{"id":54618,"date":"2025-10-10T13:42:08","date_gmt":"2025-10-10T17:42:08","guid":{"rendered":"https:\/\/www.hancockhealth.org\/?page_id=54618"},"modified":"2025-10-10T13:42:09","modified_gmt":"2025-10-10T17:42:09","slug":"healthy-community-award-nomination","status":"publish","type":"page","link":"https:\/\/www.hancockhealth.org\/de\/healthy-community-award-nomination\/","title":{"rendered":"Healthy Community Award Nomination"},"content":{"rendered":"<div class=\"container mx-auto   wordpress-block wordpress-dable\/simple-form core-simple-form\"><div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_85_container\" data-token=\"5eb24bb89f583d3830a16ee15024e366\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_foundationhealthycommunityaward\" data-token=\"5eb24bb89f583d3830a16ee15024e366\">\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Foundation Health Community Award<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"85\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_85\" id=\"frm_hide_fields_85\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"foundationhealthycommunityaward\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_85\" name=\"frm_submit_entry_85\" value=\"a835431f31\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/de\/wp-json\/wp\/v2\/pages\/54618\" \/><div id=\"frm_field_1624_container\" class=\"frm_form_field  frm_html_container form-field\"><\/div>\n<div id=\"frm_field_1625_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">HEALTHY COMMUNITY AWARDS<\/h3>\r\n\r\n\r\n<\/div>\n<div id=\"frm_field_1605_container\" class=\"frm_form_field  frm_first frm_third frm_html_container form-field\">\n<pre><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-40983 aligncenter\" src=\"https:\/\/www.hancockhealth.org\/wp-content\/uploads\/2024\/09\/Hancock-Health-Foundation-logo-color-300x57.png\" alt=\"\" width=\"206\" height=\"39\" srcset=\"https:\/\/www.hancockhealth.org\/wp-content\/uploads\/2024\/09\/Hancock-Health-Foundation-logo-color-300x57.png 300w, https:\/\/www.hancockhealth.org\/wp-content\/uploads\/2024\/09\/Hancock-Health-Foundation-logo-color-1024x193.png 1024w, https:\/\/www.hancockhealth.org\/wp-content\/uploads\/2024\/09\/Hancock-Health-Foundation-logo-color-768x145.png 768w, https:\/\/www.hancockhealth.org\/wp-content\/uploads\/2024\/09\/Hancock-Health-Foundation-logo-color-1536x290.png 1536w, https:\/\/www.hancockhealth.org\/wp-content\/uploads\/2024\/09\/Hancock-Health-Foundation-logo-color.png 1935w\" sizes=\"auto, (max-width: 206px) 100vw, 206px\" \/><\/pre>\n<\/div>\n<div id=\"frm_field_1622_container\" class=\"frm_form_field  frm_two_thirds frm_html_container form-field\"><\/div>\n<div id=\"frm_field_1606_container\" class=\"frm_form_field  frm12 frm_html_container form-field\">\n<p>Each year, the Hancock Health Foundation recognizes a local organization and individual whose service efforts have created positive change in the health and wellness of our local communities. The recipients will be notified and announced publicly before the end of the year.<\/p>\n<p><strong>Bert Curry Healthy Community Award- <\/strong>Named in honor of the Hancock Health Foundation\u2019s first Executive Director, this award recognizes an <u>individual <\/u>who has demonstrated a commitment to helping others and improving health and wellness in our community.<\/p>\n<p><strong>Bobby Keen Healthy Community Award- <\/strong>Named in honor of the former HRH President &#038; CEO, this award recognizes a <u>hospital program or local organization<\/u> that has made a significant and positive impact on the health and wellness of our community.<\/p>\n<p><strong>Selection <\/strong>\u2013 The Foundation\u2019s Awards &#038; Scholarships Committee will receive nominations and annually select at least one recipient to receive each award.<\/p>\n<p>Below you will find a nomination form. Please feel free to contact Allyson Smith with any questions or concerns at 317-468-4106 or email <a href=\"mailto:asmith@hancockhealth.org\">asmith@hancockhealth.org<\/a>.