Make a Plan Form | Ready.gov

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class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><div class="desktop-usa-search"/></div> </div> </div> </div> </div> </div> </div> </nav> </header> <div tabindex="-1" id="main-content"></div> <section class="usa-hero"> </section> <main class="usa-section"> <div class="grid-container"> <div class="grid-row grid-gap"> <div class="grid-col-12"> </div> </div> <div class="grid-row grid-gap main-content-grid"> <aside class="desktop:grid-col-3 aside-sidebar_first"> <div class="region region-sidebar-first"> <ul class="usa-sidenav"> <li class="usa-sidenav__item"> <a href="/be-informed"> <span>Disasters and Emergencies</span> </a> </li> <li class="usa-sidenav__item"> <a href="/plan" class="usa-current"> <span>Make a Plan</span> </a> <ul class="usa-sidenav__sublist"> <li class="usa-sidenav__item"> <a href="/plan" class="usa-current"> <span>Plan Ahead</span> </a> <ul class="usa-sidenav__sublist"> <li class="usa-sidenav__item"> <a href="/plan-form" class="usa-current"> <span>Make a Plan Form </span> </a> </li> </ul> </li> <li class="usa-sidenav__item"> <a href="/kit"> <span>Build a Kit</span> </a> </li> <li class="usa-sidenav__item"> <a href="/low-and-no-cost"> <span>Low and No Cost Preparedness</span> </a> </li> <li class="usa-sidenav__item"> <a href="/financial-preparedness"> <span>Financial Preparedness</span> </a> </li> <li class="usa-sidenav__item"> <a href="/get-tech-ready"> <span>Get Tech Ready</span> </a> </li> <li class="usa-sidenav__item"> <a href="/pets"> <span>Pets and Animals</span> </a> </li> <li class="usa-sidenav__item"> <a href="/summer-ready"> <span>#SummerReady </span> </a> </li> <li class="usa-sidenav__item"> <a href="/winter-ready"> <span>#WinterReady</span> </a> </li> <li class="usa-sidenav__item"> <a href="/evacuation"> <span>Evacuation</span> </a> </li> <li class="usa-sidenav__item"> <a href="/shelter"> <span>Shelter</span> </a> </li> <li class="usa-sidenav__item"> <a href="/safety-skills"> <span>Safety Skills</span> </a> </li> <li class="usa-sidenav__item"> <a href="/plan-for-locations"> <span>Plan for Locations</span> </a> </li> <li class="usa-sidenav__item"> <a href="/home-fire-escape-plan"> <span>Home Fire Escape Plan</span> </a> </li> <li class="usa-sidenav__item"> <a href="/campus"> <span>Ready Campus</span> </a> </li> </ul> </li> <li class="usa-sidenav__item"> <a href="/communities"> <span>Ready Communities</span> </a> </li> <li class="usa-sidenav__item"> <a href="/business"> <span>Ready Business</span> </a> </li> <li class="usa-sidenav__item"> <a href="/kids"> <span>Ready Kids</span> </a> </li> <li class="usa-sidenav__item"> <a href="/resources"> <span>Resources</span> </a> </li> </ul> </div> </aside> <div class="region-content desktop:grid-col-fill"> <div class="region region-content"> <div data-drupal-messages-fallback class="hidden"></div> <div id="block-makeaplanlanguageblock" class="block block-block-content block-block-contentb60c908e-7fab-4871-b614-c9f41b59e304"> <div class="layout layout--onecol"> <div class="layout__region layout__region--content"> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><div class="translations-available"> 聽聽 <img src="/profiles/readyd8_gov/themes/uswds_ready/img/world-icon-black.png" alt="world globe"> 聽聽 <ul><li><span class="translation-first"><span><a href="/plan-form">English</a></span></span></li> <li><span><a href="/es/plan-form">Espa帽ol</a></span></li> </ul></div></div> </div> </div> </div> <div id="block-planformprivacyblock" class="block block-block-content block-block-content6adbb821-2893-48a5-86d1-24c269347c55"> <div class="layout layout--onecol"> <div class="layout__region layout__region--content"> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><em><strong>The information you provide is not saved, stored or shared by any government agency.