{"id":31397,"date":"2023-02-23T15:27:34","date_gmt":"2023-02-23T20:27:34","guid":{"rendered":"https:\/\/www.vayahealth.com\/?page_id=31397"},"modified":"2025-09-25T10:38:47","modified_gmt":"2025-09-25T14:38:47","slug":"ltss-mac-membership-application","status":"publish","type":"page","link":"https:\/\/www.vayahealth.com\/es\/about\/committees\/ltss-mac\/ltss-mac-membership-application\/","title":{"rendered":"Solicitud de adhesi\u00f3n a LTSS MAC"},"content":{"rendered":"<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 gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_28' ><form method='post' enctype='multipart\/form-data'  id='gform_28'  action='\/es\/wp-json\/wp\/v2\/pages\/31397' data-formid='28' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_28' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_28_24\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Thank you for your interest in joining the Vaya Health Long-Term Services and Supports (LTSS) Member Advisory Committee. Vaya will maintain applicant confidentiality in accordance with federal and state law.<\/p>\n<p>If you have questions about the committee or this application, please contact Vaya\u2019s Member Engagement Team at <a href=\"mailto:member.engagement@vayahealth.com\" target=\"_blank\">member.engagement@vayahealth.com<\/a> or call <a href=\"tel:1-800-893-6246\" target=\"_blank\">1-800-893-6246<\/a>, ext. 4401.<\/p><\/div><div id=\"field_28_28\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">General Information<\/h3><\/div><div id=\"field_28_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_28_1'>Date Application Submitted<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_28_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_28_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_28_3'>Full Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_28_3' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_28_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_28_4'>Home Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_28_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_28_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_28_5'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_28_5' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_28_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_28_6'>State<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_28_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_28_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_28_7'>ZIP Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_28_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_28_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_28_8'>Home Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_28_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_28_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_28_9'>Work Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_28_9' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_28_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_28_10'>Fax Number<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_28_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_28_15\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_28_15'>Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_15' id='input_28_15' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_28_12\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Membership Requirements:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_28_12'><div class='gchoice gchoice_28_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='Members accessing LTSS'  id='choice_28_12_1'   aria-describedby=\"gfield_description_28_12\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_28_12_1' id='label_28_12_1' class='gform-field-label gform-field-label--type-inline'>Members accessing LTSS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='Representatives of members accessing LTSS (e.g., authorized representatives)'  id='choice_28_12_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_12_2' id='label_28_12_2' class='gform-field-label gform-field-label--type-inline'>Representatives of members accessing LTSS (e.g., authorized representatives)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_12_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.3' type='checkbox'  value='LTSS providers'  id='choice_28_12_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_12_3' id='label_28_12_3' class='gform-field-label gform-field-label--type-inline'>LTSS providers<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_12_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.4' type='checkbox'  value='Care managers from Advanced Medical Home Plus practices and Care Management Agencies serving members with LTSS needs'  id='choice_28_12_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_12_4' id='label_28_12_4' class='gform-field-label gform-field-label--type-inline'>Care managers from Advanced Medical Home Plus practices and Care Management Agencies serving members with LTSS needs<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_12_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.5' type='checkbox'  value='Vaya staff involved in LTSS authorization or care management of members receiving LTSS'  id='choice_28_12_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_12_5' id='label_28_12_5' class='gform-field-label gform-field-label--type-inline'>Vaya staff involved in LTSS authorization or care management of members receiving LTSS<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_28_12'>The LTSS Member Advisory Committee is required to reflect the LTSS populations (or their representatives) served by Vaya and includes up to five committee members in each of the following categories. Please check the category or categories that describe you.<\/div><\/fieldset><div id=\"field_28_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_28_13'>Organization Name and Job Title<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_28_13' type='text' value='' class='large'  aria-describedby=\"gfield_description_28_13\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_28_13'>If you are an LTSS provider, care manager, or Vaya staff member, provide your organization name and job title.<\/div><\/div><div id=\"field_28_31\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Demographic Information<\/h3><\/div><fieldset id=\"field_28_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >County Represented<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_28_16'><div class='gchoice gchoice_28_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Alamance'  id='choice_28_16_1'   aria-describedby=\"gfield_description_28_16\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_1' id='label_28_16_1' class='gform-field-label gform-field-label--type-inline'>Alamance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Alexander'  id='choice_28_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_2' id='label_28_16_2' class='gform-field-label gform-field-label--type-inline'>Alexander<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Alleghany'  id='choice_28_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_3' id='label_28_16_3' class='gform-field-label gform-field-label--type-inline'>Alleghany<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='Ashe'  id='choice_28_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_4' id='label_28_16_4' class='gform-field-label