{"id":27141,"date":"2022-04-04T11:00:55","date_gmt":"2022-04-04T11:00:55","guid":{"rendered":"https:\/\/www.cudeca.org\/?page_id=27141"},"modified":"2022-06-21T10:10:03","modified_gmt":"2022-06-21T10:10:03","slug":"formulario-familiar","status":"publish","type":"page","link":"https:\/\/www.cudeca.org\/en\/relatives\/","title":{"rendered":"RELATIVES"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column]\n                <div class='gf_browser_gecko gform_wrapper' id='gform_wrapper_22' style='display:none'><div id='gf_22' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_22'  action=\"\/en\/wp-json\/wp\/v2\/pages\/27141#gf_22\"> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n        <div id='gf_progressbar_wrapper_22' class='gf_progressbar_wrapper'>\n            <h3 class='gf_progressbar_title'>Step 1 of 4 - Datos del Paciente\n        <\/h3>\n            <div class='gf_progressbar'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform_body'><div id='gform_page_22_1' class='gform_page' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_22' class='gform_fields top_label form_sublabel_below description_below'><li id='field_22_46'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>PERSONAL DATA OF FAMILY MEMBERS OF PATIENTS UNDER CARE OF FUNDACI\u00d3N CUDECA<\/h2><div class='gsection_description' id='gfield_description_22_46'>Your personal data are recorded in this form, as a relative of a patient who is going to be cared by the CUDECA Hospice Foundation.\n\nWe are going to ask you to register a patient document so that we can know whose relative you are.\n\nYou can save the form and continue later<\/div><\/li><li id='field_22_28'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>PATIENT DOCUMENTATION<\/h2><div class='gsection_description' id='gfield_description_22_28'>Please provide us with the identity information of the patient so that  we can link you to the right patient<\/div><\/li><li id='field_22_58'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Please tell us the ID of the patient<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_22_58'><li class='gchoice_22_58_0'><input name='input_58' type='radio' value='DNI o SPANISH NIF'  id='choice_22_58_0'    \/><label for='choice_22_58_0' id='label_22_58_0'>DNI o SPANISH NIF<\/label><\/li><li class='gchoice_22_58_1'><input name='input_58' type='radio' value='NIE (identification document of foreign residents in Spain)'  id='choice_22_58_1'    \/><label for='choice_22_58_1' id='label_22_58_1'>NIE (identification document of foreign residents in Spain)<\/label><\/li><li class='gchoice_22_58_2'><input name='input_58' type='radio' value='PASSPORT'  id='choice_22_58_2'    \/><label for='choice_22_58_2' id='label_22_58_2'>PASSPORT<\/label><\/li><li class='gchoice_22_58_3'><input name='input_58' type='radio' value='I DO NOT HAVE DOCUMENTATION'  id='choice_22_58_3'    \/><label for='choice_22_58_3' id='label_22_58_3'>I DO NOT HAVE DOCUMENTATION<\/label><\/li><\/ul><\/div><\/li><li id='field_22_32'  class='gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_22_32' >Number of spanish DNI-NIF<span class='gfield_required'>*<\/span><\/label><div class='gfield_description' id='gfield_description_22_32'>Write only numbers and letters, do not use spaces, slashes or hyphens.<\/div><div class='ginput_container ginput_container_text'><input name='input_32' id='input_22_32' type='text' value='' class='medium'  aria-describedby=\"gfield_description_22_32\"   aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_22_53'  class='gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_22_53' >NIE number (identification document of foreign residents in Spain)<span class='gfield_required'>*<\/span><\/label><div class='gfield_description' id='gfield_description_22_53'>Write only numbers and letters, do not use spaces, slashes or hyphens.<\/div><div class='ginput_container ginput_container_text'><input name='input_53' id='input_22_53' type='text' value='' class='medium'  aria-describedby=\"gfield_description_22_53\"   aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_22_54'  class='gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_22_54' >Passport number<span class='gfield_required'>*<\/span><\/label><div class='gfield_description' id='gfield_description_22_54'>Write it the same as it appears on the original passport<\/div><div class='ginput_container ginput_container_text'><input name='input_54' id='input_22_54' type='text' value='' class='medium'  aria-describedby=\"gfield_description_22_54\"   aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_22_86'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'><\/h2><div class='gsection_description' id='gfield_description_22_86'>It is very important to have some type of document that identifies your relative, there are procedures that make it essential<\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                         <input