</strong></em></p> </div> </div> </div> </div> <div id="block-uswds-ready-ready2017-system-main" class="block block-system block-system-main-block"> <form class="makeaplan-form usa-form" data-drupal-selector="makeaplan-form" action="/plan-form" method="post" id="makeaplan-form" accept-charset="UTF-8"> <p>You may not be together when disaster strikes, so it鈥檚 important to know how you鈥檒l reconnect if separated. Use this form to create a Family Emergency Communication Plan, which you can email as a PDF file once complete.</p><h2>Household Information</h2> <div data-drupal-selector="edit-household" class="js-form-item form-item"> <table id="household-values--2" class="field-multiple-table responsive-enabled usa-table" data-striping="1"> <thead> <tr> <th colspan="2" class="field-label" scope="row"><h4 class="label"></h4></th> <th>Order</th> </tr> </thead> <tbody> <tr class="draggable odd" scope="row"> <td class="field-multiple-drag paragraph-bullet"></td> <td><div class="usa-form-group js-form-item form-item js-form-type-tel form-item-household-0-household-phone js-form-item-household-0-household-phone"> <label for="edit-household-0-household-phone" class="usa-label">Home #: <span class="usa-hint">(optional)</span></label> <input data-drupal-selector="edit-household-0-household-phone" pattern="[0-9]{3}-[0-9]{3}-[0-9]{4}" type="tel" id="edit-household-0-household-phone" name="household[0][household_phone]" value="" size="30" maxlength="128" placeholder="123-456-7890" class="form-tel" /> </div> <div class="usa-form-group js-form-item form-item js-form-type-textarea form-item-household-0-household-address js-form-item-household-0-household-address"> <label for="edit-household-0-household-address" class="usa-label">Address: <span class="usa-hint">(optional)</span></label> <div class="form-textarea-wrapper"> <textarea data-drupal-selector="edit-household-0-household-address" id="edit-household-0-household-address" name="household[0][household_address]" rows="5" cols="60" class="form-textarea usa-textarea resize-vertical"></textarea> </div> </div> </td> <td class="delta-order"><div class="usa-form-group js-form-item form-item js-form-type-select form-item-household-0--weight js-form-item-household-0--weight form-no-label"> <label for="edit-household-0-weight" class="usa-label visually-hidden">Weight for row 1 <span class="usa-hint">(optional)</span></label> <select data-drupal-selector="edit-household-0-weight" class="household-delta-order form-select usa-select" id="edit-household-0-weight" name="household[0][_weight]"><option value="0" selected="selected">0</option></select> </div> </td> </tr> </tbody> </table> </div> <h2>Family Members</h2><p>Enter information for each member of your family.</p><div id="names-add-more-wrapper"> <div data-drupal-selector="edit-names" class="js-form-item form-item"> <table id="names-values--2" class="field-multiple-table responsive-enabled usa-table" data-striping="1"> <thead> <tr> <th colspan="2" class="field-label" scope="row"><h4 class="label"></h4></th> <th>Order</th> </tr> </thead> <tbody> <tr class="draggable odd" scope="row"> <td class="field-multiple-drag"></td> <td><div class="usa-form-group js-form-item form-item js-form-type-textfield form-item-names-0-name js-form-item-names-0-name"> <label for="edit-names-0-name" class="usa-label">Name: <span class="usa-hint">(optional)</span></label> <input data-drupal-selector="edit-names-0-name" type="text" id="edit-names-0-name" name="names[0][name]" value="" size="60" maxlength="128" class="form-text usa-input" /> </div> <div class="usa-form-group js-form-item form-item js-form-type-tel form-item-names-0-mobile js-form-item-names-0-mobile"> <label for="edit-names-0-mobile" class="usa-label">Mobile #: <span class="usa-hint">(optional)</span></label> <input data-drupal-selector="edit-names-0-mobile" pattern="[0-9]{3}-[0-9]{3}-[0-9]{4}" type="tel" id="edit-names-0-mobile" name="names[0][mobile]" value="" size="30" maxlength="128" placeholder="123-456-7890" class="form-tel" /> </div> <div class="usa-form-group js-form-item form-item js-form-type-textfield form-item-names-0-other-social js-form-item-names-0-other-social"> <label for="edit-names-0-other-social" class="usa-label">Other # or social media: <span class="usa-hint">(optional)</span></label> <input