
            <script type="text/javascript">
            jQuery(document).ready(function($) {
                $.fn.checkboxLimit = function(n) {

                    var checkboxes = this;

                    this.toggleDisable = function() {

                        // if we have reached or exceeded the limit, disable all other checkboxes
                        if(this.filter(':checked').length >= n) {
                            var unchecked = this.not(':checked');
                            unchecked.prop('disabled', true);
                        }
                        // if we are below the limit, make sure all checkboxes are available
                        else {
                            this.prop('disabled', false);
                        }

                    }

                    // when form is rendered, toggle disable
                    checkboxes.bind('gform_post_render', checkboxes.toggleDisable());

                    // when checkbox is clicked, toggle disable
                    checkboxes.click(function(event) {

                        checkboxes.toggleDisable();

                        // if we are equal to or below the limit, the field should be checked
                        return checkboxes.filter(':checked').length <= n;
                    });

                }
            });
            </script>

            {"id":3396,"date":"2017-04-05T15:59:58","date_gmt":"2017-04-05T19:59:58","guid":{"rendered":"https:\/\/thetwinkiefoundation.ca\/hello\/?page_id=3396"},"modified":"2026-01-11T07:27:19","modified_gmt":"2026-01-11T12:27:19","slug":"application","status":"publish","type":"page","link":"https:\/\/thetwinkiefoundation.ca\/hello\/application\/","title":{"rendered":"Application"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;section&#8221; _builder_version=&#8221;4.25.2&#8243; collapsed=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row admin_label=&#8221;row&#8221; _builder_version=&#8221;4.25.2&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; collapsed=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_text admin_label=&#8221;Text&#8221; _builder_version=&#8221;4.25.2&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; hover_enabled=&#8221;0&#8243; use_border_color=&#8221;off&#8221; border_color=&#8221;#ffffff&#8221; border_style=&#8221;solid&#8221; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243;]<\/p>\n<p>Note: Financial assistance may vary based on the circumstances of the patient appointment and the availability of The Foundation funds at the time the request is received. Please complete one application per medical appointment. <\/p>\n<p>Qualifying criteria to receive funding from The Twinkie Foundation:<\/p>\n<p>1. You must be a resident of Sault Ste. Marie, Ontario or live within 100km&#8217;s of Sault Ste. Marie, ON<\/p>\n<p>2. You must have a confirmed medical appointment at any medical facility located outside of Sault Ste. Marie.\u00a0<\/p>\n<p>3. Applicant must be 17 years or younger. Eligibility runs up until the child\u2019s 18th birthday.<\/p>\n<p>Please ensure that your appointment has been booked and confirmed before submitting an application. As a reminder, you should apply as early as possible as we can take up to 4-6 weeks to process applications.<\/p>\n<p>Funding amounts and limits: Funding will be provided based on a specified per diem rate. Additional assistance may be available for unique circumstances.\u00a0A yearly maximum funding limit per family will apply and is dependent on funds being available<\/p>\n<p>[\/et_pb_text][et_pb_text admin_label=&#8221;Text&#8221; _builder_version=&#8221;4.25.2&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; use_border_color=&#8221;off&#8221; border_color=&#8221;#ffffff&#8221; border_style=&#8221;solid&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n\n                <div class='gf_browser_gecko gform_wrapper' id='gform_wrapper_4' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/hello\/wp-json\/wp\/v2\/pages\/3396'>\n                        <div class='gform_body'><ul id='gform_fields_4' class='gform_fields left_label form_sublabel_below description_below'><li id='field_4_1'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Patient Information<\/h2><div class='gsection_description' id='gfield_description_4_1'>(Child who has a confirmed medical appointment.)<\/div><\/li><li id='field_4_2'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Name<span class='gfield_required'>*<\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name' id='input_4_2'>\n                            \n                            <span id='input_4_2_3_container' class='name_first' >\n                                                    <input type='text' name='input_2.3' id='input_4_2_3' value='' aria-label='First name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_4_2_3' >First<\/label>\n                                                <\/span>\n                            <span id='input_4_2_4_container' class='name_middle' >\n                                                    <input type='text' name='input_2.4' id='input_4_2_4' value='' aria-label='Middle name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_4_2_4' >Middle<\/label>\n                                                <\/span>\n                            <span id='input_4_2_6_container' class='name_last' >\n                                                    <input type='text' name='input_2.6' id='input_4_2_6' value='' aria-label='Last name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_4_2_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id='field_4_3'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Date of Birth<span class='gfield_required'>*<\/span><\/label><div id='input_4_3' class='ginput_container ginput_container_date'><div class='clear-multi'><div class='gfield_date_month ginput_container ginput_container_date' id='input_4_3_1_container'>\n                                            <input type='text' maxlength='2' name='input_3[]' id='input_4_3_1' value=''    \/>\n                                            <label for='input_4_3_1' >MM<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date' id='input_4_3_2_container'>\n                                            <input type='text' maxlength='2' name='input_3[]' id='input_4_3_2' value=''    \/>\n                                            <label