gform-field-label--type-inline'>Ashe<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.5' type='checkbox'  value='Avery'  id='choice_28_16_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_5' id='label_28_16_5' class='gform-field-label gform-field-label--type-inline'>Avery<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.6' type='checkbox'  value='Buncombe'  id='choice_28_16_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_6' id='label_28_16_6' class='gform-field-label gform-field-label--type-inline'>Buncombe<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.7' type='checkbox'  value='Caldwell'  id='choice_28_16_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_7' id='label_28_16_7' class='gform-field-label gform-field-label--type-inline'>Caldwell<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.8' type='checkbox'  value='Caswell'  id='choice_28_16_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_8' id='label_28_16_8' class='gform-field-label gform-field-label--type-inline'>Caswell<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.9' type='checkbox'  value='Chatham'  id='choice_28_16_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_9' id='label_28_16_9' class='gform-field-label gform-field-label--type-inline'>Chatham<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.11' type='checkbox'  value='Cherokee'  id='choice_28_16_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_11' id='label_28_16_11' class='gform-field-label gform-field-label--type-inline'>Cherokee<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.12' type='checkbox'  value='Clay'  id='choice_28_16_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_12' id='label_28_16_12' class='gform-field-label gform-field-label--type-inline'>Clay<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.13' type='checkbox'  value='Franklin'  id='choice_28_16_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_13' id='label_28_16_13' class='gform-field-label gform-field-label--type-inline'>Franklin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.14' type='checkbox'  value='Graham'  id='choice_28_16_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_14' id='label_28_16_14' class='gform-field-label gform-field-label--type-inline'>Graham<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.15' type='checkbox'  value='Granville'  id='choice_28_16_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_15' id='label_28_16_15' class='gform-field-label gform-field-label--type-inline'>Granville<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.16' type='checkbox'  value='Haywood'  id='choice_28_16_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_16' id='label_28_16_16' class='gform-field-label gform-field-label--type-inline'>Haywood<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.17' type='checkbox'  value='Henderson'  id='choice_28_16_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_17' id='label_28_16_17' class='gform-field-label gform-field-label--type-inline'>Henderson<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.18' type='checkbox'  value='Jackson'  id='choice_28_16_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_18' id='label_28_16_18' class='gform-field-label gform-field-label--type-inline'>Jackson<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.19' type='checkbox'  value='Macon'  id='choice_28_16_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_19' id='label_28_16_19' class='gform-field-label gform-field-label--type-inline'>Macon<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.21' type='checkbox'  value='Madison'  id='choice_28_16_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_21' id='label_28_16_21' class='gform-field-label gform-field-label--type-inline'>Madison<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.22' type='checkbox'  value='McDowell'  id='choice_28_16_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_22' id='label_28_16_22' class='gform-field-label gform-field-label--type-inline'>McDowell<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.23' type='checkbox'  value='Mitchell'  id='choice_28_16_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_23' id='label_28_16_23' class='gform-field-label gform-field-label--type-inline'>Mitchell<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.24' type='checkbox'  value='Person'  id='choice_28_16_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_24' id='label_28_16_24' class='gform-field-label gform-field-label--type-inline'>Person<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.25' type='checkbox'  value='Polk'  id='choice_28_16_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_25' id='label_28_16_25' class='gform-field-label gform-field-label--type-inline'>Polk<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.26' type='checkbox'  value='Rockingham'  id='choice_28_16_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_26' id='label_28_16_26' class='gform-field-label gform-field-label--type-inline'>Rockingham<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.27' type='checkbox'  value='Rowan'  id='choice_28_16_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_27' id='label_28_16_27' class='gform-field-label gform-field-label--type-inline'>Rowan<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.28' type='checkbox'  value='Swain'  id='choice_28_16_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_28' id='label_28_16_28' class='gform-field-label gform-field-label--type-inline'>Swain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.29' type='checkbox'  value='Stokes'  id='choice_28_16_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_29' id='label_28_16_29' class='gform-field-label gform-field-label--type-inline'>Stokes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.31' type='checkbox'  value='Transylvania'  id='choice_28_16_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_31' id='label_28_16_31' class='gform-field-label gform-field-label--type-inline'>Transylvania<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.32' type='checkbox'  value='Vance'  id='choice_28_16_32'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_32' id='label_28_16_32' class='gform-field-label gform-field-label--type-inline'>Vance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.33' type='checkbox'  value='Watauga'  id='choice_28_16_33'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_33' id='label_28_16_33' class='gform-field-label gform-field-label--type-inline'>Watauga<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.34' type='checkbox'  value='Wilkes'  id='choice_28_16_34'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_34' id='label_28_16_34' class='gform-field-label gform-field-label--type-inline'>Wilkes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_16_35'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.35' type='checkbox'  value='Yancey'  id='choice_28_16_35'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_16_35' id='label_28_16_35' class='gform-field-label gform-field-label--type-inline'>Yancey<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_28_16'>Please select one option. <\/div><\/fieldset><div id=\"field_28_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_28_32'>Gender<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_28_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_28_17\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Race\/Ethnicity<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_28_17'><div