{"id":62735,"date":"2024-12-04T19:04:09","date_gmt":"2024-12-04T19:04:09","guid":{"rendered":"https:\/\/theparishtrust.org.uk\/babi-banc-atgyfeirio\/"},"modified":"2026-03-31T22:23:07","modified_gmt":"2026-03-31T21:23:07","slug":"babybankreferral","status":"publish","type":"page","link":"https:\/\/theparishtrust.org.uk\/cy\/banc-babi\/babybankreferral\/","title":{"rendered":"Atgyfeiriad Banc Babi"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"62735\" class=\"elementor elementor-62735 elementor-62730\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-779c2c5 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"779c2c5\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 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data-options=\"{&quot;id&quot;:12,&quot;uniqueId&quot;:&quot;b68a71&quot;,&quot;theme&quot;:&quot;&quot;,&quot;ajax&quot;:true,&quot;logic&quot;:{&quot;logic&quot;:{&quot;45&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;7&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;4&quot;,&quot;value&quot;:&quot;Charity&quot;}]},&quot;47&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;7&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;3&quot;,&quot;value&quot;:&quot;Local Authority&quot;}]},&quot;48&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;7&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;NHS&quot;}]},&quot;56&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;6&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;7&quot;,&quot;value&quot;:&quot;NICU Nurse\\\/Sister&quot;}]},&quot;21&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;any&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;16&quot;,&quot;operator&quot;:&quot;not_empty&quot;,&quot;optionId&quot;:null,&quot;value&quot;:&quot;&quot;},{&quot;elementId&quot;:&quot;20&quot;,&quot;operator&quot;:&quot;not_empty&quot;,&quot;optionId&quot;:null,&quot;value&quot;:&quot;&quot;}]},&quot;25&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;24&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;Maternity (Adult\\\/Antenatal)&quot;}]},&quot;26&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;31&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;Clothing&quot;}]},&quot;32&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;24&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Baby\\\/Child (up to 5 years of age)&quot;}]},&quot;37&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;35&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;Clothing&quot;}]},&quot;57&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;37&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;12&quot;,&quot;value&quot;:&quot;Prem Clothes&quot;}]},&quot;53&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;any&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;35&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;5&quot;,&quot;value&quot;:&quot;Shoes&quot;},{&quot;elementId&quot;:&quot;35&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;6&quot;,&quot;value&quot;:&quot;Wellies&quot;}]},&quot;54&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;any&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;35&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;7&quot;,&quot;value&quot;:&quot;Nappies&quot;}]},&quot;38&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;35&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Toiletries&quot;}]},&quot;39&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;35&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;4&quot;,&quot;value&quot;:&quot;Baby Equipment&quot;}]},&quot;55&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;35&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;8&quot;,&quot;value&quot;:&quot;Baby Milk&quot;}]}},&quot;dependents&quot;:{&quot;7&quot;:[45,47,48],&quot;6&quot;:[56],&quot;16&quot;:[21],&quot;20&quot;:[21],&quot;24&quot;:[25,32],&quot;31&quot;:[26],&quot;35&quot;:[37,53,53,54,38,39,55],&quot;37&quot;:[57]},&quot;elementIds&quot;:[45,47,48,56,21,25,26,32,37,57,53,54,38,39,55],&quot;dependentElementIds&quot;:[&quot;7&quot;,&quot;6&quot;,&quot;16&quot;,&quot;20&quot;,&quot;24&quot;,&quot;31&quot;,&quot;35&quot;,&quot;37&quot;],&quot;animate&quot;:true},&quot;currentPageId&quot;:1,&quot;errorsIcon&quot;:&quot;&quot;,&quot;updateFancybox&quot;:true,&quot;hasPages&quot;:true,&quot;pages&quot;:[1,13,22,41],&quot;pageProgressType&quot;:&quot;percentage&quot;,&quot;tooltipsEnabled&quot;:true,&quot;tooltipClasses&quot;:&quot;qtip-quform-dark qtip-shadow&quot;,&quot;tooltipMy&quot;:&quot;left center&quot;,&quot;tooltipAt&quot;:&quot;right center&quot;,&quot;isRtl&quot;:false,&quot;scrollOffset&quot;:-50,&quot;scrollSpeed&quot;:800}\"><button class=\"quform-default-submit\" name=\"quform_submit\" type=\"submit\" value=\"submit\" aria-hidden=\"true\" tabindex=\"-1\"><\/button><div class=\"quform-form-inner quform-form-inner-12\"><input type=\"hidden\" name=\"quform_form_id\" value=\"12\" \/><input type=\"hidden\" name=\"quform_form_uid\" value=\"b68a71\" \/><input type=\"hidden\" name=\"quform_count\" value=\"1\" \/><input type=\"hidden\" name=\"form_url\" value=\"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/pages\/62735\" \/><input type=\"hidden\" name=\"referring_url\" value=\"\" \/><input type=\"hidden\" name=\"post_id\" value=\"\" \/><input type=\"hidden\" name=\"post_title\" value=\"\" \/><input type=\"hidden\" name=\"quform_current_page_id\" value=\"1\" \/><input type=\"hidden\" name=\"quform_loaded\" value=\"1776181813|51bd6ad54bf602b9513a8e8e01b0315d\" \/><input type=\"hidden\" name=\"quform_csrf_token\" value=\"r03RaLV1zu8nCOU20oYEn0wyNHQPJ5Mqh0BAu0xd\" \/><div class=\"quform-form-title-description\"><h2 class=\"quform-form-title\">Make a Referral to the Baby Bank<\/h2><p class=\"quform-form-description\">Thank you for being willing to refer a baby and\/or parent to The Parish Trust's Caerphilly Baby Bank and Maternity Supplies Project.