<\/p>\n<p><strong><em>Nominations are due by November 21<sup>st<\/sup> at 4pm. <\/em><\/strong><\/p>\n<\/div>\n<div id=\"frm_field_1628_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Healthy Community Award Nomination Form<\/h3>\r\n\r\n\r\n<\/div>\n<div id=\"frm_field_1609_container\" class=\"frm_form_field  frm12 frm_html_container form-field\">The Hancock Health Foundation is currently accepting nominations for the Bobby Keen Healthy Community Award and the Bert Curry Healthy Community Award. The award is presented annually to a local organization and an individual, respectively, for their exemplary and innovative service effort to create positive change in the health and wellness of our community. If you would like to nominate an organization or individual for consideration, please submit the following nomination form. \u00a0\u00a0You may submit additional documentation to support your nomination<\/p>\n<p><strong><em>The Awards &#038; Scholarships Committee will make their decision solely on the information provided in this application and will not consider any prior knowledge they have of the nominee.<\/em><\/strong><\/p>\n<p><strong>Nominations are due by November 21<sup>st<\/sup> <\/strong><\/div>\n<div id=\"frm_field_1630_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n\t<div  id=\"field_nfwbc_label\" class=\"frm_primary_label\">Are You Nominating an Individual for the Bert Curry Healthy Community Award?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_nfwbc_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1630-0\">\t\t\t<label  for=\"field_nfwbc-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[1630][]\" id=\"field_nfwbc-0\" value=\"Yes\"  data-invmsg=\"Are You Nominating an Individual for the Bert Curry Healthy Community Award? is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1630-1\">\t\t\t<label  for=\"field_nfwbc-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[1630][]\" id=\"field_nfwbc-1\" value=\"No\"  data-invmsg=\"Are You Nominating an Individual for the Bert Curry Healthy Community Award? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1631_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<div  id=\"field_ocwqz_label\" class=\"frm_primary_label\">If Yes, please provide the name of the individual you are nominating:\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_ocwqz_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tIf Yes, please provide the name of the individual you are nominating:\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_1631\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_1631-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_ocwqz_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tFirst Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_ocwqz_first\" value=\"\" name=\"item_meta[1631][first]\" autocomplete=\"given-name\" data-invmsg=\"If Yes, please provide the name of the individual you are nominating: ist ung\u00fcltig\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_1631_first_desc\">First Name<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_1631-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_ocwqz_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tLast Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_ocwqz_last\" value=\"\" name=\"item_meta[1631][last]\" autocomplete=\"family-name\" data-invmsg=\"If Yes, please provide the name of the individual you are nominating: ist ung\u00fcltig\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_1631_last_desc\">Last Name<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1632_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n\t<div  id=\"field_3uhuv_label\" class=\"frm_primary_label\">Are You Nominating an organization or group for the Bobby Keen Healthy Community Award?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_3uhuv_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1632-0\">\t\t\t<label  for=\"field_3uhuv-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[1632][]\" id=\"field_3uhuv-0\" value=\"Yes\"  data-invmsg=\"Are You Nominating an organization or group for the Bobby Keen Healthy Community Award? is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1632-1\">\t\t\t<label  for=\"field_3uhuv-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[1632][]\" id=\"field_3uhuv-1\" value=\"No\"  data-invmsg=\"Are You Nominating an organization or group for the Bobby Keen Healthy Community Award? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1634_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_wx34q\" id=\"field_wx34q_label\" class=\"frm_primary_label\">If Yes, please provide the name of the organization or group you are nominating:\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_wx34q\" name=\"item_meta[1634]\" value=\"\"  data-invmsg=\"If Yes, please provide the name of the organization or group you are nominating: is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1635_container\" class=\"frm_form_field form-field  frm_top_container frm12 frm_first\">\r\n\t<label for=\"field_i8tkt\" id=\"field_i8tkt_label\" class=\"frm_primary_label\">1.