data-drupal-selector="edit-names-0-other-social" type="text" id="edit-names-0-other-social" name="names[0][other_social]" value="" size="60" maxlength="128" class="form-text usa-input" /> </div> <div class="usa-form-group js-form-item form-item js-form-type-email form-item-names-0-email js-form-item-names-0-email"> <label for="edit-names-0-email" class="usa-label">E-mail: <span class="usa-hint">(optional)</span></label> <input data-drupal-selector="edit-names-0-email" type="email" id="edit-names-0-email" name="names[0][email]" value="" size="60" maxlength="254" class="form-email usa-input" /> </div> <div class="usa-form-group js-form-item form-item js-form-type-textarea form-item-names-0-other-medical js-form-item-names-0-other-medical"> <label for="edit-names-0-other-medical" class="usa-label">Important medical or other information: <span class="usa-hint">(optional)</span></label> <div class="form-textarea-wrapper"> <textarea data-drupal-selector="edit-names-0-other-medical" id="edit-names-0-other-medical" name="names[0][other_medical]" rows="5" cols="30" class="form-textarea usa-textarea resize-vertical"></textarea> </div> </div> </td> <td class="delta-order"><div class="usa-form-group js-form-item form-item js-form-type-select form-item-names-0--weight js-form-item-names-0--weight form-no-label"> <label for="edit-names-0-weight" class="usa-label visually-hidden">Weight for row 1 <span class="usa-hint">(optional)</span></label> <select data-drupal-selector="edit-names-0-weight" class="names-delta-order form-select usa-select" id="edit-names-0-weight" name="names[0][_weight]"><option value="0" selected="selected">0</option></select> </div> </td> </tr> </tbody> </table> <div class="clearfix"><input class="multivalue-add-more-submit button js-form-submit form-submit usa-button" data-drupal-selector="edit-names-add-more" formnovalidate="formnovalidate" type="submit" id="edit-names-add-more" name="names_add_more" value="Add Another Name" /> </div> </div> </div><h2>Emergency Plans</h2><p>Enter information for schools, childcare, caregivers and workplaces.</p><div id="emergency-plans-add-more-wrapper"> <div data-drupal-selector="edit-emergency-plans" class="js-form-item form-item"> <table id="emergency-plans-values--2" class="field-multiple-table responsive-enabled usa-table" data-striping="1"> <thead> <tr> <th colspan="2" class="field-label" scope="row"><h4 class="label"></h4></th> <th>Order</th> </tr> </thead> <tbody> <tr class="draggable odd" scope="row"> <td class="field-multiple-drag"></td> <td><div class="usa-form-group js-form-item form-item js-form-type-textfield form-item-emergency-plans-0-emergency-name js-form-item-emergency-plans-0-emergency-name"> <label for="edit-emergency-plans-0-emergency-name" class="usa-label">Name: <span class="usa-hint">(optional)</span></label> <input data-drupal-selector="edit-emergency-plans-0-emergency-name" type="text" id="edit-emergency-plans-0-emergency-name" name="emergency_plans[0][emergency_name]" value="" size="60" maxlength="128" class="form-text usa-input" /> </div> <div class="usa-form-group js-form-item form-item js-form-type-textarea form-item-emergency-plans-0-emergency-address js-form-item-emergency-plans-0-emergency-address"> <label for="edit-emergency-plans-0-emergency-address" class="usa-label">Address: <span class="usa-hint">(optional)</span></label> <div class="form-textarea-wrapper"> <textarea data-drupal-selector="edit-emergency-plans-0-emergency-address" id="edit-emergency-plans-0-emergency-address" name="emergency_plans[0][emergency_address]" rows="5" cols="30" class="form-textarea usa-textarea resize-vertical"></textarea> </div> </div> <div class="usa-form-group js-form-item form-item js-form-type-tel form-item-emergency-plans-0-emergency-hotline js-form-item-emergency-plans-0-emergency-hotline"> <label for="edit-emergency-plans-0-emergency-hotline" class="usa-label">Emergency/Hotline #: <span class="usa-hint">(optional)</span></label> <input data-drupal-selector="edit-emergency-plans-0-emergency-hotline" pattern="[0-9]{3}-[0-9]{3}-[0-9]{4}" type="tel" id="edit-emergency-plans-0-emergency-hotline" name="emergency_plans[0][emergency_hotline]" value="" size="30" maxlength="128" placeholder="123-456-7890" class="form-tel" /> </div> <div