\n\nPlease be aware that this form is for professionals only. If you are a parent in need of support for yourself or your baby, please contact your health visitor, social worker, or other professional who is caring for you.\n\nOnce this form is submitted, our team will contact you and work with you to arrange for you to collect the support package at a date and time convenient to you, so that you can pass it on to the baby and\/or parent(s) that you're supporting.<\/p><\/div><div class=\"quform-elements quform-elements-12 quform-cf quform-responsive-elements-phone-landscape\"><div class=\"quform-page-progress quform-page-progress-type-percentage\"><div class=\"quform-page-progress-bar\" style=\"width: 25%;\"><span class=\"quform-page-progress-text\"><span class=\"quform-page-progress-percentage\">25<\/span>%<\/span><\/div><\/div><div class=\"quform-element quform-element-page quform-page-1 quform-page-12_1 quform-cf quform-group-style-plain quform-first-page quform-current-page\"><div class=\"quform-page-title-description\"><h3 class=\"quform-page-title\">Referrer Details<\/h3><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-name quform-element-12_4 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_4\"><label class=\"quform-label-text\" id=\"quform_12_4_b68a71_label\">Name<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-name quform-inner-12_4\"><div class=\"quform-input quform-input-name quform-input-12_4 quform-cf\"><div class=\"quform-element-row quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element-column\"><div class=\"quform-element quform-element-text quform-element-12_4_2 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-text quform-inner-12_4_2\"><div class=\"quform-input quform-input-text quform-input-12_4_2 quform-cf\"><input type=\"text\" id=\"quform_12_4_2_b68a71\" name=\"quform_12_4[2]\" class=\"quform-field quform-field-text quform-field-12_4_2\" aria-labelledby=\"quform_12_4_b68a71_label quform_12_4_2_b68a71_sub_label_below\" \/><\/div><label id=\"quform_12_4_2_b68a71_sub_label_below\" class=\"quform-sub-label quform-sub-label-below\">First<\/label><\/div><\/div><\/div><\/div><div class=\"quform-element-column\"><div class=\"quform-element quform-element-text quform-element-12_4_4 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-text quform-inner-12_4_4\"><div class=\"quform-input quform-input-text quform-input-12_4_4 quform-cf\"><input type=\"text\" id=\"quform_12_4_4_b68a71\" name=\"quform_12_4[4]\" class=\"quform-field quform-field-text quform-field-12_4_4\" aria-labelledby=\"quform_12_4_b68a71_label quform_12_4_4_b68a71_sub_label_below\" \/><\/div><label id=\"quform_12_4_4_b68a71_sub_label_below\" class=\"quform-sub-label quform-sub-label-below\">Last<\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-12_9 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-12_10\"><div class=\"quform-element quform-element-email quform-element-12_8 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_8\"><label class=\"quform-label-text\" for=\"quform_12_8_b68a71\">Email address<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-email quform-inner-12_8\"><p class=\"quform-description quform-description-above\">Please ensure that this email address is an official work email address.<\/p><div class=\"quform-input quform-input-email quform-input-12_8 quform-cf\"><input type=\"email\" id=\"quform_12_8_b68a71\" name=\"quform_12_8\" class=\"quform-field quform-field-email quform-field-12_8\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-12_11\"><div class=\"quform-element quform-element-text quform-element-12_12 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_12\"><span class=\"quform-label-icon\"><i class=\"fa fa-phone\"><\/i><\/span><label class=\"quform-label-text\" for=\"quform_12_12_b68a71\">Telephone Number<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-12_12\"><p class=\"quform-description quform-description-above\">Please ensure that this is the best number for you, so that we can contact you to discuss this request.<\/p><div class=\"quform-input quform-input-text quform-input-12_12 quform-cf\"><input type=\"text\" id=\"quform_12_12_b68a71\" name=\"quform_12_12\" class=\"quform-field quform-field-text quform-field-12_12\" maxlength=\"11\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-select quform-element-12_6 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_6\"><label class=\"quform-label-text\" for=\"quform_12_6_b68a71\">Job Role \/ Profession<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-12_6\"><div class=\"quform-input quform-input-select quform-input-12_6 quform-cf\"><select id=\"quform_12_6_b68a71\" name=\"quform_12_6\" class=\"quform-field quform-field-select quform-field-12_6\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"Charity Worker\">Charity Worker<\/option><option value=\"Health Visitor\">Health Visitor<\/option><option value=\"IDVA\">IDVA<\/option><option value=\"Midwife\">Midwife<\/option><option value=\"NICU Nurse\/Sister\">NICU Nurse\/Sister<\/option><option value=\"Social Worker\">Social Worker<\/option><option value=\"Teacher\/Nursery Worker\">Teacher\/Nursery Worker<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-select quform-element-12_7 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_7\"><label class=\"quform-label-text\" for=\"quform_12_7_b68a71\">Agency \/ Organisation<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-12_7\"><div class=\"quform-input quform-input-select quform-input-12_7 quform-cf\"><select id=\"quform_12_7_b68a71\" name=\"quform_12_7\" class=\"quform-field quform-field-select quform-field-12_7\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"NHS\">NHS<\/option><option value=\"Flying Start\">Flying Start<\/option><option value=\"Local Authority\">Local Authority<\/option><option value=\"Charity\">Charity<\/option><option value=\"Growbaby\">Growbaby<\/option><option value=\"Other\">Other<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-12_45 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_45\"><label class=\"quform-label-text\" for=\"quform_12_45_b68a71\">Which charity do you represent?