{"id":127,"date":"2025-07-29T11:59:45","date_gmt":"2025-07-29T16:59:45","guid":{"rendered":"https:\/\/www.bemidjistate.edu\/services\/health-counseling\/?page_id=127"},"modified":"2025-11-18T12:10:32","modified_gmt":"2025-11-18T18:10:32","slug":"required-immunizations","status":"publish","type":"page","link":"https:\/\/www.bemidjistate.edu\/services\/health-counseling\/required-immunizations\/","title":{"rendered":"Required Immunizations"},"content":{"rendered":"<div class=\"gf_browser_gecko gform_wrapper gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital\" data-form-theme=\"orbital\" data-form-index=\"0\" id=\"gform_wrapper_1\" style=\"display:none\"><style>#gform_wrapper_1[data-form-index=\"0\"].gform-theme,[data-parent-form=\"1_0\"]{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 229;--gf-color-primary-contrast: #fff;--gf-color-primary-contrast-rgb: 255, 255, 255;--gf-color-primary-darker: #001AB3;--gf-color-primary-lighter: #527EFF;--gf-color-secondary: #fff;--gf-color-secondary-rgb: 255, 255, 255;--gf-color-secondary-contrast: #112337;--gf-color-secondary-contrast-rgb: 17, 35, 55;--gf-color-secondary-darker: #F5F5F5;--gf-color-secondary-lighter: #FFFFFF;--gf-color-out-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-out-ctrl-light-rgb: 17, 35, 55;--gf-color-out-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-out-ctrl-light-lighter: #F5F5F5;--gf-color-out-ctrl-dark: #585e6a;--gf-color-out-ctrl-dark-rgb: 88, 94, 106;--gf-color-out-ctrl-dark-darker: #112337;--gf-color-out-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-color-in-ctrl: #fff;--gf-color-in-ctrl-rgb: 255, 255, 255;--gf-color-in-ctrl-contrast: #112337;--gf-color-in-ctrl-contrast-rgb: 17, 35, 55;--gf-color-in-ctrl-darker: #F5F5F5;--gf-color-in-ctrl-lighter: #FFFFFF;--gf-color-in-ctrl-primary: #204ce5;--gf-color-in-ctrl-primary-rgb: 32, 76, 229;--gf-color-in-ctrl-primary-contrast: #fff;--gf-color-in-ctrl-primary-contrast-rgb: 255, 255, 255;--gf-color-in-ctrl-primary-darker: #001AB3;--gf-color-in-ctrl-primary-lighter: #527EFF;--gf-color-in-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-in-ctrl-light-rgb: 17, 35, 55;--gf-color-in-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-in-ctrl-light-lighter: #F5F5F5;--gf-color-in-ctrl-dark: #585e6a;--gf-color-in-ctrl-dark-rgb: 88, 94, 106;--gf-color-in-ctrl-dark-darker: #112337;--gf-color-in-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-radius: 3px;--gf-font-size-secondary: 14px;--gf-font-size-tertiary: 13px;--gf-icon-ctrl-number: url(\"data:image\/svg+xml,%3Csvg width='8' height='14' viewBox='0 0 8 14' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-select: url(\"data:image\/svg+xml,%3Csvg width='10' height='6' viewBox='0 0 10 6' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-search: url(\"data:image\/svg+xml,%3Csvg width='640' height='640' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class=\"gform_heading\">\n                            <h2 class=\"gform_title\">Immunization Form<\/h2>\n                            <p class=\"gform_description\"><\/p>\n                        <\/div><form method=\"post\" enctype=\"multipart\/form-data\" id=\"gform_1\" action=\"\/services\/health-counseling\/wp-json\/wp\/v2\/pages\/127\" data-formid=\"1\" novalidate>\n                        <div class=\"gform-body gform_body\"><div id=\"gform_fields_1\" class=\"gform_fields top_label form_sublabel_below description_below validation_below\"><div id=\"field_1_14\" 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\">Minnesota Law (<a href=\"https:\/\/www.revisor.mn.gov\/statutes\/cite\/135A.14\" target=\"_blank\" rel=\"noopener noreferrer nofollow\">Minn. Stat.135A.14<i title=\"External link\" class=\"bsu-icon bsu-icon-external-link small ms-1\"><\/i><\/a>) requires students enrolled in a public or private post-secondary school in Minnesota to be immunized against tetanus and diphtheria (Tdap\/Td). The most recent vaccination must have been within the last ten years.\n<br>\nMinnesota Law (<a href=\"https:\/\/www.revisor.mn.gov\/statutes\/cite\/135A.14\" target=\"_blank\" rel=\"noopener noreferrer nofollow\">Minn. Stat.135A.14<i title=\"External link\" class=\"bsu-icon bsu-icon-external-link small ms-1\"><\/i><\/a>) also requires students be immunized against measles, mumps and rubella (MMR). All doses of MMR vaccine must have been received after the age of 12 months.\n<br>\nStudents are exempt from this law if they were born before 1957, graduated from a Minnesota high school after 1996, enrolled in one class and not housed on campus or enrolled in online classes only.\n<br>\nTo provide this information, students must complete an Immunization Form within the first 45 days of classes. Without this form, you will not be able to register for subsequent semesters. Please note that holds are not immediately removed.