data-field_name="state_province_region" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6"><label class="control-label">ZIP / Postal Code</label><input value="" name="zip_postal_code" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Zip code" class="form-control" data-field="zip_postal_code" data-field_name="zip_postal_code" data-provides="anomaly.field_type.text" id="zip_code" ></div><div class="form-group col-md-6"><label class="control-label">Country</label><input value="" name="country" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Country" class="form-control" data-field="country" data-field_name="country" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-12"><label class="control-label">I am available to meet</label><div class="custom-inputs-stacked"> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Monday" name="available_to_meet[]" > <span class=""></span> Monday </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Tuesday" name="available_to_meet[]" > <span class=""></span> Tuesday </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Wednesday" name="available_to_meet[]" > <span class=""></span> Wednesday </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Thursday" name="available_to_meet[]" > <span class=""></span> Thursday </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Friday" name="available_to_meet[]" > <span class=""></span> Friday </label> </div></div><div class="form-group col-md-6"><label class="control-label">From:</label><div class="bft_time cust-timepicker"><input value="" name="from" data-max="20" data-mask="" data-alias="" data-regex="" type="text" placeholder="" class="form-control" data-field="from" data-field_name="from" data-provides="anomaly.field_type.text" ></div></div><div class="form-group col-md-6"><label class="control-label">Untill:</label><div class="bft_time cust-timepicker"><input value="" name="until" data-max="20" data-mask="" data-alias="" data-regex="" type="text" placeholder="" class="form-control" data-field="until" data-field_name="until" data-provides="anomaly.field_type.text" ></div></div><div class="form-group col-md-6"><label class="control-label">Email<span>*</span></label><input type="email" value="" name="email" placeholder="[email protected]" class="form-control" data-field="email" data-field_name="email" data-provides="anomaly.field_type.email" required="required" ></div><div class="form-group col-md-6"><label class="control-label">Phone</label> <input value="" name="phone" data-max="255" data-mask="(999) 999-9999" data-alias="" data-regex="" type="text" placeholder="Phone" class="form-control" data-field="phone" data-field_name="phone" data-provides="anomaly.field_type.text" id="form_phone" ></div><div class="form-group col-md-6"><label class="control-label">Best time to call</label><div class="bft_time cust-timepicker"><input value="" name="best_time_to_call" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="10:00 AM" class="form-control" data-field="best_time_to_call" data-field_name="best_time_to_call" data-provides="anomaly.field_type.text" ></div></div><div class="form-group col-md-6"><label class="control-label">Occupation</label><input value="" name="occupation" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Occupation" class="form-control" data-field="occupation" data-field_name="occupation" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-12"><label class="control-label">Have you been convicted of a felony within the last 7 years? <span>*</span></label><div data-field="convicted_of_a_felony" data-field_name="convicted_of_a_felony" data-provides="anomaly.field_type.select" required="required" id="check_felony"> <label class=" custom-radio" style="display: block;"> <input type="radio" value="Yes" name="convicted_of_a_felony" > <span class=""></span> Yes </label> <label class=" custom-radio" style="display: block;"> <input type="radio" value="No" name="convicted_of_a_felony" > <span class=""></span> No </label> </div></div><div class="form-group col-md-12"><button id="brd_nxt_1" class="btn btn-primary nextBtn" type="button">Next</button></div></div></div></div><div class="panel panel-primary setup-content" id="step-2"><!-- <div class="panel-heading"><h3 class="panel-title">Personal History</h3></div> --><div class="panel-body"><div class="row"><div class="form-group col-md-12"><label class="control-label">SKILLS AND QUALIFICATIONS: Summarize any special training, skills, licenses, certificates and/or characteristics that may qualify 
1you as Governing Board member.</label><textarea name="skills_and_qualifications" data-max="" rows="6" data-autogrow="1" placeholder="" class="form-control" data-field="skills_and_qualifications" data-field_name="skills_and_qualifications" data-provides="anomaly.field_type.textarea" ></textarea></div><div class="form-group col-md-12"><label class="control-label">Please Check any/all That Apply</label><div class="custom-inputs-stacked"> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="I am/have Current or Former Head Start Parent" name="please_check[]" > <span class=""></span> I am/have Current or Former Head Start Parent </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Licensed Attorney" name="please_check[]" > <span class=""></span> Licensed Attorney </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="CPA, Accountant or have Fiscal Background" name="please_check[]" > <span class=""></span> CPA, Accountant or have Fiscal Background </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Degree in Early Childhood Education" name="please_check[]" > <span class=""></span> Degree in Early Childhood Education </label> </div></div><div class="form-group col-md-12"><label class="control-label">List professional, trade, business, or civic associations and any offices held.</label><textarea name="professional_trade" data-max="" rows="6" data-autogrow="1" placeholder="" class="form-control" data-field="professional_trade" data-field_name="professional_trade" data-provides="anomaly.field_type.textarea" ></textarea></div><div class="form-group col-md-12"><label class="control-label">List special accomplishments, publications, and/or awards.</label><textarea name="special_accomplishments" data-max="" rows="6" data-autogrow="1" placeholder="" class="form-control" data-field="special_accomplishments" data-field_name="special_accomplishments" data-provides="anomaly.field_type.textarea" ></textarea></div><div class="form-group col-md-12"><label class="control-label">List any additional information you think is relevant and would like us to consider.</label><textarea name="additional_information" data-max="" rows="6" data-autogrow="1" placeholder="" class="form-control" data-field="additional_information" data-field_name="additional_information" data-provides="anomaly.field_type.textarea" ></textarea></div><div class="form-group col-md-12 support_doc"><label class="control-label">Any Supporting Documents</label><input type="file" class="form-control" accept=".png, .jpg, .pdf, .doc, .docx" name="support_pic" id="support_pic"></div><div class="form-group col-md-12"><button class="btn btn-primary nextBtn" type="button">Next</button></div></div></div></div><div class="panel panel-primary setup-content" id="step-3"><div class="panel-body"><div class="row"><div class="form-group col-md-12"><label class="control-label">Personal References (List at least 3) <span>*</span></label></div><div class="form-group col-md-4"><label class="control-label">1. Name</label><input value="" name="reference_name1" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Name" class="form-control" data-field="reference_name1" data-field_name="reference_name1" data-provides="anomaly.field_type.text" required="required" required ></div><div class="form-group col-md-4"><label class="control-label">Address</label><input value="" name="reference_address1" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Address" class="form-control" data-field="reference_address1" data-field_name="reference_address1" data-provides="anomaly.field_type.text" required="required" ></div><div