class="usa-form-group js-form-item form-item js-form-type-textfield form-item-emergency-plans-0-emergency-website js-form-item-emergency-plans-0-emergency-website"> <label for="edit-emergency-plans-0-emergency-website" class="usa-label">Website: <span class="usa-hint">(optional)</span></label> <input data-drupal-selector="edit-emergency-plans-0-emergency-website" type="text" id="edit-emergency-plans-0-emergency-website" name="emergency_plans[0][emergency_website]" value="" size="60" maxlength="128" class="form-text usa-input" /> </div> <div class="usa-form-group js-form-item form-item js-form-type-textarea form-item-emergency-plans-0-emergency-plan js-form-item-emergency-plans-0-emergency-plan"> <label for="edit-emergency-plans-0-emergency-plan" class="usa-label">Emergency Plan/Pick-Up: <span class="usa-hint">(optional)</span></label> <div class="form-textarea-wrapper"> <textarea data-drupal-selector="edit-emergency-plans-0-emergency-plan" id="edit-emergency-plans-0-emergency-plan" name="emergency_plans[0][emergency_plan]" rows="5" cols="30" class="form-textarea usa-textarea resize-vertical"></textarea> </div> </div> </td> <td class="delta-order"><div class="usa-form-group js-form-item form-item js-form-type-select form-item-emergency-plans-0--weight js-form-item-emergency-plans-0--weight form-no-label"> <label for="edit-emergency-plans-0-weight" class="usa-label visually-hidden">Weight for row 1 <span class="usa-hint">(optional)</span></label> <select data-drupal-selector="edit-emergency-plans-0-weight" class="emergency_plans-delta-order form-select usa-select" id="edit-emergency-plans-0-weight" name="emergency_plans[0][_weight]"><option value="0" selected="selected">0</option></select> </div> </td> </tr> </tbody> </table> <div class="clearfix"><input class="multivalue-add-more-submit button js-form-submit form-submit usa-button" data-drupal-selector="edit-emergency-plans-add-more" formnovalidate="formnovalidate" type="submit" id="edit-emergency-plans-add-more" name="emergency_plans_add_more" value="Add Another Emergency Plan" /> </div> </div> </div><h2>Emergency Contacts</h2><div id="emergency-contact-add-more-wrapper"> <div data-drupal-selector="edit-emergency-contact" class="js-form-item form-item"> <table id="emergency-contact-values--2" class="field-multiple-table responsive-enabled usa-table" data-striping="1"> <thead> <tr> <th colspan="2" class="field-label" scope="row"><h4 class="label"></h4></th> <th>Order</th> </tr> </thead> <tbody> <tr class="draggable odd" scope="row"> <td class="field-multiple-drag"></td> <td><div class="usa-form-group js-form-item form-item js-form-type-textfield form-item-emergency-contact-0-contact-name js-form-item-emergency-contact-0-contact-name"> <label for="edit-emergency-contact-0-contact-name" class="usa-label">Name: <span class="usa-hint">(optional)</span></label> <input data-drupal-selector="edit-emergency-contact-0-contact-name" type="text" id="edit-emergency-contact-0-contact-name" name="emergency_contact[0][contact_name]" value="" size="60" maxlength="128" class="form-text usa-input" /> </div> <div class="usa-form-group js-form-item form-item js-form-type-tel form-item-emergency-contact-0-contact-mobile js-form-item-emergency-contact-0-contact-mobile"> <label for="edit-emergency-contact-0-contact-mobile" class="usa-label">Mobile: <span class="usa-hint">(optional)</span></label> <input data-drupal-selector="edit-emergency-contact-0-contact-mobile" pattern="[0-9]{3}-[0-9]{3}-[0-9]{4}" type="tel" id="edit-emergency-contact-0-contact-mobile" name="emergency_contact[0][contact_mobile]" value="" size="30" maxlength="128" placeholder="123-456-7890" class="form-tel" /> </div> <div class="usa-form-group js-form-item form-item js-form-type-tel form-item-emergency-contact-0-contact-home js-form-item-emergency-contact-0-contact-home"> <label for="edit-emergency-contact-0-contact-home" class="usa-label">Home #: <span class="usa-hint">(optional)</span></label> <input