{"id":1366,"date":"2021-07-30T16:20:56","date_gmt":"2021-07-30T20:20:56","guid":{"rendered":"https:\/\/wwwcp.umes.edu\/atod\/?page_id=1366"},"modified":"2021-07-30T16:38:55","modified_gmt":"2021-07-30T20:38:55","slug":"program-request","status":"publish","type":"page","link":"https:\/\/wwwcp.umes.edu\/atod\/program-request\/","title":{"rendered":"Program Request"},"content":{"rendered":"\n<h2 class=\"wp-block-heading\">PEER EDUCATION PROGRAM\/PRESENTATION REQUEST FORM<\/h2>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\">If you are interested in requesting the services of our Peer Educators to provide a program\/presentation, please fill out this form and submit your request at least one (1) week in advance.&nbsp; Thank You!<\/p>\n\n\n\n<div class=\"forminator-guttenberg\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-1365 forminator-design--default forminator-enclosed forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-1365\" data-uid=\"6a4b3bc259627\"><br\/><\/div><form\r\n\t\t\t\tid=\"forminator-module-1365\"\r\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-1365 forminator-design--default forminator-enclosed forminator_ajax\"\r\n\t\t\t\tmethod=\"post\"\r\n\t\t\t\tdata-forminator-render=\"0\"\r\n\t\t\t\tdata-form-id=\"1365\"\r\n\t\t\t\t data-color-option=\"default\" data-design=\"default\" data-grid=\"enclosed\" style=\"display: none;\"\r\n\t\t\t\tdata-uid=\"6a4b3bc259627\"\r\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6a4b3bc259627\" id=\"forminator-field-name-1_6a4b3bc259627-label\" class=\"forminator-label\">Name (First and Last) <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_6a4b3bc259627\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_6a4b3bc259627\" id=\"forminator-field-text-1_6a4b3bc259627-label\" class=\"forminator-label\">UMES Department\/Office\/Organization <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_6a4b3bc259627\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6a4b3bc259627\" id=\"forminator-field-email-1_6a4b3bc259627-label\" class=\"forminator-label\">UMES Email Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6a4b3bc259627\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6a4b3bc259627\" id=\"forminator-field-phone-1_6a4b3bc259627-label\" class=\"forminator-label\">Phone # <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"(123) 456-7890\" id=\"forminator-field-phone-1_6a4b3bc259627\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_6a4b3bc259627\" id=\"forminator-field-date-1-picker_6a4b3bc259627-label\" class=\"forminator-label\">Program Date<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_6a4b3bc259627\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-1365__field--select-1_6a4b3bc259627\" id=\"forminator-form-1365__field--select-1_6a4b3bc259627-label\" class=\"forminator-label\">Program Topic<\/label><select  id=\"forminator-form-1365__field--select-1_6a4b3bc259627\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-1\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" data-search-placeholder=\"\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-1365__field--select-1_6a4b3bc259627-label\"><option value=\"alcohol\"  data-calculation=\"0\">Alcohol<\/option><option value=\"binge-drinking\"  data-calculation=\"0\">Binge Drinking<\/option><option value=\"tobacco\"  data-calculation=\"0\">Cannabis<\/option><option value=\"drugs\"  data-calculation=\"0\">Other Drugs (i.e. Tobacco, Opioids, etc.)<\/option><option value=\"sexual-responsibility\"  data-calculation=\"0\">Sexual Responsibility<\/option><option value=\"sexually-transmitted-infectionsdiseases\"  data-calculation=\"0\">Sexually Transmitted Infections (STI&#8217;s)<\/option><option value=\"hivaids\"  data-calculation=\"0\">HIV\/AIDS<\/option><option value=\"Problem-Gambling\"  data-calculation=\"0\">Problem Gambling<\/option><option value=\"other\"  data-calculation=\"0\">Other<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_6a4b3bc259627\" id=\"forminator-field-text-2_6a4b3bc259627-label\" class=\"forminator-label\">Program Location<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_6a4b3bc259627\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"time-1\" class=\"forminator-field-time forminator-col forminator-col-12 \"><label for=\"forminator-field-time-1\" id=\"forminator-field-time-1-label\" class=\"forminator-label\">Start Time<\/label><div class=\"forminator-timepicker\" ><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"time-1-hours\" class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-time-1-hours_6a4b3bc259627\" id=\"forminator-field-time-1-hours_6a4b3bc259627-label\" class=\"forminator-label\">Hours<\/label><input type=\"number\" name=\"time-1-hours\" min=\"0\" max=\"12\" placeholder=\"\" id=\"forminator-field-time-1-hours_6a4b3bc259627\" class=\"forminator-input time-hours \" data-field=\"hours\" value=\"\" \/><\/div><\/div><div id=\"time-1-minutes\" class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-time-1-minutes_6a4b3bc259627\" id=\"forminator-field-time-1-minutes_6a4b3bc259627-label\" class=\"forminator-label\">Minutes<\/label><input type=\"number\" min=\"0\" max=\"59\" name=\"time-1-minutes\" placeholder=\"\" id=\"forminator-field-time-1-minutes_6a4b3bc259627\" class=\"forminator-input time-minutes \" data-field=\"minutes\" value=\"\" \/><\/div><\/div><div id=\"time-1-ampm\" class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-1365__field--time-1-ampm_6a4b3bc259627\" id=\"forminator-field-1365__field--time-1-ampm_6a4b3bc259627-label\" class=\"forminator-label\">AM\/PM<\/label><select name=\"time-1-ampm\" id=\"forminator-field-1365__field--time-1-ampm_6a4b3bc259627\" class=\"forminator-select2 time-ampm \" data-field=\"ampm\" aria-labelledby=\"forminator-field-1365__field--time-1-ampm_6a4b3bc259627-label\" data-default-value=\"\"><option value=\"am\" >AM<\/option><option value=\"pm\" >PM<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"time-2\" class=\"forminator-field-time forminator-col forminator-col-12 \"><label for=\"forminator-field-time-2\" id=\"forminator-field-time-2-label\" class=\"forminator-label\">End Time<\/label><div class=\"forminator-timepicker\" ><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"time-2-hours\" class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-time-2-hours_6a4b3bc259627\" id=\"forminator-field-time-2-hours_6a4b3bc259627-label\" class=\"forminator-label\">Hours<\/label><input type=\"number\" name=\"time-2-hours\" min=\"0\" max=\"12\" placeholder=\"\" id=\"forminator-field-time-2-hours_6a4b3bc259627\" class=\"forminator-input time-hours \" data-field=\"hours\" value=\"\" \/><\/div><\/div><div id=\"time-2-minutes\" class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-time-2-minutes_6a4b3bc259627\" id=\"forminator-field-time-2-minutes_6a4b3bc259627-label\" class=\"forminator-label\">Minutes<\/label><input type=\"number\" min=\"0\" max=\"59\" name=\"time-2-minutes\" placeholder=\"\" id=\"forminator-field-time-2-minutes_6a4b3bc259627\" class=\"forminator-input time-minutes \" data-field=\"minutes\" value=\"\" \/><\/div><\/div><div id=\"time-2-ampm\" class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-1365__field--time-2-ampm_6a4b3bc259627\" id=\"forminator-field-1365__field--time-2-ampm_6a4b3bc259627-label\" class=\"forminator-label\">AM\/PM<\/label><select name=\"time-2-ampm\" id=\"forminator-field-1365__field--time-2-ampm_6a4b3bc259627\" class=\"forminator-select2 time-ampm \" data-field=\"ampm\" aria-labelledby=\"forminator-field-1365__field--time-2-ampm_6a4b3bc259627-label\" data-default-value=\"\"><option value=\"am\" >AM<\/option><option value=\"pm\" >PM<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_6a4b3bc259627\" id=\"forminator-field-text-3_6a4b3bc259627-label\" class=\"forminator-label\"># Attending (Residents or Participants)<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_6a4b3bc259627\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_6a4b3bc259627\" id=\"forminator-field-textarea-1_6a4b3bc259627-label\" class=\"forminator-label\">Additional Requests<\/label><textarea name=\"textarea-1\" placeholder=\"Example: Would like to use the game buzzers\" id=\"forminator-field-textarea-1_6a4b3bc259627\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"captcha-1\" class=\"forminator-field-captcha forminator-col forminator-col-12 \"><div class=\"forminator-captcha-left forminator-g-recaptcha recaptcha-invisible\" data-theme=\"light\" data-badge=\"inline\" data-sitekey=\"6LcCCBQdAAAAAP73y91aYkTmlJsRh0SvZzWKMuhk\" data-size=\"invisible\"><\/div> <\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Submit<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"b9d578a575\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/atod\/wp-json\/wp\/v2\/pages\/1366\" \/><input type=\"hidden\" name=\"form_id\" value=\"1365\"><input type=\"hidden\" name=\"page_id\" value=\"1366\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/wwwcp.umes.edu\/atod\/program-request\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"<p>PEER EDUCATION PROGRAM\/PRESENTATION REQUEST FORM If you are interested in requesting the services of our Peer Educators to provide a program\/presentation, please fill out this form and submit your request at least one (1) week in advance.&nbsp; Thank You!&#8230;<span class=\"cpschool-read-more-link-holder\"><a class=\"btn btn-basic cpschool-read-more-link\" href=\"https:\/\/wwwcp.umes.edu\/atod\/program-request\/\">Read more <span class=\"sr-only\">Program Request<\/span><\/a><\/span><\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_coblocks_attr":"","_coblocks_dimensions":"","_coblocks_responsive_height":"","_coblocks_accordion_ie_support":"","footnotes":""},"folder":[],"class_list":["post-1366","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/wwwcp.umes.edu\/atod\/wp-json\/wp\/v2\/pages\/1366","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/wwwcp.umes.edu\/atod\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/wwwcp.umes.edu\/atod\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/wwwcp.umes.edu\/atod\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/wwwcp.umes.edu\/atod\/wp-json\/wp\/v2\/comments?post=1366"}],"version-history":[{"count":0,"href":"https:\/\/wwwcp.umes.edu\/atod\/wp-json\/wp\/v2\/pages\/1366\/revisions"}],"wp:attachment":[{"href":"https:\/\/wwwcp.umes.edu\/atod\/wp-json\/wp\/v2\/media?parent=1366"}],"wp:term":[{"taxonomy":"folder","embeddable":true,"href":"https:\/\/wwwcp.umes.edu\/atod\/wp-json\/wp\/v2\/folder?post=1366"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}