<\/div><fieldset id=\"field_1_1\" class=\"gfield gfield--type-name gfield--input-type-name 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\">Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class=\"ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row\" id=\"input_1_1\">\n                            \n                            <span id=\"input_1_1_3_container\" class=\"name_first gform-grid-col gform-grid-col--size-auto\">\n                                                    <input type=\"text\" name=\"input_1.3\" id=\"input_1_1_3\" value=\"\" aria-required=\"true\">\n                                                    <label for=\"input_1_1_3\" class=\"gform-field-label gform-field-label--type-sub \">First<\/label>\n                                                <\/span>\n                            <span id=\"input_1_1_4_container\" class=\"name_middle gform-grid-col gform-grid-col--size-auto\">\n                                                    <input type=\"text\" name=\"input_1.4\" id=\"input_1_1_4\" value=\"\" aria-required=\"false\">\n                                                    <label for=\"input_1_1_4\" class=\"gform-field-label gform-field-label--type-sub \">Middle<\/label>\n                                                <\/span>\n                            <span id=\"input_1_1_6_container\" class=\"name_last gform-grid-col gform-grid-col--size-auto\">\n                                                    <input type=\"text\" name=\"input_1.6\" id=\"input_1_1_6\" value=\"\" aria-required=\"true\">\n                                                    <label for=\"input_1_1_6\" class=\"gform-field-label gform-field-label--type-sub \">Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_1_3\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield 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\">Birthdate<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id=\"input_1_3\" class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"gfield_date_month ginput_container ginput_container_date gform-grid-col\" id=\"input_1_3_1_container\">\n                                            <input type=\"number\" maxlength=\"2\" name=\"input_3[]\" id=\"input_1_3_1\" value=\"\" aria-required=\"true\" placeholder=\"MM\" min=\"1\" max=\"12\" step=\"1\">\n                                            <label for=\"input_1_3_1\" class=\"gform-field-label gform-field-label--type-sub screen-reader-text\">Month<\/label>\n                                        <\/div><div class=\"gfield_date_day ginput_container ginput_container_date gform-grid-col\" id=\"input_1_3_2_container\">\n                                            <input type=\"number\" maxlength=\"2\" name=\"input_3[]\" id=\"input_1_3_2\" value=\"\" aria-required=\"true\" placeholder=\"DD\" min=\"1\" max=\"31\" step=\"1\">\n                                            <label for=\"input_1_3_2\" class=\"gform-field-label gform-field-label--type-sub screen-reader-text\">Day<\/label>\n                                        <\/div><div class=\"gfield_date_year ginput_container ginput_container_date gform-grid-col\" id=\"input_1_3_3_container\">\n                                            <input type=\"number\" maxlength=\"4\" name=\"input_3[]\" id=\"input_1_3_3\" value=\"\" aria-required=\"true\" placeholder=\"YYYY\" min=\"1920\" max=\"2027\" step=\"1\">\n                                            <label for=\"input_1_3_3\" class=\"gform-field-label gform-field-label--type-sub screen-reader-text\">Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_1_4\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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\">Institution<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_1_4\">\n\t\t\t<div class=\"gchoice gchoice_1_4_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_4\" type=\"radio\" value=\"Bemidji State University\" id=\"choice_1_4_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_1_4_0\" id=\"label_1_4_0\" class=\"gform-field-label gform-field-label--type-inline\">Bemidji State University<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_1_4_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_4\" type=\"radio\" value=\"Northwest Technical College\" id=\"choice_1_4_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_1_4_1\" id=\"label_1_4_1\" class=\"gform-field-label gform-field-label--type-inline\">Northwest Technical College<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"><label class=\"gfield_label gform-field-label\" for=\"input_1_5\">Student I.D. Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_text\"><input name=\"input_5\" id=\"input_1_5\" type=\"text\" value=\"\" class=\"large\" aria-describedby=\"gfield_description_1_5\" aria-required=\"true\" aria-invalid=\"false\"><\/div><div class=\"gfield_description\" id=\"gfield_description_1_5\">Your Student I.D. is an 8-digit number that was assigned to you when you were admitted to BSU. <\/div><\/div><div id=\"field_1_6\" 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_1_6\">Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_email\">\n                            <input name=\"input_6\" id=\"input_1_6\" type=\"email\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\">\n                        <\/div><\/div><div id=\"field_1_7\" class=\"gfield gfield--type-phone gfield--input-type-phone 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_1_7\">Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_phone\"><input name=\"input_7\" id=\"input_1_7\" type=\"tel\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><\/div><\/div><fieldset id=\"field_1_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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\">Please check the appropriate category<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_1_8\">\n\t\t\t<div class=\"gchoice gchoice_1_8_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_8\" type=\"radio\" value=\"Graduated from a Minnesota high school after 1996\" id=\"choice_1_8_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_1_8_0\" id=\"label_1_8_0\" class=\"gform-field-label gform-field-label--type-inline\">Graduated from a Minnesota high school after 1996<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_1_8_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_8\" type=\"radio\" value=\"Born before 1957\" id=\"choice_1_8_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_1_8_1\" id=\"label_1_8_1\" class=\"gform-field-label