{"id":13,"date":"2021-01-22T21:30:53","date_gmt":"2021-01-22T21:30:53","guid":{"rendered":"https:\/\/fightingchance.org.uk\/babybank\/?page_id=13"},"modified":"2026-10-23T15:51:05","modified_gmt":"2026-10-23T14:51:05","slug":"self-referral","status":"publish","type":"page","link":"https:\/\/fightingchance.org.uk\/babybank\/self-referral\/","title":{"rendered":"Self Referral"},"content":{"rendered":"<p><strong>Please complete the below referral form and we will be in touch as quickly as possible.<\/strong><br \/>\nAll information is submitted securely and in confidence.<\/p>\n<h4><strong>SELF REFERRAL FORM<\/strong><\/h4>\n<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_2' style='display:none'><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_2' id='gform_2'  action='\/babybank\/wp-json\/wp\/v2\/pages\/13#gf_2' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_above description_above validation_below' data-column-layout='fill'><li id=\"field_2_60\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"><label id='gfield_label_2_60' class='gfield_label gform-field-label' for='input_2_60'><span class='gform-field-label__text'>LinkedIn<\/span><\/label><div class='gfield_description' id='gfield_description_2_60'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_60' id='input_2_60' type='text' value='' autocomplete='new-password'\/><\/div><\/li><li id=\"field_2_3\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"060fe0d0\" data-field-span=\"12\"><label id='gfield_label_2_3' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_3'>\n                            \n                            <span id='input_2_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_2_3_3' id='input_2_3_3_label' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_3.3' id='input_2_3_3' value=''   aria-required='true'     aria-labelledby=\"input_2_3_3_label gfield_label_2_3\"\/>\n                                                <\/span>\n                            \n                            <span id='input_2_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_2_3_6' id='input_2_3_6_label' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_3.6' id='input_2_3_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_4\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"410b9e6e\" data-field-span=\"12\"><label id='gfield_label_2_4' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_2_4_container'>\n                                <span id='input_2_4_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_2_4' id='input_2_4_label' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                    <input class='' type='email' name='input_4' id='input_2_4' value=''    aria-required=\"true\" aria-invalid=\"false\"  aria-labelledby=\"input_2_4_label gfield_label_2_4\" \/>\n                                <\/span>\n                                <span id='input_2_4_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_2_4_2' id='input_2_4_2_label' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                    <input class='' type='email' name='input_4_2' id='input_2_4_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_2_5\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"8ac42162\" data-field-span=\"12\"><label id='gfield_label_2_5' class='gfield_label gform-field-label' for='input_2_5'><span class='gform-field-label__text'>Postcode<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_5'>We need your postcode to ascertain your approximate location.<\/div><div class='ginput_container ginput_container_text'><input name='input_5' id='input_2_5' type='text' value='' class='medium'  aria-describedby=\"gfield_description_2_5\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_6\" class=\"gfield gfield--type-phone gfield--phone-format-international gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"72791a5a\" data-field-span=\"12\"><label id='gfield_label_2_6' class='gfield_label gform-field-label' for='input_2_6'><span class='gform-field-label__text'>Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_6'>We will only use this number if we can't reach you via email regarding the collection or delivery of items. We will share this number with the foodbank if you ask us for a foodbank referral.<\/div><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_2_6' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_2_6\"   \/><\/div><\/li><li id=\"field_2_9\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"f9572f0a\" data-field-span=\"12\">[vc_empty_space height=\"36px\"]<\/li><li id=\"field_2_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"8ed34102\" data-field-span=\"12\"><label id='gfield_label_2_11' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are You Currently Pregnant?