{"id":2962,"date":"2018-07-18T15:39:55","date_gmt":"2018-07-18T19:39:55","guid":{"rendered":"https:\/\/www.med.unc.edu\/healthsciences\/?page_id=2962"},"modified":"2020-02-05T15:53:00","modified_gmt":"2020-02-05T20:53:00","slug":"ahec-request-form","status":"publish","type":"page","link":"https:\/\/www.med.unc.edu\/healthsciences\/outreach\/ahec\/ahec-request-form\/","title":{"rendered":"AHEC Course Request Form"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\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\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_2' >\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">AHEC Course Request Form<\/h3>\n                            <p class='gform_description'>The \"Form Type\" field will default to the division offering the course you have selected. If you wish to request a course from another division, please return to the Allied Health Hot Topics Page, click on the name of that division, and follow the link for that division\u2019s form.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/healthsciences\/wp-json\/wp\/v2\/pages\/2962\/' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_2_1\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_1'>Form Type<\/label><div class='ginput_container ginput_container_select'><select name='input_1' id='input_2_1' class='medium gfield_select'     aria-invalid=\"false\" ><option value='AHEC Course Request Form' >AHEC Course Request Form<\/option><\/select><\/div><\/li><li id=\"field_2_2\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_2'>CASCE#<\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_2_2' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_3\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_3'>Event #<\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_2_3' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_4\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon 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_2_4'>Date of Request<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input aria-describedby='field_2_4_dmessage' name='input_4' id='input_2_4' type='text' value='' class='datepicker gform-datepicker ymd_slash datepicker_with_icon gdatepicker_with_icon'   placeholder='yyyy\/mm\/dd' aria-describedby=\"input_2_4_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_4_date_format' class='screen-reader-text'>YYYY slash MM slash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_4' class='gform_hidden' value='https:\/\/www.med.unc.edu\/healthsciences\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_5\" class=\"gfield gfield--type-select 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_2_5'>AHEC Region<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_5' id='input_2_5' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Area L' >Area L<\/option><option value='Charlotte' >Charlotte<\/option><option value='Eastern' >Eastern<\/option><option value='Greensboro' >Greensboro<\/option><option value='Mountain' >Mountain<\/option><option value='Northwest' >Northwest<\/option><option value='Southeast' >Southeast<\/option><option value='Southern Regional' >Southern Regional<\/option><option value='Wake' >Wake<\/option><\/select><\/div><\/li><li id=\"field_2_6\" class=\"gfield gfield--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_2_6'>Contact Person<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_2_6' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_7\" class=\"gfield gfield--type-phone 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_2_7'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_2_7' type='tel' value='' class='small'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_8\" class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_8'>Email Address<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_8' id='input_2_8' type='email' value='' class='small'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_9\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Target Audience<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_9'>Choose all that apply<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_9'><li class='gchoice gchoice_2_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Audiologists'  id='choice_2_9_1'   aria-describedby=\"gfield_description_2_9\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_1' id='label_2_9_1' class='gform-field-label gform-field-label--type-inline'>Audiologists<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='Medical Technologists'  id='choice_2_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_2' id='label_2_9_2' class='gform-field-label gform-field-label--type-inline'>Medical Technologists<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='Nuclear Medicine Technologists'  id='choice_2_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_3' id='label_2_9_3' class='gform-field-label gform-field-label--type-inline'>Nuclear Medicine Technologists<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.4' type='checkbox'  value='Occupational Therapists'  id='choice_2_9_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_4' id='label_2_9_4' class='gform-field-label gform-field-label--type-inline'>Occupational Therapists<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.5' type='checkbox'  value='Physical Therapists'  id='choice_2_9_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_5' id='label_2_9_5' class='gform-field-label gform-field-label--type-inline'>Physical Therapists<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.6' type='checkbox'  value='Radiologic Technologists'  id='choice_2_9_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_6' id='label_2_9_6' class='gform-field-label gform-field-label--type-inline'>Radiologic Technologists<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.7' type='checkbox'  