{"id":329,"date":"2023-05-01T04:20:03","date_gmt":"2023-05-01T04:20:03","guid":{"rendered":"https:\/\/mypopi.org\/?page_id=329"},"modified":"2023-05-01T04:24:37","modified_gmt":"2023-05-01T04:24:37","slug":"register","status":"publish","type":"page","link":"https:\/\/mypopi.org\/bm\/register\/","title":{"rendered":"Daftar"},"content":{"rendered":"<div id=\"fws_6a1af585dbcd0\"  data-column-margin=\"default\" data-midnight=\"dark\"  class=\"wpb_row vc_row-fluid vc_row\"  style=\"padding-top: 0px; padding-bottom: 0px; \"><div class=\"row-bg-wrap\" data-bg-animation=\"none\" data-bg-animation-delay=\"\" data-bg-overlay=\"false\"><div class=\"inner-wrap row-bg-layer\" ><div class=\"row-bg viewport-desktop\"  style=\"\"><\/div><\/div><\/div><div class=\"row_col_wrap_12 col span_12 dark left\">\n\t<div  class=\"vc_col-sm-12 wpb_column column_container vc_column_container col no-extra-padding inherit_tablet inherit_phone\"  data-padding-pos=\"all\" data-has-bg-color=\"false\" data-bg-color=\"\" data-bg-opacity=\"1\" data-animation=\"\" data-delay=\"0\" >\n\t\t<div class=\"vc_column-inner\" >\n\t\t\t<div class=\"wpb_wrapper\">\n\t\t\t\t\n<div class=\"wpb_text_column wpb_content_element\" >\n\t<div class=\"wpb_wrapper\">\n\t\t<h2>Pendaftaran menjadi ahli MYPOPI (Pendaftaran Keahlian MYPOPI)<\/h2>\n<p>Terima Kasih kerana berminat untuk menjadi sebahagian daripada ahli MYPOPI<\/p>\n<div>\n<p>Data yang dikumpul oleh MYPOPI akan digunakan untuk tujuan berikut:<\/p>\n<ul>\n<li>Data peribadi akan digunakan oleh MYPOPI untuk perkongsian maklumat (tidak terhad kepada surat berita dan risalah) yang diterbitkan untuk ahlinya dan pihak berkepentingan yang berminat. Pihak ketiga mungkin mempunyai akses kepada data ini hanya untuk tujuan mel atau emel.<\/li>\n<li>Data perubatan hanya akan diakses oleh MYPOPI untuk mengumpulkan data, analisis keahliannya untuk menambah baik perwakilan yang dilakukan oleh MYPOPI untuk pesakit imunodefisiensi primer (PID) di Malaysia. Data individu tidak akan didedahkan pada bila-bila masa. Data yang dikumpul melalui sistem ini hanya akan dipaparkan dalam bentuk tanpa nama dan terkumpul.<\/li>\n<\/ul>\n<div>Terima kasih kerana berminat menjadi ahli MYPOPI<br \/>\nSelamat datang!<\/div>\n<div>\n<p>Data yang dikumpul oleh MyPOPI hendaklah digunakan untuk tujuan berikut:<\/p>\n<ul>\n<li>Data peribadi akan digunakan oleh MyPOPI untuk perkongsian maklumat dan bahan (termasuk surat berita, bahan\u2026) yang dibangunkan untuk ahlinya dan pihak berkepentingan yang berminat. Pihak ketiga mungkin mempunyai akses kepada data ini hanya untuk tujuan mel keluar.<\/li>\n<li>Data perubatan hanya akan digunakan dan diakses oleh MyPOPI untuk pengumpulan data, analisis keahliannya untuk menambah baik perwakilan yang dilakukan oleh MyPOPI untuk pesakit dengan kekurangan imun primer (PID) di Malaysia. Data individu tidak akan didedahkan pada bila-bila masa. Data yang dikumpul melalui sistem ini hanya akan dipaparkan dalam bentuk tanpa nama dan terkumpul.<\/li>\n<\/ul>\n<\/div>\n<\/div>\n\t<\/div>\n<\/div>\n\n\n\n\n\t\t\t<\/div> \n\t\t<\/div>\n\t<\/div> \n<\/div><\/div>\n\t\t<div id=\"fws_6a1af585dcbc5\"  data-column-margin=\"default\" data-midnight=\"dark\"  class=\"wpb_row vc_row-fluid vc_row\"  style=\"padding-top: 0px; padding-bottom: 0px; \"><div class=\"row-bg-wrap\" data-bg-animation=\"none\" data-bg-animation-delay=\"\" data-bg-overlay=\"false\"><div class=\"inner-wrap row-bg-layer\" ><div class=\"row-bg viewport-desktop\"  style=\"\"><\/div><\/div><\/div><div class=\"row_col_wrap_12 col span_12 dark left\">\n\t<div  class=\"vc_col-sm-12 wpb_column column_container vc_column_container col no-extra-padding inherit_tablet inherit_phone\"  data-padding-pos=\"all\" data-has-bg-color=\"false\" data-bg-color=\"\" data-bg-opacity=\"1\" data-animation=\"\" data-delay=\"0\" >\n\t\t<div class=\"vc_column-inner\" >\n\t\t\t<div class=\"wpb_wrapper\">\n\t\t\t\t\n\t<div class=\"wpb_raw_code wpb_content_element wpb_raw_html\" >\n\t\t<div class=\"wpb_wrapper\">\n\t\t\t<div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-324\"><form id=\"wpforms-form-324\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"324\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/bm\/wp-json\/wp\/v2\/pages\/329\" data-token=\"a6fdf83fa78a7c7aa062286c6ce6023c\" data-trp-original-action=\"\/bm\/wp-json\/wp\/v2\/pages\/329\"><noscript class=\"wpforms-error-noscript\">Sila dayakan JavaScript dalam penyemak imbas anda untuk melengkapkan borang ini.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Sila dayakan JavaScript dalam penyemak imbas anda untuk melengkapkan borang ini.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-324-field_3-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-324-field_3\">E-mel <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-324-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" spellcheck=\"false\" aria-errormessage=\"wpforms-324-field_3-error\" required><\/div><div id=\"wpforms-324-field_35-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-324-field_35\">Siapakah diri anda untuk menjadi ahli MYPOPI? (Siapa anda untuk menjadi ahli MYPOPI?)<\/label><select id=\"wpforms-324-field_35\" class=\"wpforms-field-medium\" name=\"wpforms[fields][35]\"><option value=\"saya adalah pesakit PID dewasa (I am an adult PID patient)\"  selected='selected'>saya adalah pesakit PID dewasa (I am an adult PID patient)<\/option><option value=\"saya adalah ibubapa\/penjaga kepada anak PID ( I am a Parent \/ Guardian  to PID child \/ children)\" >saya adalah ibubapa\/penjaga kepada anak PID ( I am a Parent \/ Guardian to PID child \/ children)<\/option><option value=\"saya adalah saudara \/ adik beradik pesakit PID yang berumur &gt;18 tahun (I am relative \/ siblings to a PID patient and I am over 18 years old)\" >saya adalah saudara \/ adik beradik pesakit PID yang berumur &gt;18 tahun (I am relative \/ siblings to a PID patient and I am over 18 years old)<\/option><option value=\"saya hendak menjadi ahli bersekutu \/ sukarelawan (I want to be an Associate Member \/ Volunteer)\" >saya hendak menjadi ahli bersekutu \/ sukarelawan (I want to be an Associate Member \/ Volunteer)<\/option><\/select><\/div><div id=\"wpforms-324-field_32-container\" class=\"wpforms-field wpforms-field-divider wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"32\" style=\"display:none;\"><h3 id=\"wpforms-324-field_32\" name=\"wpforms[fields][32]\" aria-errormessage=\"wpforms-324-field_32-error\">BORANG KEAHLIAN PESAKIT PID DEWASA<\/h3><\/div><div id=\"wpforms-324-field_51-container\" class=\"wpforms-field wpforms-field-divider wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"51\" style=\"display:none;\"><h3 id=\"wpforms-324-field_51\" name=\"wpforms[fields][51]\" aria-errormessage=\"wpforms-324-field_51-error\">Saya adalah ibubapa\/penjaga kepada anak PID ( I am a Parent \/ Guardian to PID child \/ children)<\/h3><\/div><div id=\"wpforms-324-field_52-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"52\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Adakah hubungan anda dengan pesakit? (Apakah hubungan anda dengan pesakit)<\/legend><ul id=\"wpforms-324-field_52\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_52_1\" name=\"wpforms[fields][52]\" value=\"Bapa \/ Penjaga (Father \/ Guardian \/ Caretaker)\" aria-errormessage=\"wpforms-324-field_52_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_52_1\">Bapa \/ Penjaga (Bapa \/ Penjaga \/ Penjaga)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_52_2\" name=\"wpforms[fields][52]\" value=\"Ibu (Mother)\" aria-errormessage=\"wpforms-324-field_52_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_52_2\">ibu (ibu)<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_52_3\" name=\"wpforms[fields][52]\" value=\"Saudara mara (relatives)\" aria-errormessage=\"wpforms-324-field_52_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_52_3\">Saudara mara (saudara mara)<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_52_4\" name=\"wpforms[fields][52]\" value=\"Other\" aria-errormessage=\"wpforms-324-field_52_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_52_4\">Lain-lain<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-324-field_44-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"44\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-324-field_44\" aria-hidden=\"false\">Susun