for='input_4_3_2' >DD<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date' id='input_4_3_3_container'>\n                                            <input type='text' maxlength='4' name='input_3[]' id='input_4_3_3' value=''      \/>\n                                            <label for='input_4_3_3' >YYYY<\/label>\n                                       <\/div>\n                                   <\/div><\/div><\/li><li id='field_4_4'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Home Address<span class='gfield_required'>*<\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_4_4' >\n                         <span class='ginput_full address_line_1' id='input_4_4_1_container' >\n                                        <input type='text' name='input_4.1' id='input_4_4_1' value=''    aria-required=\"true\"\/>\n                                        <label for='input_4_4_1' id='input_4_4_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2' id='input_4_4_2_container' >\n                                        <input type='text' name='input_4.2' id='input_4_4_2' value=''   \/>\n                                        <label for='input_4_4_2' id='input_4_4_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_4_4_3_container' >\n                                    <input type='text' name='input_4.3' id='input_4_4_3' value=''    aria-required=\"true\"\/>\n                                    <label for='input_4_4_3' id='input_4_4_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state' id='input_4_4_4_container' >\n                                        <select name='input_4.4' id='input_4_4_4'     aria-required=\"true\"><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='British Columbia' >British Columbia<\/option><option value='Manitoba' >Manitoba<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Newfoundland and Labrador' >Newfoundland and Labrador<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' selected='selected'>Ontario<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Quebec' >Quebec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_4_4_4' id='input_4_4_4_label' >Province<\/label>\n                                      <\/span><span class='ginput_left address_zip' id='input_4_4_5_container' >\n                                    <input type='text' name='input_4.5' id='input_4_4_5' value=''    aria-required=\"true\"\/>\n                                    <label for='input_4_4_5' id='input_4_4_5_label' >Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_4_4_6' value='Canada'\/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id='field_4_5'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_5' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_4_5' type='text' value='' class='medium'     aria-invalid=\"false\" aria-describedby=\"gfield_description_4_5\"\/>\n                        <\/div><div class='gfield_description' id='gfield_description_4_5'>if available<\/div><\/li><li id='field_4_6'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_6' >Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_4_6' type='text' value='' class='medium'    aria-invalid=\"false\" aria-describedby=\"gfield_description_4_6\" \/><\/div><div class='gfield_description' id='gfield_description_4_6'>if available<\/div><\/li><li id='field_4_51'  class='gfield gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Does the child identify as First Nations, Inuit, or M\u00e9tis?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_51'><li class='gchoice_4_51_0'><input name='input_51' type='radio' value='Yes'  id='choice_4_51_0'    \/><label for='choice_4_51_0' id='label_4_51_0'>Yes<\/label><\/li><li class='gchoice_4_51_1'><input name='input_51' type='radio' value='No'  id='choice_4_51_1'    \/><label for='choice_4_51_1' id='label_4_51_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_4_7'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_7' >Patient Diagnosis and location of appointment (I.e. London, SicKKids)<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_7' id='input_4_7' class='textarea medium'  aria-describedby=\"gfield_description_4_7\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_4_7'>Medical diagnosis as well as location of medical appointment (I.e. SickKids, CHEO)<\/div><\/li><li id='field_4_8'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Caregiver Information<\/h2><\/li><li id='field_4_9'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Name<span class='gfield_required'>*<\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name' id='input_4_9'>\n                            \n                            <span id='input_4_9_3_container' class='name_first' >\n                                                    <input type='text' name='input_9.3' id='input_4_9_3' value='' aria-label='First name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_4_9_3' >First<\/label>\n                                                <\/span>\n                            <span id='input_4_9_4_container' class='name_middle' >\n                                                    <input type='text' name='input_9.4' id='input_4_9_4' value='' aria-label='Middle name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_4_9_4' >Middle<\/label>\n                                                <\/span>\n                            <span id='input_4_9_6_container' class='name_last' >\n                                                    <input type='text' name='input_9.6' id='input_4_9_6' value='' aria-label='Last name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_4_9_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id='field_4_10'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_10' >Relationship to Child<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_4_10' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_11'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Date of Birth<span class='gfield_required'>*<\/span><\/label><div id='input_4_11' class='ginput_container ginput_container_date'><div class='clear-multi'><div class='gfield_date_month ginput_container ginput_container_date' id='input_4_11_1_container'>\n                                            <input type='text' maxlength='2' name='input_11[]' id='input_4_11_1' value=''    \/>\n                                            <label for='input_4_11_1' >MM<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date' id='input_4_11_2_container'>\n                                            <input