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-12_45\"><div class=\"quform-input quform-input-text quform-input-12_45 quform-cf\"><input type=\"text\" id=\"quform_12_45_b68a71\" name=\"quform_12_45\" class=\"quform-field quform-field-text quform-field-12_45\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-select quform-element-12_47 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_47\"><label class=\"quform-label-text\" for=\"quform_12_47_b68a71\">Which Local Authority do you represent?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-12_47\"><div class=\"quform-input quform-input-select quform-input-12_47 quform-cf\"><select id=\"quform_12_47_b68a71\" name=\"quform_12_47\" class=\"quform-field quform-field-select quform-field-12_47\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"Cardiff\">Cardiff<\/option><option value=\"Caerphilly\">Caerphilly<\/option><option value=\"Newport\">Newport<\/option><option value=\"Gwent\">Gwent<\/option><option value=\"Torfaen\">Torfaen<\/option><option value=\"Monmouthshire\">Monmouthshire<\/option><option value=\"Other\">Other<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-select quform-element-12_48 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_48\"><label class=\"quform-label-text\" for=\"quform_12_48_b68a71\">Which Health Board do you represent?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-12_48\"><div class=\"quform-input quform-input-select quform-input-12_48 quform-cf\"><select id=\"quform_12_48_b68a71\" name=\"quform_12_48\" class=\"quform-field quform-field-select quform-field-12_48\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"Aneurin Bevan University Health Board\">Aneurin Bevan University Health Board<\/option><option value=\"Cardiff and Vale University Health Board\">Cardiff and Vale University Health Board<\/option><option value=\"Cwm Taf Health Board\">Cwm Taf Health Board<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-12_56 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_56\"><label class=\"quform-label-text\" for=\"quform_12_56_b68a71\">Details of Delivery<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-12_56\"><p class=\"quform-description quform-description-above\">As you have informed us that you are a NICU Nurse\/Sister, we assume that you will need the items delivered to the ward. Please give us full details of a contact, address, and any other helpful information, as well as the timeframe in which the items are needed.<br><br>\n\neg - NICU Ward, Grange University Hospital, Contact: Joanne Bloggs, Needed within the next 2 weeks. Baby is currently 27+2.<\/p><div class=\"quform-input quform-input-textarea quform-input-12_56 quform-cf\"><textarea id=\"quform_12_56_b68a71\" name=\"quform_12_56\" class=\"quform-field quform-field-textarea quform-field-12_56\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-12_2 quform-cf quform-button-style-theme\"><div class=\"quform-button-next quform-button-next-default quform-button-next-12_2\" data-animation=\"two\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Next<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-13 quform-page-12_13 quform-cf quform-group-style-plain\"><div class=\"quform-page-title-description\"><h3 class=\"quform-page-title\">Parent\/Carer Details<\/h3><p class=\"quform-page-description\">Filling in this page is <b>optional<\/b>. However, we strongly encourage you to share details with us with the parent's consent in order for us to offer other services that may be of benefit to them such as food support, free data, calls and texts, and ongoing support.<\/p><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-name quform-element-12_15 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_15\"><label class=\"quform-label-text\" id=\"quform_12_15_b68a71_label\">Parent\/Carer Name<\/label><\/div><div class=\"quform-inner quform-inner-name quform-inner-12_15\"><div class=\"quform-input quform-input-name quform-input-12_15 quform-cf\"><div class=\"quform-element-row quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element-column\"><div class=\"quform-element quform-element-text quform-element-12_15_2 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-text quform-inner-12_15_2\"><div class=\"quform-input quform-input-text quform-input-12_15_2 quform-cf\"><input type=\"text\" id=\"quform_12_15_2_b68a71\" name=\"quform_12_15[2]\" class=\"quform-field quform-field-text quform-field-12_15_2\" aria-labelledby=\"quform_12_15_b68a71_label quform_12_15_2_b68a71_sub_label_below\" \/><\/div><label id=\"quform_12_15_2_b68a71_sub_label_below\" class=\"quform-sub-label quform-sub-label-below\">First<\/label><\/div><\/div><\/div><\/div><div class=\"quform-element-column\"><div class=\"quform-element quform-element-text quform-element-12_15_4 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-text quform-inner-12_15_4\"><div class=\"quform-input quform-input-text quform-input-12_15_4 quform-cf\"><input type=\"text\" id=\"quform_12_15_4_b68a71\" name=\"quform_12_15[4]\" class=\"quform-field quform-field-text quform-field-12_15_4\" aria-labelledby=\"quform_12_15_b68a71_label quform_12_15_4_b68a71_sub_label_below\" \/><\/div><label id=\"quform_12_15_4_b68a71_sub_label_below\" class=\"quform-sub-label quform-sub-label-below\">Last<\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-12_17 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-12_18\"><div class=\"quform-element quform-element-email quform-element-12_16 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_16\"><span class=\"quform-label-icon\"><i