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_11'>\n\t\t\t<li class='gchoice gchoice_2_11_0'>\n\t\t\t\t<input name='input_11' type='radio' value='Yes'  id='choice_2_11_0'    \/>\n\t\t\t\t<label for='choice_2_11_0' id='label_2_11_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_11_1'>\n\t\t\t\t<input name='input_11' type='radio' value='No'  id='choice_2_11_1'    \/>\n\t\t\t\t<label for='choice_2_11_1' id='label_2_11_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_34\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"bff79f52\" data-field-span=\"12\"><label id='gfield_label_2_34' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Due Date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_2_34' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\">\n                                    <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_2_34_2_container'>\n                                        <label for='input_2_34_2' id='input_2_34_2_label' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <input type='number' maxlength='2' name='input_34[]' id='input_2_34_2' value=''   aria-required='true'   aria-labelledby=\"input_2_34_2_label gfield_label_2_34\"  placeholder='DD' min='1' max='31' step='1'\/>\n                                    <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_2_34_1_container'>\n                                    <label for='input_2_34_1' id='input_2_34_1_label' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                    <input type='number' maxlength='2' name='input_34[]' id='input_2_34_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                               <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_2_34_3_container'>\n                                        <label for='input_2_34_3' id='input_2_34_3_label' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                        <input type='number' maxlength='4' name='input_34[]' id='input_2_34_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                   <\/div>\n                                <\/div><\/div><\/li><li id=\"field_2_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"d1164855\" data-field-span=\"12\"><label id='gfield_label_2_12' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Baby&#039;s Gender<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_12'>\n\t\t\t<li class='gchoice gchoice_2_12_0'>\n\t\t\t\t<input name='input_12' type='radio' value='Boy'  id='choice_2_12_0'    \/>\n\t\t\t\t<label for='choice_2_12_0' id='label_2_12_0' class='gform-field-label gform-field-label--type-inline'>Boy<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_12_1'>\n\t\t\t\t<input name='input_12' type='radio' value='Girl'  id='choice_2_12_1'    \/>\n\t\t\t\t<label for='choice_2_12_1' id='label_2_12_1' class='gform-field-label gform-field-label--type-inline'>Girl<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_12_2'>\n\t\t\t\t<input name='input_12' type='radio' value='Unknown'  id='choice_2_12_2'    \/>\n\t\t\t\t<label for='choice_2_12_2' id='label_2_12_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_12_3'>\n\t\t\t\t<input name='input_12' type='radio' value='gf_other_choice'  id='choice_2_12_3'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_2_12_other' name='input_12_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"1230864a\" data-field-span=\"12\"><label id='gfield_label_2_29' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you have any other children who would need to access the baby bank?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_29'>\n\t\t\t<li class='gchoice gchoice_2_29_0'>\n\t\t\t\t<input name='input_29' type='radio' value='Yes'  id='choice_2_29_0'    \/>\n\t\t\t\t<label for='choice_2_29_0' id='label_2_29_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_29_1'>\n\t\t\t\t<input name='input_29' type='radio' value='No'  id='choice_2_29_1'    \/>\n\t\t\t\t<label for='choice_2_29_1' id='label_2_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_13\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"0333f3c3\" data-field-span=\"12\"><label id='gfield_label_2_13' class='gfield_label gform-field-label' for='input_2_13'><span class='gform-field-label__text'>Child&#039;s Age &amp; Gender<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_13'>Please include all children you require help for. This information is asked so we can provide appropriate items for your child(ren).<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_13' id='input_2_13' class='textarea medium'  aria-describedby=\"gfield_description_2_13\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_17\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"77ed8187\" data-field-span=\"12\">[vc_empty_space height=\"16px\"]<H4>Items Required<\/h4><BR>[vc_row][vc_column][vc_message color=\"danger\" message_box_style=\"3d\" message_box_color=\"danger\" icon_fontawesome=\"fa fa-times\"]<span style=\"color: #ff0000;\"><\/span>\n\n<span style=\"color: #ff0000;\"><strong>Please <span style=\"text-decoration: underline;\"><span style=\"color: #ff0000; text-decoration: underline;\">ONLY<\/span><\/span> select the items you <span style=\"color: #ff0000; text-decoration: underline;\">NEED<\/span>, thank you.<\/strong><\/span>[\/vc_message][\/vc_column][\/vc_row]<\/li><li id=\"field_2_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_2col field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"7e71e911\" data-field-span=\"12\"><label id='gfield_label_2_16' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Baby\/Child<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_16'><li class='gchoice gchoice_2_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Nappies'  id='choice_2_16_1'    aria-labelledby=\"label_2_16_1 gfield_label_2_16\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_1' id='label_2_16_1' class='gform-field-label gform-field-label--type-inline'>Nappies<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Wipes'  id='choice_2_16_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_2' id='label_2_16_2' class='gform-field-label gform-field-label--type-inline'>Wipes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Nappy