atur<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-324-field_33-container\" class=\"wpforms-field wpforms-field-name wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"33\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-324-field_33\">Nama Penuh (mengikut MyKad\/IC) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-324-field_33\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][33]\" aria-errormessage=\"wpforms-324-field_33-error\" required><\/div><div id=\"wpforms-324-field_36-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"36\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-324-field_36\">No. Telefon Bimbit (Nombor Mudah Alih)<\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-324-field_36\" class=\"wpforms-field-medium\" name=\"wpforms[fields][36]\" aria-errormessage=\"wpforms-324-field_36-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-324-field_34-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"34\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-324-field_34\">Nombor Kad Pengenalan (nombor kad pengenalan)<\/label><input type=\"text\" id=\"wpforms-324-field_34\" class=\"wpforms-field-medium\" name=\"wpforms[fields][34]\" aria-errormessage=\"wpforms-324-field_34-error\" ><\/div><div id=\"wpforms-324-field_37-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"37\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-324-field_37\">Tarikh Lahir (Tarikh Lahir)<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-324-field_37\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][37][date]\" aria-errormessage=\"wpforms-324-field_37-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-324-field_42-container\" class=\"wpforms-field wpforms-field-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"42\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Alamat surat-menyurat (Alamat surat menyurat)<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-324-field_42\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][42][address1]\" aria-errormessage=\"wpforms-324-field_42-error\" ><label for=\"wpforms-324-field_42\" class=\"wpforms-field-sublabel after\">Alamat Baris 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-324-field_42-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][42][address2]\" aria-errormessage=\"wpforms-324-field_42-address2-error\" ><label for=\"wpforms-324-field_42-address2\" class=\"wpforms-field-sublabel after\">Alamat 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-324-field_42-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][42][city]\" aria-errormessage=\"wpforms-324-field_42-city-error\" ><label for=\"wpforms-324-field_42-city\" class=\"wpforms-field-sublabel after\">Bandar<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-324-field_42-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][42][state]\" aria-errormessage=\"wpforms-324-field_42-state-error\" ><label for=\"wpforms-324-field_42-state\" class=\"wpforms-field-sublabel after\">Negeri \/ Wilayah \/ Wilayah<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-324-field_42-postal\" class=\"wpforms-field-address-postal\" name=\"wpforms[fields][42][postal]\" aria-errormessage=\"wpforms-324-field_42-postal-error\" ><label for=\"wpforms-324-field_42-postal\" class=\"wpforms-field-sublabel after\">Poskod<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-324-field_42-country\" class=\"wpforms-field-address-country\" name=\"wpforms[fields][42][country]\" value=\"MY\" aria-errormessage=\"wpforms-324-field_42-country-error\" ><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antartika<\/option><option value=\"AG\" >Antigua dan Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Negeri Plurinasi)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius dan Saba<\/option><option value=\"BA\" >Bosnia dan Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Pulau Bouvet<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >Wilayah Lautan Hindi British<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Kemboja<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Kanada<\/option><option value=\"KY\" >Pulau Cayman<\/option><option value=\"CF\" >Republik Afrika Tengah<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Pulau Krismas<\/option><option value=\"CC\" >Kepulauan Cocos (Keeling).<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Republik Demokratik)<\/option><option value=\"CK\" >Kepulauan Cook<\/option><option value=\"CR\" >Costa rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Republik Czech<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Republik Dominican<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Mesir<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Guinea Khatulistiwa<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kerajaan)<\/option><option value=\"ET\" >Habsyah<\/option><option value=\"FK\" >Kepulauan Falkland (Malvinas)<\/option><option value=\"FO\" >Pulau Faroe<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >Perancis<\/option><option value=\"GF\" >Guiana Perancis<\/option><option value=\"PF\" >Polynesia Perancis<\/option><option value=\"TF\" >Wilayah Selatan Perancis<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Jerman<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Pulau Heard dan Pulau McDonald<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Republik Islam)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republik)<\/option><option value=\"IM\" >Pulau Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Itali<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Jepun<\/option><option value=\"JE\" >Jersi<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Republik Rakyat Demokrasi&#039;)<\/option><option value=\"KR\" >Republik Korea)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Republik Demokratik Rakyat Lao<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lubnan<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macau<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\"  selected='selected'>Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Pulau Marshall<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Negeri Bersekutu)<\/option><option value=\"MD\" >Moldova (Republik)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Maghribi<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Belanda<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Pulau Norfolk<\/option><option value=\"MK\" >Macedonia Utara (Republik)<\/option><option value=\"MP\" >Kepulauan Mariana Utara<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestin (Negeri)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Filipina<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Persekutuan Russia<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension dan Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts dan Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (bahagian Perancis)<\/option><option value=\"PM\" >Saint Pierre dan Miquelon<\/option><option value=\"VC\" >Saint Vincent dan Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome dan Principe<\/option><option value=\"SA\" >Arab Saudi<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapura<\/option><option value=\"SX\" >Sint Maarten (bahagian Belanda)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Kepulauan Solomon<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >Afrika Selatan<\/option><option value=\"GS\" >Georgia Selatan dan Kepulauan Sandwich Selatan<\/option><option value=\"SS\" >selatan Sudan<\/option><option value=\"ES\" >Sepanyol<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard dan Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Republik Arab Syria<\/option><option value=\"TW\" >Taiwan, Republik China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (Republik Bersatu)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Untuk pergi<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad dan Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Kepulauan Turks dan Caicos<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >Emiriah