class=\"fa fa-envelope\"><\/i><\/span><label class=\"quform-label-text\" for=\"quform_12_16_b68a71\">Email address<\/label><\/div><div class=\"quform-inner quform-inner-email quform-inner-12_16\"><div class=\"quform-input quform-input-email quform-input-12_16 quform-cf\"><input type=\"email\" id=\"quform_12_16_b68a71\" name=\"quform_12_16\" class=\"quform-field quform-field-email quform-field-12_16\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-12_19\"><div class=\"quform-element quform-element-text quform-element-12_20 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_20\"><span class=\"quform-label-icon\"><i class=\"fa fa-phone\"><\/i><\/span><label class=\"quform-label-text\" for=\"quform_12_20_b68a71\">Telephone Number<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-12_20\"><div class=\"quform-input quform-input-text quform-input-12_20 quform-cf\"><input type=\"text\" id=\"quform_12_20_b68a71\" name=\"quform_12_20\" class=\"quform-field quform-field-text quform-field-12_20\" maxlength=\"11\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-12_21 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_21\"><label class=\"quform-label-text\" id=\"quform_12_21_b68a71_label\">By ticking this box, you confirm that you have sought and confirmed consent for the parent\/carer's details to be shared with us under GDPR regulations.<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-12_21\"><div class=\"quform-input quform-input-checkbox quform-input-12_21 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_12_21_b68a71_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_21[]\" id=\"quform_12_21_b68a71_4\" class=\"quform-field quform-field-checkbox quform-field-12_21 quform-field-12_21_4\" value=\"I confirm\" \/><label for=\"quform_12_21_b68a71_4\" class=\"quform-option-label quform-option-label-12_21_4\"><span class=\"quform-option-text\">I confirm<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-12_14 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-12_14\" data-animation=\"two\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Back<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-12_14\" data-animation=\"two\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Next<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-22 quform-page-12_22 quform-cf quform-group-style-plain\"><div class=\"quform-page-title-description\"><h3 class=\"quform-page-title\">The Request<\/h3><p class=\"quform-page-description\">Please use this page to make your request. You can request maternity supplies which will include items such as maternity clothing and toiletries, or you can request for a child. \n\nYou can only request for one person (adult or child) at a time. If you need to request for an adult and a child, or multiple children, please complete another referral request after submitting this one.<\/p><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-select quform-element-12_24 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_24\"><label class=\"quform-label-text\" for=\"quform_12_24_b68a71\">What type of referral is this?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-12_24\"><div class=\"quform-input quform-input-select quform-input-12_24 quform-cf\"><select id=\"quform_12_24_b68a71\" name=\"quform_12_24\" class=\"quform-field quform-field-select quform-field-12_24\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"Maternity (Adult\/Antenatal)\">Maternity (Adult\/Antenatal)<\/option><option value=\"Baby\/Child (up to 5 years of age)\">Baby\/Child (up to 5 years of age)<\/option><option value=\"Birth Pack (Items required for hospital bag)\">Birth Pack (Items required for hospital bag)<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-12_25 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Maternity \/ Antenatal Pack<\/h4><p class=\"quform-group-description\">The Maternity \/ Antenatal Pack is a request for maternity\/nursing clothing and hygiene items.<\/p><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-12_27 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-12_28\"><div class=\"quform-element quform-element-checkbox quform-element-12_31 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_31\"><label class=\"quform-label-text\" id=\"quform_12_31_b68a71_label\">Items Requested<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-12_31\"><div class=\"quform-input quform-input-checkbox quform-input-12_31 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_12_31_b68a71_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_31[]\" id=\"quform_12_31_b68a71_1\" class=\"quform-field quform-field-checkbox quform-field-12_31 quform-field-12_31_1\" value=\"Clothing\" \/><label for=\"quform_12_31_b68a71_1\" class=\"quform-option-label quform-option-label-12_31_1\"><span class=\"quform-option-text\">Clothing<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_31[]\" id=\"quform_12_31_b68a71_2\" class=\"quform-field quform-field-checkbox quform-field-12_31 quform-field-12_31_2\" value=\"Hygiene Items\" \/><label for=\"quform_12_31_b68a71_2\" class=\"quform-option-label quform-option-label-12_31_2\"><span class=\"quform-option-text\">Hygiene Items<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-12_29\"><div class=\"quform-element quform-element-select quform-element-12_26 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_26\"><label class=\"quform-label-text\" for=\"quform_12_26_b68a71\">Size<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-12_26\"><div class=\"quform-input quform-input-select quform-input-12_26 quform-cf\"><select id=\"quform_12_26_b68a71\" name=\"quform_12_26\" class=\"quform-field quform-field-select quform-field-12_26\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"6\">6<\/option><option value=\"8\">8<\/option><option value=\"10\">10<\/option><option value=\"12\">12<\/option><option