Sacks'  id='choice_2_16_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_3' id='label_2_16_3' class='gform-field-label gform-field-label--type-inline'>Nappy Sacks<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='Nappy Cream'  id='choice_2_16_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_4' id='label_2_16_4' class='gform-field-label gform-field-label--type-inline'>Nappy Cream<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.5' type='checkbox'  value='Formula'  id='choice_2_16_5'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_5' id='label_2_16_5' class='gform-field-label gform-field-label--type-inline'>Formula<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.6' type='checkbox'  value='Bottles'  id='choice_2_16_6'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_6' id='label_2_16_6' class='gform-field-label gform-field-label--type-inline'>Bottles<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.7' type='checkbox'  value='Dummies'  id='choice_2_16_7'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_7' id='label_2_16_7' class='gform-field-label gform-field-label--type-inline'>Dummies<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.8' type='checkbox'  value='Hairbrush'  id='choice_2_16_8'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_8' id='label_2_16_8' class='gform-field-label gform-field-label--type-inline'>Hairbrush<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.9' type='checkbox'  value='Nail Clippers \/ Scissors'  id='choice_2_16_9'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_9' id='label_2_16_9' class='gform-field-label gform-field-label--type-inline'>Nail Clippers \/ Scissors<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.11' type='checkbox'  value='Cotton Wool'  id='choice_2_16_11'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_11' id='label_2_16_11' class='gform-field-label gform-field-label--type-inline'>Cotton Wool<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.12' type='checkbox'  value='Body Wash'  id='choice_2_16_12'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_12' id='label_2_16_12' class='gform-field-label gform-field-label--type-inline'>Body Wash<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.13' type='checkbox'  value='Moisturiser'  id='choice_2_16_13'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_13' id='label_2_16_13' class='gform-field-label gform-field-label--type-inline'>Moisturiser<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.14' type='checkbox'  value='Talc'  id='choice_2_16_14'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_14' id='label_2_16_14' class='gform-field-label gform-field-label--type-inline'>Talc<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.15' type='checkbox'  value='Toothbrush'  id='choice_2_16_15'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_15' id='label_2_16_15' class='gform-field-label gform-field-label--type-inline'>Toothbrush<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.16' type='checkbox'  value='Toothpaste'  id='choice_2_16_16'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_16' id='label_2_16_16' class='gform-field-label gform-field-label--type-inline'>Toothpaste<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.17' type='checkbox'  value='Muslins'  id='choice_2_16_17'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_17' id='label_2_16_17' class='gform-field-label gform-field-label--type-inline'>Muslins<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.18' type='checkbox'  value='Blankets'  id='choice_2_16_18'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_18' id='label_2_16_18' class='gform-field-label gform-field-label--type-inline'>Blankets<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.19' type='checkbox'  value='Sheets'  id='choice_2_16_19'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_19' id='label_2_16_19' class='gform-field-label gform-field-label--type-inline'>Sheets<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.21' type='checkbox'  value='Duvet Covers'  id='choice_2_16_21'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_21' id='label_2_16_21' class='gform-field-label gform-field-label--type-inline'>Duvet Covers<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.22' type='checkbox'  value='Sleeping Bags'  id='choice_2_16_22'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_22' id='label_2_16_22' class='gform-field-label gform-field-label--type-inline'>Sleeping Bags<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.23' type='checkbox'  value='Changing Mat'  id='choice_2_16_23'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_23' id='label_2_16_23' class='gform-field-label gform-field-label--type-inline'>Changing Mat<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.24' type='checkbox'  value='Potty'  id='choice_2_16_24'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_24' id='label_2_16_24' class='gform-field-label gform-field-label--type-inline'>Potty<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.25' type='checkbox'  value='Step'  id='choice_2_16_25'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_25' id='label_2_16_25' class='gform-field-label gform-field-label--type-inline'>Step<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.26' type='checkbox'  value='Feeding \/ Weaning Items'  id='choice_2_16_26'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_26' id='label_2_16_26' class='gform-field-label