Arab Bersatu<\/option><option value=\"GB\" >United Kingdom of Great Britain dan Ireland Utara<\/option><option value=\"UM\" >Kepulauan Terpencil Kecil Amerika Syarikat<\/option><option value=\"US\" >Amerika Syarikat<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Negara Kota Vatican<\/option><option value=\"VE\" >Venezuela (Republik Bolivia)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Kepulauan Virgin (British)<\/option><option value=\"VI\" >Kepulauan Virgin (AS)<\/option><option value=\"WF\" >Wallis dan Futuna<\/option><option value=\"EH\" >Sahara Barat<\/option><option value=\"YE\" >Yaman<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >Kepulauan \u00c5land<\/option><\/select><label for=\"wpforms-324-field_42-country\" class=\"wpforms-field-sublabel after\">Negara<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-324-field_41-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"41\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Alamat Kediaman sama dengan alamat surat-menyurat<\/legend><ul id=\"wpforms-324-field_41\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-324-field_41_1\" name=\"wpforms[fields][41]\" value=\"Yes\" aria-errormessage=\"wpforms-324-field_41_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_41_1\">ya<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_41_2\" name=\"wpforms[fields][41]\" value=\"No\" aria-errormessage=\"wpforms-324-field_41_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_41_2\">Tidak<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-324-field_43-container\" class=\"wpforms-field wpforms-field-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"43\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Alamat Rumah (Alamat Kediaman)<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-324-field_43\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][43][address1]\" aria-errormessage=\"wpforms-324-field_43-error\" ><label for=\"wpforms-324-field_43\" class=\"wpforms-field-sublabel after\">Alamat Baris 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-324-field_43-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][43][address2]\" aria-errormessage=\"wpforms-324-field_43-address2-error\" ><label for=\"wpforms-324-field_43-address2\" class=\"wpforms-field-sublabel after\">Alamat 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-324-field_43-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][43][city]\" aria-errormessage=\"wpforms-324-field_43-city-error\" ><label for=\"wpforms-324-field_43-city\" class=\"wpforms-field-sublabel after\">Bandar<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-324-field_43-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][43][state]\" aria-errormessage=\"wpforms-324-field_43-state-error\" ><label for=\"wpforms-324-field_43-state\" class=\"wpforms-field-sublabel after\">Negeri \/ Wilayah \/ Wilayah<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-324-field_43-postal\" class=\"wpforms-field-address-postal\" name=\"wpforms[fields][43][postal]\" aria-errormessage=\"wpforms-324-field_43-postal-error\" ><label for=\"wpforms-324-field_43-postal\" class=\"wpforms-field-sublabel after\">Poskod<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-324-field_43-country\" class=\"wpforms-field-address-country\" name=\"wpforms[fields][43][country]\" aria-errormessage=\"wpforms-324-field_43-country-error\" ><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antartika<\/option><option value=\"AG\" >Antigua dan Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Negeri Plurinasi)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius dan Saba<\/option><option value=\"BA\" >Bosnia dan Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Pulau Bouvet<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >Wilayah Lautan Hindi British<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Kemboja<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Kanada<\/option><option value=\"KY\" >Pulau Cayman<\/option><option value=\"CF\" >Republik Afrika Tengah<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Pulau Krismas<\/option><option value=\"CC\" >Kepulauan Cocos (Keeling).<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Republik Demokratik)<\/option><option value=\"CK\" >Kepulauan Cook<\/option><option value=\"CR\" >Costa rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Republik Czech<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Republik Dominican<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Mesir<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Guinea Khatulistiwa<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kerajaan)<\/option><option value=\"ET\" >Habsyah<\/option><option value=\"FK\" >Kepulauan Falkland (Malvinas)<\/option><option value=\"FO\" >Pulau Faroe<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >Perancis<\/option><option value=\"GF\" >Guiana Perancis<\/option><option value=\"PF\" >Polynesia Perancis<\/option><option value=\"TF\" >Wilayah Selatan Perancis<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Jerman<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Pulau Heard dan Pulau McDonald<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Republik Islam)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republik)<\/option><option value=\"IM\" >Pulau Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Itali<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Jepun<\/option><option value=\"JE\" >Jersi<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Republik Rakyat Demokrasi&#039;)<\/option><option value=\"KR\" >Republik Korea)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Republik Demokratik Rakyat Lao<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lubnan<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macau<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Pulau Marshall<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Negeri Bersekutu)<\/option><option value=\"MD\" >Moldova (Republik)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Maghribi<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Belanda<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Pulau Norfolk<\/option><option value=\"MK\" >Macedonia Utara (Republik)<\/option><option value=\"MP\" >Kepulauan Mariana Utara<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestin (Negeri)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Filipina<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Persekutuan Russia<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension dan Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts dan Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (bahagian Perancis)<\/option><option value=\"PM\" >Saint Pierre dan Miquelon<\/option><option value=\"VC\" >Saint Vincent dan Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome dan Principe<\/option><option value=\"SA\" >Arab Saudi<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapura<\/option><option value=\"SX\" >Sint Maarten (bahagian Belanda)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Kepulauan Solomon<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >Afrika Selatan<\/option><option value=\"GS\" >Georgia Selatan dan Kepulauan Sandwich Selatan<\/option><option value=\"SS\" >selatan Sudan<\/option><option value=\"ES\" >Sepanyol<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard dan Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Republik Arab Syria<\/option><option value=\"TW\" >Taiwan, Republik China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (Republik Bersatu)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Untuk pergi<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad dan Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Kepulauan Turks dan Caicos<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >Emiriah Arab Bersatu<\/option><option value=\"GB\" >United Kingdom of Great Britain dan Ireland Utara<\/option><option value=\"UM\" >Kepulauan Terpencil Kecil Amerika Syarikat<\/option><option value=\"US\" >Amerika Syarikat<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Negara Kota Vatican<\/option><option value=\"VE\" >Venezuela (Republik