value=\"14\">14<\/option><option value=\"16\">16<\/option><option value=\"18\">18<\/option><option value=\"20\">20<\/option><option value=\"22\">22<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-12_32 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Baby\/Child (up to 5 years of age)<\/h4><p class=\"quform-group-description\">Please select as many options as are required for the baby in question. <\/p><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-12_33 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-12_34\"><div class=\"quform-element quform-element-radio quform-element-12_40 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_40\"><span class=\"quform-label-icon\"><i class=\"fa fa-intersex\"><\/i><\/span><label class=\"quform-label-text\" id=\"quform_12_40_b68a71_label\">Sex of Baby<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-12_40\"><div class=\"quform-input quform-input-radio quform-input-12_40 quform-cf\"><div class=\"quform-options quform-cf quform-options-columns quform-3-columns quform-responsive-columns-phone-landscape quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_12_40_b68a71_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_12_40\" id=\"quform_12_40_b68a71_1\" class=\"quform-field quform-field-radio quform-field-12_40 quform-field-12_40_1\" value=\"Male\" \/><label for=\"quform_12_40_b68a71_1\" class=\"quform-option-label quform-option-label-12_40_1\"><span class=\"quform-option-text\">Male<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_12_40\" id=\"quform_12_40_b68a71_2\" class=\"quform-field quform-field-radio quform-field-12_40 quform-field-12_40_2\" value=\"Female\" \/><label for=\"quform_12_40_b68a71_2\" class=\"quform-option-label quform-option-label-12_40_2\"><span class=\"quform-option-text\">Female<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_12_40\" id=\"quform_12_40_b68a71_4\" class=\"quform-field quform-field-radio quform-field-12_40 quform-field-12_40_4\" value=\"Unborn\/Unknown\" \/><label for=\"quform_12_40_b68a71_4\" class=\"quform-option-label quform-option-label-12_40_4\"><span class=\"quform-option-text\">Unborn\/Unknown<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-12_35 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_35\"><label class=\"quform-label-text\" id=\"quform_12_35_b68a71_label\">Items Requested<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-12_35\"><div class=\"quform-input quform-input-checkbox quform-input-12_35 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_12_35_b68a71_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_35[]\" id=\"quform_12_35_b68a71_4\" class=\"quform-field quform-field-checkbox quform-field-12_35 quform-field-12_35_4\" value=\"Baby Equipment\" \/><label for=\"quform_12_35_b68a71_4\" class=\"quform-option-label quform-option-label-12_35_4\"><span class=\"quform-option-text\">Baby Equipment<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_35[]\" id=\"quform_12_35_b68a71_8\" class=\"quform-field quform-field-checkbox quform-field-12_35 quform-field-12_35_8\" value=\"Baby Milk\" \/><label for=\"quform_12_35_b68a71_8\" class=\"quform-option-label quform-option-label-12_35_8\"><span class=\"quform-option-text\">Baby Milk<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_35[]\" id=\"quform_12_35_b68a71_1\" class=\"quform-field quform-field-checkbox quform-field-12_35 quform-field-12_35_1\" value=\"Clothing\" \/><label for=\"quform_12_35_b68a71_1\" class=\"quform-option-label quform-option-label-12_35_1\"><span class=\"quform-option-text\">Clothing<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_35[]\" id=\"quform_12_35_b68a71_7\" class=\"quform-field quform-field-checkbox quform-field-12_35 quform-field-12_35_7\" value=\"Nappies\" \/><label for=\"quform_12_35_b68a71_7\" class=\"quform-option-label quform-option-label-12_35_7\"><span class=\"quform-option-text\">Nappies<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_35[]\" id=\"quform_12_35_b68a71_5\" class=\"quform-field quform-field-checkbox quform-field-12_35 quform-field-12_35_5\" value=\"Shoes\" \/><label for=\"quform_12_35_b68a71_5\" class=\"quform-option-label quform-option-label-12_35_5\"><span class=\"quform-option-text\">Shoes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_35[]\" id=\"quform_12_35_b68a71_2\" class=\"quform-field quform-field-checkbox quform-field-12_35 quform-field-12_35_2\" value=\"Toiletries\" \/><label for=\"quform_12_35_b68a71_2\" class=\"quform-option-label quform-option-label-12_35_2\"><span class=\"quform-option-text\">Toiletries<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_35[]\" id=\"quform_12_35_b68a71_6\" class=\"quform-field quform-field-checkbox quform-field-12_35 quform-field-12_35_6\" value=\"Wellies\" \/><label for=\"quform_12_35_b68a71_6\" class=\"quform-option-label quform-option-label-12_35_6\"><span class=\"quform-option-text\">Wellies<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-12_36\"><div class=\"quform-element quform-element-select quform-element-12_37 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_37\"><label class=\"quform-label-text\" for=\"quform_12_37_b68a71\">Clothing Size<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-12_37\"><div class=\"quform-input quform-input-select quform-input-12_37 quform-cf\"><select id=\"quform_12_37_b68a71\" name=\"quform_12_37\" class=\"quform-field quform-field-select quform-field-12_37\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"Prem Clothes\">Prem Clothes<\/option><option value=\"0-1 Months\">0-1 Months<\/option><option value=\"0-3 Months\">0-3 Months<\/option><option value=\"3-6 Months\">3-6 Months<\/option><option value=\"6-9 Months\">6-9 Months<\/option><option value=\"9-12 Months\">9-12 Months<\/option><option value=\"12-18 Months\">12-18 Months<\/option><option value=\"18-24 Months\">18-24 Months<\/option><option value=\"2-3 Years\">2-3 Years<\/option><option value=\"3-4 Years\">3-4 Years<\/option><option value=\"4-5 Years\">4-5 Years<\/option><option value=\"5-6 Years\">5-6 Years<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-12_57 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_57\"><label class=\"quform-label-text\" for=\"quform_12_57_b68a71\">Premature Clothing - Further Details<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-12_57\"><p class=\"quform-description quform-description-above\">Please tell us details of the premature sizing needed (such as rough weight of baby if you can, so that we can try and accommodate the request as best as we can) If it doesn't matter, please just put N\/A.