class="form-group col-md-4"><label class="control-label">Phone Number</label><input value="" name="reference_phone1" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Phone" class="form-control" data-field="reference_phone1" data-field_name="reference_phone1" data-provides="anomaly.field_type.text" id="reference_phone1" required="required" ></div><div class="form-group col-md-4"><label class="control-label">2. Name</label><input value="" name="reference_name2" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Name" class="form-control" data-field="reference_name2" data-field_name="reference_name2" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-4"><label class="control-label">Address</label><input value="" name="reference_address2" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Address" class="form-control" data-field="reference_address2" data-field_name="reference_address2" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-4"><label class="control-label">Phone Number</label><input value="" name="reference_phone2" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Phone" class="form-control" data-field="reference_phone2" data-field_name="reference_phone2" data-provides="anomaly.field_type.text" id="reference_phone2" ></div><div class="form-group col-md-4"><label class="control-label">3. Name</label><input value="" name="reference_name3" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Name" class="form-control" data-field="reference_name3" data-field_name="reference_name3" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-4"><label class="control-label">Address</label><input value="" name="reference_address3" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Address" class="form-control" data-field="reference_address3" data-field_name="reference_address3" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-4"><label class="control-label">Phone Number</label><input value="" name="reference_phone3" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Phone" class="form-control" data-field="reference_phone3" data-field_name="reference_phone3" data-provides="anomaly.field_type.text" id="reference_phone3" ></div><div class="form-group col-md-12"><label class="control-label">Do you have friends or family that currently work for CAPCA? <span>*</span></label><div data-field="work_for_capca" data-field_name="work_for_capca" data-provides="anomaly.field_type.select"> <label class=" custom-radio" style="display: block;"> <input type="radio" value="Yes" name="work_for_capca" > <span class=""></span> Yes </label> <label class=" custom-radio" style="display: block;"> <input type="radio" value="No" name="work_for_capca" > <span class=""></span> No </label> </div></div><div class="form-group col-md-12"><label class="control-label">If yes, list their name and relationship to you:</label><textarea name="relationship" data-max="" rows="6" data-autogrow="1" placeholder="" class="form-control" data-field="relationship" data-field_name="relationship" data-provides="anomaly.field_type.textarea" ></textarea></div><div class="form-group col-md-12"><h5>Education - High School</h5></div><div class="form-group col-md-6"><label class="control-label">Name and Location of School</label><input value="" name="name_and_location" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Name And Location Of School" class="form-control" data-field="name_and_location" data-field_name="name_and_location" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6"><label class="control-label">Course of Study</label><input value="" name="course_of_study" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Course Of Study" class="form-control" data-field="course_of_study" data-field_name="course_of_study" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-12"><label class="control-label">Number of Years Completed</label><input value="" name="years_completed" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Number of Years Completed" class="form-control" data-field="years_completed" data-field_name="years_completed" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-12"><label class="control-label">Did you graduate?</label><div data-field="graduate" data-field_name="graduate" data-provides="anomaly.field_type.select"> <label class=" custom-radio" style="display: block;"> <input type="radio" value="Yes" name="graduate" > <span class=""></span> Yes </label> <label class=" custom-radio" style="display: block;"> <input type="radio" value="No" name="graduate" > <span class=""></span> No </label> </div></div><div class="form-group col-md-12"><label class="control-label">Degree or Diploma Earned, If Any</label><input value="" name="degree_diploma" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Degree/Diploma Earned" class="form-control" data-field="degree_diploma" data-field_name="degree_diploma" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-12"><h5>Education - Business, Trade, or Technical</h5></div><div class="form-group col-md-6"><label class="control-label">Name and Location of School</label><input value="" name="name_of_trade" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Name And Location Of School" class="form-control" data-field="name_of_trade" data-field_name="name_of_trade" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6"><label class="control-label">Course of Study</label><input value="" name="course_trade" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Course Of Study" class="form-control" data-field="course_trade" data-field_name="course_trade" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-12"><label class="control-label">Number of Years Completed</label><input value="" name="number_of_years_trade" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Number of Years Completed" class="form-control" data-field="number_of_years_trade" data-field_name="number_of_years_trade" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-12"><label class="control-label">Did you graduate?</label><div data-field="graduate_trade" data-field_name="graduate_trade" data-provides="anomaly.field_type.select"> <label class=" custom-radio" style="display: block;"> <input type="radio" value="Yes" name="graduate_trade" > <span class=""></span> Yes </label> <label class=" custom-radio" style="display: block;"> <input type="radio" value="No" name="graduate_trade" > <span class=""></span> No </label> </div></div><div class="form-group col-md-12"><label class="control-label">Degree or Diploma Earned, If Any</label><input value="" name="degree_trade" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Degree/Diploma Earned" class="form-control" data-field="degree_trade" data-field_name="degree_trade" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-12"><h5>Education - College</h5></div><div class="form-group col-md-6"><label class="control-label">Name and Location of School</label><input value="" name="name_collage" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Name And Location Of School" class="form-control" data-field="name_collage" data-field_name="name_collage" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6"><label class="control-label">Course of Study</label><input value="" name="course_collage" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Course Of Study" class="form-control" data-field="course_collage" data-field_name="course_collage" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-12"><label class="control-label">Number of Years Completed</label><input value="" name="numbers_of_years_collage" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Number of Years Completed" class="form-control" data-field="numbers_of_years_collage" data-field_name="numbers_of_years_collage" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-12"><label class="control-label">Did you graduate?