{"id":208,"date":"2020-03-04T11:24:54","date_gmt":"2020-03-04T11:24:54","guid":{"rendered":"https:\/\/demo.casethemes.net\/alico\/?page_id=208"},"modified":"2025-03-12T15:37:32","modified_gmt":"2025-03-12T15:37:32","slug":"about-us","status":"publish","type":"page","link":"https:\/\/jsgblooddonors.com\/?page_id=208","title":{"rendered":"Blood Beneficiary Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"208\" class=\"elementor elementor-208\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3586797 e-con-full e-flex e-con e-parent\" data-id=\"3586797\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-e8d53e1 elementor-widget elementor-widget-shortcode\" data-id=\"e8d53e1\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_3_container\" data-token=\"127f4d28f6dd9dbbbea5b7df5e4a2206\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_i57hd\" data-token=\"127f4d28f6dd9dbbbea5b7df5e4a2206\">\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Blood Beneficiary Form<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"3\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_3\" id=\"frm_hide_fields_3\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"i57hd\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_3\" name=\"frm_submit_entry_3\" value=\"c12ff90e80\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F208\" \/><div id=\"frm_field_28_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_first\">\n\t<label for=\"field_2x9pp\" id=\"field_2x9pp_label\" class=\"frm_primary_label\">Inquiry ID\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_2x9pp\" name=\"item_meta[28]\" value=\"JHL\/BGBF1\"  readonly=\"readonly\"  data-frmval=\"JHL\/BGBF1\" data-invmsg=\"Inquiry ID is invalid\" aria-invalid=\"false\"   \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_29_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\n\t<label for=\"field_i1utf\" id=\"field_i1utf_label\" class=\"frm_primary_label\">Date\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input type=\"text\" id=\"field_i1utf\" name=\"item_meta[29]\" value=\"02\/06\/2026\"  readonly=\"readonly\"  maxlength=\"10\" data-frmval=\"02\/06\/2026\" data-invmsg=\"Date is invalid\" aria-invalid=\"false\"  \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_30_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\n\t<div  id=\"field_vgol2_label\" class=\"frm_primary_label\">Time\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/div>\n\t<input type=\"hidden\" value=\"20:05\" name=\"item_meta[30]\"  id=\"field_vgol2\" \/><div class=\"frm_time_wrap\"><span dir=\"ltr\">\r\n<select aria-label=\"Time ... hour\"  disabled=\"disabled\"  data-frmval=\"{&quot;A&quot;:&quot;&quot;,&quot;H&quot;:&quot;20&quot;,&quot;m&quot;:&quot;05&quot;,&quot;s&quot;:&quot;25&quot;}\" data-invmsg=\"Time is invalid\" class=\"auto_width frm_time_select\" aria-invalid=\"false\"  ><option value=\"\" ><\/option><option value=\"00\" >00<\/option><option value=\"01\" >01<\/option><option value=\"02\" >02<\/option><option value=\"03\" >03<\/option><option value=\"04\" >04<\/option><option value=\"05\" >05<\/option><option value=\"06\" >06<\/option><option value=\"07\" >07<\/option><option value=\"08\" >08<\/option><option value=\"09\" >09<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\"  selected='selected'>20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><\/select>\r\n<span class=\"frm_time_sep\" aria-hidden=\"true\">:<\/span>\r\n<select aria-label=\"Time ... minute\"  disabled=\"disabled\"  data-frmval=\"{&quot;A&quot;:&quot;&quot;,&quot;H&quot;:&quot;20&quot;,&quot;m&quot;:&quot;05&quot;,&quot;s&quot;:&quot;25&quot;}\" data-invmsg=\"Time is invalid\" class=\"auto_width frm_time_select auto_width frm_time_select\" aria-invalid=\"false\"  ><option value=\"\" ><\/option><option value=\"00\" >00<\/option><option value=\"30\" >30<\/option><\/select>\r\n<\/span>\r\n<\/div>\n\t\n\t\n<\/div>\n<div id=\"frm_field_31_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm_first\">\n\t<label for=\"field_k5s4v\" id=\"field_k5s4v_label\" class=\"frm_primary_label\">Donor ID 1\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_k5s4v\" name=\"item_meta[31]\" value=\"\"  data-reqmsg=\"Donor ID 1 cannot be blank.