type='button' id='gform_next_button_22_65' class='gform_next_button button' value='Siguiente '  onclick='jQuery(\"#gform_target_page_number_22\").val(\"2\");  jQuery(\"#gform_22\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_22\").val(\"2\");  jQuery(\"#gform_22\").trigger(\"submit\",[true]); } ' \/> <a href='javascript:void(0);' id='gform_save_22_2_link' class='gform_save_link'  onclick='if(window[\"gf_submitting_22\"]){return false;}  if( !jQuery(\"#gform_22\")[0].checkValidity || jQuery(\"#gform_22\")[0].checkValidity()){window[\"gf_submitting_22\"]=true;} jQuery(\"#gform_save_22\").val(1); jQuery(\"#gform_22\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_22\"]){return false;} if( !jQuery(\"#gform_22\")[0].checkValidity || jQuery(\"#gform_22\")[0].checkValidity()){window[\"gf_submitting_22\"]=true;} jQuery(\"#gform_save_22\").val(1); jQuery(\"#gform_22\").trigger(\"submit\",[true]); }'>Save & Continue<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_22_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_22_2' class='gform_fields top_label form_sublabel_below description_below'><li id='field_22_61'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>YOUR PERSONAL DATA<\/h2><div class='gsection_description' id='gfield_description_22_61'>Now we will ask for your personal data<\/div><\/li><li id='field_22_1'  class='gfield gfield_contains_required field_sublabel_above field_description_above gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Name and family names<span class='gfield_required'>*<\/span><\/label><div class='gfield_description' id='gfield_description_22_1'>This field is required.\nWrite the same as it appears on your identity document.<\/div><div class='ginput_complex ginput_container no_prefix has_first_name has_middle_name no_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_22_1'>\n                            \n                            <span id='input_22_1_3_container' class='name_first' >\n                                                    <label for='input_22_1_3' >Name<\/label>\n                                                    <input type='text' name='input_1.3' id='input_22_1_3' value='' aria-label='First name'   aria-required=\"true\" aria-invalid=\"false\" placeholder='Name'\/>\n                                                <\/span>\n                            <span id='input_22_1_4_container' class='name_middle' >\n                                                    <label for='input_22_1_4' >Surnames<\/label>\n                                                    <input type='text' name='input_1.4' id='input_22_1_4' value='' aria-label='Middle name'   aria-required=\"true\" aria-invalid=\"false\" placeholder='Surname 1'\/>\n                                                <\/span>\n                            \n                            \n                        <\/div><\/li><li id='field_22_87'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Please select your ID number<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_22_87'><li class='gchoice_22_87_0'><input name='input_87' type='radio' value='DNI o SPANISH NIF'  id='choice_22_87_0'    \/><label for='choice_22_87_0' id='label_22_87_0'>DNI o SPANISH NIF<\/label><\/li><li class='gchoice_22_87_1'><input name='input_87' type='radio' value='NIE (identification document of foreign residents in Spain)'  id='choice_22_87_1'    \/><label for='choice_22_87_1' id='label_22_87_1'>NIE (identification document of foreign residents in Spain)<\/label><\/li><li class='gchoice_22_87_2'><input name='input_87' type='radio' value='PASSPORT'  id='choice_22_87_2'    \/><label for='choice_22_87_2' id='label_22_87_2'>PASSPORT<\/label><\/li><li class='gchoice_22_87_3'><input name='input_87' type='radio' value='I DO NOT HAVE DOCUMENTATION'  id='choice_22_87_3'    \/><label for='choice_22_87_3' id='label_22_87_3'>I DO NOT HAVE DOCUMENTATION<\/label><\/li><\/ul><\/div><\/li><li id='field_22_88'  class='gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_22_88' >Number of spanish DNI-NIF<span class='gfield_required'>*<\/span><\/label><div class='gfield_description' id='gfield_description_22_88'>Write only numbers and letters, do not use spaces, slashes or hyphens.<\/div><div class='ginput_container ginput_container_text'><input name='input_88' id='input_22_88' type='text' value='' class='medium'  aria-describedby=\"gfield_description_22_88\"   aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_22_89'  class='gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_22_89' >NIE number (identification document of foreign residents in Spain)<span class='gfield_required'>*<\/span><\/label><div class='gfield_description' id='gfield_description_22_89'>Write only numbers and letters, do not use spaces, slashes or hyphens.