</label><div data-field="graduate_collage" data-field_name="graduate_collage" data-provides="anomaly.field_type.select"> <label class=" custom-radio" style="display: block;"> <input type="radio" value="Yes" name="graduate_collage" > <span class=""></span> Yes </label> <label class=" custom-radio" style="display: block;"> <input type="radio" value="No" name="graduate_collage" > <span class=""></span> No </label> </div></div><div class="form-group col-md-12"><label class="control-label">Degree or Diploma Earned, If Any</label><input value="" name="degree_collage" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Degree/Diploma Earned" class="form-control" data-field="degree_collage" data-field_name="degree_collage" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-12"><h5>Education - Graduate School</h5></div><div class="form-group col-md-6"><label class="control-label">Name and Location of School</label><input value="" name="name_school" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Name And Location Of School" class="form-control" data-field="name_school" data-field_name="name_school" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6"><label class="control-label">Course of Study</label><input value="" name="course_school" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Course Of Study" class="form-control" data-field="course_school" data-field_name="course_school" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-12"><label class="control-label">Number of Years Completed</label>
1<input value="" name="number_of_years_school" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Number of Years Completed" class="form-control" data-field="number_of_years_school" data-field_name="number_of_years_school" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-12"><label class="control-label">Did you graduate?</label><div data-field="graduate_school" data-field_name="graduate_school" data-provides="anomaly.field_type.select"> <label class=" custom-radio" style="display: block;"> <input type="radio" value="Yes" name="graduate_school" > <span class=""></span> Yes </label> <label class=" custom-radio" style="display: block;"> <input type="radio" value="No" name="graduate_school" > <span class=""></span> No </label> </div></div><div class="form-group col-md-12"><label class="control-label">Degree or Diploma Earned, If Any</label><input value="" name="degree_school" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Degree/Diploma Earned" class="form-control" data-field="degree_school" data-field_name="degree_school" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-12"><button class="btn btn-primary nextBtn" type="button">Next</button></div></div></div></div><div class="panel panel-primary setup-content" id="step-4"><div class="panel-body"><div class="row"><div class="form-group col-md-12 sign"><p>Signature: I certify that the answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not and is not intended to be a contract. In the event of membership, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the agency. <span>*</span></p></div><div class="form-group col-md-12"><input value="" name="signature" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Signature" class="form-control" data-field="signature" data-field_name="signature" data-provides="anomaly.field_type.text" required="required" required ></div><div class="form-group col-md-12"><label class="control-label">Date <span>*</span></label><input value="" name="date" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="04/19/2022" class="datepicker form-control" data-field="date" data-field_name="date" data-provides="anomaly.field_type.text" required="required" autocomplete="off" required ></div><div class="form-group col-md-12"><h3 class="panel-title">Declaration Form</h3><h5>(Criminal, Child Abuse & Violent Felony Charges & Convictions)</h5><p>Federal policies mandate that all prospective employees sign a declaration prior to employment, which lists:	1) All pending and prior criminal arrests and charges related to child sexual abuse and their disposition.	2) Convictions related to other forms of child abuse and/or neglect; and	3) All convictions of violent felonies.</p><p>The declaration may exclude:	1) Traffic fines of $200 or less;	2) Any offense, other than any offense related to child abuse and/or child sexual abuse or violent felonies, committed before the prospective employee’s 18th birthday which was finally adjudicated in a juvenile court or under a youth offender law;	3) Any conviction the record of which has been expunged under Federal or State law; and	4) Any conviction set aside under the Federal Youth Corrections Act or similar State authority.</p><p>Note: Individuals who declare, through this form, that they have been arrested, charged with or c
1onvicted of any of the offenses listed above are not automatically disqualified. CAPCA will review each case to assess the relevance of an arrest, charge or conviction prior to a hiring decision.</p></div><div class="form-group col-md-12"><label class="control-label">Please select the appropriate option below: <span>*</span></label><div data-field="declaration" data-field_name="declaration" data-provides="anomaly.field_type.select"> <label class=" custom-radio" style="display: block;"> <input type="radio" value="I have not been arrested, charged and/or convicted of one or more of the three types of offenses listed above" name="declaration" > <span class=""></span> I have not been arrested, charged and/or convicted of one or more of the three types of offenses listed above </label> <label class=" custom-radio" style="display: block;"> <input type="radio" value="I have been arrested, charged and/or convicted of one or more of the three types of offenses listed above. If so, please attach information listing the offense(s), the date(s) of the arrest, charge, and/or conviction, and other relevant information." name="declaration" > <span class=""></span> I have been arrested, charged and/or convicted of one or more of the three types of offenses listed above. If so, please attach information listing the offense(s), the date(s) of the arrest, charge, and/or conviction, and other relevant information. </label> </div></div><div class="form-group col-md-12"><label class="control-label">Date <span>*</span></label><input value="" name="date2" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="04/19/2022" class="datepicker form-control" data-field="date2" data-field_name="date2" data-provides="anomaly.field_type.text" required="required" autocomplete="off" required ></div><!-- <div class="form-group col-md-12"><label class="control-label">Untitled</label></div> --><div class="form-group col-md-12"><div class="field-group recaptcha"><div class="g-recaptcha" data-sitekey="6LdKk3YdAAAAAJdKxRyiD5Hy8-uGfSg1AnIjm7O6"></div><label style="color: red;margin-left: 2%;display: none;" class="recaptcha_error">Recaptcha is required</label></div></div><div class="form-group col-md-12"><button class="btn btn-danger submit mt-3 employe_submit_btn" type="submit">Submit</button></div></div></div></div></form></div></div></div></div> <div class="tab-pane" id="employment"><div class="container"><div class="row form_row"><div class="col-lg-12"><div class="search_form"><iframe id="inlineframe" name="HRM Direct Career Site iFrame" sandbox="allow-top-navigation allow-scripts allow-forms allow-popups allow-same-origin" src="https://capcainc.hrmdirect.com/employment/job-openings.php?nohd" frameborder="0" allowtransparency="true" title="Career Site"></iframe></div></div></div></div></div> <div class="tab-pane" id="volunteer"><div class="container"><div class="row form_row"><div class="col-lg-12"><h4>Volunteer Application</h4></div><div class="col-lg-10 volunteer_form"><div class="stepwizard"><div class="stepwizard-row setup-panel"><div class="stepwizard-step col-xs-3"> <a href="#step-a" class="btn btn-success btn-circle vol_but_1">1</a></div><div class="stepwizard-step col-xs-3"> <a href="#step-b" class="btn btn-default btn-circle vol_but_2" disabled="disabled">2</a></div><div