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MW9sLV'S#.>pZj% s=9- &y睼 Ea0b K{"^8.^zL8r7&Eaq)P'Sƍ\'\PUH*-ZUn# ˗/ϡ9wEXpFu#tUkٸq#QjY8G~@ÅJ*\]UnIY/W`ꝞdWv]AXg"8X")&=(}KgtRݗ%KNu"D /bUq텥BW6|pE(~&vg8N@&ћYfEbaN_b̘1gm[\bCΨ1jVqHڶ׫ R簢6r#$:(S%?~pv e֨QMΪ4hCiǏgW.먂@. gx{UG ԩ#XZ' -B^xRy: Nh@뮻N8m6}uǎ7T` r2ÐG=gxSOTruWT={JmD~f3:sy}| Kj 2KZz^F1W\HcT].;Jb\߿*ҥKHTKF֭[=Lej)2eP>”)S(/_|y dufQzR?4TqFuL=F_]5_|j{PO'."*sk' c0Pu:ь̓jm3ᡡ x;Ԍq3gԎ ժUFs~I @(+=Y踠ʇ %>'OR󊇨w:.f:<.HJ T h3K_p?c@J` D(:Dx kQځǠW2L8Qj />L)ջ0戱D晲ؒ:ܮ-"1<@xUuZ`(^}Hٸ@ƲeƳ|Ǎ7GP2ϟ/͙>}PN'8lׯ_ g  thFMDap&8M 1TKU*[bŊ*²0󸿳ܶ]ܽ.<tC)D\ *T4b؏Ā2d[&?1NNRr~|P3Hm މFѣC_"tO>+h͛a%`V8ڵk(/L%X#xA-̞={.pƍ41iG"NT9Ez%J-I CԊ3Od4ME氢 si̋ MzjO:4 'OƗ_~MM6-ߖTf ~XQҥ3M?)*p 3|𫯾*1p PJLÀ< wȄHW\ T_tiX7]kϖ#G;={΃H!Cn ܱ-9K`ϟUo!sy  v\SG^(ZFlpJ[u.2k֬QUuwjx~@L2x۷vkuAjSOYJSH@ch4Yf#qE}~wD UZ=E̓ ԥŠݻ7N3F=HWO.]c >տo5jW^yEiC bYjP˗T@"E+8eAOլYShk׮2貋r˻<TCL7-oUpgo@J*d] z|HA6){DΝ[X16[8*jxAW`rR(Pu1w) ^mPdI SNʕ1@>{|'{bxQbРA*>2 yDž%b%sKnɒ%m8uɴ!^8je˖T듬bȐ!B ~kO\_z:&̉ٳg6^hܸYЀ5m5C+WonS'ը ; Dr6I*$ðR$-X7o^4SB1ۅA x)*?L}mOwB*U5SF}|rsc}.V k׮:~ɳ gN @ueWhXQ;kl|pL]3۷Ьl{TWՀ}{OT*ݨǏs7)!ʯ`C߿gΩTR:)C*?QN>qӅ[iX]vٳgWH֍BTѥ OFFo/^/FD[ZM}U. ӧG++WtwE%S 9A+ ej$ZX6ۜ9srNf8x)W^yEƀ Q_lBt~ 6ܣ(5JyС//TxaXNw@K X5 H,s۶m14Ԗ]2DiaK3s!iDR=̑#pY?Vf1/4cǎLzӝxbs ل".wBΝgaoι3gH__4C! lݰaèo,cǎ~jr֬YcYm/0dDꫯ@I㩆p_m9T8u4JFۧ=6JǓײH֝笑W񘞧#)qmxQwP&BAgD vk|̈́ʕ+3ekb˗/7n?ZjqͣwmEMy*I0[QFa9yI1bD < 6A㬈Y8/ aЄW^9sQɽ9T 9 .F*TFIs8x Fa!wϟ] T?y%KP tA3f̘0a39͜=kڴ)CVJogҥ4(A,ZȶIݻ8@#ܹs0D{ռGBl/rE \|cj+S]v!A9G*-~;w.AK oAh1   7QMtk* _5JcNDQw+"mZ.Pz{JTrc`굧â Y< &A JP] endstream endobj 78 0 obj <> endobj 2 0 obj <> /ExtGState << /GS1 68 0 R >> /XObject << /TPL0 77 0 R /TPL1 83 0 R /TPL2 84 0 R >> >> endobj 95 0 obj << /Names [(EmbeddedJS) 96 0 R ] >> endobj 96 0 obj << /S /JavaScript /JS ( var requiredFieldsString = 'q3_yourName3[first]q3_yourName3[last]q31_yourContact31[area]q31_yourContact31[phone]q32_yourAddress32[addr_line1]q32_yourAddress32[addr_line2]q32_yourAddress32[city]q32_yourAddress32[state]q32_yourAddress32[postal]q30_yourChildstudents30[first]q30_yourChildstudents30[last]q21_yourChildstudents[month]q21_yourChildstudents[day]q21_yourChildstudents[year]q42_pleaseSelect42[0]q42_pleaseSelect42[1]q42_pleaseSelect42[2]q42_pleaseSelect42[3]q35_iAttestthatq35_iAttestthatq34_bySigningq34_bySigningq33_bySigning33q33_bySigning33q7_dateOf[month]q7_dateOf[day]q7_dateOf[year]'; var submitUrl = 'https://hipaa.jotform.com/submit.php'; /* eslint-disable */ console.println\(requiredFieldsString\); function replaceAll\(string, search, replacement\) { return string.split\(search\).join\(replacement\); } function isOtherFieldFilled\(fieldName\) { var otherFieldVal = this.getField\(fieldName+'[other]'\).valueAsString; if \(!otherFieldVal || otherFieldVal.length == 0\) { return false; } return true; } function isCheckboxFilled\(values\) { for \(var i = 0; i < values.length; i++\) { if \(values[i] !