value='Radiation Therapy Technologists'  id='choice_2_9_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_7' id='label_2_9_7' class='gform-field-label gform-field-label--type-inline'>Radiation Therapy Technologists<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.8' type='checkbox'  value='Rehabilitation Counselors'  id='choice_2_9_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_8' id='label_2_9_8' class='gform-field-label gform-field-label--type-inline'>Rehabilitation Counselors<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.9' type='checkbox'  value='Speech Language Pathologists'  id='choice_2_9_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_9' id='label_2_9_9' class='gform-field-label gform-field-label--type-inline'>Speech Language Pathologists<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.11' type='checkbox'  value='Ultrasonographers'  id='choice_2_9_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_11' id='label_2_9_11' class='gform-field-label gform-field-label--type-inline'>Ultrasonographers<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.12' type='checkbox'  value='Ultrasonographers'  id='choice_2_9_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_12' id='label_2_9_12' class='gform-field-label gform-field-label--type-inline'>Ultrasonographers<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_2_10\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_10'>If Other, Please List<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_2_10' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_11\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_11'>Anticipated Number of Participants<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_2_11' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_13\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_13'>Minimum Number Of Participants Required (if applicable)<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_2_13' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_14\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_14'>Maximum Number Of Participants Required (if applicable)<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_2_14' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_15\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_15'>Objectives<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_15'>Please describe what you need this course to provide or accomplish.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_15' id='input_2_15' class='textarea medium'  aria-describedby=\"gfield_description_2_15\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_16\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_16'>Location Of Course<\/label><div class='gfield_description' id='gfield_description_2_16'>Please provide full address, including zip code and suite\/office\/room number if applicable.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_16' id='input_2_16' class='textarea medium'  aria-describedby=\"gfield_description_2_16\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_17\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_17'>Tentative Date (First Choice)<\/label><div class='ginput_container ginput_container_date'>\n                            <input aria-describedby='field_2_17_dmessage' name='input_17' id='input_2_17' type='text' value='' class='datepicker gform-datepicker ymd_slash datepicker_with_icon gdatepicker_with_icon'   placeholder='yyyy\/mm\/dd' aria-describedby=\"input_2_17_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_17_date_format' class='screen-reader-text'>YYYY slash MM slash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_17' class='gform_hidden' value='https:\/\/www.med.unc.edu\/healthsciences\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_18\" class=\"gfield gfield--type-time field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Tentative Time (First Choice)<\/label><div class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"clear-multi\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_2_18'>\n                            <input type='number' name='input_18[]' id='input_2_18_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='false'   \/> <i>:<\/i>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_2_18_1'>Hours<\/label>\n                        <\/div>\n                        \n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_18[]' id='input_2_18_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_2_18_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <label for='input_2_18_3' class='sr-only' >AM\/PM<\/label><select name='input_18[]' id='input_2_18_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_2_18_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/div><\/fieldset><\/li><li id=\"field_2_20\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_20'>Tentative Date (Second Choice)<\/label><div class='ginput_container ginput_container_date'>\n                            <input aria-describedby='field_2_20_dmessage' name='input_20' id='input_2_20' type='text' value='' class='datepicker gform-datepicker ymd_slash datepicker_with_icon gdatepicker_with_icon'   placeholder='yyyy\/mm\/dd' aria-describedby=\"input_2_20_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_20_date_format' class='screen-reader-text'>YYYY slash MM slash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_20' class='gform_hidden' value='https:\/\/www.med.unc.edu\/healthsciences\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_22\" class=\"gfield gfield--type-time field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Tentative Time (Second Choice)<\/label><div class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"clear-multi\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_2_22'>\n                            <input