type='text' maxlength='2' name='input_11[]' id='input_4_11_2' value=''    \/>\n                                            <label for='input_4_11_2' >DD<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date' id='input_4_11_3_container'>\n                                            <input type='text' maxlength='4' name='input_11[]' id='input_4_11_3' value=''      \/>\n                                            <label for='input_4_11_3' >YYYY<\/label>\n                                       <\/div>\n                                   <\/div><\/div><\/li><li id='field_4_12'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Address<span class='gfield_required'>*<\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_4_12' >\n                         <span class='ginput_full address_line_1' id='input_4_12_1_container' >\n                                        <input type='text' name='input_12.1' id='input_4_12_1' value=''    aria-required=\"true\"\/>\n                                        <label for='input_4_12_1' id='input_4_12_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2' id='input_4_12_2_container' >\n                                        <input type='text' name='input_12.2' id='input_4_12_2' value=''   \/>\n                                        <label for='input_4_12_2' id='input_4_12_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_4_12_3_container' >\n                                    <input type='text' name='input_12.3' id='input_4_12_3' value=''    aria-required=\"true\"\/>\n                                    <label for='input_4_12_3' id='input_4_12_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state' id='input_4_12_4_container' >\n                                        <select name='input_12.4' id='input_4_12_4'     aria-required=\"true\"><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='British Columbia' >British Columbia<\/option><option value='Manitoba' >Manitoba<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Newfoundland and Labrador' >Newfoundland and Labrador<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' selected='selected'>Ontario<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Quebec' >Quebec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_4_12_4' id='input_4_12_4_label' >Province<\/label>\n                                      <\/span><span class='ginput_left address_zip' id='input_4_12_5_container' >\n                                    <input type='text' name='input_12.5' id='input_4_12_5' value=''    aria-required=\"true\"\/>\n                                    <label for='input_4_12_5' id='input_4_12_5_label' >Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_12.6' id='input_4_12_6' value='Canada'\/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id='field_4_13'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_13' >Phone<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_13' id='input_4_13' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id='field_4_14'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_14' >Email<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_14' id='input_4_14' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" \/>\n                        <\/div><\/li><li id='field_4_15'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_15' >Language Preference<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_4_15' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_16'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >How do you prefer we contact you?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_16'><li class='gchoice_4_16_1'>\n\t\t\t\t\t\t\t\t<input name='input_16.1' type='checkbox'  value='Phone'  id='choice_4_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_16_1' id='label_4_16_1'>Phone<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_4_16_2'>\n\t\t\t\t\t\t\t\t<input name='input_16.2' type='checkbox'  value='Email'  id='choice_4_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_16_2' id='label_4_16_2'>Email<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_4_17'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Other Family Members<\/h2><div class='gsection_description' id='gfield_description_4_17'>separate multiple entries by pressing enter.<\/div><\/li><li id='field_4_18'  class='gfield gf_left_third field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_18' >Names<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_18' id='input_4_18' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_4_19'  class='gfield gf_middle_third field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_19' >Date of Birth<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_19' id='input_4_19' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_4_20'  class='gfield gf_right_third field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_20' >Relationship to Child<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_20' id='input_4_20' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_4_21'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_21' >Household Income<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_21' id='input_4_21' class='medium gfield_select'   aria-required=\"true\" aria-invalid=\"false\"><option value='$0-$20,000' >$0-$20,000<\/option><option value='$20,001-$40,000' >$20,001-$40,000<\/option><option value='$40,001-$60,000' >$40,001-$60,000<\/option><option value='$60,001-$80,000' >$60,001-$80,000<\/option><option value='$80,001-$100,000' >$80,001-$100,000<\/option><option value='$100,001-$120,000' >$100,001-$120,000<\/option><option value='$120,001-$140,000' >$120,001-$140,000<\/option><option value='$140,001-$160,000' >$140,001-$160,000<\/option><option value='$160,001-$180,000' >$160,001-$180,000<\/option><option value='$180,001+' >$180,001+<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_4_21'>For statistical purposes, please indicate your total household income.