data-drupal-selector="edit-emergency-contact-0-contact-home" pattern="[0-9]{3}-[0-9]{3}-[0-9]{4}" type="tel" id="edit-emergency-contact-0-contact-home" name="emergency_contact[0][contact_home]" value="" size="30" maxlength="128" placeholder="123-456-7890" class="form-tel" /> </div> <div class="usa-form-group js-form-item form-item js-form-type-email form-item-emergency-contact-0-contact-email js-form-item-emergency-contact-0-contact-email"> <label for="edit-emergency-contact-0-contact-email" class="usa-label">Email: <span class="usa-hint">(optional)</span></label> <input data-drupal-selector="edit-emergency-contact-0-contact-email" type="email" id="edit-emergency-contact-0-contact-email" name="emergency_contact[0][contact_email]" value="" size="60" maxlength="254" class="form-email usa-input" /> </div> <div class="usa-form-group js-form-item form-item js-form-type-textarea form-item-emergency-contact-0-contact-address js-form-item-emergency-contact-0-contact-address"> <label for="edit-emergency-contact-0-contact-address" class="usa-label">Address: <span class="usa-hint">(optional)</span></label> <div class="form-textarea-wrapper"> <textarea data-drupal-selector="edit-emergency-contact-0-contact-address" id="edit-emergency-contact-0-contact-address" name="emergency_contact[0][contact_address]" rows="5" cols="30" class="form-textarea usa-textarea resize-vertical"></textarea> </div> </div> </td> <td class="delta-order"><div class="usa-form-group js-form-item form-item js-form-type-select form-item-emergency-contact-0--weight js-form-item-emergency-contact-0--weight form-no-label"> <label for="edit-emergency-contact-0-weight" class="usa-label visually-hidden">Weight for row 1 <span class="usa-hint">(optional)</span></label> <select data-drupal-selector="edit-emergency-contact-0-weight" class="emergency_contact-delta-order form-select usa-select" id="edit-emergency-contact-0-weight" name="emergency_contact[0][_weight]"><option value="0" selected="selected">0</option></select> </div> </td> </tr> </tbody> </table> <div class="clearfix"><input class="multivalue-add-more-submit button js-form-submit form-submit usa-button" data-drupal-selector="edit-emergency-contact-add-more" formnovalidate="formnovalidate" type="submit" id="edit-emergency-contact-add-more" name="emergency_contact_add_more" value="Add Another Emergency Contact" /> </div> </div> </div><h2>Emergency Meeting Places</h2><div id="emergency-meeting-places-add-more-wrapper"> <div data-drupal-selector="edit-emergency-meeting-places" class="js-form-item form-item"> <table id="emergency-meeting-places-values--2" class="field-multiple-table responsive-enabled usa-table" data-striping="1"> <thead> <tr> <th colspan="2" class="field-label" scope="row"><h4 class="label"></h4></th> <th>Order</th> </tr> </thead> <tbody> <tr class="draggable odd" scope="row"> <td class="field-multiple-drag"></td> <td><div class="usa-form-group js-form-item form-item js-form-type-textarea form-item-emergency-meeting-places-0-location js-form-item-emergency-meeting-places-0-location"> <label for="edit-emergency-meeting-places-0-location" class="usa-label">Location: <span class="usa-hint">(optional)</span></label> <div class="form-textarea-wrapper"> <textarea data-drupal-selector="edit-emergency-meeting-places-0-location" id="edit-emergency-meeting-places-0-location" name="emergency_meeting_places[0][location]" rows="5" cols="60" class="form-textarea usa-textarea resize-vertical"></textarea> </div> </div> <div class="usa-form-group js-form-item form-item js-form-type-textarea form-item-emergency-meeting-places-0-instructions js-form-item-emergency-meeting-places-0-instructions"> <label for="edit-emergency-meeting-places-0-instructions" class="usa-label">Instructions: <span class="usa-hint">(optional)</span></label> <div class="form-textarea-wrapper"> <textarea data-drupal-selector="edit-emergency-meeting-places-0-instructions" id="edit-emergency-meeting-places-0-instructions" name="emergency_meeting_places[0][instructions]" rows="5" cols="60" class="form-textarea usa-textarea resize-vertical"></textarea> </div> </div> </td> <td