gform-field-label--type-inline'>Feeding \/ Weaning Items<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.27' type='checkbox'  value='Hat'  id='choice_2_16_27'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_27' id='label_2_16_27' class='gform-field-label gform-field-label--type-inline'>Hat<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.28' type='checkbox'  value='Bibs'  id='choice_2_16_28'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_28' id='label_2_16_28' class='gform-field-label gform-field-label--type-inline'>Bibs<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.29' type='checkbox'  value='Scratch Mitts'  id='choice_2_16_29'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_29' id='label_2_16_29' class='gform-field-label gform-field-label--type-inline'>Scratch Mitts<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.31' type='checkbox'  value='Clothing'  id='choice_2_16_31'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_31' id='label_2_16_31' class='gform-field-label gform-field-label--type-inline'>Clothing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.32' type='checkbox'  value='Shoes'  id='choice_2_16_32'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_32' id='label_2_16_32' class='gform-field-label gform-field-label--type-inline'>Shoes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.33' type='checkbox'  value='Coat \/ Snowsuit'  id='choice_2_16_33'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_33' id='label_2_16_33' class='gform-field-label gform-field-label--type-inline'>Coat \/ Snowsuit<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.34' type='checkbox'  value='Toys'  id='choice_2_16_34'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_34' id='label_2_16_34' class='gform-field-label gform-field-label--type-inline'>Toys<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_35'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.35' type='checkbox'  value='Books'  id='choice_2_16_35'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_35' id='label_2_16_35' class='gform-field-label gform-field-label--type-inline'>Books<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_52\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"49015d76\" data-field-span=\"12\"><label id='gfield_label_2_52' class='gfield_label gform-field-label' for='input_2_52'><span class='gform-field-label__text'>Feeding Items<\/span><\/label><div class='gfield_description' id='gfield_description_2_52'>Please specify if you need a plate, bowl, cutlery, sippy cup or bibs <\/div><div class='ginput_container ginput_container_text'><input name='input_52' id='input_2_52' type='text' value='' class='large'  aria-describedby=\"gfield_description_2_52\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_51\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"a254cf96\" data-field-span=\"12\"><label id='gfield_label_2_51' class='gfield_label gform-field-label' for='input_2_51'><span class='gform-field-label__text'>Duvet Size<\/span><\/label><div class='gfield_description' id='gfield_description_2_51'>Please specify if you need cot bed or single bed<\/div><div class='ginput_container ginput_container_text'><input name='input_51' id='input_2_51' type='text' value='' class='large'  aria-describedby=\"gfield_description_2_51\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_48\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"eb7a6b6e\" data-field-span=\"12\"><label id='gfield_label_2_48' class='gfield_label gform-field-label' for='input_2_48'><span class='gform-field-label__text'>Coat \/ Snowsuit Size<\/span><\/label><div class='gfield_description' id='gfield_description_2_48'>Please specify if you need a winter coat, snowsuit, rain coat or lighter jacket (spring\/autumn).<\/div><div class='ginput_container ginput_container_text'><input name='input_48' id='input_2_48' type='text' value='' class='large'  aria-describedby=\"gfield_description_2_48\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_45\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"573a108b\" data-field-span=\"12\"><label id='gfield_label_2_45' class='gfield_label gform-field-label' for='input_2_45'><span class='gform-field-label__text'>Clothing Size<\/span><\/label><div class='gfield_description' id='gfield_description_2_45'>Please specify if you would like a bundle or only particular items<\/div><div class='ginput_container ginput_container_text'><input name='input_45' id='input_2_45' type='text' value='' class='large'  aria-describedby=\"gfield_description_2_45\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_43\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"5eacffb4\" data-field-span=\"12\"><label id='gfield_label_2_43' class='gfield_label gform-field-label' for='input_2_43'><span class='gform-field-label__text'>Hat Size<\/span><\/label><div class='gfield_description' id='gfield_description_2_43'>Please specify if you need a winter hat, sun hat or baby hat. <\/div><div class='ginput_container ginput_container_text'><input name='input_43' id='input_2_43' type='text' value='' class='large'  aria-describedby=\"gfield_description_2_43\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_41\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"e7766bba\" data-field-span=\"12\"><label id='gfield_label_2_41' class='gfield_label gform-field-label' for='input_2_41'><span class='gform-field-label__text'>Sheet