\" aria-required=\"true\" data-invmsg=\"Donor ID 1 is invalid\" aria-invalid=\"false\"   \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_32_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\n\t<label for=\"field_bakw8\" id=\"field_bakw8_label\" class=\"frm_primary_label\">Donor ID 2\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_bakw8\" name=\"item_meta[32]\" value=\"\"  data-invmsg=\"Donor ID 2 is invalid\" aria-invalid=\"false\"   \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_33_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\n\t<label for=\"field_6xmvp\" id=\"field_6xmvp_label\" class=\"frm_primary_label\">Donor ID 3\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_6xmvp\" name=\"item_meta[33]\" value=\"\"  data-invmsg=\"Donor ID 3 is invalid\" aria-invalid=\"false\"   \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_34_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm3 frm_first\">\n\t<label for=\"field_mbu1v\" id=\"field_mbu1v_label\" class=\"frm_primary_label\">Applicant Name\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_mbu1v\" name=\"item_meta[34]\" value=\"\"  data-reqmsg=\"Applicant Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Applicant Name is invalid\" aria-invalid=\"false\"   \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_35_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm3\">\n\t<label for=\"field_27zal\" id=\"field_27zal_label\" class=\"frm_primary_label\">Applicant Phone Number 1\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input type=\"tel\" id=\"field_27zal\" name=\"item_meta[35]\" value=\"\"  data-reqmsg=\"Applicant Phone Number 1 cannot be blank.\" aria-required=\"true\" data-invmsg=\"Applicant Phone Number 1 is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_36_container\" class=\"frm_form_field form-field  frm_top_container frm3\">\n\t<label for=\"field_w4x61\" id=\"field_w4x61_label\" class=\"frm_primary_label\">Applicant Phone No. 2\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input type=\"tel\" id=\"field_w4x61\" name=\"item_meta[36]\" value=\"\"  data-invmsg=\"Applicant Phone No. 2 is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_37_container\" class=\"frm_form_field form-field  frm_top_container frm3\">\n\t<label for=\"field_4rxmt\" id=\"field_4rxmt_label\" class=\"frm_primary_label\">Applicant Email ID\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input type=\"email\" id=\"field_4rxmt\" name=\"item_meta[37]\" value=\"\"  autocomplete=\"email\"  data-invmsg=\"Applicant Email ID is invalid\" aria-invalid=\"false\"  \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_38_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm_first frm_other_container\">\n\t<label for=\"field_vwtwr\" id=\"field_vwtwr_label\" class=\"frm_primary_label\">Patient Gender\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t\t\t<select name=\"item_meta[38]\" id=\"field_vwtwr\"  data-frmval=\"Male\" data-reqmsg=\"Patient Gender cannot be blank.\" aria-required=\"true\" data-invmsg=\"Patient Gender is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"Male\" selected='selected'>Male<\/option><option  value=\"Female\">Female<\/option><option  value=\"Other\" class=\"frm_other_trigger\">Other<\/option>\t<\/select>\n\t<label for=\"field_vwtwr-otext\" class=\"frm_screen_reader frm_hidden\">Patient Gender<\/label><input type=\"text\" id=\"field_vwtwr-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][38]\" value=\"\" \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_39_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4\">\n\t<label for=\"field_434t5\" id=\"field_434t5_label\" class=\"frm_primary_label\">Patient Age\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input type=\"number\" id=\"field_434t5\" name=\"item_meta[39]\" value=\"\" data-reqmsg=\"Patient Age cannot be blank.