<\/div><\/li><li id='field_4_22'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Appointment Information<\/h2><\/li><li id='field_4_23'  class='gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Date of medical appointment<span class='gfield_required'>*<\/span><\/label><div id='input_4_23' class='ginput_container ginput_container_date'><div class='clear-multi'><div class='gfield_date_month ginput_container ginput_container_date' id='input_4_23_1_container'>\n                                            <input type='text' maxlength='2' name='input_23[]' id='input_4_23_1' value=''    \/>\n                                            <label for='input_4_23_1' >MM<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date' id='input_4_23_2_container'>\n                                            <input type='text' maxlength='2' name='input_23[]' id='input_4_23_2' value=''    \/>\n                                            <label for='input_4_23_2' >DD<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date' id='input_4_23_3_container'>\n                                            <input type='text' maxlength='4' name='input_23[]' id='input_4_23_3' value=''      \/>\n                                            <label for='input_4_23_3' >YYYY<\/label>\n                                       <\/div>\n                                   <\/div><\/div><\/li><li id='field_4_24'  class='gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Time of medical appointment<span class='gfield_required'>*<\/span><\/label><div class='clear-multi'>\n                        <div class='gfield_time_hour ginput_container ginput_container_time' id='input_4_24'>\n                            <input type='text' maxlength='2' name='input_24[]' id='input_4_24_1' value=''    \/> <i>:<\/i>\n                            <label for='input_4_24_1' >HH<\/label>\n                        <\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time'>\n                            <input type='text' maxlength='2' name='input_24[]' id='input_4_24_2' value=''    \/>\n                            <label for='input_4_24_2' >MM<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time' >\n                                \n                                <select name='input_24[]' id='input_4_24_3'   aria-label='AM\/PM'>\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select>\n                           <\/div>\n                    <\/div><\/li><li id='field_4_53'  class='gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Date you plan to leave for appointment<span class='gfield_required'>*<\/span><\/label><div id='input_4_53' class='ginput_container ginput_container_date'><div class='clear-multi'><div class='gfield_date_month ginput_container ginput_container_date' id='input_4_53_1_container'>\n                                            <input type='text' maxlength='2' name='input_53[]' id='input_4_53_1' value=''    \/>\n                                            <label for='input_4_53_1' >MM<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date' id='input_4_53_2_container'>\n                                            <input type='text' maxlength='2' name='input_53[]' id='input_4_53_2' value=''    \/>\n                                            <label for='input_4_53_2' >DD<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date' id='input_4_53_3_container'>\n                                            <input type='text' maxlength='4' name='input_53[]' id='input_4_53_3' value=''      \/>\n                                            <label for='input_4_53_3' >YYYY<\/label>\n                                       <\/div>\n                                   <\/div><\/div><\/li><li id='field_4_54'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Date you plan to return from appointment (if known)<\/label><div id='input_4_54' class='ginput_container ginput_container_date'><div class='clear-multi'><div class='gfield_date_month ginput_container ginput_container_date' id='input_4_54_1_container'>\n                                            <input type='text' maxlength='2' name='input_54[]' id='input_4_54_1' value=''    \/>\n                                            <label for='input_4_54_1' >MM<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date' id='input_4_54_2_container'>\n                                            <input type='text' maxlength='2' name='input_54[]' id='input_4_54_2' value=''    \/>\n                                            <label for='input_4_54_2' >DD<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date' id='input_4_54_3_container'>\n                                            <input type='text' maxlength='4' name='input_54[]' id='input_4_54_3' value=''      \/>\n                                            <label for='input_4_54_3' >YYYY<\/label>\n                                       <\/div>\n                                   <\/div><\/div><\/li><li id='field_4_25'  class='gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_25' >Doctor who referred you to medical appointment<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_4_25' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_26'  class='gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_26' >Referral doctor phone number<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_26' id='input_4_26' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id='field_4_27'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_27' >Is your trip for more than one day?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_27' id='input_4_27' class='medium gfield_select'   aria-required=\"true\" aria-invalid=\"false\"><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/div><\/li><li id='field_4_28'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_28' >If yes, how many days?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_28' id='input_4_28' type='text'    value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_29'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_29' >If yes, where do you plan on staying?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_4_29' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_30'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_30' >Do you require anyone else to travel with you for this medical appointment?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_30' id='input_4_30' class='medium gfield_select'   aria-required=\"true\" aria-invalid=\"false\"><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/div><\/li><li id='field_4_31'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_31' >If yes, please identify the name(s) of the individuals and their relationship to the patient<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_4_31' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_4_55'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_55' >How do you plan to get to your appointment? I.e. Drive, fly, rental car, ambulance<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_55' id='input_4_55' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_4_32'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Financial Assistance<\/h2><\/li><li id='field_4_33'  class='gfield gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Have you previously received assistance from The Twinkie Foundation?