\tTell us about the individual or organization you are nominating. How long have they been in our community? What is their mission or the focus of their work? \r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[1635]\" id=\"field_i8tkt\" rows=\"5\"  data-invmsg=\"1.\tTell us about the individual or organization you are nominating. How long have they been in our community? What is their mission or the focus of their work?  is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1636_container\" class=\"frm_form_field form-field  frm_top_container frm12 frm_first\">\r\n\t<label for=\"field_gbvsy\" id=\"field_gbvsy_label\" class=\"frm_primary_label\">2.\tPlease provide specific details about the impact this individual or organization has had on the health of our community (eg volunteer hours served, number of people helped) \r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[1636]\" id=\"field_gbvsy\" rows=\"5\"  data-invmsg=\"2.\tPlease provide specific details about the impact this individual or organization has had on the health of our community (eg volunteer hours served, number of people helped)  is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1638_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_7u35m\" id=\"field_7u35m_label\" class=\"frm_primary_label\">3.\tHow does this individual or organization go above and beyond to be innovative and create positive change?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[1638]\" id=\"field_7u35m\" rows=\"5\"  data-invmsg=\"3.\tHow does this individual or organization go above and beyond to be innovative and create positive change? is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1639_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_atuw2\" id=\"field_atuw2_label\" class=\"frm_primary_label\">4.\tPlease share any other information that will be helpful for us to know. \r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[1639]\" id=\"field_atuw2\" rows=\"5\"  data-invmsg=\"4.\tPlease share any other information that will be helpful for us to know.  is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1647_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\"><\/h3>\r\n\r\n\r\n<\/div>\n<div id=\"frm_field_1646_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h6>Please provide your contact information in case we need to reach out to you:<\/h6>\n<\/div>\n<div id=\"frm_field_1640_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<div  id=\"field_vqgzy_label\" class=\"frm_primary_label\">Your Name:\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_vqgzy_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tYour Name:\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_1640\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_1640-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_vqgzy_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tFirst Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_vqgzy_first\" value=\"\" name=\"item_meta[1640][first]\" data-invmsg=\"Your Name: ist ung\u00fcltig\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_1640_first_desc\">First Name<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_1640-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_vqgzy_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tLast Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_vqgzy_last\" value=\"\" name=\"item_meta[1640][last]\" data-invmsg=\"Your Name: ist ung\u00fcltig\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_1640_last_desc\">Last Name<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1641_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<div  id=\"field_ervpo_label\" class=\"frm_primary_label\">Address\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_ervpo_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tAddress<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_1641-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_ervpo_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress\t<\/label>\n\t\t<input type=\"text\" id=\"field_ervpo_line1\" value=\"\" name=\"item_meta[1641][line1]\"  data-invmsg=\"Address ist ung\u00fcltig\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_1641-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_ervpo_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress\t<\/label>\n\t\t<input type=\"text\" id=\"field_ervpo_line2\" value=\"\" name=\"item_meta[1641][line2]\"  data-invmsg=\"Address ist ung\u00fcltig\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_1641-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_ervpo_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_ervpo_city\" value=\"\" name=\"item_meta[1641][city]\"  