class='gchoice gchoice_28_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='American Indian or Alaska Native'  id='choice_28_17_1'   aria-describedby=\"gfield_description_28_17\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_28_17_1' id='label_28_17_1' class='gform-field-label gform-field-label--type-inline'>American Indian or Alaska Native<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='Asian'  id='choice_28_17_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_17_2' id='label_28_17_2' class='gform-field-label gform-field-label--type-inline'>Asian<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_17_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.3' type='checkbox'  value='Black or African American'  id='choice_28_17_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_17_3' id='label_28_17_3' class='gform-field-label gform-field-label--type-inline'>Black or African American<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_17_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.4' type='checkbox'  value='Hispanic or Latino'  id='choice_28_17_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_17_4' id='label_28_17_4' class='gform-field-label gform-field-label--type-inline'>Hispanic or Latino<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_17_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.5' type='checkbox'  value='Middle Eastern or North African'  id='choice_28_17_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_17_5' id='label_28_17_5' class='gform-field-label gform-field-label--type-inline'>Middle Eastern or North African<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_17_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.6' type='checkbox'  value='Native Hawaiian or Pacific Islander'  id='choice_28_17_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_17_6' id='label_28_17_6' class='gform-field-label gform-field-label--type-inline'>Native Hawaiian or Pacific Islander<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_17_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.7' type='checkbox'  value='White'  id='choice_28_17_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_17_7' id='label_28_17_7' class='gform-field-label gform-field-label--type-inline'>White<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_17_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.8' type='checkbox'  value='Some other race'  id='choice_28_17_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_17_8' id='label_28_17_8' class='gform-field-label gform-field-label--type-inline'>Some other race<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_17_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.9' type='checkbox'  value='Prefer not to share'  id='choice_28_17_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_17_9' id='label_28_17_9' class='gform-field-label gform-field-label--type-inline'>Prefer not to share<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_28_17'>Check all options that apply. <\/div><\/fieldset><div id=\"field_28_33\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Additional Information<\/h3><\/div><fieldset id=\"field_28_18\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I am willing to have my name placed on the LTSS Member Advisory Committee member list.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_28_18'><div class='gchoice gchoice_28_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='Yes'  id='choice_28_18_1'   aria-describedby=\"gfield_description_28_18\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_28_18_1' id='label_28_18_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='No'  id='choice_28_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_18_2' id='label_28_18_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_28_18'>Responsibilities: Membership on the LTSS Member Advisory Committee requires a moderate level of commitment of time and energy. Participation involves attending quarterly meetings and occasional subcommittee meetings. No special knowledge or training is required to serve on the committee, just a desire to improve the system. Additional reading on topics related to LTSS is required. Vaya will provide this material.<\/div><\/fieldset><fieldset id=\"field_28_19\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I am committed to partnering with Vaya to ensure high-quality services for all Vaya members who use LTSS.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_28_19'><div class='gchoice gchoice_28_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='Yes'  id='choice_28_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_19_1' id='label_28_19_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='No'  id='choice_28_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_19_2' id='label_28_19_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_28_20\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I am committed to attending quarterly LTSS Member Advisory Committee meetings lasting two to three hours.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_28_20'><div class='gchoice gchoice_28_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='Yes'  id='choice_28_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_20_1' id='label_28_20_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='No'  id='choice_28_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_20_2' id='label_28_20_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_28_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I am committed to reading materials that are provided.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_28_21'><div class='gchoice gchoice_28_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Yes'  id='choice_28_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_21_1' id='label_28_21_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='No'  id='choice_28_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_21_2' id='label_28_21_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_28_22\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >If applicable, I understand that my participation in public activities of the LTSS Member Advisory Committee may identify me as a Vaya member or a relative of a Vaya member who uses LTSS.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_28_22'><div class='gchoice gchoice_28_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='Yes'  id='choice_28_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_22_1' id='label_28_22_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_28_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value='No'  id='choice_28_22_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_22_2' id='label_28_22_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_28_23\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_28_23'>Please share your reasons for wanting to join the LTSS Member Advisory Committee:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_23' id='input_28_23' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_28_27\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_28_27'>CAPTCHA<\/label><div id='input_28_27' class='ginput_container ginput_recaptcha' data-sitekey='6LdbNt4ZAAAAALtDtrYGtdh7ZMYycSQYCFlrgCAZ'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_28' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' 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