{"id":1362,"date":"2013-01-17T18:59:05","date_gmt":"2013-01-17T18:59:05","guid":{"rendered":"http:\/\/freedimensional.org\/?page_id=1362"},"modified":"2015-01-21T16:56:44","modified_gmt":"2015-01-21T16:56:44","slug":"forumularia-de-registro","status":"publish","type":"page","link":"https:\/\/fd.artistsafety.net\/services\/distress-services\/distress-services-intake-form\/forumularia-de-registro\/","title":{"rendered":"Formulario de Registro"},"content":{"rendered":"<p>If you have inconsistent internet access or for whatever reason are unable to input to this form directly, a downloadable version is available here: <a href=\"http:\/\/freedimensional.org\/wp-content\/uploads\/2013\/01\/Distress-Services-Intake-Esp-20121.doc\">fD Formulario de Registro<\/a><\/p>\n<p><em>* Required<\/em><\/p>\n<div id=\"vfb-form-1\" class=\"visual-form-builder-container\"><form id=\"formulario-de-registro-1\" class=\"visual-form-builder vfb-form-1 \" method=\"post\" enctype=\"multipart\/form-data\">\n\t  \t<input type=\"hidden\" name=\"form_id\" value=\"1\" \/><fieldset class=\"vfb-fieldset vfb-fieldset-1 formulario-de-registro \" id=\"item-vfb-1\"><div class=\"vfb-legend\"><h3>Formulario de Registro<\/h3><\/div><ul class=\"vfb-section vfb-section-1\"><li class=\"vfb-item vfb-item-instructions  \" id=\"item-vfb-6\"><label class=\"vfb-desc\">La informaci\u00f3n registrada en el Formulario de Registro es totalmente confidencial, y ser\u00e1 vista solamente por personal de freeDimensional y consultores de los Servicios de Emergencia (\u201cDistress Services\u201d). <\/label><\/li><div id=\"item-vfb-8\" class=\"vfb-section-div \"><h4>INFORMACI\u00d3N DEL SOLICITANTE<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-radio  \" id=\"item-vfb-9\"><label class=\"vfb-desc\">\u00bfQui\u00e9n est\u00e1 ingresando esta informaci\u00f3n? Es Ud.:  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-span\"><input type=\"radio\" name=\"vfb-9\" id=\"vfb-9-1\" value=\"Artista en riesgo\" class=\"vfb-radio  required \" \/><label for=\"vfb-9-1\" class=\"vfb-choice\">Artista en riesgo<\/label><\/span><span class=\"vfb-span\"><input type=\"radio\" name=\"vfb-9\" id=\"vfb-9-2\" value=\"Alguien quien postula a un artista en riesgo\" class=\"vfb-radio  required \" \/><label for=\"vfb-9-2\" class=\"vfb-choice\">Alguien quien postula a un artista en riesgo<\/label><\/span><span class=\"vfb-span\"><input type=\"radio\" name=\"vfb-9\" id=\"vfb-9-3\" value=\"Amiga\/o - Familiar\" class=\"vfb-radio  required \" \/><label for=\"vfb-9-3\" class=\"vfb-choice\">Amiga\/o - Familiar<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-text  \" id=\"item-vfb-12\"><label for=\"vfb-12\" class=\"vfb-desc\">Si Ud. postula a un artista en riesgo e ingresa esta informaci\u00f3n como amigo\/a o familiar, por favor ingrese su nombre aqu\u00ed: <\/label><input type=\"text\" name=\"vfb-12\" id=\"vfb-12\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text  \" id=\"item-vfb-13\"><label for=\"vfb-13\" class=\"vfb-desc\">Nombre del solicitante  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"text\" name=\"vfb-13\" id=\"vfb-13\" value=\"\" class=\"vfb-text  vfb-medium  required  \" \/><\/li><li class=\"vfb-item vfb-item-date  \" id=\"item-vfb-14\"><label for=\"vfb-14\" class=\"vfb-desc\">Fecha de nacimiento  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"text\" name=\"vfb-14\" id=\"vfb-14\" value=\"\" class=\"vfb-text vfb-date-picker  vfb-medium  required \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><li class=\"vfb-item vfb-item-checkbox  \" id=\"item-vfb-15\"><label class=\"vfb-desc\">Sexo  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-15[]\" id=\"vfb-15-0\" value=\"Femenino\" class=\"vfb-checkbox  required \" \/><label for=\"vfb-15-0\" class=\"vfb-choice\">Femenino<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-15[]\" id=\"vfb-15-1\" value=\"Masculino\" class=\"vfb-checkbox  required \" \/><label for=\"vfb-15-1\" class=\"vfb-choice\">Masculino<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-15[]\" id=\"vfb-15-2\" value=\"Otro\" class=\"vfb-checkbox  required \" \/><label for=\"vfb-15-2\" class=\"vfb-choice\">Otro<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-address  \" id=\"item-vfb-22\"><label class=\"vfb-desc\">Domicilio <\/label><div><span class=\"vfb-full\"><input type=\"text\" name=\"vfb-22[address]\" id=\"vfb-22-address\" maxlength=\"150\" class=\"vfb-text vfb-medium  \" \/><label for=\"vfb-22-address\">Street Address<\/label><\/span><span class=\"vfb-full\"><input type=\"text\" name=\"vfb-22[address-2]\" id=\"vfb-22-address-2\" maxlength=\"150\" class=\"vfb-text vfb-medium  \" \/><label for=\"vfb-22-address-2\">Apt, Suite, Bldg. (optional)<\/label><\/span><span class=\"vfb-left\"><input type=\"text\" name=\"vfb-22[city]\" id=\"vfb-22-city\" maxlength=\"150\" class=\"vfb-text vfb-medium  \" \/><label for=\"vfb-22-city\">City<\/label><\/span><span class=\"vfb-right\"><input type=\"text\" name=\"vfb-22[state]\" id=\"vfb-22-state\" maxlength=\"150\" class=\"vfb-text vfb-medium  \" \/><label for=\"vfb-22-state\">State \/ Province \/ Region<\/label><\/span><span class=\"vfb-left\"><input type=\"text\" name=\"vfb-22[zip]\" id=\"vfb-22-zip\" maxlength=\"150\" class=\"vfb-text vfb-medium  \" \/><label for=\"vfb-22-zip\">Postal \/ Zip Code<\/label><\/span><span class=\"vfb-right\"><select name=\"vfb-22[country]\" class=\"vfb-select  \" id=\"vfb-22-country\"><option value=\"\" selected='selected'><\/option><option value=\"Afghanistan\">Afghanistan<\/option><option value=\"Albania\">Albania<\/option><option value=\"Algeria\">Algeria<\/option><option value=\"Andorra\">Andorra<\/option><option value=\"Angola\">Angola<\/option><option value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option><option value=\"Argentina\">Argentina<\/option><option value=\"Armenia\">Armenia<\/option><option value=\"Australia\">Australia<\/option><option value=\"Austria\">Austria<\/option><option value=\"Azerbaijan\">Azerbaijan<\/option><option value=\"Bahamas\">Bahamas<\/option><option value=\"Bahrain\">Bahrain<\/option><option value=\"Bangladesh\">Bangladesh<\/option><option value=\"Barbados\">Barbados<\/option><option value=\"Belarus\">Belarus<\/option><option value=\"Belgium\">Belgium<\/option><option value=\"Belize\">Belize<\/option><option value=\"Benin\">Benin<\/option><option value=\"Bhutan\">Bhutan<\/option><option value=\"Bolivia\">Bolivia<\/option><option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option><option value=\"Botswana\">Botswana<\/option><option value=\"Brazil\">Brazil<\/option><option value=\"Brunei\">Brunei<\/option><option value=\"Bulgaria\">Bulgaria<\/option><option value=\"Burkina Faso\">Burkina Faso<\/option><option value=\"Burundi\">Burundi<\/option><option value=\"Cambodia\">Cambodia<\/option><option value=\"Cameroon\">Cameroon<\/option><option value=\"Canada\">Canada<\/option><option value=\"Cape