== 'Off'\) { return true; } } return false; } function isFieldInvalid\(field\) { switch \(field.type\) { case 'text': if\(field.required && field.value.length === 0 && field.name.indexOf\('[other]'\) < 1\){ return true; } break; case 'combobox': if\(field.required && field.value.length === 0\){ return true; } default: break; } return false; } // Since we modified Single Choice and Multiple Choice fields' values before submitting the form, // PDF Readers can not fill the values back. We need to set original values after errors and submissions. function revertToOriginalValues\(valuesAtFirst\){ for \(var i = 0; i < valuesAtFirst.length; i++\) { var f = this.getField\(valuesAtFirst[i].fieldName\); console.println\("Field Name: " + f.name + " value: " + f.value\) if \(f\) { f.value = valuesAtFirst[i].originalValue; } } } if \( this.app.viewerType == "Reader" || this.app.viewerType == "Exchange" || this.app.viewerType == "Exchange-Pro" || // Taken from: https://www.adobe.com/content/dam/acom/en/devnet/acrobat/pdfs/js_api_reference.pdf \(Page 96\) this.app.viewerType == "Foxit Reader" \) { this.getField\('adobeWarning'\).display = display.hidden; this.getField\('fakeSubmitButton'\).display = display.hidden; } else { this.getField\('submitButton'\).display = display.hidden; } function FormSubmit\(\) { var postFields = new Array\(\); var checkboxGroups = {}; var valuesAtFirst = []; console.println\('new topdf function'\); for \(var j = 0; j < numFields; j++\) { var fn = getNthFieldName\(j\); var f = this.getField\(fn\); if \(f !== null\) { postFields.push\(fn\); var strippedName = f.name.replace\(/\\[.*.\\]/, ''\); if \( \(f.type !== 'button' && f.type !== 'radiobutton' && f.type !== 'checkbox'\) && isFieldInvalid\(f\) \) { revertToOriginalValues\(valuesAtFirst\); app.alert\('One or more fields are required.'\); return; } else if \(\(f.type === 'radiobutton' || f.type === 'checkbox'\)\) { if \(requiredFieldsString.match\(strippedName\) !== null\) { if \( \(f.type === 'radiobutton' && f.valueAsString === 'Off'\) || \(f.valueAsString === 'other' && !isOtherFieldFilled\(f.name\)\) \) { revertToOriginalValues\(valuesAtFirst\); app.alert\('One or more fields are required.'\); return; } if \(f.type === 'checkbox'\) { if \(checkboxGroups[strippedName] === undefined\) { checkboxGroups[strippedName] = new Array\(\); } checkboxGroups[strippedName].push\(f.value\); } } if \(typeof f.value === 'string'\) { valuesAtFirst.push\({ fieldName: f.name, originalValue: f.value }\); f.value = replaceAll\(replaceAll\(f.value, ':percentage:', '%'\), ':plus:', '+'\); 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