Size<\/span><\/label><div class='gfield_description' id='gfield_description_2_41'>Please specify if you need moses basket, cot or single bed sheets. <\/div><div class='ginput_container ginput_container_text'><input name='input_41' id='input_2_41' type='text' value='' class='large'  aria-describedby=\"gfield_description_2_41\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_40\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"1fcce81d\" data-field-span=\"12\"><label id='gfield_label_2_40' class='gfield_label gform-field-label' for='input_2_40'><span class='gform-field-label__text'>Formula Stage and Brand<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_2_40' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_38\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"af8b8204\" data-field-span=\"12\"><label id='gfield_label_2_38' class='gfield_label gform-field-label' for='input_2_38'><span class='gform-field-label__text'>Nappy Size<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_2_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_36\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"55f334de\" data-field-span=\"12\"><label id='gfield_label_2_36' class='gfield_label gform-field-label' for='input_2_36'><span class='gform-field-label__text'>Shoe Size<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_2_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_18\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"f7fc8a3e\" data-field-span=\"12\"><label id='gfield_label_2_18' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Mum<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_18'><li class='gchoice gchoice_2_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='Maternity Clothing'  id='choice_2_18_1'    aria-labelledby=\"label_2_18_1 gfield_label_2_18\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_18_1' id='label_2_18_1' class='gform-field-label gform-field-label--type-inline'>Maternity Clothing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='Breast Pads'  id='choice_2_18_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_18_2' id='label_2_18_2' class='gform-field-label gform-field-label--type-inline'>Breast Pads<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_18_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.3' type='checkbox'  value='Maternity Pads'  id='choice_2_18_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_18_3' id='label_2_18_3' class='gform-field-label gform-field-label--type-inline'>Maternity Pads<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_18_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.4' type='checkbox'  value='Nipple Cream'  id='choice_2_18_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_18_4' id='label_2_18_4' class='gform-field-label gform-field-label--type-inline'>Nipple Cream<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_18_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.5' type='checkbox'  value='Nursing Bra'  id='choice_2_18_5'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_18_5' id='label_2_18_5' class='gform-field-label gform-field-label--type-inline'>Nursing Bra<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_55\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"e902eb6e\" data-field-span=\"12\"><label id='gfield_label_2_55' class='gfield_label gform-field-label' for='input_2_55'><span class='gform-field-label__text'>Bra Size<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_2_55' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_54\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"0bb3b8be\" data-field-span=\"12\"><label id='gfield_label_2_54' class='gfield_label gform-field-label' for='input_2_54'><span class='gform-field-label__text'>Maternity Clothing Size<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_2_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_19\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"27b6dc4c\" data-field-span=\"12\">[vc_empty_space height=\"16px\"]<\/li><li id=\"field_2_20\" class=\"gfield gfield--type-textarea field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"1f263527\" data-field-span=\"12\"><label id='gfield_label_2_20' class='gfield_label gform-field-label' for='input_2_20'><span class='gform-field-label__text'>Is there anything else you are in desperate need of that hasn&#039;t been listed above?<\/span><\/label><div class='gfield_description' id='gfield_description_2_20'>Please be aware that certain items will require a third party referral<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_20' id='input_2_20' class='textarea medium'  aria-describedby=\"gfield_description_2_20\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_21\" class=\"gfield gfield--type-textarea field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"eb3b3fc9\" data-field-span=\"12\"><label id='gfield_label_2_21' class='gfield_label gform-field-label' for='input_2_21'><span class='gform-field-label__text'>Is there any further information regarding the items you require?<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_21' id='input_2_21' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_22\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"a9c1487c\" data-field-span=\"12\"><label id='gfield_label_2_22' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Please Tell Us Why You Need To Use The Baby Bank<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_22'>This is used purely for analytics and to ensure we help the right people.