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_33'><li class='gchoice_4_33_0'><input name='input_33' type='radio' value='Yes'  id='choice_4_33_0'    \/><label for='choice_4_33_0' id='label_4_33_0'>Yes<\/label><\/li><li class='gchoice_4_33_1'><input name='input_33' type='radio' value='No'  id='choice_4_33_1'    \/><label for='choice_4_33_1' id='label_4_33_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_4_47'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'><\/h2><div class='gsection_description' id='gfield_description_4_47'>Are you receiving any other form of financial assistance for this medical trip from:<\/div><\/li><li id='field_4_46'  class='gfield gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Algoma Family Services<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_46'><li class='gchoice_4_46_0'><input name='input_46' type='radio' value='Yes'  id='choice_4_46_0'    \/><label for='choice_4_46_0' id='label_4_46_0'>Yes<\/label><\/li><li class='gchoice_4_46_1'><input name='input_46' type='radio' value='No'  id='choice_4_46_1'    \/><label for='choice_4_46_1' id='label_4_46_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_4_45'  class='gfield gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >POGO<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_45'><li class='gchoice_4_45_0'><input name='input_45' type='radio' value='Yes'  id='choice_4_45_0'    \/><label for='choice_4_45_0' id='label_4_45_0'>Yes<\/label><\/li><li class='gchoice_4_45_1'><input name='input_45' type='radio' value='No'  id='choice_4_45_1'    \/><label for='choice_4_45_1' id='label_4_45_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_4_44'  class='gfield gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Northern Ontario Travel Grant<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_44'><li class='gchoice_4_44_0'><input name='input_44' type='radio' value='Yes'  id='choice_4_44_0'    \/><label for='choice_4_44_0' id='label_4_44_0'>Yes<\/label><\/li><li class='gchoice_4_44_1'><input name='input_44' type='radio' value='No'  id='choice_4_44_1'    \/><label for='choice_4_44_1' id='label_4_44_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_4_43'  class='gfield gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Hope Air<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_43'><li class='gchoice_4_43_0'><input name='input_43' type='radio' value='Yes'  id='choice_4_43_0'    \/><label for='choice_4_43_0' id='label_4_43_0'>Yes<\/label><\/li><li class='gchoice_4_43_1'><input name='input_43' type='radio' value='No'  id='choice_4_43_1'    \/><label for='choice_4_43_1' id='label_4_43_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_4_42'  class='gfield gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Ontario Works<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_42'><li class='gchoice_4_42_0'><input name='input_42' type='radio' value='Yes'  id='choice_4_42_0'    \/><label for='choice_4_42_0' id='label_4_42_0'>Yes<\/label><\/li><li class='gchoice_4_42_1'><input name='input_42' type='radio' value='No'  id='choice_4_42_1'    \/><label for='choice_4_42_1' id='label_4_42_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_4_41'  class='gfield gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Northern Ontario Families of Children with Cancer<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_41'><li class='gchoice_4_41_0'><input name='input_41' type='radio' value='Yes'  id='choice_4_41_0'    \/><label for='choice_4_41_0' id='label_4_41_0'>Yes<\/label><\/li><li class='gchoice_4_41_1'><input name='input_41' type='radio' value='No'  id='choice_4_41_1'    \/><label for='choice_4_41_1' id='label_4_41_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_4_40'  class='gfield gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Assistance for Children with Severe Disabilities (ACSD)<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_40'><li class='gchoice_4_40_0'><input name='input_40' type='radio' value='Yes'  id='choice_4_40_0'    \/><label for='choice_4_40_0' id='label_4_40_0'>Yes<\/label><\/li><li class='gchoice_4_40_1'><input name='input_40' type='radio' value='No'  id='choice_4_40_1'    \/><label for='choice_4_40_1' id='label_4_40_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_4_39'  class='gfield gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Sault Ste. Marie Firefighters Association<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_39'><li class='gchoice_4_39_0'><input name='input_39' type='radio' value='Yes'  id='choice_4_39_0'    \/><label for='choice_4_39_0' id='label_4_39_0'>Yes<\/label><\/li><li class='gchoice_4_39_1'><input name='input_39' type='radio' value='No'  id='choice_4_39_1'    \/><label for='choice_4_39_1' id='label_4_39_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_4_38'  class='gfield gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >United Way- Community Assistance Trust<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_38'><li class='gchoice_4_38_0'><input name='input_38' type='radio' value='Yes'  id='choice_4_38_0'    \/><label for='choice_4_38_0' id='label_4_38_0'>Yes<\/label><\/li><li class='gchoice_4_38_1'><input name='input_38' type='radio' value='No'  id='choice_4_38_1'    \/><label for='choice_4_38_1' id='label_4_38_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_4_37'  class='gfield gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Easter Seals<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_37'><li class='gchoice_4_37_0'><input name='input_37' type='radio' value='Yes'  id='choice_4_37_0'    \/><label for='choice_4_37_0' id='label_4_37_0'>Yes<\/label><\/li><li class='gchoice_4_37_1'><input name='input_37' type='radio' value='No'  id='choice_4_37_1'    \/><label for='choice_4_37_1' id='label_4_37_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_4_36'  class='gfield gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Children&#039;s Aid Society<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_36'><li class='gchoice_4_36_0'><input name='input_36' type='radio' value='Yes'  id='choice_4_36_0'    \/><label