gform-field-label--type-inline\">Born before 1957<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_1_8_2\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_8\" type=\"radio\" value=\"Enrolled in only one class, and NOT housed on campus\" id=\"choice_1_8_2\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_1_8_2\" id=\"label_1_8_2\" class=\"gform-field-label gform-field-label--type-inline\">Enrolled in only one class, and NOT housed on campus<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_1_8_3\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_8\" type=\"radio\" value=\"Enrolled in online or off-site classes only\" id=\"choice_1_8_3\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_1_8_3\" id=\"label_1_8_3\" class=\"gform-field-label gform-field-label--type-inline\">Enrolled in online or off-site classes only<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_1_8_4\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_8\" type=\"radio\" value=\"None of the above\" id=\"choice_1_8_4\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_1_8_4\" id=\"label_1_8_4\" class=\"gform-field-label gform-field-label--type-inline\">None of the above<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_12\" 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\">If you would like to complete a Medical and Conscientious Exemptions Form, please fill it out and secure the information and signatures required. The form can be found on the Confirmation page when you submit this form. If you are non exempt, please fill in the dates below.<\/div><fieldset id=\"field_1_10\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield 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\">Measles (rubeola, red measles), Mumps, &amp; Rubella (German Measles)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id=\"input_1_10\" class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"gfield_date_month ginput_container ginput_container_date gform-grid-col\" id=\"input_1_10_1_container\">\n                                            <input type=\"number\" maxlength=\"2\" name=\"input_10[]\" id=\"input_1_10_1\" value=\"\" aria-required=\"true\" placeholder=\"MM\" min=\"1\" max=\"12\" step=\"1\">\n                                            <label for=\"input_1_10_1\" class=\"gform-field-label gform-field-label--type-sub screen-reader-text\">Month<\/label>\n                                        <\/div><div class=\"gfield_date_day ginput_container ginput_container_date gform-grid-col\" id=\"input_1_10_2_container\">\n                                            <input type=\"number\" maxlength=\"2\" name=\"input_10[]\" id=\"input_1_10_2\" value=\"\" aria-required=\"true\" placeholder=\"DD\" min=\"1\" max=\"31\" step=\"1\">\n                                            <label for=\"input_1_10_2\" class=\"gform-field-label gform-field-label--type-sub screen-reader-text\">Day<\/label>\n                                        <\/div><div class=\"gfield_date_year ginput_container ginput_container_date gform-grid-col\" id=\"input_1_10_3_container\">\n                                            <input type=\"number\" maxlength=\"4\" name=\"input_10[]\" id=\"input_1_10_3\" value=\"\" aria-required=\"true\" placeholder=\"YYYY\" min=\"1920\" max=\"2027\" step=\"1\">\n                                            <label for=\"input_1_10_3\" class=\"gform-field-label gform-field-label--type-sub screen-reader-text\">Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_1_11\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-full 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\">Tetanus, Diphtheria &amp; Pertussis (Tdap) or Diphtheria (Td)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id=\"input_1_11\" class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"gfield_date_month ginput_container ginput_container_date gform-grid-col\" id=\"input_1_11_1_container\">\n                                            <input type=\"number\" maxlength=\"2\" name=\"input_11[]\" id=\"input_1_11_1\" value=\"\" aria-required=\"true\" placeholder=\"MM\" min=\"1\" max=\"12\" step=\"1\">\n                                            <label for=\"input_1_11_1\" class=\"gform-field-label gform-field-label--type-sub screen-reader-text\">Month<\/label>\n                                        <\/div><div class=\"gfield_date_day ginput_container ginput_container_date gform-grid-col\" id=\"input_1_11_2_container\">\n                                            <input type=\"number\" maxlength=\"2\" name=\"input_11[]\" id=\"input_1_11_2\" value=\"\" aria-required=\"true\" placeholder=\"DD\" min=\"1\" max=\"31\" step=\"1\">\n                                            <label for=\"input_1_11_2\" class=\"gform-field-label gform-field-label--type-sub screen-reader-text\">Day<\/label>\n                                        <\/div><div class=\"gfield_date_year ginput_container ginput_container_date gform-grid-col\" id=\"input_1_11_3_container\">\n                                            <input type=\"number\" maxlength=\"4\" name=\"input_11[]\" id=\"input_1_11_3\" value=\"\" aria-required=\"true\" placeholder=\"YYYY\" min=\"1920\" max=\"2027\" step=\"1\">\n                                            <label for=\"input_1_11_3\" class=\"gform-field-label gform-field-label--type-sub screen-reader-text\">Year<\/label>\n                                       <\/div>\n                                   <\/div><div class=\"gfield_description\" id=\"gfield_description_1_11\">Needs to be within 10 years.<\/div><\/fieldset><div id=\"field_1_15\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below 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