{"id":2101,"date":"2019-07-25T08:59:47","date_gmt":"2019-07-25T12:59:47","guid":{"rendered":"https:\/\/sw.edu\/health-technology\/?page_id=2101"},"modified":"2026-02-05T19:36:50","modified_gmt":"2026-02-05T19:36:50","slug":"practical-nursing-application","status":"publish","type":"page","link":"https:\/\/sw.edu\/health-technology\/practical-nursing-application\/","title":{"rendered":"Practical Nursing Application"},"content":{"rendered":"\n<p>The Practical Nursing program is a highly competitive, selective admissions program. It is your responsibility to ensure that the application and all requirements and prerequisites are completed by the application deadline.<\/p>\n\n\n\n<p class=\"has-gold-background-color has-background\">Practical Nursing Applications for <strong>2026-2027<\/strong> and any supporting documentation must be received in the Admissions Office by <strong>March 15, 2026<\/strong>. Applications submitted after April 5 will be considered for admission for the 2027-2028 academic year.<\/p>\n\n\n\n<div style=\"height:60px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n<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 gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_5' >\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/health-technology\/wp-json\/wp\/v2\/pages\/2101' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_5_15\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_15'>Company<\/label><div class='gfield_description' id='gfield_description_5_15'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_15' id='input_5_15' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_5_1\" class=\"gfield gfield--type-text gfield--input-type-text 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_5_1'>Student ID<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_1'>Number assigned to a student after college application is submitted online.<\/div><div class='ginput_container ginput_container_text'><input name='input_1' id='input_5_1' type='text' value='' class='medium' maxlength='9' aria-describedby=\"gfield_description_5_1\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_2\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above 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_asterisk\">*<\/span><\/span><\/legend><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_5_2'>\n                            \n                            <span id='input_5_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_5_2_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_2_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_5_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_2_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_8\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr \/><strong>Please ensure that your name, address and telephone numbers are correct in the MYSouthwest student information system, as these will be used to correspond with you. The college is not responsible for undeliverable mail.<\/strong><hr \/><\/div><fieldset id=\"field_5_3\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_5_3_1' value=''    aria-required='true'    \/>\n                                        <label for='input_5_3_1' id='input_5_3_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_3_2_container' >\n                                        <input type='text' name='input_3.2' id='input_5_3_2' value=''     aria-required='false'   \/>\n                                        <label for='input_5_3_2' id='input_5_3_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_5_3_3' value=''    aria-required='true'    \/>\n                                    <label for='input_5_3_3' id='input_5_3_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_3_4_container' >\n                                        <select name='input_3.4' id='input_5_3_4'     aria-required='true'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' selected='selected'>Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_5_3_4' id='input_5_3_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_5_3_5' value=''    aria-required='true'    \/>\n                                    <label for='input_5_3_5' id='input_5_3_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_3.6' id='input_5_3_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_5_4\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_4'>Phone &#8211; Home<\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_5_4' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_5\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_5'>Business or Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_5_5' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_6\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr \/><strong>First priority for acceptance will be given to applicants who reside within Southwest&#8217;s service region (Buchanan, Dickenson, Russell &#038; Tazewell counties). Secondary priority will be given to Virginia residents outside of those counties, and then out-of-state applicants.<\/strong><\/div><fieldset id=\"field_5_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Domicile<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_5_11'>Select the county or jurisdiction in which you have lived during the last consecutive 12 months.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_11'>\n\t\t\t<div class='gchoice gchoice_5_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Buchanan, Dickenson, Tazewell, Russell'  id='choice_5_11_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_11\"   \/>\n\t\t\t\t\t<label for='choice_5_11_0' id='label_5_11_0' class='gform-field-label gform-field-label--type-inline'>Buchanan, Dickenson, Tazewell, Russell<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Virginia Jurisdiction other than counties listed above'  id='choice_5_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_11_1' id='label_5_11_1' class='gform-field-label gform-field-label--type-inline'>Virginia Jurisdiction other than counties listed above<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_11_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Out of State'  id='choice_5_11_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_11_2' id='label_5_11_2' class='gform-field-label gform-field-label--type-inline'>Out of State<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_9\" class=\"gfield gfield--type-textarea gfield--input-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_5_9'>Colleges or Universities Attended<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_9'>Please indicate all the colleges or universities that you have attended until now, providing the college name, state, degree received if any, last year attended and your standing at each (good standing, probation, suspended, dismissed)\nIf None, enter none attended.