Verde\">Cape Verde<\/option><option value=\"Central African Republic\">Central African Republic<\/option><option value=\"Chad\">Chad<\/option><option value=\"Chile\">Chile<\/option><option value=\"China\">China<\/option><option value=\"Colombia\">Colombia<\/option><option value=\"Comoros\">Comoros<\/option><option value=\"Congo (Brazzaville)\">Congo (Brazzaville)<\/option><option value=\"Congo\">Congo<\/option><option value=\"Costa Rica\">Costa Rica<\/option><option value=\"Cote d\\'Ivoire\">Cote d\\'Ivoire<\/option><option value=\"Croatia\">Croatia<\/option><option value=\"Cuba\">Cuba<\/option><option value=\"Cyprus\">Cyprus<\/option><option value=\"Czech Republic\">Czech Republic<\/option><option value=\"Denmark\">Denmark<\/option><option value=\"Djibouti\">Djibouti<\/option><option value=\"Dominica\">Dominica<\/option><option value=\"Dominican Republic\">Dominican Republic<\/option><option value=\"East Timor (Timor Timur)\">East Timor (Timor Timur)<\/option><option value=\"Ecuador\">Ecuador<\/option><option value=\"Egypt\">Egypt<\/option><option value=\"El Salvador\">El Salvador<\/option><option value=\"Equatorial Guinea\">Equatorial Guinea<\/option><option value=\"Eritrea\">Eritrea<\/option><option value=\"Estonia\">Estonia<\/option><option value=\"Ethiopia\">Ethiopia<\/option><option value=\"Fiji\">Fiji<\/option><option value=\"Finland\">Finland<\/option><option value=\"France\">France<\/option><option value=\"Gabon\">Gabon<\/option><option value=\"Gambia, The\">Gambia, The<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Germany\">Germany<\/option><option value=\"Ghana\">Ghana<\/option><option value=\"Greece\">Greece<\/option><option value=\"Grenada\">Grenada<\/option><option value=\"Guatemala\">Guatemala<\/option><option value=\"Guinea\">Guinea<\/option><option value=\"Guinea-Bissau\">Guinea-Bissau<\/option><option value=\"Guyana\">Guyana<\/option><option value=\"Haiti\">Haiti<\/option><option value=\"Honduras\">Honduras<\/option><option value=\"Hungary\">Hungary<\/option><option value=\"Iceland\">Iceland<\/option><option value=\"India\">India<\/option><option value=\"Indonesia\">Indonesia<\/option><option value=\"Iran\">Iran<\/option><option value=\"Iraq\">Iraq<\/option><option value=\"Ireland\">Ireland<\/option><option value=\"Israel\">Israel<\/option><option value=\"Italy\">Italy<\/option><option value=\"Jamaica\">Jamaica<\/option><option value=\"Japan\">Japan<\/option><option value=\"Jordan\">Jordan<\/option><option value=\"Kazakhstan\">Kazakhstan<\/option><option value=\"Kenya\">Kenya<\/option><option value=\"Kiribati\">Kiribati<\/option><option value=\"Korea, North\">Korea, North<\/option><option value=\"Korea, South\">Korea, South<\/option><option value=\"Kuwait\">Kuwait<\/option><option value=\"Kyrgyzstan\">Kyrgyzstan<\/option><option value=\"Laos\">Laos<\/option><option value=\"Latvia\">Latvia<\/option><option value=\"Lebanon\">Lebanon<\/option><option value=\"Lesotho\">Lesotho<\/option><option value=\"Liberia\">Liberia<\/option><option value=\"Libya\">Libya<\/option><option value=\"Liechtenstein\">Liechtenstein<\/option><option value=\"Lithuania\">Lithuania<\/option><option value=\"Luxembourg\">Luxembourg<\/option><option value=\"Macedonia\">Macedonia<\/option><option value=\"Madagascar\">Madagascar<\/option><option value=\"Malawi\">Malawi<\/option><option value=\"Malaysia\">Malaysia<\/option><option value=\"Maldives\">Maldives<\/option><option value=\"Mali\">Mali<\/option><option