<\/div><div class='ginput_container ginput_container_text'><input name='input_89' id='input_22_89' type='text' value='' class='medium'  aria-describedby=\"gfield_description_22_89\"   aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_22_90'  class='gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_22_90' >Passport number<span class='gfield_required'>*<\/span><\/label><div class='gfield_description' id='gfield_description_22_90'>Write it the same as it appears on the original passport<\/div><div class='ginput_container ginput_container_text'><input name='input_90' id='input_22_90' type='text' value='' class='medium'  aria-describedby=\"gfield_description_22_90\"   aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_22_91' class='gform_previous_button button' value='Anterior'  onclick='jQuery(\"#gform_target_page_number_22\").val(\"1\");  jQuery(\"#gform_22\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_22\").val(\"1\");  jQuery(\"#gform_22\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_22_91' class='gform_next_button button' value='Siguiente '  onclick='jQuery(\"#gform_target_page_number_22\").val(\"3\");  jQuery(\"#gform_22\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_22\").val(\"3\");  jQuery(\"#gform_22\").trigger(\"submit\",[true]); } ' \/> <a href='javascript:void(0);' id='gform_save_22_3_link' class='gform_save_link'  onclick='if(window[\"gf_submitting_22\"]){return false;}  if( !jQuery(\"#gform_22\")[0].checkValidity || jQuery(\"#gform_22\")[0].checkValidity()){window[\"gf_submitting_22\"]=true;} jQuery(\"#gform_save_22\").val(1); jQuery(\"#gform_22\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_22\"]){return false;} if( !jQuery(\"#gform_22\")[0].checkValidity || jQuery(\"#gform_22\")[0].checkValidity()){window[\"gf_submitting_22\"]=true;} jQuery(\"#gform_save_22\").val(1); jQuery(\"#gform_22\").trigger(\"submit\",[true]); }'>Save & Continue<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_22_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_22_3' class='gform_fields top_label form_sublabel_below description_below'><li id='field_22_83'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'><\/h2><\/li><li class=\"gfmc-column gfmc-column33 gfmc-row-1-column gfmc-row-1-col-1-of-3\"><ul class=\"flex-wrapper flex-wrapper-3\"><li id='field_22_92'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_22_92' >Type of relationship with the patient<\/label><div class='ginput_container ginput_container_select'><select name='input_92' id='input_22_92' class='medium gfield_select'    aria-invalid=\"false\"><option value='Brother\/Sister' >Brother\/Sister<\/option><option value='Caregiver (professional)' >Caregiver (professional)<\/option><option value='Cousin' >Cousin<\/option><option value='Daugther\/Son' >Daugther\/Son<\/option><option value='Daugther\/Son (in law)' >Daugther\/Son (in law)<\/option><option value='Father\/Mother' >Father\/Mother<\/option><option value='Friend' >Friend<\/option><option value='Grand Daugther\/Son' >Grand Daugther\/Son<\/option><option value='Neighbor' >Neighbor<\/option><option value='Nephew' >Nephew<\/option><option value='Other first degree relative' >Other first degree relative<\/option><option value='Partner (married)' >Partner (married)<\/option><option value='Partner (not legally married)' >Partner (not legally married)<\/option><option value='Uncle\/Aunt' >Uncle\/Aunt<\/option><\/select><\/div><\/li><\/ul><\/li><li class=\"gfmc-column gfmc-column33 gfmc-row-1-column gfmc-row-1-col-2-of-3\"><ul class=\"flex-wrapper flex-wrapper-3\"><li id='field_22_63'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Are you the primary caregiver for the patient?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_22_63'><li class='gchoice_22_63_1'>\n\t\t\t\t\t\t\t\t<input name='input_63.1' type='checkbox'  value='Yes'  id='choice_22_63_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_63_1' id='label_22_63_1'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_22_63_2'>\n\t\t\t\t\t\t\t\t<input name='input_63.2' type='checkbox'  value='No'  id='choice_22_63_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_63_2' id='label_22_63_2'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><\/ul><\/li><li class=\"gfmc-column gfmc-column33 gfmc-row-1-column gfmc-row-1-col-3-of-3\"><ul class=\"flex-wrapper flex-wrapper-3\"><li id='field_22_64'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Are you the primary contact person for the patient?