\" aria-required=\"true\" data-invmsg=\"Patient Age is invalid\" aria-invalid=\"false\"   min=\"1\" max=\"125\" step=\"any\" \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_40_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4\">\n\t<label for=\"field_lgvlj\" id=\"field_lgvlj_label\" class=\"frm_primary_label\">Patient Name\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_lgvlj\" name=\"item_meta[40]\" value=\"\"  data-reqmsg=\"Patient Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Patient Name is invalid\" aria-invalid=\"false\"   \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_41_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first\">\n\t<label for=\"field_y8925\" id=\"field_y8925_label\" class=\"frm_primary_label\">Hospital Name\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_y8925\" name=\"item_meta[41]\" value=\"\"  data-reqmsg=\"Hospital Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Hospital Name is invalid\" aria-invalid=\"false\"   \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_45_container\" class=\"frm_form_field form-field  frm_top_container\">\n\t<label for=\"field_izajr\" id=\"field_izajr_label\" class=\"frm_primary_label\">Remarks (If you can not write remarks, then click on Text and then try to write remarks)\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<div id=\"wp-field_izajr-wrap\" class=\"wp-core-ui wp-editor-wrap tmce-active\"><link rel='stylesheet' id='dashicons-css' href='https:\/\/jsgblooddonors.com\/wp-includes\/css\/dashicons.min.css?ver=7.0' media='all' \/>\n<link rel='stylesheet' id='editor-buttons-css' href='https:\/\/jsgblooddonors.com\/wp-includes\/css\/editor.min.css?ver=7.0' media='all' \/>\n<div id=\"wp-field_izajr-editor-tools\" class=\"wp-editor-tools hide-if-no-js\"><div class=\"wp-editor-tabs\"><button type=\"button\" id=\"field_izajr-tmce\" aria-pressed=\"true\" class=\"wp-switch-editor switch-tmce\" data-wp-editor-id=\"field_izajr\">Visual<\/button>\n<button type=\"button\" id=\"field_izajr-html\" class=\"wp-switch-editor switch-html\" data-wp-editor-id=\"field_izajr\">Code<\/button>\n<\/div>\n<\/div>\n<div id=\"wp-field_izajr-editor-container\" class=\"wp-editor-container\"><div id=\"qt_field_izajr_toolbar\" class=\"quicktags-toolbar hide-if-no-js\"><\/div><textarea class=\"wp-editor-area\" rows=\"7\" autocomplete=\"off\" cols=\"40\" name=\"item_meta[45]\" id=\"field_izajr\"><\/textarea><\/div>\n<\/div>\n\n\n\t\n\t\n<\/div>\n<div id=\"frm_field_42_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first horizontal_radio\">\n\t<div  id=\"field_yaj8y_label\" class=\"frm_primary_label\">Are Applicant\/Beneficiary\/Other Family Member\/Friends  Willing to Donate Blood ?\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/div>\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_yaj8y_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_42-0\">\t\t\t<label  for=\"field_yaj8y-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[42]\" id=\"field_yaj8y-0\" value=\"No\"\n\t\tchecked=\"checked\"   data-frmval=\"No\" data-reqmsg=\"Are Applicant\/Beneficiary\/Other Family Member\/Friends  Willing to Donate Blood ? cannot be blank.\" data-invmsg=\"Are Applicant\/Beneficiary\/Other Family Member\/Friends  Willing to Donate Blood ? is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_42-1\">\t\t\t<label  for=\"field_yaj8y-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[42]\" id=\"field_yaj8y-1\" value=\"Yes\"\n\t\t   data-frmval=\"No\" data-reqmsg=\"Are Applicant\/Beneficiary\/Other Family Member\/Friends  Willing to Donate Blood ? cannot be blank.