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{{ lang.name }}
{{ translations[selectedLang]['formTitle'] }}
{{ translations[selectedLang]['formSubTitle'] }}
{{ translations[selectedLang]['fullLegalName'] }}
*
{{ translations[selectedLang]['firstName'] }}
{{ translations[selectedLang]['firstNameRequired'] }}
{{ translations[selectedLang]['lastName'] }}
{{ translations[selectedLang]['lastNameRequired'] }}
{{ translations[selectedLang]['phoneNumber'] }}
*
{{ translations[selectedLang]['phoneNumberValid'] }}
{{ translations[selectedLang]['phoneNumberRequired'] }}
{{ translations[selectedLang]['phoneNumberUS'] }}
{{ translations[selectedLang]['dob'] }}
*
-
{{ translations[selectedLang]['month'] }}
-
{{ translations[selectedLang]['day'] }}
{{ translations[selectedLang]['year'] }}
{{ translations[selectedLang]['dobRequired'] }}
{{ translations[selectedLang]['email'] }}
*
example@example.com
{{ translations[selectedLang]['emailValid'] }}
{{ translations[selectedLang]['language'] }}
*
{{ translations[selectedLang]['pleaseSelect'] }}
{{ translations[selectedLang]['languageRequired'] }}
{{ translations[selectedLang]['selectLocation'] }}
*
{{ translations[selectedLang]['pleaseSelect'] }}
Bronx
Brooklyn
Hudson Valley
Long Island
Manhattan
Queens
Staten Island
Other New York State
Other Outside of New York State
{{ translations[selectedLang]['locationRequired'] }}
{{ translations[selectedLang]['labelMedicalMembers'] }}
*
{{ translations[selectedLang]['yes'] }}
{{ translations[selectedLang]['no'] }}
{{ translations[selectedLang]['medicalInsuranceSubTitle'] }}
{{ translations[selectedLang]['medicalInsuranceIfYes'] }}
{{ translations[selectedLang]['medicalInsuranceInstructions'] }}
{{ translations[selectedLang]['foodInsecuritiesA'] }}
*
{{ translations[selectedLang]['foodInsecurityA1'] }}
{{ translations[selectedLang]['foodInsecurityA2'] }}
{{ translations[selectedLang]['foodInsecurityA3'] }}
{{ translations[selectedLang]['selectOption'] }}
{{ translations[selectedLang]['foodInsecuritiesB'] }}
*
{{ translations[selectedLang]['foodInsecurityB1'] }}
{{ translations[selectedLang]['foodInsecurityB2'] }}
{{ translations[selectedLang]['foodInsecurityB3'] }}
{{ translations[selectedLang]['selectOption'] }}
{{ translations[selectedLang]['privacyPolicy'] }}
{{ translations[selectedLang]['privacyPolicyText'] }}
{{ translations[selectedLang]['agreePrivacyPolicy'] }}
{{ translations[selectedLang]['termsConditions'] }}
{{ translations[selectedLang]['termsConditionsText'] }}
{{ translations[selectedLang]['termsConditionsSubText'] }}
{{ translations[selectedLang]['agreeTermsConditions'] }}
{{ translations[selectedLang]['buttonSubmit'] }}