for='choice_4_36_0' id='label_4_36_0'>Yes<\/label><\/li><li class='gchoice_4_36_1'><input name='input_36' type='radio' value='No'  id='choice_4_36_1'    \/><label for='choice_4_36_1' id='label_4_36_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_4_35'  class='gfield gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Community Living Algoma<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_35'><li class='gchoice_4_35_0'><input name='input_35' type='radio' value='Yes'  id='choice_4_35_0'    \/><label for='choice_4_35_0' id='label_4_35_0'>Yes<\/label><\/li><li class='gchoice_4_35_1'><input name='input_35' type='radio' value='No'  id='choice_4_35_1'    \/><label for='choice_4_35_1' id='label_4_35_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_4_34'  class='gfield gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Other (please identify)<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_34'><li class='gchoice_4_34_0'><input name='input_34' type='radio' value='Yes'  id='choice_4_34_0'    \/><label for='choice_4_34_0' id='label_4_34_0'>Yes<\/label><\/li><li class='gchoice_4_34_1'><input name='input_34' type='radio' value='No'  id='choice_4_34_1'    \/><label for='choice_4_34_1' id='label_4_34_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_4_48'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_48' >Please identify<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_4_48' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_49'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Completion<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_49'><li class='gchoice_4_49_1'>\n\t\t\t\t\t\t\t\t<input name='input_49.1' type='checkbox'  value='I confirm that the information provided to you in this application is complete and accurate'  id='choice_4_49_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_1' id='label_4_49_1'>I confirm that the information provided to you in this application is complete and accurate<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_4_49_2'>\n\t\t\t\t\t\t\t\t<input name='input_49.2' type='checkbox'  value='I understand and I am aware that The Twinkie Foundation may contact the doctor(s) from the information I provided to confirm the medical appointment'  id='choice_4_49_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_2' id='label_4_49_2'>I understand and I am aware that The Twinkie Foundation may contact the doctor(s) from the information I provided to confirm the medical appointment<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_4_49_3'>\n\t\t\t\t\t\t\t\t<input name='input_49.3' type='checkbox'  value='I understand that this application does not guarantee financial assistance from The Twinkie Foundation as all applications are reviewed on an individual basis and depend on funding availability'  id='choice_4_49_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_3' id='label_4_49_3'>I understand that this application does not guarantee financial assistance from The Twinkie Foundation as all applications are reviewed on an individual basis and depend on funding availability<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_4_49_4'>\n\t\t\t\t\t\t\t\t<input name='input_49.4' type='checkbox'  value='I understand that a member of The Twinkie Foundation may contact me to obtain household financial information and that I consent to provide them with this information'  id='choice_4_49_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_4' id='label_4_49_4'>I understand that a member of The Twinkie Foundation may contact me to obtain household financial information and that I consent to provide them with this information<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_4_50'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_50' ><\/label><div id='input_4_50' class='ginput_container ginput_recaptcha' data-sitekey='6Ld4xaQZAAAAALTmbQwECRfWIAGqSPKp1-uV37s7'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/li>\n                            <\/ul><\/div>\n        <div class='gform_footer left_label'> <input type='submit' id='gform_submit_button_4' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_4\"]){return false;}  window[\"gf_submitting_4\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_4\"]){return false;} window[\"gf_submitting_4\"]=true;  jQuery(\"#gform_4\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_4' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='4' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_4' value='WyJbXSIsIjY4MzdiYzIzMGEzZjUzOGRiNzgzYzM3NDJiNWI4ZjY4Il0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_4' id='gform_target_page_number_4' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_4' id='gform_source_page_number_4' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div><script type='text\/javascript'> jQuery(document).bind('gform_post_render', function(event, formId, currentPage){if(formId == 4) {jQuery(\"#field_4_49 .gfield_checkbox input:checkbox\").checkboxLimit(4);gf_global[\"number_formats\"][4] = {\"1\":{\"price\":false,\"value\":false},\"2\":{\"price\":false,\"value\":false},\"3\":{\"price\":false,\"value\":false},\"4\":{\"price\":false,\"value\":false},\"5\":{\"price\":false,\"value\":false},\"6\":{\"price\":false,\"value\":false},\"51\":{\"price\":false,\"value\":false},\"7\":{\"price\":false,\"value\":false},\"8\":{\"price\":false,\"value\":false},\"9\":{\"price\":false,\"value\":false},\"10\":{\"price\":false,\"value\":false},\"11\":{\"price\":false,\"value\":false},\"12\":{\"price\":false,\"value\":false},\"13\":{\"price\":false,\"value\":false},\"14\":{\"price\":false,\"value\":false},\"15\":{\"price\":false,\"value\":false},\"16\":{\"price\":false,\"value\":false},\"17\":{\"price\":false,\"value\":false},\"18\":{\"price\":false,\"value\":false},\"19\":{\"price\":false,\"value\":false},\"20\":{\"price\":false,\"value\":false},\"21\":{\"price\":false,\"value\":false},\"22\":{\"price\":false,\"value\":false},\"23\":{\"price\":false,\"value\":false},\"24\":{\"price\":false,\"value\":false},\"53\":{\"price\":false,\"value\":false},\"54\":{\"price\":false,\"value\":false},\"25\":{\"price\":false,\"value\":false},\"26\":{\"price\":false,\"value\":false},\"27\":{\"price\":false,\"value\":false},\"28\":{\"price\":false,\"value\":\"decimal_dot\"},\"29\":{\"price\":false,\"value\":false},\"30\":{\"price\":false,\"value\":false},\"31\":{\"price\":false,\"value\":false},\"55\":{\"price\":false,\"value\":false},\"32\":{\"price\":false,\"value\":false},\"33\":{\"price\":false,\"value\":false},\"47\":{\"price\":false,\"value\":false},\"46\":{\"price\":false,\"value\":false},\"45\":{\"price\":false,\"value\":false},\"44\":{\"price\":false,\"value\":false},\"43\":{\"price\":false,\"value\":false},\"42\":{\"price\":false,\"value\":false},\"41\":{\"price\":false,\"value\":false},\"40\":{\"price\":false,\"value\":false},\"39\":{\"price\":false,\"value\":false},\"38\":{\"price\":false,\"value\":false},\"37\":{\"price\":false,\"value\":false},\"36\":{\"price\":false,\"value\":false},\"35\":{\"price\":false,\"value\":false},\"34\":{\"price\":false,\"value\":false},\"48\":{\"price\":false,\"value\":false},\"49\":{\"price\":false,\"value\":false},\"50\":{\"price\":false,\"value\":false}};if(window['jQuery']){if(!window['gf_form_conditional_logic'])window['gf_form_conditional_logic'] = new