Bolivia)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Kepulauan Virgin (British)<\/option><option value=\"VI\" >Kepulauan Virgin (AS)<\/option><option value=\"WF\" >Wallis dan Futuna<\/option><option value=\"EH\" >Sahara Barat<\/option><option value=\"YE\" >Yaman<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >Kepulauan \u00c5land<\/option><\/select><label for=\"wpforms-324-field_43-country\" class=\"wpforms-field-sublabel after\">Negara<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-324-field_45-container\" class=\"wpforms-field wpforms-field-divider wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"45\" style=\"display:none;\"><h3 id=\"wpforms-324-field_45\" name=\"wpforms[fields][45]\" aria-errormessage=\"wpforms-324-field_45-error\">Mengenal pasti tahap kesihatan Pesakit PID dewasa (Mengenal pasti tahap kesihatan pesakit PID dewasa)<\/h3><\/div><div id=\"wpforms-324-field_47-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"47\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Nyatakan Jenis PID yang anda alami (Sila nyatakan Jenis PID anda)<\/legend><ul id=\"wpforms-324-field_47\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_47_1\" name=\"wpforms[fields][47][]\" value=\"Ataxia Telangiectasia (A-T)\" aria-errormessage=\"wpforms-324-field_47_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_47_1\">Ataxia Telangiectasia (AT)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_47_2\" name=\"wpforms[fields][47][]\" value=\"Autoimmune Lymphoproliferative Syndrome (ALPS)\" aria-errormessage=\"wpforms-324-field_47_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_47_2\">Sindrom Limfoproliferatif Autoimun (ALPS)<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_47_3\" name=\"wpforms[fields][47][]\" value=\"Bruton&#039;s Agammaglobulinemia (XLA)\" aria-errormessage=\"wpforms-324-field_47_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_47_3\">Agammaglobulinemia Bruton (XLA)<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_47_4\" name=\"wpforms[fields][47][]\" value=\"Chronic Granulomatous Disease (CGD)\" aria-errormessage=\"wpforms-324-field_47_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_47_4\">Penyakit Granulomatosa Kronik (CGD)<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_47_5\" name=\"wpforms[fields][47][]\" value=\"Combined Variable Immunodeficiency (CVID)\" aria-errormessage=\"wpforms-324-field_47_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_47_5\">Kekurangan Imunobolehubah Gabungan (CVID)<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_47_6\" name=\"wpforms[fields][47][]\" value=\"Hyper IgE Syndrome (HyperIgE)\" aria-errormessage=\"wpforms-324-field_47_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_47_6\">Sindrom Hyper IgE (HyperIgE)<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_47_7\" name=\"wpforms[fields][47][]\" value=\"Hyper IgM Syndrome (HyperIgM)\" aria-errormessage=\"wpforms-324-field_47_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_47_7\">Sindrom Hyper IgM (HyperIgM)<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_47_8\" name=\"wpforms[fields][47][]\" value=\"Hypoagammaglobulinemia Syndrome\" aria-errormessage=\"wpforms-324-field_47_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_47_8\">Sindrom Hypoagammaglobulinemia<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_47_9\" name=\"wpforms[fields][47][]\" value=\"Immunoglobulin A Deficiency (IgA)\" aria-errormessage=\"wpforms-324-field_47_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_47_9\">Kekurangan Imunoglobulin A (IgA)<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_47_10\" name=\"wpforms[fields][47][]\" value=\"Primary Hemophagocytic LymphoHistiocytosis (HLH)\" aria-errormessage=\"wpforms-324-field_47_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_47_10\">LimfoHistiositosis Hemophagocytic Primer (HLH)<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_47_11\" name=\"wpforms[fields][47][]\" value=\"Severe Combined Immunodeficiency (SCID)\" aria-errormessage=\"wpforms-324-field_47_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_47_11\">Kekurangan Imun Gabungan Teruk (SCID)<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_47_12\" name=\"wpforms[fields][47][]\" value=\"Severe Congenital Neutropenia (SCN)4\" aria-errormessage=\"wpforms-324-field_47_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_47_12\">Neutropenia Kongenital Teruk (SCN)4<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_47_13\" name=\"wpforms[fields][47][]\" value=\"Wiskott-Aldrich Syndrome (WAS)\" aria-errormessage=\"wpforms-324-field_47_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_47_13\">Sindrom Wiskott-Aldrich (WAS)<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_47_14\" name=\"wpforms[fields][47][]\" value=\"Other\" aria-errormessage=\"wpforms-324-field_47_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_47_14\">Lain-lain<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-324-field_80-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"80\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-324-field_80\" aria-hidden=\"false\">Susun atur<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-324-field_48-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"48\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-324-field_48\">Di hospital manakah anda mendapat rawatan sekarang? Nyatakan Hospital yang berkenaan. (Di manakah anda mendapatkan rawatan anda? Sila nyatakan hospital anda yang merawat)<\/label><input type=\"text\" id=\"wpforms-324-field_48\" class=\"wpforms-field-medium\" name=\"wpforms[fields][48]\" aria-errormessage=\"wpforms-324-field_48-error\" ><\/div><div id=\"wpforms-324-field_49-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"49\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-324-field_49\">Di hospital mana anda mendapatkan rawatan klinikal? Sila nyatakan Hospital berkenaan. (Di manakah anda mendapatkan perundingan klinikal anda? Sila nyatakan hospital klinikal anda)<\/label><input type=\"text\" id=\"wpforms-324-field_49\" class=\"wpforms-field-medium\" name=\"wpforms[fields][49]\" aria-errormessage=\"wpforms-324-field_49-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-324-field_50-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"50\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Siapa doktor imunologi klinikal anda?<\/legend><ul id=\"wpforms-324-field_50\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_50_1\" name=\"wpforms[fields][50]\" value=\"Prof Dr Lokman M Noh\" aria-errormessage=\"wpforms-324-field_50_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_50_1\">Prof Dr Lokman M Noh<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_50_2\" name=\"wpforms[fields][50]\" value=\"Dr. Amir Abdul Latiff, HPKL\" aria-errormessage=\"wpforms-324-field_50_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_50_2\">Dr Amir Abdul Latiff, HPKL<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_50_3\" name=\"wpforms[fields][50]\" value=\"Assoc. Prof. Dr. Intan Hakimah, HUPM\" aria-errormessage=\"wpforms-324-field_50_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_50_3\">Prof. Madya Dr Intan Hakimah, HUPM<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_50_4\" name=\"wpforms[fields][50]\" value=\"Dr. Adli Ali, HPKK UKM\" aria-errormessage=\"wpforms-324-field_50_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_50_4\">Dr Adli Ali, HPKK UKM<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_50_5\" name=\"wpforms[fields][50]\" value=\"Dr. Intan Juliana, HUSM\" aria-errormessage=\"wpforms-324-field_50_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_50_5\">Dr Intan Juliana, HUSM<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_50_6\" name=\"wpforms[fields][50]\" value=\"Dr. Mohd Azri, HUPM\" aria-errormessage=\"wpforms-324-field_50_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_50_6\">Dr Mohd Azri, HUPM<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_50_7\" name=\"wpforms[fields][50]\" value=\"Dr. Sangeetha Sinah, HTA KL\" aria-errormessage=\"wpforms-324-field_50_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_50_7\">Dr Sangeetha Sinah, HTA KL<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_50_8\" name=\"wpforms[fields][50]\" value=\"Dr. Marina Sham, HTA KL\" aria-errormessage=\"wpforms-324-field_50_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_50_8\">Dr Marina Sham, HTA KL<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_50_9\" name=\"wpforms[fields][50]\" value=\"Other\" aria-errormessage=\"wpforms-324-field_50_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_50_9\">Lain-lain<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-324-field_77-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"77\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-324-field_77\" aria-hidden=\"false\">Susun atur<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-324-field_53-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"53\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Adakah anak anda masih mendapat rawatan atau telah meninggal dunia? (Adakah anak anda masih menerima rawatan atau sudah meninggal dunia?)