class="stepwizard-step col-xs-3"> <a href="#step-c" class="btn btn-default btn-circle vol_but_3" disabled="disabled">3</a></div><div class="stepwizard-step col-xs-3"> <a href="#step-d" class="btn btn-default btn-circle vol_but_4" disabled="disabled">4</a></div><div class="stepwizard-step col-xs-3"> <a href="#step-e" class="btn btn-default btn-circle vol_but_5" disabled="disabled">5</a></div></div></div><form method="POST" action="https://capcainc.org/form/handle/6a51f9f082059f1d38a4d6a6f706fd67" accept-charset="UTF-8"><input name="_token" type="hidden" value="8vlpbN59Bo9Ud3jieIWu9iwffAeqTKdg7uGkIgzd"><div class="panel panel-primary setup-content" id="step-a"><div class="panel-body"><div class="row"><div class="form-group col-md-12"><label class="control-label">Site</label><input value="" name="site" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Site" class="form-control" data-field="site" data-field_name="site" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-12"><label class="control-label">Department</label><div data-field="department" data-field_name="department" data-provides="anomaly.field_type.select"> <label class=" custom-radio" style="display: block;"> <input type="radio" value="Administrative" name="department" > <span class=""></span> Administrative </label> <label class=" custom-radio" style="display: block;"> <input type="radio" value="Community Services" name="department" > <span class=""></span> Community Services </label> <label class=" custom-radio" style="display: block;"> <input type="radio" value="Head Start" name="department" > <span class=""></span> Head Start </label> <label class=" custom-radio" style="display: block;"> <input type="radio" value="Emergency Shelter" name="department" > <span class=""></span> Emergency Shelter </label> </div></div><div class="form-group col-md-12"><label class="control-label">Date of Birth</label><input value="" name="date" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Date of Birth" class="datepicker form-control" data-field="date" data-field_name="date" data-provides="anomaly.field_type.text" autocomplete="off" ></div><div class="form-group col-md-6"><label class="control-label">Name <span>*</span></label><input value="" name="first_name" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="First Name" class="form-control" data-field="first_name" data-field_name="first_name" data-provides="anomaly.field_type.text" required="required" ></div><div class="form-group col-md-6"><label class="control-label">Maiden Name</label><input value="" name="last_name" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Last Name" class="form-control" data-field="last_name" data-field_name="last_name" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-12"><label class="control-label">Alias</label><input value="" name="alias" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Alias" class="form-control" data-field="alias" data-field_name="alias" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6"><label class="control-label">Street Address <span>*</span></label><input value="" name="street_address" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Street Address" class="form-control" data-field="street_address" data-field_name="street_address" data-provides="anomaly.field_type.text" required="required" ></div><div class="form-group col-md-6"><label class="control-label">Address Line 2</label><input value="" name="address_line_2" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Address Line 2" class="form-control" data-field="address_line_2" data-field_name="address_line_2" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6"><label class="control-label">City</label><input value="" name="city" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="City" class="form-control" data-field="city" data-field_name="city" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6"><label class="control-label">State / Province / Region</label><input value="" name="state_province_region" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="State" class="form-control" data-field="state_province_region" data-field_name="state_province_region" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6"><label class="control-label">ZIP / Postal Code</label><input value="" name="zip_postal_code" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Zip code" class="form-control" data-field="zip_postal_code" data-field_name="zip_postal_code" data-provides="anomaly.field_type.text" id="volunteer_zip" ></div><div class="form-group col-md-6"><label class="control-label">Country</label><input value="" name="country" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Country" class="form-control" data-field="country" data-field_name="country" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-12 mb-0"><h5>Telephone Numbers:</h5></div><div class="form-group col-md-4"><label class="control-label">1. Home</label><input value="" name="home1" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Phone" class="form-control" data-field="home1" data-field_name="home1" data-provides="anomaly.field_type.text" id="home1" ></div><div class="form-group col-md-4"><label class="control-label">Work</label><input value="" name="work1" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Phone" class="form-control" data-field="work1" data-field_name="work1" data-provides="anomaly.field_type.text" id="work1" ></div><div class="form-group col-md-4"><label class="control-label">Message</label><input value="" name="message1" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Message" class="form-control" data-field="message1" data-field_name="message1" data-provides="anomaly.field_type.text" id="message1" ></div><div class="form-group col-md-4"><label class="control-label">2. Home</label><input value="" name="home2" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Phone" class="form-control" data-field="home2" data-field_name="home2" data-provides="anomaly.field_type.text" id="home2" ></div><div class="form-group col-md-4"><label class="control-label">Work</label><input value="" name="work2" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Phone" class="form-control" data-field="work2" data-field_name="work2" data-provides="anomaly.field_type.text" id="work2" ></div><div class="form-group col-md-4"><label class="control-label">Message</label><input value="" name="message2" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Message" class="form-control" data-field="message2" data-field_name="message2" data-provides="anomaly.field_type.text" id="message2" ></div><div class="form-group col-md-4"><label class="control-label">3. Home</label><input value="" name="home3" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Phone" class="form-control" data-field="home3" data-field_name="home3" data-provides="anomaly.field_type.text" id="home3" ></div><div class="form-group col-md-4"><label class="control-label">Work</label><input value="" name="work3" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Phone" class="form-control" data-field="work3" data-field_name="work3" data-provides="anomaly.field_type.text" id="work3" ></div><div class="form-group col-md-4"><label class="control-label">Message</label><input value="" name="message3" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Message" class="form-control" data-field="message3" data-field_name="message3" data-provides="anomaly.field_type.text" id="message3" ></div><div class="form-group col-md-6"><label class="control-label">Email</label><input type="email" value="" name="email" placeholder="[email protected]" class="form-control" data-field="email" data-field_name="email" data-provides="anomaly.field_type.email" ></div><div class="form-group col-md-6"><label class="control-label">Occupation</label><input value="" name="occupation" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Occupation" class="form-control" data-field="occupation" data-field_name="occupation" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-12"><button