class="delta-order"><div class="usa-form-group js-form-item form-item js-form-type-select form-item-emergency-meeting-places-0--weight js-form-item-emergency-meeting-places-0--weight form-no-label"> <label for="edit-emergency-meeting-places-0-weight" class="usa-label visually-hidden">Weight for row 1 <span class="usa-hint">(optional)</span></label> <select data-drupal-selector="edit-emergency-meeting-places-0-weight" class="emergency_meeting_places-delta-order form-select usa-select" id="edit-emergency-meeting-places-0-weight" name="emergency_meeting_places[0][_weight]"><option value="0" selected="selected">0</option></select> </div> </td> </tr> </tbody> </table> <div class="clearfix"><input class="multivalue-add-more-submit button js-form-submit form-submit usa-button" data-drupal-selector="edit-emergency-meeting-places-add-more" formnovalidate="formnovalidate" type="submit" id="edit-emergency-meeting-places-add-more" name="emergency_meeting_places_add_more" value="Add Another Emergency Meeting Place" /> </div> </div> </div><h2>Medical Information</h2> <div data-drupal-selector="edit-medical" class="js-form-item form-item"> <table id="medical-values--2" class="field-multiple-table responsive-enabled usa-table" data-striping="1"> <thead> <tr> <th colspan="2" class="field-label" scope="row"><h4 class="label"></h4></th> <th>Order</th> </tr> </thead> <tbody> <tr class="draggable odd" scope="row"> <td class="field-multiple-drag paragraph-bullet"></td> <td><div class="usa-form-group js-form-item form-item js-form-type-textfield form-item-medical-0-poison-control js-form-item-medical-0-poison-control form-disabled"> <label for="edit-medical-0-poison-control" class="usa-label">Poison Control: <span class="usa-hint">(optional)</span></label> <input data-drupal-selector="edit-medical-0-poison-control" disabled="disabled" type="text" id="edit-medical-0-poison-control" name="medical[0][poison_control]" value="1-800-222-1222" size="60" maxlength="128" class="form-text usa-input" /> </div> </td> <td class="delta-order"><div class="usa-form-group js-form-item form-item js-form-type-select form-item-medical-0--weight js-form-item-medical-0--weight form-no-label"> <label for="edit-medical-0-weight" class="usa-label visually-hidden">Weight for row 1 <span class="usa-hint">(optional)</span></label> <select data-drupal-selector="edit-medical-0-weight" class="medical-delta-order form-select usa-select" id="edit-medical-0-weight" name="medical[0][_weight]"><option value="0" selected="selected">0</option></select> </div> </td> </tr> </tbody> </table> </div> <div id="doctor-add-more-wrapper"> <div data-drupal-selector="edit-doctor" class="js-form-item form-item"> <table id="doctor-values--2" class="field-multiple-table responsive-enabled usa-table" data-striping="1"> <thead> <tr> <th colspan="2" class="field-label" scope="row"><h4 class="label"></h4></th> <th>Order</th> </tr> </thead> <tbody> <tr class="draggable odd" scope="row"> <td class="field-multiple-drag"></td> <td><div class="usa-form-group js-form-item form-item js-form-type-textfield form-item-doctor-0-doctor-name js-form-item-doctor-0-doctor-name"> <label for="edit-doctor-0-doctor-name" class="usa-label">Doctor Name: <span class="usa-hint">(optional)</span></label> <input data-drupal-selector="edit-doctor-0-doctor-name" type="text" id="edit-doctor-0-doctor-name" name="doctor[0][doctor_name]" value="" size="60" maxlength="128" class="form-text usa-input" /> </div> <div class="usa-form-group js-form-item form-item js-form-type-tel form-item-doctor-0-doctor-phone js-form-item-doctor-0-doctor-phone"> <label for="edit-doctor-0-doctor-phone" class="usa-label">Doctor #: <span class="usa-hint">(optional)</span></label> <input data-drupal-selector="edit-doctor-0-doctor-phone" pattern="[0-9]{3}-[0-9]{3}-[0-9]{4}" type="tel" id="edit-doctor-0-doctor-phone" name="doctor[0][doctor_phone]" value="" size="30" maxlength="128" placeholder="123-456-7890" class="form-tel" /> </div> </td> <td class="delta-order"><div class="usa-form-group js-form-item form-item js-form-type-select form-item-doctor-0--weight