<\/legend><ul id=\"wpforms-324-field_53\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_53_1\" name=\"wpforms[fields][53]\" value=\"Ya, masih dirawat (yes, still treated )\" aria-errormessage=\"wpforms-324-field_53_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_53_1\">Ya, masih dirawat (yes, still treated )<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_53_2\" name=\"wpforms[fields][53]\" value=\"Tidak, anak saya telah meninggal dunia (no, my child has deceased)\" aria-errormessage=\"wpforms-324-field_53_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_53_2\">Tidak, anak saya telah meninggal dunia (tidak, anak saya telah meninggal dunia)<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-324-field_55-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"55\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-324-field_55\">Nyatakan jumlah anak - termasuk yang telah meninggal dunia (Total No of Children including deceased)<\/label><input type=\"text\" id=\"wpforms-324-field_55\" class=\"wpforms-field-medium\" name=\"wpforms[fields][55]\" aria-errormessage=\"wpforms-324-field_55-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-324-field_56-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"56\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">berapa bilangan anak yang meninggal dunia? (Jumlah Bilangan Anak Meninggal Dunia)<\/legend><ul id=\"wpforms-324-field_56\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_56_1\" name=\"wpforms[fields][56]\" value=\"1\" aria-errormessage=\"wpforms-324-field_56_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_56_1\">1<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_56_2\" name=\"wpforms[fields][56]\" value=\"2\" aria-errormessage=\"wpforms-324-field_56_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_56_2\">2<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_56_3\" name=\"wpforms[fields][56]\" value=\"3\" aria-errormessage=\"wpforms-324-field_56_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_56_3\">3<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_56_4\" name=\"wpforms[fields][56]\" value=\"More than 3\" aria-errormessage=\"wpforms-324-field_56_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_56_4\">Lebih daripada 3<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-324-field_57-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"57\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Berapa anak pesakit PID? (Berapa ramai kanak-kanak pesakit PID?)<\/legend><ul id=\"wpforms-324-field_57\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_57_1\" name=\"wpforms[fields][57]\" value=\"1\" aria-errormessage=\"wpforms-324-field_57_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_57_1\">1<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_57_2\" name=\"wpforms[fields][57]\" value=\"2\" aria-errormessage=\"wpforms-324-field_57_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_57_2\">2<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_57_3\" name=\"wpforms[fields][57]\" value=\"3\" aria-errormessage=\"wpforms-324-field_57_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_57_3\">3<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_57_4\" name=\"wpforms[fields][57]\" value=\"More than 3\" aria-errormessage=\"wpforms-324-field_57_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_57_4\">Lebih daripada 3<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-324-field_58-container\" class=\"wpforms-field wpforms-field-divider wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"58\" style=\"display:none;\"><h3 id=\"wpforms-324-field_58\" name=\"wpforms[fields][58]\" aria-errormessage=\"wpforms-324-field_58-error\">Informasi Anak Pesakit PID (Maklumat Anak PID)<\/h3><\/div><div id=\"wpforms-324-field_59-container\" class=\"wpforms-field wpforms-field-name wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"59\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-324-field_59\">Nama Penuh Anak Pertama (Mengikut MyKid) 1st Child Full Name (as per MyKid)<\/label><input type=\"text\" id=\"wpforms-324-field_59\" class=\"wpforms-field-medium\" name=\"wpforms[fields][59]\" aria-errormessage=\"wpforms-324-field_59-error\" ><\/div><div id=\"wpforms-324-field_63-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"63\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Nyatakan Jenis PID yang anda alami (Sila nyatakan Jenis PID anda) - Anak Pertama<\/legend><ul id=\"wpforms-324-field_63\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_63_1\" name=\"wpforms[fields][63][]\" value=\"Ataxia Telangiectasia (A-T)\" aria-errormessage=\"wpforms-324-field_63_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_63_1\">Ataxia Telangiectasia (AT)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_63_2\" name=\"wpforms[fields][63][]\" value=\"Autoimmune Lymphoproliferative Syndrome (ALPS)\" aria-errormessage=\"wpforms-324-field_63_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_63_2\">Sindrom Limfoproliferatif Autoimun (ALPS)<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_63_3\" name=\"wpforms[fields][63][]\" value=\"Bruton&#039;s Agammaglobulinemia (XLA)\" aria-errormessage=\"wpforms-324-field_63_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_63_3\">Agammaglobulinemia Bruton (XLA)<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_63_4\" name=\"wpforms[fields][63][]\" value=\"Chronic Granulomatous Disease (CGD)\" aria-errormessage=\"wpforms-324-field_63_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_63_4\">Penyakit Granulomatosa Kronik (CGD)<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_63_5\" name=\"wpforms[fields][63][]\" value=\"Combined Variable Immunodeficiency (CVID)\" aria-errormessage=\"wpforms-324-field_63_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_63_5\">Kekurangan Imunobolehubah Gabungan (CVID)<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_63_6\" name=\"wpforms[fields][63][]\" value=\"Hyper IgE Syndrome (HyperIgE)\" aria-errormessage=\"wpforms-324-field_63_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_63_6\">Sindrom Hyper IgE (HyperIgE)<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_63_7\" name=\"wpforms[fields][63][]\" value=\"Hyper IgM Syndrome (HyperIgM)\" aria-errormessage=\"wpforms-324-field_63_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_63_7\">Sindrom Hyper IgM (HyperIgM)<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_63_8\" name=\"wpforms[fields][63][]\" value=\"Hypoagammaglobulinemia Syndrome\" aria-errormessage=\"wpforms-324-field_63_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_63_8\">Sindrom Hypoagammaglobulinemia<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_63_9\" name=\"wpforms[fields][63][]\" value=\"Immunoglobulin A Deficiency (IgA)\" aria-errormessage=\"wpforms-324-field_63_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_63_9\">Kekurangan Imunoglobulin A (IgA)<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_63_10\" name=\"wpforms[fields][63][]\" value=\"Primary Hemophagocytic LymphoHistiocytosis (HLH)\" aria-errormessage=\"wpforms-324-field_63_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_63_10\">LimfoHistiositosis Hemophagocytic Primer (HLH)<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_63_11\" name=\"wpforms[fields][63][]\" value=\"Severe Combined Immunodeficiency (SCID)\" aria-errormessage=\"wpforms-324-field_63_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_63_11\">Kekurangan Imun Gabungan Teruk (SCID)<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_63_12\" name=\"wpforms[fields][63][]\" value=\"Severe Congenital Neutropenia (SCN)4\" aria-errormessage=\"wpforms-324-field_63_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_63_12\">Neutropenia Kongenital Teruk (SCN)4<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_63_13\" name=\"wpforms[fields][63][]\" value=\"Wiskott-Aldrich Syndrome (WAS)\" aria-errormessage=\"wpforms-324-field_63_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_63_13\">Sindrom Wiskott-Aldrich (WAS)<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_63_14\" name=\"wpforms[fields][63][]\" value=\"Other\" aria-errormessage=\"wpforms-324-field_63_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_63_14\">Lain-lain<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-324-field_60-container\" class=\"wpforms-field wpforms-field-name wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"60\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-324-field_60\">Nama Penuh Anak Kedua (Jika ada) 2nd Child Full Name (as per MyKid) (option)<\/label><input type=\"text\" id=\"wpforms-324-field_60\" class=\"wpforms-field-medium\" name=\"wpforms[fields][60]\" aria-errormessage=\"wpforms-324-field_60-error\" ><\/div><div id=\"wpforms-324-field_64-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"64\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Nyatakan Jenis PID yang anda alami (Sila nyatakan Jenis PID anda) - Anak Ke-2 <\/legend><ul id=\"wpforms-324-field_64\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_64_1\" name=\"wpforms[fields][64][]\" value=\"Ataxia Telangiectasia (A-T)\" aria-errormessage=\"wpforms-324-field_64_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_64_1\">Ataxia Telangiectasia (AT)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_64_2\" name=\"wpforms[fields][64][]\" value=\"Autoimmune Lymphoproliferative Syndrome (ALPS)\" aria-errormessage=\"wpforms-324-field_64_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_64_2\">Sindrom Limfoproliferatif Autoimun (ALPS)<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_64_3\" name=\"wpforms[fields][64][]\" value=\"Bruton&#039;s Agammaglobulinemia (XLA)\" aria-errormessage=\"wpforms-324-field_64_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_64_3\">Agammaglobulinemia Bruton (XLA)<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_64_4\" name=\"wpforms[fields][64][]\" value=\"Chronic Granulomatous Disease (CGD)\" aria-errormessage=\"wpforms-324-field_64_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_64_4\">Penyakit Granulomatosa Kronik (CGD)<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_64_5\" name=\"wpforms[fields][64][]\" value=\"Combined Variable Immunodeficiency (CVID)\" aria-errormessage=\"wpforms-324-field_64_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_64_5\">Kekurangan Imunobolehubah Gabungan (CVID)<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_64_6\" name=\"wpforms[fields][64][]\" value=\"Hyper IgE Syndrome (HyperIgE)\" aria-errormessage=\"wpforms-324-field_64_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_64_6\">Sindrom Hyper IgE (HyperIgE)<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_64_7\" name=\"wpforms[fields][64][]\" value=\"Hyper IgM Syndrome (HyperIgM)\" aria-errormessage=\"wpforms-324-field_64_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_64_7\">Sindrom Hyper IgM (HyperIgM)<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_64_8\" name=\"wpforms[fields][64][]\" value=\"Hypoagammaglobulinemia Syndrome\" aria-errormessage=\"wpforms-324-field_64_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_64_8\">Sindrom Hypoagammaglobulinemia<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_64_9\" name=\"wpforms[fields][64][]\" value=\"Immunoglobulin A Deficiency (IgA)\" aria-errormessage=\"wpforms-324-field_64_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_64_9\">Kekurangan Imunoglobulin A (IgA)<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_64_10\" name=\"wpforms[fields][64][]\" value=\"Primary Hemophagocytic LymphoHistiocytosis (HLH)\" aria-errormessage=\"wpforms-324-field_64_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_64_10\">LimfoHistiositosis Hemophagocytic Primer (HLH)<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_64_11\" name=\"wpforms[fields][64][]\" value=\"Severe Combined Immunodeficiency (SCID)\" aria-errormessage=\"wpforms-324-field_64_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_64_11\">Kekurangan Imun Gabungan Teruk (SCID)<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_64_12\" name=\"wpforms[fields][64][]\" value=\"Severe Congenital Neutropenia (SCN)4\" aria-errormessage=\"wpforms-324-field_64_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_64_12\">Neutropenia Kongenital Teruk (SCN)4<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_64_13\" name=\"wpforms[fields][64][]\" value=\"Wiskott-Aldrich Syndrome (WAS)\" aria-errormessage=\"wpforms-324-field_64_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_64_13\">Sindrom Wiskott-Aldrich (WAS)<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_64_14\" name=\"wpforms[fields][64][]\" value=\"Other\" aria-errormessage=\"wpforms-324-field_64_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_64_14\">Lain-lain<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-324-field_61-container\" class=\"wpforms-field wpforms-field-name wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"61\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-324-field_61\">Nama Penuh Anak Ketiga (jika ada) 3rd Child Full Name (option)<\/label><input type=\"text\" id=\"wpforms-324-field_61\" class=\"wpforms-field-medium\" name=\"wpforms[fields][61]\" aria-errormessage=\"wpforms-324-field_61-error\" ><\/div><div id=\"wpforms-324-field_65-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"65\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Nyatakan Jenis PID yang anda alami (Sila nyatakan Jenis PID anda) - Anak Ke-3 <\/legend><ul id=\"wpforms-324-field_65\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_65_1\" name=\"wpforms[fields][65][]\" value=\"Ataxia Telangiectasia (A-T)\" aria-errormessage=\"wpforms-324-field_65_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_65_1\">Ataxia Telangiectasia (AT)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_65_2\" name=\"wpforms[fields][65][]\" value=\"Autoimmune Lymphoproliferative Syndrome (ALPS)\" aria-errormessage=\"wpforms-324-field_65_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_65_2\">Sindrom Limfoproliferatif Autoimun (ALPS)<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_65_3\" name=\"wpforms[fields][65][]\" value=\"Bruton&#039;s Agammaglobulinemia (XLA)\" aria-errormessage=\"wpforms-324-field_65_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_65_3\">Agammaglobulinemia Bruton (XLA)<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_65_4\" name=\"wpforms[fields][65][]\" value=\"Chronic Granulomatous Disease (CGD)\" aria-errormessage=\"wpforms-324-field_65_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_65_4\">Penyakit Granulomatosa Kronik (CGD)<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_65_5\" name=\"wpforms[fields][65][]\" value=\"Combined Variable Immunodeficiency (CVID)\" aria-errormessage=\"wpforms-324-field_65_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_65_5\">Kekurangan Imunobolehubah Gabungan (CVID)<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_65_6\" name=\"wpforms[fields][65][]\" value=\"Hyper IgE Syndrome (HyperIgE)\" aria-errormessage=\"wpforms-324-field_65_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_65_6\">Sindrom Hyper IgE (HyperIgE)<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_65_7\" name=\"wpforms[fields][65][]\" value=\"Hyper IgM Syndrome (HyperIgM)\" aria-errormessage=\"wpforms-324-field_65_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_65_7\">Sindrom Hyper IgM (HyperIgM)<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_65_8\" name=\"wpforms[fields][65][]\" value=\"Hypoagammaglobulinemia Syndrome\" aria-errormessage=\"wpforms-324-field_65_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_65_8\">Sindrom Hypoagammaglobulinemia<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_65_9\" name=\"wpforms[fields][65][]\" value=\"Immunoglobulin A Deficiency (IgA)\" aria-errormessage=\"wpforms-324-field_65_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_65_9\">Kekurangan Imunoglobulin A (IgA)<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_65_10\" name=\"wpforms[fields][65][]\" value=\"Primary Hemophagocytic LymphoHistiocytosis (HLH)\" aria-errormessage=\"wpforms-324-field_65_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_65_10\">LimfoHistiositosis Hemophagocytic Primer (HLH)<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_65_11\" name=\"wpforms[fields][65][]\" value=\"Severe Combined Immunodeficiency (SCID)\" aria-errormessage=\"wpforms-324-field_65_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_65_11\">Kekurangan Imun Gabungan Teruk (SCID)<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_65_12\" name=\"wpforms[fields][65][]\" value=\"Severe Congenital Neutropenia (SCN)4\" aria-errormessage=\"wpforms-324-field_65_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_65_12\">Neutropenia Kongenital Teruk (SCN)4<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_65_13\" name=\"wpforms[fields][65][]\" value=\"Wiskott-Aldrich Syndrome (WAS)\" aria-errormessage=\"wpforms-324-field_65_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_65_13\">Sindrom Wiskott-Aldrich (WAS)<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_65_14\" name=\"wpforms[fields][65][]\" value=\"Other\" aria-errormessage=\"wpforms-324-field_65_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_65_14\">Lain-lain<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-324-field_62-container\" class=\"wpforms-field wpforms-field-name wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"62\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-324-field_62\">Nama Penuh Anak Keempat (jika ada) 4th Child Full Name (option)<\/label><input type=\"text\" id=\"wpforms-324-field_62\" class=\"wpforms-field-medium\" name=\"wpforms[fields][62]\" aria-errormessage=\"wpforms-324-field_62-error\" ><\/div><div id=\"wpforms-324-field_66-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"66\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Nyatakan Jenis PID yang anda alami (Sila nyatakan Jenis PID anda) - Anak Ke-4 <\/legend><ul id=\"wpforms-324-field_66\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_66_1\" name=\"wpforms[fields][66][]\" value=\"Ataxia Telangiectasia (A-T)\" aria-errormessage=\"wpforms-324-field_66_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_66_1\">Ataxia Telangiectasia (AT)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_66_2\" name=\"wpforms[fields][66][]\" value=\"Autoimmune Lymphoproliferative Syndrome (ALPS)\" aria-errormessage=\"wpforms-324-field_66_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_66_2\">Sindrom Limfoproliferatif Autoimun (ALPS)<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_66_3\" name=\"wpforms[fields][66][]\" value=\"Bruton&#039;s Agammaglobulinemia (XLA)\" aria-errormessage=\"wpforms-324-field_66_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_66_3\">Agammaglobulinemia Bruton (XLA)<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_66_4\" name=\"wpforms[fields][66][]\" value=\"Chronic Granulomatous Disease (CGD)\" aria-errormessage=\"wpforms-324-field_66_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_66_4\">Penyakit Granulomatosa Kronik (CGD)<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_66_5\" name=\"wpforms[fields][66][]\" value=\"Combined Variable Immunodeficiency (CVID)\" aria-errormessage=\"wpforms-324-field_66_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_66_5\">Kekurangan Imunobolehubah Gabungan (CVID)<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_66_6\" name=\"wpforms[fields][66][]\" value=\"Hyper IgE Syndrome (HyperIgE)\" aria-errormessage=\"wpforms-324-field_66_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_66_6\">Sindrom Hyper IgE (HyperIgE)<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_66_7\" name=\"wpforms[fields][66][]\" value=\"Hyper IgM Syndrome (HyperIgM)\" aria-errormessage=\"wpforms-324-field_66_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_66_7\">Sindrom Hyper IgM (HyperIgM)<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_66_8\" name=\"wpforms[fields][66][]\" value=\"Hypoagammaglobulinemia Syndrome\" aria-errormessage=\"wpforms-324-field_66_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_66_8\">Sindrom Hypoagammaglobulinemia<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_66_9\" name=\"wpforms[fields][66][]\" value=\"Immunoglobulin A Deficiency (IgA)\" aria-errormessage=\"wpforms-324-field_66_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_66_9\">Kekurangan Imunoglobulin A (IgA)<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_66_10\" name=\"wpforms[fields][66][]\" value=\"Primary Hemophagocytic LymphoHistiocytosis (HLH)\" aria-errormessage=\"wpforms-324-field_66_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_66_10\">LimfoHistiositosis Hemophagocytic Primer (HLH)<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_66_11\" name=\"wpforms[fields][66][]\" value=\"Severe Combined Immunodeficiency (SCID)\" aria-errormessage=\"wpforms-324-field_66_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_66_11\">Kekurangan Imun Gabungan Teruk (SCID)<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_66_12\" name=\"wpforms[fields][66][]\" value=\"Severe Congenital Neutropenia (SCN)4\" aria-errormessage=\"wpforms-324-field_66_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_66_12\">Neutropenia Kongenital Teruk (SCN)4<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_66_13\" name=\"wpforms[fields][66][]\" value=\"Wiskott-Aldrich Syndrome (WAS)\" aria-errormessage=\"wpforms-324-field_66_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_66_13\">Sindrom Wiskott-Aldrich (WAS)<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-324-field_66_14\" name=\"wpforms[fields][66][]\" value=\"Other\" aria-errormessage=\"wpforms-324-field_66_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_66_14\">Lain-lain<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-324-field_67-container\" class=\"wpforms-field wpforms-field-divider wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"67\" style=\"display:none;\"><h3 id=\"wpforms-324-field_67\" name=\"wpforms[fields][67]\" aria-errormessage=\"wpforms-324-field_67-error\">Saya adalah saudara mara \/ adik beradik pesakit PID yang berumur &gt;18 tahun (Yes, I am relative \/ siblings to a PID patient and I am over 18 years old)<\/h3><\/div><div id=\"wpforms-324-field_78-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"78\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-324-field_78\" aria-hidden=\"false\">Susun atur<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-324-field_68-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"68\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Adakah hubungan anda dengan pesakit PID? (Apakah hubungan anda dengan pesakit PID?)