\" data-invmsg=\"Are Applicant\/Beneficiary\/Other Family Member\/Friends  Willing to Donate Blood ? is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n<\/div>\n\t\n\t\n<\/div>\n<div id=\"frm_field_43_container\" class=\"frm_form_field  frm6 frm_html_container form-field\">\n<h3>You Have to Fill Form as Donor, Before Availing Donation<\/h3>\n<\/div>\n<div id=\"frm_field_44_container\" class=\"frm_form_field form-field  frm_embed_form_container\">\n<input type=\"hidden\" name=\"item_meta[44][form]\" value=\"2\" class=\"frm_dnc\" \/>\n\t\t\t<div id=\"frm_section_44-0\" class=\"frm_repeat_sec frm_repeat_44 frm_first_repeat frm_grid_container\">\n<input type=\"hidden\" name=\"item_meta[44][row_ids][]\" value=\"0\" \/><input type=\"hidden\" name=\"item_meta[44][0][0]\" value=\"\" \/><div id=\"frm_field_6-44-0_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_first frm_field_6_container\">\n\t<label for=\"field_odilv-0\" id=\"field_odilv-0_label\" class=\"frm_primary_label\">UID\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_odilv-0\" name=\"item_meta[44][0][6]\" value=\"JSG\/BG\/7033\"  readonly=\"readonly\"  data-frmval=\"JSG\/BG\/7033\" data-invmsg=\"UID is invalid\" aria-invalid=\"false\"   \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_7-44-0_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm_field_7_container\">\n\t<label for=\"field_8xywj-0\" id=\"field_8xywj-0_label\" class=\"frm_primary_label\">Regn. Date\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input type=\"text\" id=\"field_8xywj-0\" name=\"item_meta[44][0][7]\" value=\"02\/06\/2026\"  readonly=\"readonly\"  maxlength=\"10\" data-frmval=\"02\/06\/2026\" data-reqmsg=\"Regn. Date cannot be blank.\" aria-required=\"true\" data-invmsg=\"Regn. Date is invalid\" aria-invalid=\"false\"  \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_8-44-0_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_field_8_container\">\n\t<div  id=\"field_p1upf-0_label\" class=\"frm_primary_label\">Regn. Time\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/div>\n\t<input type=\"hidden\" value=\"20:05\" name=\"item_meta[44][0][8]\"  id=\"field_p1upf-0\" \/><div class=\"frm_time_wrap\"><span dir=\"ltr\">\r\n<select aria-label=\"Regn. Time ... hour\"  disabled=\"disabled\"  data-frmval=\"{&quot;A&quot;:&quot;&quot;,&quot;H&quot;:&quot;20&quot;,&quot;m&quot;:&quot;05&quot;,&quot;s&quot;:&quot;25&quot;}\" data-invmsg=\"Regn. Time is invalid\" class=\"auto_width frm_time_select\" aria-invalid=\"false\"  ><option value=\"\" ><\/option><option value=\"00\" >00<\/option><option value=\"01\" >01<\/option><option value=\"02\" >02<\/option><option value=\"03\" >03<\/option><option value=\"04\" >04<\/option><option value=\"05\" >05<\/option><option value=\"06\" >06<\/option><option value=\"07\" >07<\/option><option value=\"08\" >08<\/option><option value=\"09\" >09<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\"  selected='selected'>20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><\/select>\r\n<span class=\"frm_time_sep\" aria-hidden=\"true\">:<\/span>\r\n<select aria-label=\"Regn. Time ... minute\"  disabled=\"disabled\"  data-frmval=\"{&quot;A&quot;:&quot;&quot;,&quot;H&quot;:&quot;20&quot;,&quot;m&quot;:&quot;05&quot;,&quot;s&quot;:&quot;25&quot;}\" data-invmsg=\"Regn. Time is invalid\" class=\"auto_width frm_time_select auto_width frm_time_select\" aria-invalid=\"false\"  ><option value=\"\" ><\/option><option value=\"00\" >00<\/option><option value=\"30\" >30<\/option><\/select>\r\n<\/span>\r\n<\/div>\n\t\n\t\n<\/div>\n<div id=\"frm_field_9-44-0_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm2 frm_first frm_field_9_container\">\n\t<label for=\"field_284yv-0\" id=\"field_284yv-0_label\" class=\"frm_primary_label\">Donor Full Name\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_284yv-0\" name=\"item_meta[44][0][9]\" value=\"\"  data-reqmsg=\"Donor Full Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Donor Full Name is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_284yv-0\" \/>\n\t<div class=\"frm_description\" id=\"frm_desc_field_284yv-0\">First & Last Letter of Your Name Will Be Displayed Publically on Our WhatsApp<\/div>\n\t\n<\/div>\n<div id=\"frm_field_10-44-0_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm2 frm_field_10_container frm_other_container\">\n\t<label for=\"field_lt0q0-0\" id=\"field_lt0q0-0_label\" class=\"frm_primary_label\">Gender\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t\t\t<select name=\"item_meta[44][0][10]\" id=\"field_lt0q0-0\"  data-frmval=\"Male\" data-reqmsg=\"Gender cannot be blank.