data-invmsg=\"Address ist ung\u00fcltig\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_1641-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_ervpo_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\t<\/label>\n\t\t\t<select name=\"item_meta[1641][state]\" id=\"field_ervpo_state\"  data-invmsg=\"Address ist ung\u00fcltig\" aria-invalid=\"false\"   autocomplete=\"address-level1\">\n\t\t\t<option value=\"\" class=\"\">\n\t\t\t\t \t\t\t<\/option>\n\t\t\t<option  value=\"Alabama\">Alabama<\/option><option  value=\"Alaska\">Alaska<\/option><option  value=\"Arkansas\">Arkansas<\/option><option  value=\"Arizona\">Arizona<\/option><option  value=\"California\">California<\/option><option  value=\"Colorado\">Colorado<\/option><option  value=\"Connecticut\">Connecticut<\/option><option  value=\"Delaware\">Delaware<\/option><option  value=\"District of Columbia\">District of Columbia<\/option><option  value=\"Florida\">Florida<\/option><option  value=\"Georgia\">Georgia<\/option><option  value=\"Hawaii\">Hawaii<\/option><option  value=\"Idaho\">Idaho<\/option><option  value=\"Illinois\">Illinois<\/option><option  value=\"Indiana\">Indiana<\/option><option  value=\"Iowa\">Iowa<\/option><option  value=\"Kansas\">Kansas<\/option><option  value=\"Kentucky\">Kentucky<\/option><option  value=\"Louisiana\">Louisiana<\/option><option  value=\"Maine\">Maine<\/option><option  value=\"Maryland\">Maryland<\/option><option  value=\"Massachusetts\">Massachusetts<\/option><option  value=\"Michigan\">Michigan<\/option><option  value=\"Minnesota\">Minnesota<\/option><option  value=\"Mississippi\">Mississippi<\/option><option  value=\"Missouri\">Missouri<\/option><option  value=\"Montana\">Montana<\/option><option  value=\"Nebraska\">Nebraska<\/option><option  value=\"Nevada\">Nevada<\/option><option  value=\"New Hampshire\">New Hampshire<\/option><option  value=\"New Jersey\">New Jersey<\/option><option  value=\"New Mexico\">New Mexico<\/option><option  value=\"New York\">New York<\/option><option  value=\"North Carolina\">North Carolina<\/option><option  value=\"North Dakota\">North Dakota<\/option><option  value=\"Ohio\">Ohio<\/option><option  value=\"Oklahoma\">Oklahoma<\/option><option  value=\"Oregon\">Oregon<\/option><option  value=\"Pennsylvania\">Pennsylvania<\/option><option  value=\"Rhode Island\">Rhode Island<\/option><option  value=\"South Carolina\">South Carolina<\/option><option  value=\"South Dakota\">South Dakota<\/option><option  value=\"Tennessee\">Tennessee<\/option><option  value=\"Texas\">Texas<\/option><option  value=\"Utah\">Utah<\/option><option  value=\"Vermont\">Vermont<\/option><option  value=\"Virginia\">Virginia<\/option><option  value=\"Washington\">Washington<\/option><option  value=\"West Virginia\">West Virginia<\/option><option  value=\"Wisconsin\">Wisconsin<\/option><option  value=\"Wyoming\">Wyoming<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">State\/Province<\/div><\/div>\n<div id=\"frm_field_1641-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_ervpo_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_ervpo_zip\" value=\"\" name=\"item_meta[1641][zip]\"  data-invmsg=\"Address ist ung\u00fcltig\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal<\/div><\/div>\n<div id=\"frm_field_1641-state_abbreviation_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_ervpo_state_abbreviation\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress\t<\/label>\n\t\t<input type=\"hidden\" id=\"field_ervpo_state_abbreviation\" value=\"\" name=\"item_meta[1641][state_abbreviation]\"  data-invmsg=\"Address ist ung\u00fcltig\" class=\"frm_optional\" aria-invalid=\"false\"   \/>\n\t<\/div>\n<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1643_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_e58zp\" id=\"field_e58zp_label\" class=\"frm_primary_label\">Email\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"email\" id=\"field_e58zp\" name=\"item_meta[1643]\" value=\"\"  autocomplete=\"email\"  data-invmsg=\"Email is invalid\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1642_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_fo5z0\" id=\"field_fo5z0_label\" class=\"frm_primary_label\">Phone\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_fo5z0\" name=\"item_meta[1642]\" value=\"\"  data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1619_container\" class=\"frm_form_field form-field  frm12 frm_first\">\r\n\t<div 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