<\/p><div class=\"quform-input quform-input-textarea quform-input-12_57 quform-cf\"><textarea id=\"quform_12_57_b68a71\" name=\"quform_12_57\" class=\"quform-field quform-field-textarea quform-field-12_57\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-select quform-element-12_53 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_53\"><label class=\"quform-label-text\" for=\"quform_12_53_b68a71\">Shoes\/Wellies Size<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-12_53\"><div class=\"quform-input quform-input-select quform-input-12_53 quform-cf\"><select id=\"quform_12_53_b68a71\" name=\"quform_12_53\" class=\"quform-field quform-field-select quform-field-12_53\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"2\">2<\/option><option value=\"2.5\">2.5<\/option><option value=\"3\">3<\/option><option value=\"3.5\">3.5<\/option><option value=\"4\">4<\/option><option value=\"4.5\">4.5<\/option><option value=\"5\">5<\/option><option value=\"5.5\">5.5<\/option><option value=\"6\">6<\/option><option value=\"6.5\">6.5<\/option><option value=\"7\">7<\/option><option value=\"7.5\">7.5<\/option><option value=\"8\">8<\/option><option value=\"8.5\">8.5<\/option><option value=\"9\">9<\/option><option value=\"9.5\">9.5<\/option><option value=\"10\">10<\/option><option value=\"10.5\">10.5<\/option><option value=\"11\">11<\/option><option value=\"11.5\">11.5<\/option><option value=\"12\">12<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-select quform-element-12_54 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_54\"><label class=\"quform-label-text\" for=\"quform_12_54_b68a71\">Nappy Size<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-12_54\"><div class=\"quform-input quform-input-select quform-input-12_54 quform-cf\"><select id=\"quform_12_54_b68a71\" name=\"quform_12_54\" class=\"quform-field quform-field-select quform-field-12_54\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-12_38 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_38\"><label class=\"quform-label-text\" for=\"quform_12_38_b68a71\">Any specific toiletries? (such as creams, lotions etc)<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-12_38\"><p class=\"quform-description quform-description-above\">Please put N\/A if you'd just like to request general toiletries<\/p><div class=\"quform-input quform-input-textarea quform-input-12_38 quform-cf\"><textarea id=\"quform_12_38_b68a71\" name=\"quform_12_38\" class=\"quform-field quform-field-textarea quform-field-12_38\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-12_39 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_39\"><label class=\"quform-label-text\" id=\"quform_12_39_b68a71_label\">What Equipment would you like to request?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-12_39\"><p class=\"quform-description quform-description-above\">Please note, these items are subject to availability and not guaranteed. <\/p><div class=\"quform-input quform-input-checkbox quform-input-12_39 quform-cf\"><div class=\"quform-options quform-cf quform-options-columns quform-2-columns quform-responsive-columns-phone-landscape quform-options-simple\" role=\"group\" aria-labelledby=\"quform_12_39_b68a71_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_10\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_10\" value=\"Baby Bath\" \/><label for=\"quform_12_39_b68a71_10\" class=\"quform-option-label quform-option-label-12_39_10\"><span class=\"quform-option-text\">Baby Bath<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_7\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_7\" value=\"Bedding\" \/><label for=\"quform_12_39_b68a71_7\" class=\"quform-option-label quform-option-label-12_39_7\"><span class=\"quform-option-text\">Bedding<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_5\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_5\" value=\"Blanket\" \/><label for=\"quform_12_39_b68a71_5\" class=\"quform-option-label quform-option-label-12_39_5\"><span class=\"quform-option-text\">Blanket<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_3\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_3\" value=\"Bouncer Chair\" \/><label for=\"quform_12_39_b68a71_3\" class=\"quform-option-label quform-option-label-12_39_3\"><span class=\"quform-option-text\">Bouncer Chair<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_15\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_15\" value=\"Breast Pump\" \/><label for=\"quform_12_39_b68a71_15\" class=\"quform-option-label quform-option-label-12_39_15\"><span class=\"quform-option-text\">Breast Pump<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_16\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_16\" value=\"Buggy Board\" \/><label for=\"quform_12_39_b68a71_16\" class=\"quform-option-label quform-option-label-12_39_16\"><span class=\"quform-option-text\">Buggy Board<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_2\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_2\" value=\"Cot\" \/><label for=\"quform_12_39_b68a71_2\" class=\"quform-option-label quform-option-label-12_39_2\"><span class=\"quform-option-text\">Cot<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_17\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_17\" value=\"Cot