\" aria-required=\"true\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"Male\" selected='selected'>Male<\/option><option  value=\"Female\">Female<\/option><option  value=\"Transgender\">Transgender<\/option><option  value=\"Other\" class=\"frm_other_trigger\">Other<\/option>\t<\/select>\n\t<label for=\"field_lt0q0-0-otext\" class=\"frm_screen_reader frm_hidden\">Gender<\/label><input type=\"text\" id=\"field_lt0q0-0-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[44][0][other][10]\" value=\"\" \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_14-44-0_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm2 frm_field_14_container\">\n\t<label for=\"field_w6x1b-0\" id=\"field_w6x1b-0_label\" class=\"frm_primary_label\">Country\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_w6x1b-0\" name=\"item_meta[44][0][14]\" value=\"\"  data-reqmsg=\"Country cannot be blank.\" aria-required=\"true\" data-invmsg=\"Country is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_w6x1b-0\" \/>\n\t<div class=\"frm_description\" id=\"frm_desc_field_w6x1b-0\">Country Name Will Be Displayed Publically on Our WhatsApp<\/div>\n\t\n<\/div>\n<div id=\"frm_field_13-44-0_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm2 frm_field_13_container\">\n\t<label for=\"field_1qcz3-0\" id=\"field_1qcz3-0_label\" class=\"frm_primary_label\">State\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_1qcz3-0\" name=\"item_meta[44][0][13]\" value=\"\"  data-reqmsg=\"State cannot be blank.\" aria-required=\"true\" data-invmsg=\"State is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_1qcz3-0\" \/>\n\t<div class=\"frm_description\" id=\"frm_desc_field_1qcz3-0\">State Name Will Be Displayed Publically on Our WhatsApp<\/div>\n\t\n<\/div>\n<div id=\"frm_field_12-44-0_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm2 frm_field_12_container\">\n\t<label for=\"field_devhh-0\" id=\"field_devhh-0_label\" class=\"frm_primary_label\">City\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_devhh-0\" name=\"item_meta[44][0][12]\" value=\"\"  data-reqmsg=\"City cannot be blank.\" aria-required=\"true\" data-invmsg=\"City is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_devhh-0\" \/>\n\t<div class=\"frm_description\" id=\"frm_desc_field_devhh-0\">City Name Will Be Displayed Publically on Our WhatsApp<\/div>\n\t\n<\/div>\n<div id=\"frm_field_11-44-0_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm2 frm_field_11_container\">\n\t<label for=\"field_k9e6j-0\" id=\"field_k9e6j-0_label\" class=\"frm_primary_label\">Suburb \/ Area\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_k9e6j-0\" name=\"item_meta[44][0][11]\" value=\"\"  data-reqmsg=\"Suburb \/ Area cannot be blank.\" aria-required=\"true\" data-invmsg=\"Suburb \/ Area is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_k9e6j-0\" \/>\n\t<div class=\"frm_description\" id=\"frm_desc_field_k9e6j-0\">Suburb\/Area Name Will Be Displayed Publically on Our WhatsApp<\/div>\n\t\n<\/div>\n<div id=\"frm_field_15-44-0_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm_first frm_field_15_container\">\n\t<label for=\"field_21z5m-0\" id=\"field_21z5m-0_label\" class=\"frm_primary_label\">Birth Year\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_21z5m-0\" name=\"item_meta[44][0][15]\" value=\"\"  data-frmmask=\"0000\" maxlength=\"4\" data-reqmsg=\"Birth Year cannot be blank.\" aria-required=\"true\" data-invmsg=\"Birth Year is invalid\" aria-invalid=\"false\" pattern=\"\\d\\d\\d\\d$\"   aria-describedby=\"frm_desc_field_21z5m-0\" \/>\n\t<div class=\"frm_description\" id=\"frm_desc_field_21z5m-0\">Birth Year  of Donor Will Be Displayed Publically on Our WhatsApp<\/div>\n\t\n<\/div>\n<div id=\"frm_field_16-44-0_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm2 frm_field_16_container\">\n\t<label for=\"field_7gmbs-0\" id=\"field_7gmbs-0_label\" class=\"frm_primary_label\">Mobile Number\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input type=\"tel\" id=\"field_7gmbs-0\" name=\"item_meta[44][0][16]\" value=\"\"  data-reqmsg=\"Mobile Number cannot be blank.