<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_22'><li class='gchoice gchoice_2_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='Financial Hardship'  id='choice_2_22_1'   aria-describedby=\"gfield_description_2_22\" aria-labelledby=\"label_2_22_1 gfield_label_2_22\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_1' id='label_2_22_1' class='gform-field-label gform-field-label--type-inline'>Financial Hardship<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value='Ill-Health'  id='choice_2_22_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_2' id='label_2_22_2' class='gform-field-label gform-field-label--type-inline'>Ill-Health<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_22_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.3' type='checkbox'  value='Refugee \/ Asylum Seeker'  id='choice_2_22_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_3' id='label_2_22_3' class='gform-field-label gform-field-label--type-inline'>Refugee \/ Asylum Seeker<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_22_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.4' type='checkbox'  value='Escaping Violence Or Abuse'  id='choice_2_22_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_4' id='label_2_22_4' class='gform-field-label gform-field-label--type-inline'>Escaping Violence Or Abuse<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_22_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.5' type='checkbox'  value='Other'  id='choice_2_22_5'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_5' id='label_2_22_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_23\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"d4fdd917\" data-field-span=\"12\"><label id='gfield_label_2_23' class='gfield_label gform-field-label' for='input_2_23'><span class='gform-field-label__text'>Please Specify<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_2_23' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_59\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"9dcd31c5\" data-field-span=\"12\"><label id='gfield_label_2_59' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Household Income<\/span><\/label><div class='gfield_description' id='gfield_description_2_59'>Please tick all that apply<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_59'><li class='gchoice gchoice_2_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='Working'  id='choice_2_59_1'   aria-describedby=\"gfield_description_2_59\" aria-labelledby=\"label_2_59_1 gfield_label_2_59\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_59_1' id='label_2_59_1' class='gform-field-label gform-field-label--type-inline'>Working<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_59_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.2' type='checkbox'  value='Benefits'  id='choice_2_59_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_59_2' id='label_2_59_2' class='gform-field-label gform-field-label--type-inline'>Benefits<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_59_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.3' type='checkbox'  value='Working and Benefits'  id='choice_2_59_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_59_3' id='label_2_59_3' class='gform-field-label gform-field-label--type-inline'>Working and Benefits<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_59_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.4' type='checkbox'  value='Neither'  id='choice_2_59_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_59_4' id='label_2_59_4' class='gform-field-label gform-field-label--type-inline'>Neither<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_59_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.5' type='checkbox'  value='Prefer not to say'  id='choice_2_59_5'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_59_5' id='label_2_59_5' class='gform-field-label gform-field-label--type-inline'>Prefer not to say<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_25\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"2ae317dc\" data-field-span=\"12\">[vc_empty_space height=\"26px\"]<\/li><li id=\"field_2_24\" class=\"gfield gfield--type-textarea field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"78896289\" data-field-span=\"12\"><label id='gfield_label_2_24' class='gfield_label gform-field-label' for='input_2_24'><span class='gform-field-label__text'>Is there any other information you would like us to know or that will enable us to help you?<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_24' id='input_2_24' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_26\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"13c95907\" data-field-span=\"12\"><label id='gfield_label_2_26' class='gfield_label gform-field-label' for='input_2_26'><span class='gform-field-label__text'>How did you hear about the Baby Bank?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_2_26' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_31\" class=\"gfield gfield--type-select field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"49d77857\" data-field-span=\"12\"><label id='gfield_label_2_31' class='gfield_label gform-field-label' for='input_2_31'><span class='gform-field-label__text'>Would you like delivery or collection?<\/span><\/label><div class='gfield_description' id='gfield_description_2_31'>Please select collection wherever possible. Delivery will take longer.