Array();window['gf_form_conditional_logic'][4] = { logic: { 28: {\"field\":{\"actionType\":\"show\",\"logicType\":\"all\",\"rules\":[{\"fieldId\":\"27\",\"operator\":\"is\",\"value\":\"Yes\"}]},\"nextButton\":null,\"section\":\"\"},29: {\"field\":{\"actionType\":\"show\",\"logicType\":\"all\",\"rules\":[{\"fieldId\":\"27\",\"operator\":\"is\",\"value\":\"Yes\"}]},\"nextButton\":null,\"section\":\"\"},31: {\"field\":{\"actionType\":\"show\",\"logicType\":\"all\",\"rules\":[{\"fieldId\":\"30\",\"operator\":\"is\",\"value\":\"Yes\"}]},\"nextButton\":null,\"section\":\"\"},55: {\"field\":{\"actionType\":\"show\",\"logicType\":\"all\",\"rules\":[{\"fieldId\":\"30\",\"operator\":\"is\",\"value\":\"Yes\"}]},\"nextButton\":null,\"section\":\"\"},48: {\"field\":{\"actionType\":\"show\",\"logicType\":\"all\",\"rules\":[{\"fieldId\":\"34\",\"operator\":\"is\",\"value\":\"Yes\"}]},\"nextButton\":null,\"section\":\"\"} }, dependents: { 28: [28],29: [29],31: [31],55: [55],48: [48] }, animation: 1, defaults: {\"2\":{\"2.2\":\"\",\"2.3\":\"\",\"2.4\":\"\",\"2.6\":\"\",\"2.8\":\"\"},\"3\":{\"m\":\"\",\"d\":\"\",\"y\":\"\"},\"4\":{\"4.1\":\"\",\"4.2\":\"\",\"4.3\":\"\",\"4.4\":\"Ontario\",\"4.5\":\"\",\"4.6\":\"Canada\"},\"9\":{\"9.2\":\"\",\"9.3\":\"\",\"9.4\":\"\",\"9.6\":\"\",\"9.8\":\"\"},\"11\":{\"m\":\"\",\"d\":\"\",\"y\":\"\"},\"12\":{\"12.1\":\"\",\"12.2\":\"\",\"12.3\":\"\",\"12.4\":\"Ontario\",\"12.5\":\"\",\"12.6\":\"Canada\"},\"23\":{\"m\":\"\",\"d\":\"\",\"y\":\"\"},\"24\":{\"24.1\":\"\",\"24.2\":\"\",\"24.3\":\"\"},\"53\":{\"m\":\"\",\"d\":\"\",\"y\":\"\"},\"54\":{\"m\":\"\",\"d\":\"\",\"y\":\"\"}}, fields: {\"1\":[],\"2\":[],\"3\":[],\"4\":[],\"5\":[],\"6\":[],\"51\":[],\"7\":[],\"8\":[],\"9\":[],\"10\":[],\"11\":[],\"12\":[],\"13\":[],\"14\":[],\"15\":[],\"16\":[],\"17\":[],\"18\":[],\"19\":[],\"20\":[],\"21\":[],\"22\":[],\"23\":[],\"24\":[],\"53\":[],\"54\":[],\"25\":[],\"26\":[],\"27\":[28,29],\"28\":[],\"29\":[],\"30\":[31,55],\"31\":[],\"55\":[],\"32\":[],\"33\":[],\"47\":[],\"46\":[],\"45\":[],\"44\":[],\"43\":[],\"42\":[],\"41\":[],\"40\":[],\"39\":[],\"38\":[],\"37\":[],\"36\":[],\"35\":[],\"34\":[48],\"48\":[],\"49\":[],\"50\":[]} }; if(!window['gf_number_format'])window['gf_number_format'] = 'decimal_dot';jQuery(document).ready(function(){gf_apply_rules(4, [28,29,31,55,48], true);jQuery('#gform_wrapper_4').show();jQuery(document).trigger('gform_post_conditional_logic', [4, null, true]);} );} jQuery('#input_4_6').mask('(999) 999-9999').bind('keypress', function(e){if(e.which == 13){jQuery(this).blur();} } );jQuery('#input_4_13').mask('(999) 999-9999').bind('keypress', function(e){if(e.which == 13){jQuery(this).blur();} } );jQuery('#input_4_26').mask('(999) 999-9999').bind('keypress', function(e){if(e.which == 13){jQuery(this).blur();} } );} } );jQuery(document).bind('gform_post_conditional_logic', function(event, formId, fields, isInit){} );<\/script><script type='text\/javascript'> jQuery(document).ready(function(){jQuery(document).trigger('gform_post_render', [4, 1]) } ); <\/script>\n<p>[\/et_pb_text][et_pb_text admin_label=&#8221;Text&#8221; _builder_version=&#8221;4.16&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; use_border_color=&#8221;off&#8221; border_color=&#8221;#ffffff&#8221; border_style=&#8221;solid&#8221; global_colors_info=&#8221;{}&#8221;]The Twinkie Foundation is committed to protecting\u00a0the privacy of personal information. Personal information obtained in the application and subsequent proceedings\u00a0will not be collected, used or disclosed except in compliance\u00a0with the governing legislation.<\/p>\n<p>We are committed to maintaining the accuracy, confidentiality, and security of all\u00a0personal information provided to us.<\/p>\n<p><a href=\"https:\/\/thetwinkiefoundation.ca\/hello\/privacy-policy\/\">Please click HERE for our complete Privacy Policy<\/a><br \/>\n[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Note: Financial assistance may vary based on the circumstances of the patient appointment and the availability of The Foundation funds at the time the request is received. Please complete one application per medical appointment. Qualifying criteria to receive funding from The Twinkie Foundation: 1. You must be a resident of Sault Ste. Marie, Ontario or [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":""},"class_list":["post-3396","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v21.4 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Application - The Twinkie Foundation<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/thetwinkiefoundation.ca\/hello\/application\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Application - The Twinkie Foundation\" \/>\n<meta property=\"og:description\" content=\"Note: Financial assistance may vary based on the circumstances of the patient appointment and the availability of The Foundation funds at the time the request is received. Please complete one application per medical appointment. Qualifying criteria to receive funding from The Twinkie Foundation: 1. You must be a resident of Sault Ste. Marie, Ontario or [&hellip;]\" \/>\n<meta property=\"og:url\" content=\"https:\/\/thetwinkiefoundation.ca\/hello\/application\/\" \/>\n<meta property=\"og:site_name\" content=\"The Twinkie Foundation\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/The-Twinkie-Foundation-101229243754921\/\" \/>\n<meta property=\"article:modified_time\" content=\"2026-01-11T12:27:19+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/thetwinkiefoundation.ca\/hello\/wp-content\/uploads\/2017\/04\/the_twinkie_foundation.png\" \/>\n\t<meta