type='number' name='input_22[]' id='input_2_22_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='false'   \/> <i>:<\/i>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_2_22_1'>Hours<\/label>\n                        <\/div>\n                        \n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_22[]' id='input_2_22_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_2_22_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <label for='input_2_22_3' class='sr-only' >AM\/PM<\/label><select name='input_22[]' id='input_2_22_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_2_22_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/div><\/fieldset><\/li><li id=\"field_2_19\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_19'>Tentative Date (Third Choice)<\/label><div class='ginput_container ginput_container_date'>\n                            <input aria-describedby='field_2_19_dmessage' name='input_19' id='input_2_19' type='text' value='' class='datepicker gform-datepicker ymd_slash datepicker_with_icon gdatepicker_with_icon'   placeholder='yyyy\/mm\/dd' aria-describedby=\"input_2_19_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_19_date_format' class='screen-reader-text'>YYYY slash MM slash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_19' class='gform_hidden' value='https:\/\/www.med.unc.edu\/healthsciences\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_21\" class=\"gfield gfield--type-time field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Tentative Time (Third Choice)<\/label><div class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"clear-multi\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_2_21'>\n                            <input type='number' name='input_21[]' id='input_2_21_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='false'   \/> <i>:<\/i>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_2_21_1'>Hours<\/label>\n                        <\/div>\n                        \n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_21[]' id='input_2_21_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_2_21_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <label for='input_2_21_3' class='sr-only' >AM\/PM<\/label><select name='input_21[]' id='input_2_21_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_2_21_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/div><\/fieldset><\/li><li id=\"field_2_23\" class=\"gfield gfield--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_2_23'>Length Of Course\/Program In Hours<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_2_23' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_24\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Decide which presentation style you prefer (Live or Webinar) and choose one topic from that style\u2019s drop down list. Leave the other set on &quot;Not Selected.&quot;<\/h2><\/li><li id=\"field_2_25\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_25'>Live Presentation<\/label><div class='ginput_container ginput_container_select'><select name='input_25' id='input_2_25' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Not Selected' >Not Selected<\/option><option value='Lower Quarter Assessment (Gross)' >Lower Quarter Assessment (Gross)<\/option><option value='Measuring What Matters: Outcome Measures for TBI (McCulloch)' >Measuring What Matters: Outcome Measures for TBI (McCulloch)<\/option><option value='Mild Brain Injury\/Concussion (including wounded warriors)\u2013PT Practice Implications (McCulloch)' >Mild Brain Injury\/Concussion (including wounded warriors)\u2013PT Practice Implications (McCulloch)<\/option><option value='Mild to Moderate Brain Injury: Vestibular and Balance Manifestations (McCulloch)' >Mild to Moderate Brain Injury: Vestibular and Balance Manifestations (McCulloch)<\/option><option value='Parkinson\u2019s Disease: New Perspectives from Clinical Research (Mercer)' >Parkinson\u2019s Disease: New Perspectives from Clinical Research (Mercer)<\/option><option value='Recovery of Postural Control Following Mild to Moderate Stroke (Mercer)' >Recovery of Postural Control Following Mild to Moderate Stroke (Mercer)<\/option><option value='Tests and Measures for Adults with Neuromuscular Disorders (Mercer)' >Tests and Measures for Adults with Neuromuscular Disorders (Mercer)<\/option><option value='School-Based PT (Ray)' >School-Based PT (Ray)<\/option><option value='Medicaid Cost Recovery in Public Schools (Ray)' >Medicaid Cost Recovery in Public Schools (Ray)<\/option><\/select><\/div><\/li><li id=\"field_2_27\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_27'>Webinar Presentation<\/label><div class='ginput_container ginput_container_select'><select name='input_27' id='input_2_27' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Not Selected' >Not Selected<\/option><option value='Lower Quarter Assessment (Gross)' >Lower Quarter Assessment (Gross)<\/option><option value='Measuring What Matters: Outcome Measures for TBI (McCulloch)' >Measuring What Matters: Outcome Measures for TBI (McCulloch)<\/option><option value='Mild Brain Injury\/Concussion (including wounded warriors)\u2013PT Practice Implications (McCulloch)' >Mild Brain Injury\/Concussion (including wounded warriors)\u2013PT Practice Implications (McCulloch)<\/option><option value='Mild to Moderate Brain Injury: Vestibular and Balance Manifestations (McCulloch)' >Mild to Moderate Brain Injury: Vestibular and Balance Manifestations (McCulloch)<\/option><option value='School-Based PT (Ray)' >School-Based PT (Ray)<\/option><option value='Medicaid Cost Recovery in Public Schools (Ray)' >Medicaid Cost Recovery in Public Schools (Ray)<\/option><\/select><\/div><\/li><li id=\"field_2_28\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Would You Be Open To Alternative Presentation Style For This Topic?