value=\"Malta\">Malta<\/option><option value=\"Marshall Islands\">Marshall Islands<\/option><option value=\"Mauritania\">Mauritania<\/option><option value=\"Mauritius\">Mauritius<\/option><option value=\"Mexico\">Mexico<\/option><option value=\"Micronesia\">Micronesia<\/option><option value=\"Moldova\">Moldova<\/option><option value=\"Monaco\">Monaco<\/option><option value=\"Mongolia\">Mongolia<\/option><option value=\"Montenegro\">Montenegro<\/option><option value=\"Morocco\">Morocco<\/option><option value=\"Mozambique\">Mozambique<\/option><option value=\"Myanmar\">Myanmar<\/option><option value=\"Namibia\">Namibia<\/option><option value=\"Nauru\">Nauru<\/option><option value=\"Nepal\">Nepal<\/option><option value=\"Netherlands\">Netherlands<\/option><option value=\"New Zealand\">New Zealand<\/option><option value=\"Nicaragua\">Nicaragua<\/option><option value=\"Niger\">Niger<\/option><option value=\"Nigeria\">Nigeria<\/option><option value=\"Norway\">Norway<\/option><option value=\"Oman\">Oman<\/option><option value=\"Pakistan\">Pakistan<\/option><option value=\"Palestinian Territory\">Palestinian Territory<\/option><option value=\"Palau\">Palau<\/option><option value=\"Panama\">Panama<\/option><option value=\"Papua New Guinea\">Papua New Guinea<\/option><option value=\"Paraguay\">Paraguay<\/option><option value=\"Peru\">Peru<\/option><option value=\"Philippines\">Philippines<\/option><option value=\"Poland\">Poland<\/option><option value=\"Portugal\">Portugal<\/option><option value=\"Qatar\">Qatar<\/option><option value=\"Romania\">Romania<\/option><option value=\"Russia\">Russia<\/option><option value=\"Rwanda\">Rwanda<\/option><option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\">Saint Lucia<\/option><option value=\"Saint Vincent\">Saint Vincent<\/option><option value=\"Samoa\">Samoa<\/option><option value=\"San Marino\">San Marino<\/option><option value=\"Sao Tome and Principe\">Sao Tome and Principe<\/option><option value=\"Saudi Arabia\">Saudi Arabia<\/option><option value=\"Senegal\">Senegal<\/option><option value=\"Serbia\">Serbia<\/option><option value=\"Seychelles\">Seychelles<\/option><option value=\"Sierra Leone\">Sierra Leone<\/option><option value=\"Singapore\">Singapore<\/option><option value=\"Slovakia\">Slovakia<\/option><option value=\"Slovenia\">Slovenia<\/option><option value=\"Solomon Islands\">Solomon Islands<\/option><option value=\"Somalia\">Somalia<\/option><option value=\"South Africa\">South Africa<\/option><option value=\"Spain\">Spain<\/option><option value=\"Sri Lanka\">Sri Lanka<\/option><option value=\"Sudan\">Sudan<\/option><option value=\"Suriname\">Suriname<\/option><option value=\"Swaziland\">Swaziland<\/option><option value=\"Sweden\">Sweden<\/option><option value=\"Switzerland\">Switzerland<\/option><option value=\"Syria\">Syria<\/option><option value=\"Taiwan\">Taiwan<\/option><option value=\"Tajikistan\">Tajikistan<\/option><option value=\"Tanzania\">Tanzania<\/option><option value=\"Thailand\">Thailand<\/option><option value=\"Togo\">Togo<\/option><option value=\"Tonga\">Tonga<\/option><option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option><option value=\"Tunisia\">Tunisia<\/option><option value=\"Turkey\">Turkey<\/option><option value=\"Turkmenistan\">Turkmenistan<\/option><option value=\"Tuvalu\">Tuvalu<\/option><option value=\"Uganda\">Uganda<\/option><option value=\"Ukraine\">Ukraine<\/option><option value=\"United Arab Emirates\">United