\" aria-required=\"true\" data-invmsg=\"Mobile Number is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"   aria-describedby=\"frm_desc_field_7gmbs-0\"\/>\n\t<div class=\"frm_description\" id=\"frm_desc_field_7gmbs-0\">First & Last Digit of Phone Number Will Be Displayed Publically on Our WhatsApp<\/div>\n\t\n<\/div>\n<div id=\"frm_field_17-44-0_container\" class=\"frm_form_field form-field  frm_top_container frm2 frm_field_17_container\">\n\t<label for=\"field_acwll-0\" id=\"field_acwll-0_label\" class=\"frm_primary_label\">Alternate Mobile No.\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input type=\"tel\" id=\"field_acwll-0\" name=\"item_meta[44][0][17]\" value=\"\"  data-invmsg=\"Alternate Mobile No. is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"   aria-describedby=\"frm_desc_field_acwll-0\"\/>\n\t<div class=\"frm_description\" id=\"frm_desc_field_acwll-0\">Alternate Number Will Not Be Displayed Publically on Our WhatsApp<\/div>\n\t\n<\/div>\n<div id=\"frm_field_18-44-0_container\" class=\"frm_form_field form-field  frm_top_container frm2 frm_field_18_container\">\n\t<label for=\"field_vr736-0\" id=\"field_vr736-0_label\" class=\"frm_primary_label\">Email\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input type=\"email\" id=\"field_vr736-0\" name=\"item_meta[44][0][18]\" value=\"\"  autocomplete=\"email\"  data-invmsg=\"Email is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_vr736-0\"\/>\n\t<div class=\"frm_description\" id=\"frm_desc_field_vr736-0\">Email ID Will NOT Be Displayed Publically on Our WhatsApp<\/div>\n\t\n<\/div>\n<div id=\"frm_field_19-44-0_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm2 frm_field_19_container\">\n\t<label for=\"field_ujk9r-0\" id=\"field_ujk9r-0_label\" class=\"frm_primary_label\">Last Date Of Blood Donated\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input type=\"text\" id=\"field_ujk9r-0\" name=\"item_meta[44][0][19]\" value=\"\"  maxlength=\"10\" data-reqmsg=\"Last Date Of Blood Donated cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last Date Of Blood Donated is invalid\" class=\"frm_date\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_ujk9r-0\"\/>\n\t<div class=\"frm_description\" id=\"frm_desc_field_ujk9r-0\">Last Date of Blood Donation Will Be Displayed Publically on Our WhatsApp<\/div>\n\t\n<\/div>\n<div id=\"frm_field_20-44-0_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm3 frm_first frm_field_20_container\">\n\t<label for=\"field_sygdw-0\" id=\"field_sygdw-0_label\" class=\"frm_primary_label\">Blood Type Combination\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t\t\t<select name=\"item_meta[44][0][20]\" id=\"field_sygdw-0\"  data-frmval=\"O+\" data-reqmsg=\"Blood Type Combination cannot be blank.\" aria-required=\"true\" data-invmsg=\"Blood Type Combination is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"A+\">A+<\/option><option  value=\"A-\">A-<\/option><option  value=\"B+\">B+<\/option><option  value=\"B-\">B-<\/option><option  value=\"AB+\">AB+<\/option><option  value=\"AB-\">AB-<\/option><option  value=\"O+\" selected='selected'>O+<\/option><option  value=\"O-\">O-<\/option>\t<\/select>\n\t\n\t<div class=\"frm_description\" id=\"frm_desc_field_sygdw-0\">Blood Group Will Be Displayed Publically on Our WhatsApp<\/div>\n\t\n<\/div>\n<div id=\"frm_field_21-44-0_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm3 horizontal_radio frm_field_21_container\">\n\t<div  id=\"field_z9zqy-0_label\" class=\"frm_primary_label\">Do you suffer from any Disease ?\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/div>\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_z9zqy-0_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_21-0\">\t\t\t<label  for=\"field_z9zqy-0-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[44][0][21]\" id=\"field_z9zqy-0-0\" value=\"No\"\n\t\t   data-reqmsg=\"Do you suffer from any Disease ? cannot be blank.