class="btn btn-primary nextBtn" type="button">Next</button></div></div></div></div><div class="panel panel-primary setup-content" id="step-b"><div class="panel-body"><div class="row"><div class="form-group col-12"><label class="control-label">Volunteer interest please check areas you’re interested in volunteering:</label><div class="area_volun"><div class="custom-inputs-stacked"> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Office Work" name="areas_interest_volunteer[]" > <span class=""></span> Office Work </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Commodities Distribution" name="areas_interest_volunteer[]" > <span class=""></span> Commodities Distribution </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Fundraising" name="areas_interest_volunteer[]" > <span class=""></span> Fundraising </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Donations" name="areas_interest_volunteer[]" > <span class=""></span> Donations </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Accounting" name="areas_interest_volunteer[]" > <span class=""></span> Accounting </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Technology" name="areas_interest_volunteer[]" > <span class=""></span> Technology </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Other" name="areas_interest_volunteer[]" > <span class=""></span> Other </label> </div></div><div class="only_other_vol" style="display: none;"><input value="" name="other" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Other" class="form-control" data-field="other" data-field_name="other" data-provides="anomaly.field_type.text" ></div></div><div class="form-group col-12"><label class="control-label">Have you ever been convicted of any law violation other than traffic violations?</label><select name="convicted" class="custom-select form-control" data-field="convicted" data-field_name="convicted" data-provides="anomaly.field_type.select" > <option value="">Choose an option...</option> <option value="Yes" >Yes</option> <option value="No" >No</option> </select><div class="only_yes_convicted"><label class="control-label">if yes, please explain</label><textarea name="if_yes_explain" data-max="" rows="6" data-autogrow="1" placeholder="If yes, please explain" class="form-control" data-field="if_yes_explain" data-field_name="if_yes_explain" data-provides="anomaly.field_type.textarea" ></textarea></div></div><div class="form-group col-6"><label class="control-label">I can volunteer on these days:</label><div class="week_check"><div class="custom-inputs-stacked"> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Monday" name="week_days[]" > <span class=""></span> Monday </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Tuesday" name="week_days[]" > <span class=""></span> Tuesday </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Wednesday" name="week_days[]" > <span class=""></span> Wednesday </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Thursday" name="week_days[]" > <span class=""></span> Thursday </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Friday" name="week_days[]" > <span class=""></span> Friday </label> </div></div></div><div class="form-group col-6"><label class="control-label timing_label">I can volunteer on these times:</label><div class="from_to mon_time"><div class="from_time cust-timepicker" style="display: none;"><input value="" name="monday_from" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="From" class="form-control" data-field="monday_from" data-field_name="monday_from" data-provides="anomaly.field_type.text" ></div><div class="to_time cust-timepicker" style="display: none;"><input va
1lue="" name="monday_until" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Until" class="form-control" data-field="monday_until" data-field_name="monday_until" data-provides="anomaly.field_type.text" ></div></div><div class="from_to tue_time"><div class="from_time cust-timepicker" style="display: none;"><input value="" name="tuesday_from" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="From" class="form-control" data-field="tuesday_from" data-field_name="tuesday_from" data-provides="anomaly.field_type.text" ></div><div class="to_time cust-timepicker" style="display: none;"><input value="" name="tuesday_until" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Until" class="form-control" data-field="tuesday_until" data-field_name="tuesday_until" data-provides="anomaly.field_type.text" ></div></div><div class="from_to wed_time"><div class="from_time cust-timepicker" style="display: none;"><input value="" name="wednesday_form" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="From" class="form-control" data-field="wednesday_form" data-field_name="wednesday_form" data-provides="anomaly.field_type.text" ></div><div class="to_time cust-timepicker" style="display: none;"><input value="" name="wednesday_until" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Until" class="form-control" data-field="wednesday_until" data-field_name="wednesday_until" data-provides="anomaly.field_type.text" ></div></div><div class="from_to thu_time"><div class="from_time cust-timepicker" style="display: none;"><input value="" name="thursday_from" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="From" class="form-control" data-field="thursday_from" data-field_name="thursday_from" data-provides="anomaly.field_type.text" ></div><div class="to_time cust-timepicker" style="display: none;"><input value="" name="thursday_until" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Until" class="form-control" data-field="thursday_until" data-field_name="thursday_until" data-provides="anomaly.field_type.text" ></div></div><div class="from_to fri_time"><div class="from_time cust-timepicker" style="display: none;"><input value="" name="friday_from" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="From" class="form-control" data-field="friday_from" data-field_name="friday_from" data-provides="anomaly.field_type.text" ></div><div class="to_time cust-timepicker" style="display: none;"><input value="" name="friday_until" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Until" class="form-control" data-field="friday_until" data-field_name="friday_until" data-provides="anomaly.field_type.text" ></div></div></div><div class="form-group col-12 just_sent_cnt"><h6><strong>AFFIDAVIT: </strong>I certify that everything in this application is true and correct to the best of my knowledge. I understand that misleading or incorrect statements or consequential omissions may render this application void, or if accepted as a volunteer, would be cause for termination. I authorize individuals named above to give information regarding my character and qualifications, hereby releasing them from all liability for issuing such information</h6></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Applicant’s Signature:</label><input value="" name="applicant_s_signature" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Applicant’s Signature" class="form-control" data-field="applicant_s_signature" data-field_name="applicant_s_signature" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Date:</label><input value="" name="date2" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Date" class="datepicker form-control" data-field="date2" data-field_name="date2" data-provides="anomaly.field_type.text" autocomplete="off" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Approved by:</label><input value="" name="approved_by" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Approved by" class="form-control" data-field="approved_by" data-field_name="approved_by" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Date:</label><input value="" name="date6" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Date" class="datepicker form-control" data-field="date6" data-field_name="date6" data-provides="anomaly.field_type.text" autocomplete="off" ></div><div class="form-group col-12 just_sent_cnt text-center"><h6><i>CAPCA’s policy states that all non-vaccinated individuals must wear a mask when inside CAPCA’s facilities. If you are vaccinated and choose to do so, please provide a copy of your original vaccination card to place with your application.