Arab Emirates<\/option><option value=\"United Kingdom\">United Kingdom<\/option><option value=\"United States of America\">United States of America<\/option><option value=\"Uruguay\">Uruguay<\/option><option value=\"Uzbekistan\">Uzbekistan<\/option><option value=\"Vanuatu\">Vanuatu<\/option><option value=\"Vatican City\">Vatican City<\/option><option value=\"Venezuela\">Venezuela<\/option><option value=\"Vietnam\">Vietnam<\/option><option value=\"Western Sahara\">Western Sahara<\/option><option value=\"Western Samoa\">Western Samoa<\/option><option value=\"Yemen\">Yemen<\/option><option value=\"Zambia\">Zambia<\/option><option value=\"Zimbabwe\">Zimbabwe<\/option><\/select><label for=\"vfb-22-country\">Country<\/label><\/span><\/div><\/li><li class=\"vfb-item vfb-item-email  \" id=\"item-vfb-17\"><label for=\"vfb-17\" class=\"vfb-desc\">Correo electr\u00f3nico  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"email\" name=\"vfb-17\" id=\"vfb-17\" value=\"\" class=\"vfb-text  vfb-medium  required  email \" \/><\/li><li class=\"vfb-item vfb-item-phone  \" id=\"item-vfb-18\"><label for=\"vfb-18\" class=\"vfb-desc\">N\u00fameros de contacto telef\u00f3nico  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"tel\" name=\"vfb-18\" id=\"vfb-18\" value=\"\" class=\"vfb-text  vfb-medium  required  phone \" \/><\/li><li class=\"vfb-item vfb-item-phone  \" id=\"item-vfb-19\"><label for=\"vfb-19\" class=\"vfb-desc\">N\u00fameros de contacto telef\u00f3nico 2 <\/label><input type=\"tel\" name=\"vfb-19\" id=\"vfb-19\" value=\"\" class=\"vfb-text  vfb-medium   phone \" \/><\/li><li class=\"vfb-item vfb-item-text  \" id=\"item-vfb-20\"><label for=\"vfb-20\" class=\"vfb-desc\">Pa\u00eds(es) de ciudadan\u00eda  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"text\" name=\"vfb-20\" id=\"vfb-20\" value=\"\" class=\"vfb-text  vfb-medium  required  \" \/><\/li><li class=\"vfb-item vfb-item-text  \" id=\"item-vfb-21\"><label for=\"vfb-21\" class=\"vfb-desc\">D\u00f3nde se encuentra en este momento  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"text\" name=\"vfb-21\" id=\"vfb-21\" value=\"\" class=\"vfb-text  vfb-medium  required  \" \/><\/li><li class=\"vfb-item vfb-item-text  \" id=\"item-vfb-23\"><label for=\"vfb-23\" class=\"vfb-desc\">Idiomas que habla  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"text\" name=\"vfb-23\" id=\"vfb-23\" value=\"\" class=\"vfb-text  vfb-medium  required  \" \/><\/li><li class=\"vfb-item vfb-item-checkbox  \" id=\"item-vfb-25\"><label class=\"vfb-desc\">INDIQUE LOS SERVICIOS CORRESPONDIENTES QUE SOLICITA  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-25[]\" id=\"vfb-25-0\" value=\"Refugio Creativo (residencia de corto plazo \u2013 largo plazo)\" class=\"vfb-checkbox  required \" \/><label for=\"vfb-25-0\" class=\"vfb-choice\">Refugio Creativo (residencia de corto plazo \u2013 largo plazo)<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-25[]\" id=\"vfb-25-1\" value=\"Fondo de Resistencia Creativa (\u201cCreative Resistance Fund\u201d: peque\u00f1a beca de emergencia)\" class=\"vfb-checkbox  required \" \/><label for=\"vfb-25-1\" class=\"vfb-choice\">Fondo de Resistencia Creativa (\u201cCreative Resistance Fund\u201d: peque\u00f1a beca de emergencia)<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-25[]\" id=\"vfb-25-2\" value=\"Servicios\/ Recursos\" class=\"vfb-checkbox  required \" \/><label for=\"vfb-25-2\" class=\"vfb-choice\">Servicios\/ Recursos<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-checkbox  \" id=\"item-vfb-26\"><label class=\"vfb-desc\">Servicios\/ Recursos Necesarios <\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-26[]\" id=\"vfb-26-0\" value=\"Psico-sociales\" class=\"vfb-checkbox  \" \/><label for=\"vfb-26-0\" class=\"vfb-choice\">Psico-sociales<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-26[]\" id=\"vfb-26-1\" value=\"Legales\" class=\"vfb-checkbox  \" \/><label for=\"vfb-26-1\" class=\"vfb-choice\">Legales<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-26[]\" id=\"vfb-26-2\" value=\"M\u00e9dicos\" class=\"vfb-checkbox  \" \/><label for=\"vfb-26-2\" class=\"vfb-choice\">M\u00e9dicos<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-26[]\" id=\"vfb-26-3\" value=\"Empleo\" class=\"vfb-checkbox  \" \/><label for=\"vfb-26-3\" class=\"vfb-choice\">Empleo<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-26[]\" id=\"vfb-26-4\" value=\"Educaci\u00f3n\" class=\"vfb-checkbox  \" \/><label for=\"vfb-26-4\" class=\"vfb-choice\">Educaci\u00f3n<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-26[]\" id=\"vfb-26-5\" value=\"Alojamiento\/Comida\/Ropa\" class=\"vfb-checkbox  \" \/><label for=\"vfb-26-5\" class=\"vfb-choice\">Alojamiento\/Comida\/Ropa<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-26[]\" id=\"vfb-26-6\" value=\"Desarrollo Profesional\" class=\"vfb-checkbox  \" \/><label for=\"vfb-26-6\" class=\"vfb-choice\">Desarrollo Profesional<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-26[]\" id=\"vfb-26-7\" value=\"Contactos Comunitarios\" class=\"vfb-checkbox  \" \/><label for=\"vfb-26-7\" class=\"vfb-choice\">Contactos Comunitarios<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-text  \" id=\"item-vfb-27\"><label for=\"vfb-27\" class=\"vfb-desc\">Otros Servicios\/ Recursos Necesarios <\/label><input type=\"text\" name=\"vfb-27\" id=\"vfb-27\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><div id=\"item-vfb-28\" class=\"vfb-section-div \"><h4>INFORMACI\u00d3N DEL CASO<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-radio  \" id=\"item-vfb-29\"><label class=\"vfb-desc\">Por favor indique el grado de emergencia de su solicitud  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-span\"><input type=\"radio\" name=\"vfb-29\" id=\"vfb-29-1\" value=\"Bajo\" class=\"vfb-radio  required \" \/><label for=\"vfb-29-1\" class=\"vfb-choice\">Bajo<\/label><\/span><span class=\"vfb-span\"><input type=\"radio\" name=\"vfb-29\" id=\"vfb-29-2\" value=\"Constante\" class=\"vfb-radio  required \" \/><label for=\"vfb-29-2\" class=\"vfb-choice\">Constante<\/label><\/span><span class=\"vfb-span\"><input type=\"radio\" name=\"vfb-29\" id=\"vfb-29-3\" value=\"Inmediato\" class=\"vfb-radio  required \" \/><label for=\"vfb-29-3\" class=\"vfb-choice\">Inmediato<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-textarea  \" id=\"item-vfb-30\"><label for=\"vfb-30\" class=\"vfb-desc\">Por favor indique el motivo por el que solicita asistencia de freeDimensional, y d\u00e9 una descripci\u00f3n detallada de su situaci\u00f3n actual.  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><textarea name=\"vfb-30\" id=\"vfb-30\" class=\"vfb-textarea  vfb-medium  required \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-textarea  \" id=\"item-vfb-31\"><label for=\"vfb-31\" class=\"vfb-desc\">\u00bfCu\u00e1l(es) es\/son sus area(s) de trabajo? Por favor describa sus proyectos recientes y la relaci\u00f3n entre ellos y su situaci\u00f3n actual.  