\" data-invmsg=\"Do you suffer from any Disease ? is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_21-1\">\t\t\t<label  for=\"field_z9zqy-0-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[44][0][21]\" id=\"field_z9zqy-0-1\" value=\"Yes\"\n\t\t   data-reqmsg=\"Do you suffer from any Disease ? cannot be blank.\" data-invmsg=\"Do you suffer from any Disease ? is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n<\/div>\n\t<div class=\"frm_description\" id=\"frm_desc_field_z9zqy-0\">Disease Will Be Displayed Publically on Our WhatsApp<\/div>\n\t\n<\/div>\n<div id=\"frm_field_22-44-0_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm3 frm_field_22_container\">\n\t<label for=\"field_nkp4j-0\" id=\"field_nkp4j-0_label\" class=\"frm_primary_label\">Name of The Disease, Describe Your History in Remarks Field.\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_nkp4j-0\" name=\"item_meta[44][0][22]\" value=\"\"  data-reqmsg=\"Name of The Disease, Describe Your History in Remarks Field. cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name of The Disease, Describe Your History in Remarks Field. is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_nkp4j-0\" \/>\n\t<div class=\"frm_description\" id=\"frm_desc_field_nkp4j-0\">Disease Name Will Be Displayed Publically on Our WhatsApp<\/div>\n\t\n<\/div>\n<div id=\"frm_field_23-44-0_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm3 vertical_radio frm_field_23_container frm_other_container\">\n\t<div  id=\"field_948ws-0_label\" class=\"frm_primary_label\">Directly Who Can Contact You ?\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/div>\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_948ws-0_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-0\">\t\t\t<label  for=\"field_948ws-0-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[44][0][23][]\" id=\"field_948ws-0-0\" value=\"RaktMitra Volunteer\"  data-reqmsg=\"Directly Who Can Contact You ? cannot be blank.\" data-invmsg=\"Directly Who Can Contact You ? is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> RaktMitra Volunteer<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-1\">\t\t\t<label  for=\"field_948ws-0-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[44][0][23][]\" id=\"field_948ws-0-1\" value=\"Beneficiary\"  data-reqmsg=\"Directly Who Can Contact You ? cannot be blank.\" data-invmsg=\"Directly Who Can Contact You ? is invalid\" aria-invalid=\"false\"   \/> Beneficiary<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-2\">\t\t\t<label  for=\"field_948ws-0-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[44][0][23][]\" id=\"field_948ws-0-2\" value=\"Hospital Authority\"  data-reqmsg=\"Directly Who Can Contact You ? cannot be blank.\" data-invmsg=\"Directly Who Can Contact You ? is invalid\" aria-invalid=\"false\"   \/> Hospital Authority<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-other_3\">\t\t\t<label  for=\"field_948ws-0-other_3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[44][0][23][other_3]\" id=\"field_948ws-0-other_3\" value=\"Other\"  data-reqmsg=\"Directly Who Can Contact You ? cannot be blank.\" data-invmsg=\"Directly Who Can Contact You ? is invalid\" aria-invalid=\"false\"   \/> Other<\/label><label for=\"field_948ws-0-other_3-otext\" class=\"frm_screen_reader frm_hidden\">Other<\/label><input type=\"text\" id=\"field_948ws-0-other_3-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[44][0][other][23][other_3]\" value=\"\" \/><\/div>\n<\/div>\n\t<div class=\"frm_description\" id=\"frm_desc_field_948ws-0\">Source of Contact Will Be Displayed Publically on Our WhatsApp<\/div>\n\t\n<\/div>\n<div id=\"frm_field_24-44-0_container\" class=\"frm_form_field form-field  frm_top_container frm_field_24_container\">\n\t<label for=\"field_3efky-0\" id=\"field_3efky-0_label\" class=\"frm_primary_label\">Remarks\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<div id=\"wp-field_3efky-0-wrap\" class=\"wp-core-ui