</i></h6></div><div class="form-group col-12"><button class="btn btn-primary nextBtn" type="button">Next</button></div></div></div></div><div class="panel panel-primary setup-content" id="step-c"><div class="panel-body"><div class="row"><div class="form-group col-12 text-center"><h4>CAPCA OATH OF CONFIDENTIALITY</h4><h5>Confidentiality Policy</h5></div><div class="form-group col-12 just_sent_cnt"><p>All personally identifiable information concerning employees, clients and parent/guardians (of a Head Start child) is kept confidential. Only CAPCA staff and authorized personnel (i.e., monitors, licensing or evaluation teams) have access to a client/child records. Clients are prohibited from reviewing any records other than their own. Parents or guardians are prohibited from reviewing any records other than their own child’s. Clients need to be aware that in order for staff to provide assistance or act as an advocate, some information may need to be given to other agencies or persons bonded by client confidentiality. Written consent by the client or Head Start parent/guardian must be obtained to release information to anyone not bonded by client confidentiality. Head Start staff will review records as needed to perform their assigned duties.</p><p>Records are kept in locked files when not in use. Employees reviewing records must insure that visual monitoring and confidentiality of such records is kept at all times. Any Head Start staff viewing data must sign the Confidentiality of Records and Person Obtaining Data form located in the front of the child’s re
1cord. Records are to be returned to locked files when completed.</p><p>In addition to information given by parents or guardians, information obtained by staff about a child, clients or their families, verbal or written, must be kept confidential as stated above.</p><p>Head Start employees, under State Law and Federal Register Policy N-30-356-1-30, are mandated reporters of suspected child abuse and neglect. Thus, information related to such a case involving a Head Start child will be reported as stated in the CAPCA Head Start Child Abuse Reporting Procedures. Employees and children may be interviewed by Child Care Licensing, child maltreatment investigators, or by law enforcement for investigative purposes and/or for determining compliance with licensing requirements.</p></div><div class="form-group col-12"><label class="control-label">As a condition of performing my work as:</label><div class="custom-inputs-stacked"> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Volunteer" name="my_work_as[]" > <span class=""></span> Volunteer </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Employee" name="my_work_as[]" > <span class=""></span> Employee </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Substitute" name="my_work_as[]" > <span class=""></span> Substitute </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Contracted Services Personnel" name="my_work_as[]" > <span class=""></span> Contracted Services Personnel </label> </div></div><div class="form-group col-12 just_sent_cnt"><h6>I, the undersigned, hereby agree not to divulge any personally identifiable information or recordsconcerning any clients, children, families, or employee(s) without proper authorization.</h6></div><div class="form-group col-12"><label class="control-label">Name:</label><input value="" name="volunteer_name" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Name" class="form-control" data-field="volunteer_name" data-field_name="volunteer_name" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Position:</label><input value="" name="position" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Position" class="form-control" data-field="position" data-field_name="position" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Site:</label><input value="" name="site2" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Site" class="form-control" data-field="site2" data-field_name="site2" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Signature:</label><input value="" name="signature" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Signature" class="form-control" data-field="signature" data-field_name="signature" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Date:</label><input value="" name="date3" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Date" class="datepicker form-control" data-field="date3" data-field_name="date3" data-provides="anomaly.field_type.text" autocomplete="off" ></div><div class="form-group col-12 text-center"><h4>Community Service’s Standards of Conduct Acknowledgement Form</h4></div><div class="form-group col-12 just_sent_cnt"><p>All staff, consultants and volunteers will abide by the program's standards of conduct. These standards include:</p><p>(i) Refrain from stereotyping on the basis of gender, race, ethnicity, culture, religion or disability.<br>(ii) Follow program confidentiality policies concerning information about children, families and other staff members.</p><p>I, the undersigned, have read the Standards of Conduct and hereby agree to abide by them. I also understand that a violation of the Standards of Conduct will result in discontinuing my volunteer opportunities with the agency.</p></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Name:</label><input value="" name="name2" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Name" class="form-control" data-field="name2" data-field_name="name2" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Site:</label><input value="" name="site3" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Site" class="form-control" data-field="site3" data-field_name="site3" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Volunteer Signature:</label><input value="" name="volunteer_signature" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Volunteer Signature" class="form-control" data-field="volunteer_signature" data-field_name="volunteer_signature" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Date:</label><input value="" name="date4" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Date" class="datepicker form-control" data-field="date4" data-field_name="date4" data-provides="anomaly.field_type.text" autocomplete="off" ></div><div class="form-group col-12 just_sent_cnt text-center"><h6>Thank you for agreeing to volunteer at CAPCA, the contribution of your valuable time is a special gift.</h6></div><div class="form-group col-12"><button class="btn btn-primary nextBtn" type="button">Next</button></div></div></div></div><div class="panel panel-primary setup-content" id="step-d"><div class="panel-body"><div class="row"><div class="form-group col-12 text-center"><h4>EMERGENCY CONTACT INFORMATION</h4></div><div class="form-group col-12"><div class="custom-inputs-stacked"> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Employee" name="contact_info[]" > <span class=""></span> Employee </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Volunteer" name="contact_info[]" > <span class=""></span> Volunteer </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Substitute" name="contact_info[]" > <span class=""></span> Substitute </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Temporary" name="contact_info[]" > <span class=""></span> Temporary </label> <label class=" custom-checkbox" style="display: block;"> <input type="checkbox" value="Contracted" name="contact_info[]" > <span class=""></span> Contracted </label> </div></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Name:</label><input value="" name="name3" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Name" class="form-control" data-field="name3" data-field_name="name3" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Date: <span>*</span></label><input value="" name="date5" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Date" class="datepicker form-control" data-field="date5" data-field_name="date5" data-provides="anomaly.field_type.text" required="required" autocomplete="off" ></div><div class="form-group col-12"><label class="control-label">Address:</label><input value="" name="address" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Address" class="form-control" data-field="address" data-field_name="address" data-provides="anomaly.field_type.text" ></div><div class="form-group col-12"><label class="control-label">City, State & Zip Code:</label><input value="" name="city_state_zip_code" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="City, State &amp; Zip Code" class="form-control" data-field="city_state_zip_code" data-field_name="city_state_zip_code" data-provides="anomaly.field_type.text" ></div><div class="form-group col-12"><label class="control-label">Telephone Number:</label></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Cell:</label><input value="" name="cell" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Cell" class="form-control" data-field="cell" data-field_name="cell" data-provides="anomaly.field_type.text" id="cel_num" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Home: If applicable</label><input value="" name="home_if_applicable" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Home If applicable" class="form-control" data-field="home_if_applicable" data-field_name="home_if_applicable" data-provides="anomaly.field_type.text" id="hm_num" ></div></div><div class="row emergency_row"><div class="form-group col-12"><label class="control-label">In the event of emergency, please notify:</label></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Name:</label><input value="" name="emergency_name1" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="" class="form-control" data-field="emergency_name1" data-field_name="emergency_name1" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Name:</label><input value="" name="emergency_name2" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="" class="form-control" data-field="emergency_name2" data-field_name="emergency_name2" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Relationship:</label><input value="" name="emergency_relationship1" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="" class="form-control" data-field="emergency_relationship1" data-field_name="emergency_relationship1" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Relationship:</label><input value="" name="emergency_relationship2" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="" class="form-control" data-field="emergency_relationship2" data-field_name="emergency_relationship2" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Cell/Home Telephone:</label><input value="" name="emergency_home_telephone1" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="" class="form-control" data-field="emergency_home_telephone1" data-field_name="emergency_home_telephone1" data-provides="anomaly.field_type.text" id="ref_home1" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Cell/Home Telephone:</label><input value="" name="emergency_home_telephone2" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="" class="form-control" data-field="emergency_home_telephone2" data-field_name="emergency_home_telephone2" data-provides="anomaly.field_type.text" id="ref_home2" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Work Telephone:</label><input value="" name="emergency_work_telephone1" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="" class="form-control" data-field="emergency_work_telephone1" data-field_name="emergency_work_telephone1" data-provides="anomaly.field_type.text" id="ref_work1" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Work Telephone:</label><input value="" name="emergency_work_telephone2" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="" class="form-control" data-field="emergency_work_telephone2" data-field_name="emergency_work_telephone2" data-provides="anomaly.field_type.text" id="ref_work2" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Work Place:</label><input value="" name="emergency_work_place1" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="" class="form-control" data-field="emergency_work_place1" data-field_name="emergency_work_place1" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Work Place:</label><input value="" name="emergency_work_place2" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="" class="form-control" data-field="emergency_work_place2" data-field_name="emergency_work_place2" data-provides="anomaly.field_type.text" ></div></div><div class="row"><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Preferred Physician:</label><input value="" name="preferred_physician" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Preferred Physician" class="form-control" data-field="preferred_physician" data-field_name="preferred_physician" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Physician Telephone:</label><input value="" name="physician_telephone" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Physician Telephone" class="form-control" data-field="physician_telephone" data-field_name="physician_telephone" data-provides="anomaly.field_type.text" id="phy_num" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Preferred Hospital:</label><input value="" name="preferred_hospital" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Preferred Hospital" class="form-control" data-field="preferred_hospital" data-field_name="preferred_hospital" data-provides="anomaly.field_type.text" ></div><div class="form-group col-md-6 col-sm-12 col-12"><label class="control-label">Hospital Telephone:</label>
1<input value="" name="hospital_telephone" data-max="255" data-mask="" data-alias="" data-regex="" type="text" placeholder="Hospital Telephone" class="form-control" data-field="hospital_telephone" data-field_name="hospital_telephone" data-provides="anomaly.field_type.text" id="hosp_num" ></div><div class="form-group col-12"><label class="control-label">Relevant Health information:</label><textarea name="relevant_health_information" data-max="" rows="6" data-autogrow="1" placeholder="Relevant Health information" class="form-control" data-field="relevant_health_information" data-field_name="relevant_health_information" data-provides="anomaly.field_type.textarea" ></textarea></div><div class="form-group col-12"><label class="control-label">Allergies:</label><textarea name="allergies" data-max="" rows="6" data-autogrow="1" placeholder="Allergies" class="form-control" data-field="allergies" data-field_name="allergies" data-provides="anomaly.field_type.textarea" ></textarea></div><div class="form-group col-12 just_sent_cnt text-center"><h6>Place form in the Health Information file on site<br>File copy in Personnel file<br>Update annually</h6></div><div class="form-group col-12"><button class="btn btn-primary nextBtn" type="button">Save & Continue Later</button></div></div></div></div><div class="panel panel-primary setup-content" id="step-e"><div class="panel-body"><div class="row"><div class="form-group col-md-12 email_cont"><p>Please use the following link to return to your form from any computer.<br><a href="https://testcapca.aceone.io/how-do-i/apply#volunteer">https://testcapca.aceone.io/how-do-i/apply#volunteer</a><br>This link will expire after 30 days.<br>Enter your email address to send the link by email.</p></div><div class="form-group col-md-12"><div class="email_link"><input type="email" value="" name="email" placeholder="[email protected]" class="form-control" data-field="email" data-field_name="email" data-provides="anomaly.field_type.email" ></div></div><div class="form-group col-md-12"><div class="field-group recaptcha"><div class="g-recaptcha" data-sitekey="6LdKk3YdAAAAAJdKxRyiD5Hy8-uGfSg1AnIjm7O6"></div><label style="color: red;margin-left: 2%;display: none;" class="recaptcha_error">Recaptcha is required</label></div></div><div class="form-group col-md-12 text-center"><div class="email_link"><button type="submit" class="email_submit">Send Link</button></div></div></div></div></div></form></div></div></div></div></div> </div></div><div class="input-group-btn col-md-12 career_msg mt-5"><section id="messages"> <!