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><textarea name=\"vfb-31\" id=\"vfb-31\" class=\"vfb-textarea  vfb-medium  required \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-textarea  \" id=\"item-vfb-32\"><label for=\"vfb-32\" class=\"vfb-desc\">\u00bfEst\u00e1 Ud. siendo perseguido\/a debido a su trabajo art\u00edstico? (amenazas, ataques, acoso, arresto, marginalizaci\u00f3n social, \u201clista negra\u201d, censura, etc.) Si es posible, d\u00e9 ejemplos concretos con fechas, sitios, e individuos clave involucrados.  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><textarea name=\"vfb-32\" id=\"vfb-32\" class=\"vfb-textarea  vfb-medium  required \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-textarea  \" id=\"item-vfb-33\"><label for=\"vfb-33\" class=\"vfb-desc\">Existe una relaci\u00f3n entre la persecuci\u00f3n que Ud. sufre y aspectos de su identidad personal? (por ejemplo, raza, clase social, etnia, sexo u orientaci\u00f3n sexual.) Si es as\u00ed, favor de explicar.  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><textarea name=\"vfb-33\" id=\"vfb-33\" class=\"vfb-textarea  vfb-medium  required \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-textarea  \" id=\"item-vfb-34\"><label for=\"vfb-34\" class=\"vfb-desc\">\u00bfHa estado en contacto con otras organizaciones en relaci\u00f3n a su situaci\u00f3n actual, o solicitado apoyo a otros medios? Si es as\u00ed, indique la(s) organizacion(es) y la(s) persona(s) con la(s) que hizo contacto.  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><textarea name=\"vfb-34\" id=\"vfb-34\" class=\"vfb-textarea  vfb-medium  required \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-textarea  \" id=\"item-vfb-35\"><label for=\"vfb-35\" class=\"vfb-desc\">\u00bfEs Ud. miembra\/o de alguna organizaci\u00f3n, instituci\u00f3n acad\u00e9mica, o asociaci\u00f3n profesional? Si es as\u00ed, por favor describa la misi\u00f3n u objetivos profesionales de \u00e9stas, domicilio, n\u00fameros telef\u00f3nicos, correo electr\u00f3nico y nombre de una persona responsable.  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><textarea name=\"vfb-35\" id=\"vfb-35\" class=\"vfb-textarea  vfb-medium  required \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-textarea  \" id=\"item-vfb-36\"><label for=\"vfb-36\" class=\"vfb-desc\">\u00bfTiene Ud. empleo actualmente? Si es as\u00ed, por favor indique los datos de contacto de su empleador, si existe relaci\u00f3n con su situaci\u00f3n.  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><textarea name=\"vfb-36\" id=\"vfb-36\" class=\"vfb-textarea  vfb-medium  required \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-textarea  \" id=\"item-vfb-37\"><label for=\"vfb-37\" class=\"vfb-desc\">Use este espacio para cualquier otra informaci\u00f3n pertinente a su situaci\u00f3n. <\/label><div><textarea name=\"vfb-37\" id=\"vfb-37\" class=\"vfb-textarea  vfb-medium  \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-instructions  \" id=\"item-vfb-133\"><label class=\"vfb-desc\">Instructions <\/label>Please be sure to click \"Submit\" and wait until your browser finishes before going to another page. You may wish to print this page, or copy and paste your answers into an email to us, to ensure your submission is saved, in case it doesn't go through. 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