Bed \/ Toddler Bed\" \/><label for=\"quform_12_39_b68a71_17\" class=\"quform-option-label quform-option-label-12_39_17\"><span class=\"quform-option-text\">Cot Bed \/ Toddler Bed<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_18\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_18\" value=\"Cot Mattress\" \/><label for=\"quform_12_39_b68a71_18\" class=\"quform-option-label quform-option-label-12_39_18\"><span class=\"quform-option-text\">Cot Mattress<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_12\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_12\" value=\"High Chair\" \/><label for=\"quform_12_39_b68a71_12\" class=\"quform-option-label quform-option-label-12_39_12\"><span class=\"quform-option-text\">High Chair<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_1\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_1\" value=\"Moses Basket\" \/><label for=\"quform_12_39_b68a71_1\" class=\"quform-option-label quform-option-label-12_39_1\"><span class=\"quform-option-text\">Moses Basket<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_9\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_9\" value=\"Muslin Cloths\" \/><label for=\"quform_12_39_b68a71_9\" class=\"quform-option-label quform-option-label-12_39_9\"><span class=\"quform-option-text\">Muslin Cloths<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_4\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_4\" value=\"Play Mat\" \/><label for=\"quform_12_39_b68a71_4\" class=\"quform-option-label quform-option-label-12_39_4\"><span class=\"quform-option-text\">Play Mat<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_13\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_13\" value=\"Pushchair\" \/><label for=\"quform_12_39_b68a71_13\" class=\"quform-option-label quform-option-label-12_39_13\"><span class=\"quform-option-text\">Pushchair<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_14\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_14\" value=\"Pram with Newborn Attachment\" \/><label for=\"quform_12_39_b68a71_14\" class=\"quform-option-label quform-option-label-12_39_14\"><span class=\"quform-option-text\">Pram with Newborn Attachment<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_6\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_6\" value=\"Sleeping Bag\" \/><label for=\"quform_12_39_b68a71_6\" class=\"quform-option-label quform-option-label-12_39_6\"><span class=\"quform-option-text\">Sleeping Bag<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_11\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_11\" value=\"Sling\" \/><label for=\"quform_12_39_b68a71_11\" class=\"quform-option-label quform-option-label-12_39_11\"><span class=\"quform-option-text\">Sling<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_20\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_20\" value=\"Stair Gate\" \/><label for=\"quform_12_39_b68a71_20\" class=\"quform-option-label quform-option-label-12_39_20\"><span class=\"quform-option-text\">Stair Gate<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_19\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_19\" value=\"Steriliser\" \/><label for=\"quform_12_39_b68a71_19\" class=\"quform-option-label quform-option-label-12_39_19\"><span class=\"quform-option-text\">Steriliser<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_8\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_8\" value=\"Towel\" \/><label for=\"quform_12_39_b68a71_8\" class=\"quform-option-label quform-option-label-12_39_8\"><span class=\"quform-option-text\">Towel<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_39[]\" id=\"quform_12_39_b68a71_21\" class=\"quform-field quform-field-checkbox quform-field-12_39 quform-field-12_39_21\" value=\"Weaning Kit\" \/><label for=\"quform_12_39_b68a71_21\" class=\"quform-option-label quform-option-label-12_39_21\"><span class=\"quform-option-text\">Weaning Kit<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-12_55 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_55\"><label class=\"quform-label-text\" for=\"quform_12_55_b68a71\">Which brand of Baby Milk is needed?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-12_55\"><div class=\"quform-input quform-input-text quform-input-12_55 quform-cf\"><input type=\"text\" id=\"quform_12_55_b68a71\" name=\"quform_12_55\" class=\"quform-field quform-field-text quform-field-12_55\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-12_23 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-12_23\" data-animation=\"two\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Back<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-12_23\" data-animation=\"two\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Next<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-41 quform-page-12_41 quform-cf quform-group-style-plain quform-last-page\"><div class=\"quform-page-title-description\"><h3 class=\"quform-page-title\">Final Details<\/h3><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-checkbox quform-element-12_43 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_43\"><label class=\"quform-label-text\" id=\"quform_12_43_b68a71_label\">What are the reasons for the request?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-12_43\"><p class=\"quform-description quform-description-above\">Tick all that apply.