js-form-item-doctor-0--weight form-no-label"> <label for="edit-doctor-0-weight" class="usa-label visually-hidden">Weight for row 1 <span class="usa-hint">(optional)</span></label> <select data-drupal-selector="edit-doctor-0-weight" class="doctor-delta-order form-select usa-select" id="edit-doctor-0-weight" name="doctor[0][_weight]"><option value="0" selected="selected">0</option></select> </div> </td> </tr> </tbody> </table> <div class="clearfix"><input class="multivalue-add-more-submit button js-form-submit form-submit usa-button" data-drupal-selector="edit-doctor-add-more" formnovalidate="formnovalidate" type="submit" id="edit-doctor-add-more" name="doctor_add_more" value="Add Another Doctor Name and Phone" /> </div> </div> </div> <div data-drupal-selector="edit-medical2" class="js-form-item form-item"> <table id="medical2-values--2" class="field-multiple-table responsive-enabled usa-table" data-striping="1"> <thead> <tr> <th colspan="2" class="field-label" scope="row"><h4 class="label"></h4></th> <th>Order</th> </tr> </thead> <tbody> <tr class="draggable odd" scope="row"> <td class="field-multiple-drag paragraph-bullet"></td> <td><div class="usa-form-group js-form-item form-item js-form-type-textfield form-item-medical2-0-pediatrician-name js-form-item-medical2-0-pediatrician-name"> <label for="edit-medical2-0-pediatrician-name" class="usa-label">Pediatrician Name: <span class="usa-hint">(optional)</span></label> <input data-drupal-selector="edit-medical2-0-pediatrician-name" type="text" id="edit-medical2-0-pediatrician-name" name="medical2[0][pediatrician_name]" value="" size="60" maxlength="128" class="form-text usa-input" /> </div> <div class="usa-form-group js-form-item form-item js-form-type-tel form-item-medical2-0-pediatrician-phone js-form-item-medical2-0-pediatrician-phone"> <label for="edit-medical2-0-pediatrician-phone" class="usa-label">Pediatrician #: <span class="usa-hint">(optional)</span></label> <input data-drupal-selector="edit-medical2-0-pediatrician-phone" pattern="[0-9]{3}-[0-9]{3}-[0-9]{4}" type="tel" id="edit-medical2-0-pediatrician-phone" name="medical2[0][pediatrician_phone]" value="" size="30" maxlength="128" placeholder="123-456-7890" class="form-tel" /> </div> <div class="usa-form-group js-form-item form-item js-form-type-textarea form-item-medical2-0-allergies js-form-item-medical2-0-allergies"> <label for="edit-medical2-0-allergies" class="usa-label">Allergy information and prescriptions: <span class="usa-hint">(optional)</span></label> <div class="form-textarea-wrapper"> <textarea data-drupal-selector="edit-medical2-0-allergies" id="edit-medical2-0-allergies" name="medical2[0][allergies]" rows="5" cols="30" class="form-textarea usa-textarea resize-vertical"></textarea> </div> </div> </td> <td class="delta-order"><div class="usa-form-group js-form-item form-item js-form-type-select form-item-medical2-0--weight js-form-item-medical2-0--weight form-no-label"> <label for="edit-medical2-0-weight" class="usa-label visually-hidden">Weight for row 1 <span class="usa-hint">(optional)</span></label> <select data-drupal-selector="edit-medical2-0-weight" class="medical2-delta-order form-select usa-select" id="edit-medical2-0-weight" name="medical2[0][_weight]"><option value="0" selected="selected">0</option></select> </div> </td> </tr> </tbody> </table> </div> <div id="insurance-add-more-wrapper"> <div data-drupal-selector="edit-insurance" class="js-form-item form-item"> <table id="insurance-values--2" class="field-multiple-table responsive-enabled usa-table" data-striping="1"> <thead> <tr> <th colspan="2" class="field-label" scope="row"><h4 class="label"></h4></th> <th>Order</th> </tr> </thead> <tbody> <tr class="draggable odd" scope="row"> <td class="field-multiple-drag"></td> <td><div class="usa-form-group js-form-item form-item js-form-type-textfield form-item-insurance-0-insurance-name js-form-item-insurance-0-insurance-name"> <label for="edit-insurance-0-insurance-name" class="usa-label">Medical Insurance Name: <span class="usa-hint">(optional)</span></label> <input