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_9' id='input_5_9' class='textarea medium'  aria-describedby=\"gfield_description_5_9\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_12\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><strong>Acknowledgement of Reciprocity Statement: Pursuant to United States Department of Education (US DOE) regulation 34 CFR 668.43 (a) (5) (v), the Southwest Virginia Community College Certificate in Practical Nursing (LPN) program provides the following information for all prospective and current students:<\/strong>\n<ul><li>The Southwest Virginia Community College LPN program is approved by the Virginia Board of Nursing. <\/li>\n<li>The Southwest Virginia Community College LPN program meets all Virginia Board of Nursing requirements for pre-licensure nursing education programs in the Commonwealth of Virginia. <\/li>\n<li>The Commonwealth of Virginia participates with multiple other states in the National Council of State Boards of Nursing (NCSBN) National Licensing Compact (NLC) to allow nurses licensed in one state (primary state of residence) to provide nursing care across state lines in other compact states. Applicants are encouraged to visit https:\/\/www.ncsbn.org\/nurse-licensure-compact.htm to learn more about the <a href=\"https:\/\/www.ncsbn.org\/nurse-licensure-compact.htm\">Nurse Licensure Compact.<\/a>  <\/li>\n<li>Southwest Virginia Community College is regionally accredited by the Southern Association of Colleges and Schools Commission on Colleges (SACSCOC).<\/li>\n<\/li><li><a href=\"https:\/\/sw.edu\/health-technology\/wp-content\/uploads\/sites\/5\/2022\/03\/Licensure-Reciprocity.pdf\">LICENSURE RECIPROCITY<\/a><\/li><\/ul><\/div><fieldset id=\"field_5_13\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_13.1' id='input_5_13_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_13_1' >I understand the Practical Nursing Program Reciprocity Statement above<\/label><input type='hidden' name='input_13.2' value='I understand the Practical Nursing Program Reciprocity Statement above' class='gform_hidden' \/><input type='hidden' name='input_13.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_5_10\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Agreement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_5_10' tabindex='0'>I have read and understand ALL requirements as described in the SWCC catalog online at sw.edu and the Practical Nursing Selective Admissions Procedures checklist. (A download link to this PDF checklist is provided at the top of this page.)  I also understand that I must submit this application form by the deadline for each year that I wish to be considered. It is my responsibility to make sure that all admissions requirements are met and all required documents are received by the SWCC Admissions Office by the March 6th deadline.<\/div><div class='ginput_container ginput_container_consent'><input name='input_10.1' id='input_5_10_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_5_10\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_10_1' >I agree to the statement above to apply to the LPN program at SWCC.<\/label><input type='hidden' name='input_10.2' value='I agree to the statement above to apply to the LPN program at SWCC.' class='gform_hidden' \/><input type='hidden' name='input_10.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_5_14\" class=\"gfield gfield--type-captcha gfield--input-type-captcha field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_14'>CAPTCHA<\/label><div id='input_5_14' class='ginput_container ginput_recaptcha' data-sitekey='6Ler-DQoAAAAAHP-AM2kyCjb-tpEWinagTwDnSBd'  data-theme='light' data-tabindex='-1' data-size='invisible' data-badge='bottomright'><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_5' 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_5' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_5' id='gform_theme_5' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_5' id='gform_style_settings_5' value='{&quot;inputPrimaryColor&quot;:&quot;#204ce5&quot;}' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_5' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='5' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='o1A3r5WcgRfAfQCfgpTFwPp++IX2V+I8NvFw3Nw0Bz9gGsycjUjHhZDuS9PTo2tDBoOhSrIx9VtKD2\/IXppQRMtBCiia6rWJ2RH4Umn0X9I6coU=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_5' value='WyJ7XCIxMy4xXCI6XCJmNzBiMjQzZjAzZDY5NDJkNWZlZGIxY2ZiZGE1YmQzZFwiLFwiMTMuMlwiOlwiOGQ3OGMwOGY5NmIzYmU1NmYzM2EzMzYxYzgyMDkyM2ZcIixcIjEzLjNcIjpcImY5ZWZhMTJhNTlkZDE0NmE5ZTRiNTQ0NzY3OGVmMTIzXCIsXCIxMC4xXCI6XCJmNzBiMjQzZjAzZDY5NDJkNWZlZGIxY2ZiZGE1YmQzZFwiLFwiMTAuMlwiOlwiMTlmYjExOWEzOTFjZmNkZDE0MzYwZmQ2NWY2YjFjYjdcIixcIjEwLjNcIjpcImY5ZWZhMTJhNTlkZDE0NmE5ZTRiNTQ0NzY3OGVmMTIzXCJ9IiwiNzEyMDhlN2U4Njc1ZGM5ODVkYjFhODYzOGVkZmJjNWEiXQ==' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_5' id='gform_target_page_number_5' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_5' id='gform_source_page_number_5' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 5, 'https:\/\/sw.edu\/health-technology\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_5').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_5');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_5').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! 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