<\/p><div class=\"quform-input quform-input-checkbox quform-input-12_43 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_12_43_b68a71_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_43[]\" id=\"quform_12_43_b68a71_1\" class=\"quform-field quform-field-checkbox quform-field-12_43 quform-field-12_43_1\" value=\"Poverty (low income, unemployment, financial hardship)\" \/><label for=\"quform_12_43_b68a71_1\" class=\"quform-option-label quform-option-label-12_43_1\"><span class=\"quform-option-text\">Poverty (low income, unemployment, financial hardship)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_43[]\" id=\"quform_12_43_b68a71_2\" class=\"quform-field quform-field-checkbox quform-field-12_43 quform-field-12_43_2\" value=\"Single Parent Family\" \/><label for=\"quform_12_43_b68a71_2\" class=\"quform-option-label quform-option-label-12_43_2\"><span class=\"quform-option-text\">Single Parent Family<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_43[]\" id=\"quform_12_43_b68a71_3\" class=\"quform-field quform-field-checkbox quform-field-12_43 quform-field-12_43_3\" value=\"Mental Health\" \/><label for=\"quform_12_43_b68a71_3\" class=\"quform-option-label quform-option-label-12_43_3\"><span class=\"quform-option-text\">Mental Health<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_43[]\" id=\"quform_12_43_b68a71_4\" class=\"quform-field quform-field-checkbox quform-field-12_43 quform-field-12_43_4\" value=\"Domestic Violence\" \/><label for=\"quform_12_43_b68a71_4\" class=\"quform-option-label quform-option-label-12_43_4\"><span class=\"quform-option-text\">Domestic Violence<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_43[]\" id=\"quform_12_43_b68a71_5\" class=\"quform-field quform-field-checkbox quform-field-12_43 quform-field-12_43_5\" value=\"Refugee\/Asylum Seeker\" \/><label for=\"quform_12_43_b68a71_5\" class=\"quform-option-label quform-option-label-12_43_5\"><span class=\"quform-option-text\">Refugee\/Asylum Seeker<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_43[]\" id=\"quform_12_43_b68a71_6\" class=\"quform-field quform-field-checkbox quform-field-12_43 quform-field-12_43_6\" value=\"Homelessness\" \/><label for=\"quform_12_43_b68a71_6\" class=\"quform-option-label quform-option-label-12_43_6\"><span class=\"quform-option-text\">Homelessness<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_12_43[]\" id=\"quform_12_43_b68a71_7\" class=\"quform-field quform-field-checkbox quform-field-12_43 quform-field-12_43_7\" value=\"Emergency (Fire\/Flood Victim etc)\" \/><label for=\"quform_12_43_b68a71_7\" class=\"quform-option-label quform-option-label-12_43_7\"><span class=\"quform-option-text\">Emergency (Fire\/Flood Victim etc)<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-12_336205 quform-sr-only quform-cf\" style=\"clip: rect(1px, 1px, 1px, 1px); clip-path: inset(50%); position: absolute !important; height: 1px; width: 1px; overflow: hidden;\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_336205\"><label class=\"quform-label-text\" for=\"quform_12_336205_b68a71\">Your Website<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-12_336205\"><textarea id=\"quform_12_336205_b68a71\" name=\"quform_12_336205\" class=\"quform-field quform-field-textarea quform-field-12_336205\" tabindex=\"-1\" autocomplete=\"new-password\"><\/textarea><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-12_44 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-12_44\"><label class=\"quform-label-text\" id=\"quform_12_44_b68a71_label\">Has this family accessed our Baby Bank  before?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-12_44\"><p class=\"quform-description quform-description-above\">This will not affect the ability for the family to receive support from us.<\/p><div class=\"quform-input quform-input-radio quform-input-12_44 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_12_44_b68a71_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_12_44\" id=\"quform_12_44_b68a71_1\" class=\"quform-field quform-field-radio quform-field-12_44 quform-field-12_44_1\" value=\"Yes\" \/><label for=\"quform_12_44_b68a71_1\" class=\"quform-option-label quform-option-label-12_44_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_12_44\" id=\"quform_12_44_b68a71_2\" class=\"quform-field quform-field-radio quform-field-12_44 quform-field-12_44_2\" value=\"No\" \/><label for=\"quform_12_44_b68a71_2\" class=\"quform-option-label quform-option-label-12_44_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_12_44\" id=\"quform_12_44_b68a71_3\" class=\"quform-field quform-field-radio quform-field-12_44 quform-field-12_44_3\" value=\"Not known\" \/><label for=\"quform_12_44_b68a71_3\" class=\"quform-option-label quform-option-label-12_44_3\"><span class=\"quform-option-text\">Not known<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-12_42 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-12_42\" data-animation=\"two\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Back<\/span><\/button><\/div><div class=\"quform-button-submit quform-button-submit-default quform-button-submit-12_42\" data-animation=\"two\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-submit\" value=\"submit\"><span class=\"quform-button-text quform-button-submit-text\">Send<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/form><\/div><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":90,"featured_media":0,"parent":62232,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"give_campaign_id":0,"footnotes":""},"categories":[],"tags":[],"class_list":["post-62735","page","type-page","status-publish","hentry"],"campaignId":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/pages\/62735","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/users\/90"}],"replies":[{"embeddable":true,"href":"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/comments?post=62735"}],"version-history":[{"count":0,"href":"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/pages\/62735\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/pages\/62232"}],"wp:attachment":[{"href":"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/media?parent=62735"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/categories?post=62735"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/tags?post=62735"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}