data-drupal-selector="edit-insurance-0-insurance-name" type="text" id="edit-insurance-0-insurance-name" name="insurance[0][insurance_name]" value="" size="60" maxlength="128" class="form-text usa-input" /> </div> <div class="usa-form-group js-form-item form-item js-form-type-textfield form-item-insurance-0-insurance-policy js-form-item-insurance-0-insurance-policy"> <label for="edit-insurance-0-insurance-policy" class="usa-label">Medical Insurance Policy #: <span class="usa-hint">(optional)</span></label> <input data-drupal-selector="edit-insurance-0-insurance-policy" type="text" id="edit-insurance-0-insurance-policy" name="insurance[0][insurance_policy]" value="" size="60" maxlength="128" class="form-text usa-input" /> </div> </td> <td class="delta-order"><div class="usa-form-group js-form-item form-item js-form-type-select form-item-insurance-0--weight js-form-item-insurance-0--weight form-no-label"> <label for="edit-insurance-0-weight" class="usa-label visually-hidden">Weight for row 1 <span class="usa-hint">(optional)</span></label> <select data-drupal-selector="edit-insurance-0-weight" class="insurance-delta-order form-select usa-select" id="edit-insurance-0-weight" name="insurance[0][_weight]"><option value="0" selected="selected">0</option></select> </div> </td> </tr> </tbody> </table> <div class="clearfix"><input class="multivalue-add-more-submit button js-form-submit form-submit usa-button" data-drupal-selector="edit-insurance-add-more" formnovalidate="formnovalidate" type="submit" id="edit-insurance-add-more" name="insurance_add_more" value="Add Another Insurance Name and Policy" /> </div> </div> </div><div class="usa-form-group js-form-item form-item js-form-type-textarea form-item-device js-form-item-device"> <label for="edit-device" class="usa-label">Assistive device make(s), model(s), supplier(s), and serial number(s): <span class="usa-hint">(optional)</span></label> <div class="form-textarea-wrapper"> <textarea data-drupal-selector="edit-device" id="edit-device" name="device" rows="5" cols="30" class="form-textarea usa-textarea resize-vertical"></textarea> </div> </div> <div data-drupal-selector="edit-medical3" class="js-form-item form-item"> <table id="medical3-values--2" class="field-multiple-table responsive-enabled usa-table" data-striping="1"> <thead> <tr> <th colspan="2" class="field-label" scope="row"><h4 class="label"></h4></th> <th>Order</th> </tr> </thead> <tbody> <tr class="draggable odd" scope="row"> <td class="field-multiple-drag paragraph-bullet"></td> <td><div class="usa-form-group js-form-item form-item js-form-type-textfield form-item-medical3-0-veterinarian-name js-form-item-medical3-0-veterinarian-name"> <label for="edit-medical3-0-veterinarian-name" class="usa-label">Veterinarian Name: <span class="usa-hint">(optional)</span></label> <input data-drupal-selector="edit-medical3-0-veterinarian-name" type="text" id="edit-medical3-0-veterinarian-name" name="medical3[0][veterinarian_name]" value="" size="60" maxlength="128" class="form-text usa-input" /> </div> 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id="edit-medical3-0-additional-information" name="medical3[0][additional_information]" rows="5" cols="60" class="form-textarea usa-textarea resize-vertical"></textarea> </div> </div> </td> <td class="delta-order"><div class="usa-form-group js-form-item form-item js-form-type-select form-item-medical3-0--weight js-form-item-medical3-0--weight form-no-label"> <label for="edit-medical3-0-weight" class="usa-label visually-hidden">Weight for row 1 <span class="usa-hint">(optional)</span></label> <select data-drupal-selector="edit-medical3-0-weight" class="medical3-delta-order form-select usa-select" id="edit-medical3-0-weight" name="medical3[0][_weight]"><option value="0" selected="selected">0</option></select> </div> </td> </tr> </tbody> </table> </div> <h2>Send Email</h2> <div data-drupal-selector="edit-send-email" class="js-form-item form-item"> <table id="send-email-values--2" class="field-multiple-table responsive-enabled usa-table" data-striping="1"> <thead> <tr> <th colspan="2" 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