\n\nWe are based in Petworth and can only deliver within a 5-10 mile radius. <\/div><div class='ginput_container ginput_container_select'><select name='input_31' id='input_2_31' class='medium gfield_select'  aria-describedby=\"gfield_description_2_31\"   aria-invalid=\"false\" ><option value='Collection' >Collection<\/option><option value='Delivery' >Delivery<\/option><\/select><\/div><\/li><li id=\"field_2_33\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"886959bd\" data-field-span=\"12\"><label id='gfield_label_2_33' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Delivery Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_zip ginput_container_address gform-grid-row' id='input_2_33' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_33_1_container' >\n                                        <label for='input_2_33_1' id='input_2_33_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_33.1' id='input_2_33_1' value=''    aria-required='true'    aria-labelledby=\"input_2_33_1_label gfield_label_2_33\"\/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_2_33_2_container' >\n                                        <label for='input_2_33_2' id='input_2_33_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_33.2' id='input_2_33_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_33_3_container' >\n                                    <label for='input_2_33_3' id='input_2_33_3_label' class='gform-field-label gform-field-label--type-sub '>Town<\/label>\n                                    <input type='text' name='input_33.3' id='input_2_33_3' value=''    aria-required='true'    \/>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_33.4' id='input_2_33_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_2_33_5_container' >\n                                    <label for='input_2_33_5' id='input_2_33_5_label' class='gform-field-label gform-field-label--type-sub '>Postcode<\/label>\n                                    <input type='text' name='input_33.5' id='input_2_33_5' value=''    aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_33.6' id='input_2_33_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_32\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"863d2d0c\" data-field-span=\"12\">Our address is Unit K, The Old Bakery, Golden Square, Petworth. GU28 0AP.<\/li><li id=\"field_2_28\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"8b1535c6\" data-field-span=\"12\"><label id='gfield_label_2_28' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>By submitting this form you are agreeing to our privacy and disclosure policy as well as our assumption of risk policy.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_28'>Please ensure you've taken the time to read and understand both policies fully. <a href=\"https:\/\/fightingchancebabybank.org.uk\/documents\" target=\"_blank\">Click here to view these policies<\/a>.<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_28'><li class='gchoice gchoice_2_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value='I have read and agree to both policies'  id='choice_2_28_1'   aria-describedby=\"gfield_description_2_28\" aria-labelledby=\"label_2_28_1 gfield_label_2_28\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_28_1' id='label_2_28_1' class='gform-field-label gform-field-label--type-inline'>I have read and agree to both policies<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_30\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"c4416efc\" data-field-span=\"12\">We understand all families will have different needs regarding the items they require from the Baby Bank. We will always do our best to provide as many of the items required as possible but we won't always be able to fulfil 100% of the referral.<\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit Referral<\/button> <a type='button' href=\"javascript:void(0);\" id='gform_save_2_footer_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a><input type='hidden' name='gform_ajax' value='form_id=2&amp;title=&amp;description=&amp;tabindex=0&amp;theme=legacy&amp;styles=[]&amp;hash=8a697b2b26cd1d51d06ed7358eda5e34' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_2' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_2' id='gform_theme_2' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_2' id='gform_style_settings_2' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            <input type='hidden' class='gform_hidden' name='gform_save' id='gform_save_2' value='' \/>\n                             <input type='hidden' class='gform_hidden' name='gform_resume_token' id='gform_resume_token_2' value='' \/>\n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='GBP' value='eWCn0I58yuwIG1L5ZeV1amKAti6ziPGlmfyyAUfZDBLhlQAYBL0cemNCmRJ8PA0X\/e3QYePkJ\/eG\/7Gz9\/rWcNervSyNqoP1p7akZEjdX7lXHj4=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_2' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_2' id='gform_target_page_number_2' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_2' id='gform_source_page_number_2' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_2' id='gform_ajax_frame_2' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script>\ngform.initializeOnLoaded( function() {jQuery('#gform_ajax_frame_2').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_2');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_2').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! 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