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_22_64'><li class='gchoice_22_64_1'>\n\t\t\t\t\t\t\t\t<input name='input_64.1' type='checkbox'  value='Yes'  id='choice_22_64_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_64_1' id='label_22_64_1'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_22_64_2'>\n\t\t\t\t\t\t\t\t<input name='input_64.2' type='checkbox'  value='No'  id='choice_22_64_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_64_2' id='label_22_64_2'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><\/ul><\/li><li id='field_22_73'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'><\/h2><\/li><li class=\"gfmc-column gfmc-column33 gfmc-row-2-column gfmc-row-2-col-1-of-3\"><ul class=\"flex-wrapper flex-wrapper-3\"><li id='field_22_18'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_22_18' >Genre<\/label><div class='ginput_container ginput_container_select'><select name='input_18' id='input_22_18' class='small gfield_select'    aria-invalid=\"false\"><option value='Male' >Male<\/option><option value='Female' >Female<\/option><option value='No answer' >No answer<\/option><\/select><\/div><\/li><\/ul><\/li><li class=\"gfmc-column gfmc-column33 gfmc-row-2-column gfmc-row-2-col-2-of-3\"><ul class=\"flex-wrapper flex-wrapper-3\"><li id='field_22_26'  class='gfield field_sublabel_above field_description_above gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Country of birth<\/label>    \n                    <div class='ginput_complex ginput_container has_country ginput_container_address' id='input_22_26' >\n                        <input type='hidden' class='gform_hidden' name='input_26.4' id='input_22_26_4' value=''\/><span class='ginput_left address_country' id='input_22_26_6_container' >\n                                        <label for='input_22_26_6' id='input_22_26_6_label' >Country of birth<\/label>\n                                        <select name='input_26.6' id='input_22_26_6'   ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darrussalam' >Brunei Darrussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><\/ul><\/li><li class=\"gfmc-column gfmc-column33 gfmc-row-2-column gfmc-row-2-col-3-of-3\"><ul class=\"flex-wrapper flex-wrapper-3\"><li id='field_22_22'  class='gfield field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_22_22' >Date of birth<\/label><div class='gfield_description' id='gfield_description_22_22'>You must use two figures for the day, two for the month and four for the year, for example: 03\/06\/1970<\/div><div class='ginput_container ginput_container_date'>\n                            <input name='input_22' id='input_22_22' type='text' value='' class='datepicker large dmy datepicker_with_icon'    aria-describedby='input_22_22_date_format' \/>\n                            <span id='input_22_22_date_format' class='screen-reader-text'>Date Format: DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_22_22' class='gform_hidden' value='https:\/\/www.cudeca.org\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><\/ul><\/li><li id='field_22_74'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'><\/h2><\/li><li id='field_22_4'  class='gfield field_sublabel_above field_description_above gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Your address<\/label><div class='gfield_description' id='gfield_description_22_4'>In the address specify in this order:\nType of street: Street, Road, Avenue, Square, etc. -- Name of the street -- Number of the street -- Details of the dwelling, if any: portal, floor, etc.<\/div>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_22_4' >\n                         <span class='ginput_full address_line_1' id='input_22_4_1_container' >\n                                        <label for='input_22_4_1' id='input_22_4_1_label' >Street Address<\/label>\n                                        <input type='text' name='input_4.1' id='input_22_4_1' value=''   placeholder='Address' \/>\n                                    <\/span><span class='ginput_full address_line_2' id='input_22_4_2_container' >\n                                        <label for='input_22_4_2' id='input_22_4_2_label' >Address Line 2<\/label>\n                                        <input type='text' name='input_4.2' id='input_22_4_2' value=''   placeholder='supplementary information'\/>\n                                    <\/span><span class='ginput_left address_city' id='input_22_4_3_container' >\n                                    <label for='input_22_4_3' id='input_22_4_3_label' >City<\/label>\n                                    <input type='text' name='input_4.3' id='input_22_4_3' value=''   placeholder='City' \/>\n                                 <\/span><span class='ginput_right address_state' id='input_22_4_4_container' >\n                                        <label for='input_22_4_4' id='input_22_4_4_label' >State \/ Province<\/label>\n                                        <input type='text' name='input_4.4' id='input_22_4_4' value='M\u00e1laga'     placeholder='Province' \/>\n                                      <\/span><span class='ginput_left address_zip' id='input_22_4_5_container' >\n                                    <label for='input_22_4_5' id='input_22_4_5_label' >Zip \/ Postal Code<\/label>\n                                    <input type='text' name='input_4.5' id='input_22_4_5' value=''   placeholder='Post Code' \/>\n                                <\/span><span class='ginput_right address_country' id='input_22_4_6_container' >\n                                        <label