property=\"og:image:width\" content=\"1200\" \/>\n\t<meta property=\"og:image:height\" content=\"572\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/png\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"2 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/thetwinkiefoundation.ca\/hello\/application\/\",\"url\":\"https:\/\/thetwinkiefoundation.ca\/hello\/application\/\",\"name\":\"Application - The Twinkie Foundation\",\"isPartOf\":{\"@id\":\"https:\/\/thetwinkiefoundation.ca\/hello\/#website\"},\"datePublished\":\"2017-04-05T19:59:58+00:00\",\"dateModified\":\"2026-01-11T12:27:19+00:00\",\"breadcrumb\":{\"@id\":\"https:\/\/thetwinkiefoundation.ca\/hello\/application\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/thetwinkiefoundation.ca\/hello\/application\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/thetwinkiefoundation.ca\/hello\/application\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\/\/thetwinkiefoundation.ca\/hello\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Application\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\/\/thetwinkiefoundation.ca\/hello\/#website\",\"url\":\"https:\/\/thetwinkiefoundation.ca\/hello\/\",\"name\":\"The Twinkie Foundation\",\"description\":\"\",\"publisher\":{\"@id\":\"https:\/\/thetwinkiefoundation.ca\/hello\/#organization\"},\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\/\/thetwinkiefoundation.ca\/hello\/?s={search_term_string}\"},\"query-input\":\"required name=search_term_string\"}],\"inLanguage\":\"en-US\"},{\"@type\":\"Organization\",\"@id\":\"https:\/\/thetwinkiefoundation.ca\/hello\/#organization\",\"name\":\"The Twinkie Foundation\",\"url\":\"https:\/\/thetwinkiefoundation.ca\/hello\/\",\"logo\":{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\/\/thetwinkiefoundation.ca\/hello\/#\/schema\/logo\/image\/\",\"url\":\"https:\/\/thetwinkiefoundation.ca\/hello\/wp-content\/uploads\/2017\/04\/the_twinkie_foundation.png\",\"contentUrl\":\"https:\/\/thetwinkiefoundation.ca\/hello\/wp-content\/uploads\/2017\/04\/the_twinkie_foundation.png\",\"width\":1200,\"height\":572,\"caption\":\"The Twinkie Foundation\"},\"image\":{\"@id\":\"https:\/\/thetwinkiefoundation.ca\/hello\/#\/schema\/logo\/image\/\"},\"sameAs\":[\"https:\/\/www.facebook.com\/The-Twinkie-Foundation-101229243754921\/\",\"https:\/\/www.instagram.com\/twinkiefoundation\/\"]}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Application - The Twinkie Foundation","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/thetwinkiefoundation.ca\/hello\/application\/","og_locale":"en_US","og_type":"article","og_title":"Application - The Twinkie Foundation","og_description":"Note: Financial assistance may vary based on the circumstances of the patient appointment and the availability of The Foundation funds at the time the request is received. Please complete one application per medical appointment. Qualifying criteria to receive funding from The Twinkie Foundation: 1. You must be a resident of Sault Ste. Marie, Ontario or [&hellip;]","og_url":"https:\/\/thetwinkiefoundation.ca\/hello\/application\/","og_site_name":"The Twinkie Foundation","article_publisher":"https:\/\/www.facebook.com\/The-Twinkie-Foundation-101229243754921\/","article_modified_time":"2026-01-11T12:27:19+00:00","og_image":[{"width":1200,"height":572,"url":"https:\/\/thetwinkiefoundation.ca\/hello\/wp-content\/uploads\/2017\/04\/the_twinkie_foundation.png","type":"image\/png"}],"twitter_card":"summary_large_image","twitter_misc":{"Est. reading time":"2 minutes"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/thetwinkiefoundation.ca\/hello\/application\/","url":"https:\/\/thetwinkiefoundation.ca\/hello\/application\/","name":"Application - The Twinkie Foundation","isPartOf":{"@id":"https:\/\/thetwinkiefoundation.ca\/hello\/#website"},"datePublished":"2017-04-05T19:59:58+00:00","dateModified":"2026-01-11T12:27:19+00:00","breadcrumb":{"@id":"https:\/\/thetwinkiefoundation.ca\/hello\/application\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/thetwinkiefoundation.ca\/hello\/application\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/thetwinkiefoundation.ca\/hello\/application\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/thetwinkiefoundation.ca\/hello\/"},{"@type":"ListItem","position":2,"name":"Application"}]},{"@type":"WebSite","@id":"https:\/\/thetwinkiefoundation.ca\/hello\/#website","url":"https:\/\/thetwinkiefoundation.ca\/hello\/","name":"The Twinkie Foundation","description":"","publisher":{"@id":"https:\/\/thetwinkiefoundation.ca\/hello\/#organization"},"potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/thetwinkiefoundation.ca\/hello\/?s={search_term_string}"},"query-input":"required name=search_term_string"}],"inLanguage":"en-US"},{"@type":"Organization","@id":"https:\/\/thetwinkiefoundation.ca\/hello\/#organization","name":"The Twinkie Foundation","url":"https:\/\/thetwinkiefoundation.ca\/hello\/","logo":{"@type":"ImageObject","inLanguage":"en-US","@id":"https:\/\/thetwinkiefoundation.ca\/hello\/#\/schema\/logo\/image\/","url":"https:\/\/thetwinkiefoundation.ca\/hello\/wp-content\/uploads\/2017\/04\/the_twinkie_foundation.png","contentUrl":"https:\/\/thetwinkiefoundation.ca\/hello\/wp-content\/uploads\/2017\/04\/the_twinkie_foundation.png","width":1200,"height":572,"caption":"The Twinkie Foundation"},"image":{"@id":"https:\/\/thetwinkiefoundation.ca\/hello\/#\/schema\/logo\/image\/"},"sameAs":["https:\/\/www.facebook.com\/The-Twinkie-Foundation-101229243754921\/","https:\/\/www.instagram.com\/twinkiefoundation\/"]}]}},"_links":{"self":[{"href":"https:\/\/thetwinkiefoundation.ca\/hello\/wp-json\/wp\/v2\/pages\/3396","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/thetwinkiefoundation.ca\/hello\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/thetwinkiefoundation.ca\/hello\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/thetwinkiefoundation.ca\/hello\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/thetwinkiefoundation.ca\/hello\/wp-json\/wp\/v2\/comments?post=3396"}],"version-history":[{"count":11,"href":"https:\/\/thetwinkiefoundation.ca\/hello\/wp-json\/wp\/v2\/pages\/3396\/revisions"}],"predecessor-version":[{"id":4516,"href":"https:\/\/thetwinkiefoundation.ca\/hello\/wp-json\/wp\/v2\/pages\/3396\/revisions\/4516"}],"wp:attachment":[{"href":"https:\/\/thetwinkiefoundation.ca\/hello\/wp-json\/wp\/v2\/media?parent=3396"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}