Estancia – Ciudad Real

[et_pb_section bb_built=»1″][et_pb_row][et_pb_column type=»4_4″][et_pb_contact_form admin_label=»Estancia – Ciudad Real» _builder_version=»3.0.92″ captcha=»off» use_redirect=»off» custom_button=»off» button_icon_placement=»right» title=»Estancia – Ciudad Real» success_message=»Gracias por rellenar este formulario para solicitar el apoyo por horas» submit_button_text=»Enviar» email=»elenamacias@plenainclusionclm.org»][et_pb_contact_field field_title=»Nombre y apellidos de la persona con discapacidad» field_type=»text» field_id=»Nombre» required_mark=»on» fullwidth_field=»on» _builder_version=»3.0.92″ checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22Nombre%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22Nombre%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22Nombre%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22email%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» /][et_pb_contact_field field_title=»Grado de dependencia» field_type=»select» field_id=»Dependencia» required_mark=»on» fullwidth_field=»on» _builder_version=»3.0.92″ checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22Nombre%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22Nombre%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22Grado 1%22,%22checked%22:0},{%22value%22:%22Grado 2%22,%22checked%22:0},{%22value%22:%22Grado 3%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»Discapacidad» field_title=»Diagnóstico de discapacidad (síndrome de Down, autismo…)» field_type=»text» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»on» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»Porcentaje_Discapacidad» field_title=»Porcentaje de discapacidad» field_type=»text» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»on» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»Nacimiento» field_title=»Fecha de nacimiento» field_type=»text» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»on» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][et_pb_contact_field field_title=»Nombre y apellidos del solicitante» field_type=»text» field_id=»Nombre_2″ required_mark=»on» fullwidth_field=»on» _builder_version=»3.0.92″ checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22Nombre%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22Nombre%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22Nombre%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»Dirección» field_title=»Dirección del familiar solicitante» field_type=»text» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»on» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»Población» field_title=»Población del familiar solicitante» field_type=»text» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»on» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»Parentesco» field_title=»Tipo de parentesco» field_type=»select» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22Madre%22,%22checked%22:0},{%22value%22:%22Padre%22,%22checked%22:0},{%22value%22:%22Tutor%22,%22checked%22:0},{%22value%22:%22Otro%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»on» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»Otro» field_title=»Si la opción anterior es %22otro%22 especifica tu parentesco» field_type=»text» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»on» conditional_logic=»on» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22parentesco%22,%22condition%22:%22is%22,%22value%22:%22Otro%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»NIE» field_title=»NIF/NIE del familiar» field_type=»text» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»on» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»Teléfono» field_title=»Teléfono móvil» field_type=»text» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»on» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»Correo_electrónico» field_title=»Correo electrónico» field_type=»email» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»off» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»Asociación» field_title=»¿Pertenece a alguna asociación?» field_type=»checkbox» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22Sí%22,%22checked%22:0},{%22value%22:%22No%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»on» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»Asociación_2″ field_title=»Si la respuesta es sí dinos por favor el nombre» field_type=»text» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»off» conditional_logic=»on» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22asociación%22,%22condition%22:%22is%22,%22value%22:%22Sí%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»Fecha» field_title=»Fechas solicitadas» field_type=»text» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»on» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»Horario_solicitado» field_title=»Horario de entrada y hora de salida» field_type=»text» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»on» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»Motivo» field_title=»Motivo de la solicitud» field_type=»text» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»on» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»Lugar» field_title=»Localidad de realización de preferencia» field_type=»text» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»on» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»Contacto» field_title=»Persona y contacto. Centro/Servicio que gestiona la solicitud:» field_type=»input» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»on» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»Vez» field_title=»¿Es la primera vez que solicita el servicio?» field_type=»checkbox» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22Sí%22,%22checked%22:0},{%22value%22:%22No%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»on» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»Cambios» field_title=»¿Ha cambiado la situación de su familiar en el último año (cambio de medicación, estado de salud, ingreso hospitalario, aparición de algún problema de conducta):» field_type=»text» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»on» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»Información» field_title=»Me considero debidamente informado sobre las condiciones establecidas para solicitar el servicio de Respiro» field_type=»checkbox» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22Sí%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»on» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][et_pb_contact_field _builder_version=»3.0.92″ field_id=»Responsabilidad» field_title=»Declaro bajo mi responsabilidad que son ciertos los datos aportados en esta solicitud» field_type=»checkbox» checkbox_checked=»off» checkbox_options=»%91{%22value%22:%22Sí%22,%22checked%22:0}%93″ radio_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=»%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=»0″ max_length=»0″ allowed_symbols=»all» required_mark=»on» conditional_logic=»off» conditional_logic_relation=»off» conditional_logic_rules=»%91{%22field%22:%22nombre%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ use_background_color_gradient=»off» background_color_gradient_start=»#2b87da» background_color_gradient_end=»#29c4a9″ background_color_gradient_type=»linear» background_color_gradient_direction=»180deg» background_color_gradient_direction_radial=»center» background_color_gradient_start_position=»0%» background_color_gradient_end_position=»100%» background_color_gradient_overlays_image=»off» parallax=»off» parallax_method=»on» background_size=»cover» background_position=»center» background_repeat=»no-repeat» background_blend=»normal» allow_player_pause=»off» fullwidth_field=»on» /][/et_pb_contact_form][/et_pb_column][/et_pb_row][/et_pb_section]