for='input_22_4_6' id='input_22_4_6_label' >Country<\/label>\n                                        <select name='input_4.6' id='input_22_4_6'   ><option value='' >Country<\/option><option value='Afghanistan' >Afghanistan<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darrussalam' >Brunei Darrussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id='field_22_76'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'><\/h2><\/li><li class=\"gfmc-column gfmc-column50 gfmc-row-3-column gfmc-row-3-col-1-of-2\"><ul class=\"flex-wrapper flex-wrapper-2\"><li id='field_22_5'  class='gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_22_5' >Your telephone number<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_22_5' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><\/ul><\/li><li class=\"gfmc-column gfmc-column50 gfmc-row-3-column gfmc-row-3-col-2-of-2\"><ul class=\"flex-wrapper flex-wrapper-2\"><li id='field_22_20'  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ginput_container_textarea'><textarea name='input_56' id='input_22_56' class='textarea medium'  aria-describedby=\"gfield_description_22_56\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_22_56'>Please add any questions or comments you may have.<\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_22_51' class='gform_previous_button button' value='Anterior'  onclick='jQuery(\"#gform_target_page_number_22\").val(\"2\");  jQuery(\"#gform_22\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_22\").val(\"2\");  jQuery(\"#gform_22\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_22_51' class='gform_next_button button' value='Siguiente '  onclick='jQuery(\"#gform_target_page_number_22\").val(\"4\");  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style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_22_4' class='gform_fields top_label form_sublabel_below description_below'><li id='field_22_81'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Legal agreements<\/h2><div class='gsection_description' id='gfield_description_22_81'>In this last part we ask for your consent to the use of the personal data that we have requested from you<\/div><\/li><li id='field_22_66'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >ACCEPTANCE OF CUDECA HOSPICE PRIVACY POLICY<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_66.1' id='input_22_66_1' type='checkbox' value='1'  aria-describedby='gfield_consent_description_22_66' aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gfield_consent_label\" for='input_22_66_1' ><font color=red>I accept the privacy policy of the Cudeca Hospice Foundation. <\/font> <\/label><input type='hidden' name='input_66.2' value='&lt;font color=red&gt;I accept the privacy policy of the Cudeca Hospice Foundation. &lt;\/font&gt; ' class='gform_hidden' \/><input type='hidden' name='input_66.3' value='70' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_22_66'>Our privacy policy is available in this link:  <a href=\"https:\/\/www.cudeca.org\/en\/politica-de-privacidad\/\"> Privacy policy - Cudeca Cancer Care Hospice<\/a><\/div><\/li><li id='field_22_94'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >CONSENT FOR THE ASSIGNMENT OF PERSONAL DATA TO CUDECA<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_22_94'><li class='gchoice_22_94_1'>\n\t\t\t\t\t\t\t\t<input name='input_94.1' type='checkbox'  value='Si'  id='choice_22_94_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_94_1' id='label_22_94_1'><font color=\"red\">Check this box to receive information about our special care and the different activities via email and\/or phone. <\/font><\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_22_94_2'>\n\t\t\t\t\t\t\t\t<input name='input_94.2' type='checkbox'  value='No'  id='choice_22_94_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_94_2' id='label_22_94_2'><font>Check this box to not receive information about our special care and the different activities via email and\/or phone. <\/font><\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_22_94'>Text available in this link: <a href=\"https:\/\/www.cudeca.org\/wp-content\/uploads\/2022\/03\/Consentimiento-cesion-datos-personales-de-familiar-o-cuidador-v_inglesa.docx\">CONSENT FOR THE ASSIGNMENT OF PERSONAL DATA TO CUDECA<\/a>\n<\/div><\/li><li id='field_22_13'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_22_13' >CAPTCHA<\/label><div id='input_22_13' class='ginput_container ginput_recaptcha' data-sitekey='6LfZCkQsAAAAAPQCM5nA78jklRamDtzgIKY4iWbA'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/li><li id='field_22_93'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>LEGAL DISCLAIMER<\/h2><div class='gsection_description' id='gfield_description_22_93'><font size=-1> In accordance with the provisions of the regulations in force on the protection of personal data, Regulation (EU) 2016\/679 of April 27, 2016 (GDPR) and the Spanish Organic Law 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