-- Success Messages --> <!-- Informational Messages --> <!-- Warning Messages --> <!-- Error Messages --> </section></div></div></section><style>.innerrow {	padding: 70px 0px;	}	.tab-pane .panel_body iframe{	width: 100%;	}	.tabs-left {	border-bottom: none;	display: block;	}	.tabs-left li a.active {	background: #00121b;	color: #fff !important;	padding: 10px 15px;	width: 100%;	display: block;	font-size: 16px;	}	.tabs-left li a {	color: #191919;	width: 100%;	display: block;	border-bottom: none;	padding: 10px 15px;	cursor: pointer;	font-size: 16px;	background: #eee;	}	.panel_body a {	font-size: 16px;	color: #e31d1a;	font-weight: 500;	margin-top: 6px;	}	.panel_body h3 {	font-size: 28px;	/* font-weight: 700; */	color: #060606;	}	.panel_body h5 {	font-size: 22px;	font-weight: 700;	}	.tab-content p{	color: #000000;	text-align: left;	margin-bottom: 10px;	}	.stepwizard-step p {	margin-top: 0px;	color:#666;	text-align: center;	}
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11.stepwizard-row:before {	top: 20px;	bottom: 0;	position: absolute;	content:" ";	width: 100%;	height: 1px;	background-color: #ccc;	z-index: 0;
12}
13.stepwizard-step {	display: table-cell;	text-align: center;	position: relative;
14}
15.btn-circle {
16width: 40px;	height: 40px;	text-align: center;	padding: 6px 0;	font-size: 15px;
16	line-height: 26px;	border-radius: 50px;	background: #ddd;	color: #000;
17}	.career_form, .volunteer_form {	margin: auto;	background: #fff;	padding: 30px;	}	.btn-success {	color: #fff;	background-color: #dd5656;	border-color: #dd5656;
18}	.panel-title {	text-align: center;	text-transform: uppercase;	font-size: 21px;	font-weight: 700;	padding-bottom: 10px;	padding-top: 15px;	}	.nextBtn {	color: #fff !important;	background: #dd5656 !important;	border: 2px solid #dd5656 !important;	border-radius: 0;	padding: 8px 10px !important;	text-transform: uppercase !important;	margin-top: 15px !important;	width: 30%;	margin: auto;	display: block;	text-align: center;	}	.career_form button.btn.btn-primary:hover, .career_form button.btn.btn-primary:focus, .career_form button.btn.btn-primary:active {	color: #fff;	background: #333359 !important;	border: 2px solid #333359 !important;;	}	.career_form .nextBtn:hover, .career_form .nextBtn:active {	color: #fff;	background: #333359 !important;	border: 2px solid #333359 !important;;	}	.nextBtn:focus, .form-control:focus{	box-shadow: none !important;	}	.form-control:focus {	border-color: #2b2b2b;	}	.control-label {	font-weight: 600;	font-size: 16px;	font-family: 'Open Sans';	}	.panel-body h5 {	font-size: 20px;	font-weight: 700;	color: #c71d1d;	margin-bottom: 0px;	margin-top: 10px;	padding-bottom: 10px;	}	.fa-times, .input-group-addon {	display: none;	}	.form-group p{	font-size: 16px;	}	.submit {	width: 30%;	display: block;	border: 1px solid #c41230;	background: #c41230;	padding: 10px;	margin: auto;	}	.form-group span {	color: #c71d1d;	}	.btn-danger:hover {	background-color: #c41230 !important;	border-color: #c41230 !important;	}	.stepwizard-step .btn-success{	background-color: #dd5656 !important;	border-color: #dd5656 !important;	color: #fff !important;	}	.employe_submit_btn:hover{	background:white;	color: #212529;	}	.body_employment-application .career_msg .alert{	width: 100%;	max-width: 570px;	margin: 10px auto;	}	.btn-success.focus, .btn-success:focus {	box-shadow: 0 0 0 0.2rem rgb(221 86 86 / 48%) !important;	}	.btn.focus, .btn:focus {	box-shadow: 0 0 0 0.2rem rgb(221 86 86 / 48%) !important;	}	.btn-success:hover {	background-color: #333359 !important;	border-color: #333359 !important;	}	.form_row {	background: #eaeaea;	padding: 50px 0;	}	.form_row h4 {	text-align: center;	font-size: 25px;	font-weight: 700;	color: #333359;	padding-bottom: 15px;	}	label.custom-radio {	font-size: 16px;	line-height: 1.25;	}	label.custom-checkbox {	font-size: 16px;	}	.support_doc .selected {	font-size: 16px;	}	.support_doc .btn-info {	color: #fff;	background-color: #333359;	border-color: #333359;	}	.sign p {	font-weight: 600;	}	.form-group.has-error input {	border: 1px solid red;	}	.search_form {	overflow: hidden;	width: 100%;	position: relative;	z-index: 10;	}	.search_form iframe#inlineframe {	width: 100%;	height: 100%;	overflow: hidden;	min-height: 340px;	}	.volunteer_form .nextBtn {	width: 50% !important;	}	.volunteer_form button.btn.btn-primary:hover {	background: #333359 !important;	}	.email_cont p {	text-align: center;	}	.email_link .form-control {	height: 45px;	font-size: 16px;	padding: 10px;	float: left;	border-radius: 6px;	border: 1px solid #ddd;	/* width: 65%; */	font-family: 'Open Sans';	background: #eaeaea;	}	.email_submit {	background: #d55;	height: 45px;	border: none;	font-size: 16px;	text-transform: uppercase;	padding: 10px;	color: #fff;	font-weight: 600;	border-radius: 5px;	margin-left: 10px;	font-family: 'Open Sans';	width: 33%;	}	.email_cont a {	font-size: 16px;	color: #dd5656;	}	.email_cont a:hover {	color: #333359;	}	@media screen and (max-width: 575px) {	.form_row {	padding: 50px 25px !important;	}	.g-recaptcha {	transform: scale(0.6) !important;	margin-left: -20px;	}	.email_cont a {	word-break: break-all;	}	.recaptcha_error {	top: 66px;	font-size: 15px;	left: 62px;	}	}	@media screen and (max-width: 992px) {	.volunteer_form .nextBtn {	width: 100% !important;	}	.email_submit {	width: 55%;	}	}	#support_pic {	height: 45px;	}	.g-recaptcha {	transform: scale(0.8);	}	.g-recaptcha > div {	margin: auto;	}	.recaptcha_error {	font-size: 17px;	}
19.week_check .custom-inputs-stacked input[type="checkbox"] {	margin-bottom: 20px;
20}
21.from_to {	position: relative;	min-height: 43px;
22}
23.from_to .from_time.cust-timepicker {	width: 49%;	display: inline-block;	padding-right: 1%;
24}
25label.control-label.timing_label {	color: #fff;
26}
27.from_to .to_time.cust-timepicker {	width: 49%;	display: inline-block;	padding-left: 1%;
28}
29.bft_time.cust-timepicker .form-control[readonly],
30.from_to .cust-timepicker .form-control[readonly] {	background-color: #fff;	border-radius: 0.25rem;
31}
32.from_to .cust-timepicker input.form-control {	margin-bottom: 5px;
33}
34.just_sent_cnt h6, .just_sent_cnt p {	font-size: 14px;
35}
36@media(max-width:575px){	.from_to .cust-timepicker .form-control[readonly] {	font-size: 10px;	}
37}
38.row.emergency_row {	border: 2px solid #eee;	border-radius: 20px;	background-color: #eee;	padding: 10px 0;
39}</style> <!-- FOOTER --><footer id="cc_footer"><div class="container-fluid"><div class="container footer_container"><div class="row footer_menu_wrap">
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39<div class="fb-page" data-href="https://www.facebook.com/capcapage/" data-tabs="timeline" data-width="350" data-height="250" data-small-header="false" data-adapt-container-width="true" data-hide-cover="false" data-show-facepile="true"><blockquote cite="https://www.facebook.com/capcapage/" class="fb-xfbml-parse-ignore"><a href="https://www.facebook.com/capcapage/">Facebook</a></blockquote></div></div></div></div></div></div><div class="container-fluid"><div class="container copy_container"><div class="row copyright_row justify-content-between"><div>Copyright 2026 &copy; <a href="#" target="_blank">Community Action Program CAPCA</a>.<span> All Rights Reserved.</span></div><div>Designed &amp; Hosted by <a href="http://aceonetechnologies.com/" target="_blank">AceOne Technologies.</a></div></div></div></div></footer><!-- FOOTER --><div class='scrolltop' style="display:none;"> <div class='scroll icon'><i class="fa fa-4x fa-angle-up"></i></div></div>
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40});</script>
40</body></html>

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