wp-editor-wrap tmce-active\"><div id=\"wp-field_3efky-0-editor-tools\" class=\"wp-editor-tools hide-if-no-js\"><div class=\"wp-editor-tabs\"><button type=\"button\" id=\"field_3efky-0-tmce\" aria-pressed=\"true\" class=\"wp-switch-editor switch-tmce\" data-wp-editor-id=\"field_3efky-0\">Visual<\/button>\n<button type=\"button\" id=\"field_3efky-0-html\" class=\"wp-switch-editor switch-html\" data-wp-editor-id=\"field_3efky-0\">Code<\/button>\n<\/div>\n<\/div>\n<div id=\"wp-field_3efky-0-editor-container\" class=\"wp-editor-container\"><div id=\"qt_field_3efky-0_toolbar\" class=\"quicktags-toolbar hide-if-no-js\"><\/div><textarea class=\"wp-editor-area\" rows=\"7\" autocomplete=\"off\" cols=\"40\" name=\"item_meta[44][0][24]\" id=\"field_3efky-0\"><\/textarea><\/div>\n<\/div>\n\n\n\t<div class=\"frm_description\" id=\"frm_desc_field_3efky-0\">Remarks Will Not Be Displayed Publically on WhatsApp<\/div>\n\t\n<\/div>\n<div id=\"frm_field_25-44-0_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio frm_field_25_container\">\n\t<div  id=\"field_38fco-0_label\" class=\"frm_primary_label\">Disclaimer\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/div>\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_38fco-0_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-0\">\t\t\t<label  for=\"field_38fco-0-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[44][0][25][]\" id=\"field_38fco-0-0\" value=\"We are just Facilitate Donor&#039;s Data. We are not responsible for any direct\/indirect losses\/damages occurs out of using this data. You are using this information at your sole discretion for which none of our volunteer to be held responsible.\"  data-frmlimit=\"1\"  data-frmmin=\"1\"  data-reqmsg=\"Disclaimer cannot be blank.\" data-invmsg=\"Disclaimer is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> We are just Facilitate Donor's Data. We are not responsible for any direct\/indirect losses\/damages occurs out of using this data. You are using this information at your sole discretion for which none of our volunteer to be held responsible.<\/label><\/div>\n<\/div>\n\t\n\t\n<\/div>\n<div id=\"frm_field_26-44-0_container\" class=\"frm_form_field form-field  frm_none_container frm_field_26_container\">\n\t<label for=\"g-recaptcha-response\" id=\"field_3jbv3-0_label\" class=\"frm_primary_label\">Captcha\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t\n\t\n\t\n<\/div>\n<\/div>\n\n<\/div>\n<div id=\"frm_field_46_container\" class=\"frm_form_field form-field  frm12 frm_first\">\n\t<div class=\"frm_submit frm_flex\">\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"   formnovalidate=\"formnovalidate\">Submit<\/button>\r\n\r\n\r\n\r\n<\/div>\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_47_container\">\n\t\t\t<label for=\"field_gv8jg\" >\n\t\t\t\tIf you are human, leave this field blank.\t\t\t<\/label>\n\t\t\t<input  id=\"field_gv8jg\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[47]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"tv+HB+mbmqxiMIR1bbQ9BImbOlhzjaShvK3B7Er35OhPHbh9ftKxSTCaTpMKqcMU\" \/><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-208","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/jsgblooddonors.com\/index.php?rest_route=\/wp\/v2\/pages\/208","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/jsgblooddonors.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/jsgblooddonors.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/jsgblooddonors.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/jsgblooddonors.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=208"}],"version-history":[{"count":4,"href":"https:\/\/jsgblooddonors.com\/index.php?rest_route=\/wp\/v2\/pages\/208\/revisions"}],"predecessor-version":[{"id":4580,"href":"https:\/\/jsgblooddonors.com\/index.php?rest_route=\/wp\/v2\/pages\/208\/revisions\/4580"}],"wp:attachment":[{"href":"https:\/\/jsgblooddonors.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=208"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}