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_28'>\n\t\t\t<li class='gchoice gchoice_2_28_0'>\n\t\t\t\t<input name='input_28' type='radio' value='Yes'  id='choice_2_28_0'    \/>\n\t\t\t\t<label for='choice_2_28_0' id='label_2_28_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_28_1'>\n\t\t\t\t<input name='input_28' type='radio' value='No'  id='choice_2_28_1'    \/>\n\t\t\t\t<label for='choice_2_28_1' id='label_2_28_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_2_29\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >If Yes, Please Indicate Which Style You Would Consider<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_29'><li class='gchoice gchoice_2_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Live'  id='choice_2_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_1' id='label_2_29_1' class='gform-field-label gform-field-label--type-inline'>Live<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='Teleconference'  id='choice_2_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_2' id='label_2_29_2' class='gform-field-label gform-field-label--type-inline'>Teleconference<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_29_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.3' type='checkbox'  value='Webinar'  id='choice_2_29_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_3' id='label_2_29_3' class='gform-field-label gform-field-label--type-inline'>Webinar<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_2_30\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Will Lunch\/Dinner Be Provided For Presenter?<\/label><div class='gfield_description' id='gfield_description_2_30'>(for live presentation only)<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_30'><li class='gchoice gchoice_2_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='Yes'  id='choice_2_30_1'   aria-describedby=\"gfield_description_2_30\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_1' id='label_2_30_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='No'  id='choice_2_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_2' id='label_2_30_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_30_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.3' type='checkbox'  value='If Requested'  id='choice_2_30_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_3' id='label_2_30_3' class='gform-field-label gform-field-label--type-inline'>If Requested<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_2_31\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_31'>Transportation Contact<\/label><div class='gfield_description' id='gfield_description_2_31'>If air travel will be necessary, please provide the name and phone number of the person who will pick up the speaker.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_2_31' class='textarea small'  aria-describedby=\"gfield_description_2_31\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_32\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_32'>Additional Comments Or Considerations<\/label><div class='gfield_description' id='gfield_description_2_32'>Please include any additional requests or information that will assist the AHEC coordinator in scheduling your course.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_2_32' class='textarea medium'  aria-describedby=\"gfield_description_2_32\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_33\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_33'>\n                            \n                            <span id='input_2_33_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_33.3' id='input_2_33_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_33_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_33_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_33.6' id='input_2_33_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_33_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_2' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_2' id='gform_theme_2' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_2' id='gform_style_settings_2' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='ZrZlMEHNkeZ7qADEK7kWKvOeVrdVcdpYDdNP3wT\/8tCwe\/jnZphIT+AgvH1375WAzd4I6ZwQxZcPVZuLcYxHVJTcf+EE6vicZoXWd5OFE0vTtyI=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_2' value='WyJbXSIsImExMjcwMDVhZmYzNGMzOTQwMTdkYWU5Y2EzMDZiMzUyIl0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_2' id='gform_target_page_number_2' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_2' id='gform_source_page_number_2' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"ak_\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"114\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 2, 'https:\/\/www.med.unc.edu\/healthsciences\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_2').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_2');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_2').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_2').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_2').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_2').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_2').val();gformInitSpinner( 2, 'https:\/\/www.med.unc.edu\/healthsciences\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [2, current_page]);window['gf_submitting_2'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_2').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [2]);window['gf_submitting_2'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_2').text());}else{jQuery('#gform_2').