<\/legend><ul id=\"wpforms-324-field_68\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_68_1\" name=\"wpforms[fields][68]\" value=\"Anak buah (neice\/nephew)\" aria-errormessage=\"wpforms-324-field_68_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_68_1\">Anak buah (neice\/nephew)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_68_2\" name=\"wpforms[fields][68]\" value=\"Adik-beradik (Siblings)\" aria-errormessage=\"wpforms-324-field_68_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_68_2\">Adik-beradik (Adik Beradik)<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_68_3\" name=\"wpforms[fields][68]\" value=\"Seupupu (Cousin)\" aria-errormessage=\"wpforms-324-field_68_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_68_3\">Seupupu (Sepupu)<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_68_4\" name=\"wpforms[fields][68]\" value=\"Other\" aria-errormessage=\"wpforms-324-field_68_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_68_4\">Lain-lain<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-324-field_69-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"69\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-324-field_69\">Nama Pesakit PID (Nama Pesakit PID)<\/label><input type=\"text\" id=\"wpforms-324-field_69\" class=\"wpforms-field-medium\" name=\"wpforms[fields][69]\" aria-errormessage=\"wpforms-324-field_69-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-324-field_70-container\" class=\"wpforms-field wpforms-field-divider wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"70\" style=\"display:none;\"><h3 id=\"wpforms-324-field_70\" name=\"wpforms[fields][70]\" aria-errormessage=\"wpforms-324-field_70-error\" aria-describedby=\"wpforms-324-field_70-description\">Saya hendak menjadi Ahli Bersekutu \/ Sukarelawan (I want to become an Associate Member \/ Volunteer)<\/h3><div id=\"wpforms-324-field_70-description\" class=\"wpforms-field-description\">Saya bukan pesakit PID atau sanak saudara pesakit PID. Saya berumur &gt;18 tahun (Saya bukan pesakit PID atau saudara kepada pesakit PID. Saya berumur &gt;18 tahun) Nota: Ahli Bersekutu tidak mempunyai hak mengundi <br>\r\n(Nota: Ahli Bersekutu tidak mempunyai hak mengundi)<\/div><\/div><div id=\"wpforms-324-field_79-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"79\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-324-field_79\" aria-hidden=\"false\">Susun atur<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-324-field_71-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"71\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Saya mahu menjadi ahli MYPOPI kerana..(Saya ingin menjadi ahli MYPOPI kerana ...)<\/legend><ul id=\"wpforms-324-field_71\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_71_1\" name=\"wpforms[fields][71]\" value=\"saya ingin menyebar lebih kesedaran kepada orang awam  (I wish to raise awareness among general public)\" aria-errormessage=\"wpforms-324-field_71_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_71_1\">saya ingin menyebarkan lebih kesedaran kepada orang awam (Saya ingin meningkatkan kesedaran di kalangan masyarakat umum)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_71_2\" name=\"wpforms[fields][71]\" value=\"saya ingin berkhidmat sebagai sukarelawan (I wish to volunteer my service)\" aria-errormessage=\"wpforms-324-field_71_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_71_2\">saya ingin berkhidmat sebagai sukarelawan (I wish to volunteer my service)<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_71_3\" name=\"wpforms[fields][71]\" value=\"saya ingin menyokong aktiviti aktiviti MYPOPI (I wish to support MYPOPI activities)\" aria-errormessage=\"wpforms-324-field_71_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_71_3\">saya ingin menyokong aktiviti aktiviti MYPOPI (saya ingin menyokong aktiviti MYPOPI)<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_71_4\" name=\"wpforms[fields][71]\" value=\"Other\" aria-errormessage=\"wpforms-324-field_71_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_71_4\">Lain-lain<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-324-field_72-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"72\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Bagaimana anda mengenali MYPOPI? (Bagaimana anda mengenali MYPOPI?)<\/legend><ul id=\"wpforms-324-field_72\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_72_1\" name=\"wpforms[fields][72]\" value=\"Social Media (MYPOPI Facebook \/ Website)\" aria-errormessage=\"wpforms-324-field_72_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_72_1\">Media Sosial (MYPOPI Facebook \/ Laman Web)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_72_2\" name=\"wpforms[fields][72]\" value=\"Suratkhabar dan Majalah (Newspaper &amp; Magazines)\" aria-errormessage=\"wpforms-324-field_72_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_72_2\">Suratkhabar dan Majalah (Akhbar &amp; Majalah)<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_72_3\" name=\"wpforms[fields][72]\" value=\"Saluran Berita TV (TV News Channel)\" aria-errormessage=\"wpforms-324-field_72_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_72_3\">Saluran Berita TV (Saluran Berita TV)<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_72_4\" name=\"wpforms[fields][72]\" value=\"Roadshow, Pameran dan National Walk-About\" aria-errormessage=\"wpforms-324-field_72_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_72_4\">Jerayawara, Pameran dan National Walk-About<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_72_5\" name=\"wpforms[fields][72]\" value=\"Aktiviti-aktiviti pengumpulan amal (Fundraising Activities)\" aria-errormessage=\"wpforms-324-field_72_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_72_5\">Aktiviti-aktiviti pengumpulan amal (Aktiviti Penggalangan Dana)<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_72_6\" name=\"wpforms[fields][72]\" value=\"Other\" aria-errormessage=\"wpforms-324-field_72_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_72_6\">Lain-lain<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-324-field_73-container\" class=\"wpforms-field wpforms-field-divider wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"73\" style=\"display:none;\"><h3 id=\"wpforms-324-field_73\" name=\"wpforms[fields][73]\" aria-errormessage=\"wpforms-324-field_73-error\" aria-describedby=\"wpforms-324-field_73-description\">Pembayaran Pendaftaran (Yuran Pendaftaran)<\/h3><div id=\"wpforms-324-field_73-description\" class=\"wpforms-field-description\">Yuran pendaftaran - RM1 <br>\r\nYuran Tahunan 2023 - RM1 <br>\r\nYuran seumur hidup - RM10<\/div><\/div><div id=\"wpforms-324-field_74-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"74\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Pilihan manakah anda ingin menjadi ahli MYPOPI? (yang manakah anda lebih suka menjadi ahli MYPOPI?)<\/legend><ul id=\"wpforms-324-field_74\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_74_1\" name=\"wpforms[fields][74]\" value=\"Ahli Biasa Baru (New Ordinary Member) - Yuran Pendaftaran RM1 (Registration Fee - RM1)\" aria-errormessage=\"wpforms-324-field_74_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_74_1\">Ahli Biasa Baru (Ahli Biasa Baru) - Yuran Pendaftaran RM1 (Yuran Pendaftaran - RM1)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_74_2\" name=\"wpforms[fields][74]\" value=\"Ahli Biasa Sedia Ada (Existing Ordinary Member) - Yuran Tahunan RM1 (Yearly Membership Fee RM1)n 2\" aria-errormessage=\"wpforms-324-field_74_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_74_2\">Ahli Biasa Sedia Ada (Ahli Biasa Sedia Ada) - Yuran Tahunan RM1 (Yuran Keahlian Tahunan RM1)n 2<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-324-field_74_3\" name=\"wpforms[fields][74]\" value=\"Ahli Biasa Sedia Ada to upgrade to Ahli Seumur Hidup (Ordinary Member to upgrade to Lifetime member) - Yuran Sekali gus RM10 (One Time Fee R10)\" aria-errormessage=\"wpforms-324-field_74_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-324-field_74_3\">Ahli Biasa Sedia Ada to upgrade to Ahli Seumur Hidup (Ordinary Member to upgrade to Lifetime member) - Yuran Sekali gus RM10 (One Time Fee R10)<\/label><\/li><\/ul><\/fieldset><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"324\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-324\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Hantar<\/button><img src=\"https:\/\/mypopi.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><input type=\"hidden\" name=\"trp-form-language\" value=\"bm\"\/><\/form><\/div>  <!-- .wpforms-container -->\n\t\t<\/div>\n\t<\/div>\n\n\t\t\t<\/div> \n\t\t<\/div>\n\t<\/div> \n<\/div><\/div>","protected":false},"excerpt":{"rendered":"Pendaftaran menjadi ahli MYPOPI (MYPOPI Membership Registration) Terima Kasih kerana berminat untuk menjadi sebahagian dari ahli MYPOPI Data yang dikumpul oleh MYPOPI akan digunakan untuk tujuan berikut: Data peribadi akan...","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v20.6 - 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