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"2\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_2\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_2\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_2\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 2, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":84796,"featured_media":0,"parent":2290,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"layout":"","cellInformation":"","apiCallInformation":"","footnotes":"","_links_to":"","_links_to_target":""},"template-home":[],"class_list":["post-2962","page","type-page","status-publish","hentry","odd"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>AHEC Course Request Form | Department of Health Sciences<\/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:\/\/www.med.unc.edu\/healthsciences\/outreach\/ahec\/ahec-request-form\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"AHEC Course Request Form | Department of Health Sciences\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.med.unc.edu\/healthsciences\/outreach\/ahec\/ahec-request-form\/\" \/>\n<meta property=\"og:site_name\" content=\"Department of Health Sciences\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/UNCHealthSciences\/\" \/>\n<meta property=\"article:modified_time\" content=\"2020-02-05T20:53:00+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:site\" content=\"@UNC_AHS\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/www.med.unc.edu\/healthsciences\/outreach\/ahec\/ahec-request-form\/\",\"url\":\"https:\/\/www.med.unc.edu\/healthsciences\/outreach\/ahec\/ahec-request-form\/\",\"name\":\"AHEC Course Request Form | Department of Health Sciences\",\"isPartOf\":{\"@id\":\"https:\/\/www.med.unc.edu\/healthsciences\/#website\"},\"datePublished\":\"2018-07-18T19:39:55+00:00\",\"dateModified\":\"2020-02-05T20:53:00+00:00\",\"breadcrumb\":{\"@id\":\"https:\/\/www.med.unc.edu\/healthsciences\/outreach\/ahec\/ahec-request-form\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/www.med.unc.edu\/healthsciences\/outreach\/ahec\/ahec-request-form\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/www.med.unc.edu\/healthsciences\/outreach\/ahec\/ahec-request-form\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\/\/www.med.unc.edu\/healthsciences\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Outreach\",\"item\":\"https:\/\/www.med.unc.edu\/healthsciences\/outreach\/\"},{\"@type\":\"ListItem\",\"position\":3,\"name\":\"AHEC\",\"item\":\"https:\/\/www.med.unc.edu\/healthsciences\/outreach\/ahec\/\"},{\"@type\":\"ListItem\",\"position\":4,\"name\":\"AHEC Course Request Form\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\/\/www.med.unc.edu\/healthsciences\/#website\",\"url\":\"https:\/\/www.med.unc.edu\/healthsciences\/\",\"name\":\"UNC Department of Health Sciences\",\"description\":\"\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\/\/www.med.unc.edu\/healthsciences\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"AHEC Course Request Form | Department of Health Sciences","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:\/\/www.med.unc.edu\/healthsciences\/outreach\/ahec\/ahec-request-form\/","og_locale":"en_US","og_type":"article","og_title":"AHEC Course Request Form | Department of Health Sciences","og_url":"https:\/\/www.med.unc.edu\/healthsciences\/outreach\/ahec\/ahec-request-form\/","og_site_name":"Department of Health Sciences","article_publisher":"https:\/\/www.facebook.com\/UNCHealthSciences\/","article_modified_time":"2020-02-05T20:53:00+00:00","twitter_card":"summary_large_image","twitter_site":"@UNC_AHS","schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/www.med.unc.edu\/healthsciences\/outreach\/ahec\/ahec-request-form\/","url":"https:\/\/www.med.unc.edu\/healthsciences\/outreach\/ahec\/ahec-request-form\/","name":"AHEC Course Request Form | Department of Health Sciences","isPartOf":{"@id":"https:\/\/www.med.unc.edu\/healthsciences\/#website"},"datePublished":"2018-07-18T19:39:55+00:00","dateModified":"2020-02-05T20:53:00+00:00","breadcrumb":{"@id":"https:\/\/www.med.unc.edu\/healthsciences\/outreach\/ahec\/ahec-request-form\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/www.med.unc.edu\/healthsciences\/outreach\/ahec\/ahec-request-form\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/www.med.unc.edu\/healthsciences\/outreach\/ahec\/ahec-request-form\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/www.med.unc.edu\/healthsciences\/"},{"@type":"ListItem","position":2,"name":"Outreach","item":"https:\/\/www.med.unc.edu\/healthsciences\/outreach\/"},{"@type":"ListItem","position":3,"name":"AHEC","item":"https:\/\/www.med.unc.edu\/healthsciences\/outreach\/ahec\/"},{"@type":"ListItem","position":4,"name":"AHEC Course Request Form"}]},{"@type":"WebSite","@id":"https:\/\/www.med.unc.edu\/healthsciences\/#website","url":"https:\/\/www.med.unc.edu\/healthsciences\/","name":"UNC Department of Health Sciences","description":"","potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/www.med.unc.edu\/healthsciences\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-US"}]}},"_links_to":[],"_links_to_target":[],"_links":{"self":[{"href":"https:\/\/www.med.unc.edu\/healthsciences\/wp-json\/wp\/v2\/pages\/2962","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.med.unc.edu\/healthsciences\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.med.unc.edu\/healthsciences\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.med.unc.edu\/healthsciences\/wp-json\/wp\/v2\/users\/84796"}],"replies":[{"embeddable":true,"href":"https:\/\/www.med.unc.edu\/healthsciences\/wp-json\/wp\/v2\/comments?post=2962"}],"version-history":[{"count":0,"href":"https:\/\/www.med.unc.edu\/healthsciences\/wp-json\/wp\/v2\/pages\/2962\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/www.med.unc.edu\/healthsciences\/wp-json\/wp\/v2\/pages\/2290"}],"wp:attachment":[{"href":"https:\/\/www.med.unc.edu\/healthsciences\/wp-json\/wp\/v2\/media?parent=2962"}],"wp:term":[{"taxonomy":"template-home","embeddable":true,"href":"https:\/\/www.med.unc.edu\/healthsciences\/wp-json\/wp\/v2\/template-home?post=2962"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}