{"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\/ta\/register\/","title":{"rendered":"Register"},"content":{"rendered":"<div id=\"fws_6a1af59c10b5c\"  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 (MYPOPI Membership Registration)<\/h2>\n<p>Terima Kasih kerana berminat untuk menjadi sebahagian dari 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 pengumpulan 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 dikumpulkan melalui sistem ini hanya akan dipaparkan dalam bentuk tanpa nama dan terkumpul.<\/li>\n<\/ul>\n<div>Thank you for being interested in becoming a member of MYPOPI<br \/>\nWelcome!<\/div>\n<div>\n<p>MyPOPI \u0b86\u0bb2\u0bcd \u0b9a\u0bc7\u0b95\u0bb0\u0bbf\u0b95\u0bcd\u0b95\u0baa\u0bcd\u0baa\u0b9f\u0bcd\u0b9f \u0ba4\u0bb0\u0bb5\u0bc1 \u0baa\u0bbf\u0ba9\u0bcd\u0bb5\u0bb0\u0bc1\u0bae\u0bcd \u0ba8\u0bcb\u0b95\u0bcd\u0b95\u0b99\u0bcd\u0b95\u0bb3\u0bc1\u0b95\u0bcd\u0b95\u0bbe\u0b95\u0baa\u0bcd \u0baa\u0baf\u0ba9\u0bcd\u0baa\u0b9f\u0bc1\u0ba4\u0bcd\u0ba4\u0baa\u0bcd\u0baa\u0b9f\u0bc1\u0bae\u0bcd:<\/p>\n<ul>\n<li>Personal data will be used by MyPOPI for information and material sharing (including newsletter, material\u2026) developed for its members and interested stakeholders. Third parties may have access to this data only for mail out purposes.<\/li>\n<li>Medical data will only be used and accessed by MyPOPI for data collection, analysis of its membership to improve the representation done by MyPOPI for patients with primary immunodeficiencies (PID) in Malaysia. Individual data will not be disclosed at any time. Data gathered through this system would only be displayed in an anonymised and aggregated form.<\/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_6a1af59c113e7\"  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=\"\/ta\/wp-json\/wp\/v2\/pages\/329\" data-token=\"a6fdf83fa78a7c7aa062286c6ce6023c\" data-trp-original-action=\"\/ta\/wp-json\/wp\/v2\/pages\/329\"><noscript class=\"wpforms-error-noscript\">\u0b87\u0ba8\u0bcd\u0ba4\u0baa\u0bcd \u0baa\u0b9f\u0bbf\u0bb5\u0ba4\u0bcd\u0ba4\u0bc8\u0baa\u0bcd \u0baa\u0bc2\u0bb0\u0bcd\u0ba4\u0bcd\u0ba4\u0bbf \u0b9a\u0bc6\u0baf\u0bcd\u0baf \u0b89\u0b99\u0bcd\u0b95\u0bb3\u0bcd \u0b89\u0bb2\u0bbe\u0bb5\u0bbf\u0baf\u0bbf\u0bb2\u0bcd JavaScript \u0b90 \u0b87\u0baf\u0b95\u0bcd\u0b95\u0bb5\u0bc1\u0bae\u0bcd.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">\u0b87\u0ba8\u0bcd\u0ba4\u0baa\u0bcd \u0baa\u0b9f\u0bbf\u0bb5\u0ba4\u0bcd\u0ba4\u0bc8\u0baa\u0bcd \u0baa\u0bc2\u0bb0\u0bcd\u0ba4\u0bcd\u0ba4\u0bbf \u0b9a\u0bc6\u0baf\u0bcd\u0baf \u0b89\u0b99\u0bcd\u0b95\u0bb3\u0bcd \u0b89\u0bb2\u0bbe\u0bb5\u0bbf\u0baf\u0bbf\u0bb2\u0bcd JavaScript \u0b90 \u0b87\u0baf\u0b95\u0bcd\u0b95\u0bb5\u0bc1\u0bae\u0bcd.<\/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\">\u0bae\u0bbf\u0ba9\u0bcd\u0ba9\u0b9e\u0bcd\u0b9a\u0bb2\u0bcd <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? (Who are you to become a MYPOPI member?)<\/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\">Apakah hubungan anda dengan pesakit? (What is your relationship to the patient)<\/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 (Father \/ Guardian \/ Caretaker)<\/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 (Mother)<\/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 (relatives)<\/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\">Other<\/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\">Layout<\/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\">Full Name (as per 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 (Mobile Number)<\/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 (IC number)<\/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 (Date of Birth)<\/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  (Correspondence address)<\/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\">Address Line 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\">Address Line 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\">\u0ba8\u0b95\u0bb0\u0bae\u0bcd<\/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\">State \/ Province \/ Region<\/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\">Postal Code<\/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\" >Antarctica<\/option><option value=\"AG\" >Antigua and 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 (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/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\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/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\" >Czech Republic<\/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\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/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\" >Heard Island and McDonald Islands<\/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 (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/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 (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/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\" >Macao<\/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\" >Marshall Islands<\/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 (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/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\" >Netherlands<\/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\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/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\" >Philippines<\/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\" >Russian Federation<\/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 and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/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\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/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\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-324-field_42-country\" class=\"wpforms-field-sublabel after\">Country<\/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\">Residence Address same as correspondence address<\/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\">Yes<\/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\">No<\/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 (Residence Address)<\/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\">Address Line 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\">Address Line 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\">\u0ba8\u0b95\u0bb0\u0bae\u0bcd<\/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\">State \/ Province \/ Region<\/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\">Postal Code<\/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\" >Antarctica<\/option><option value=\"AG\" >Antigua and 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 (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/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\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/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\" >Czech Republic<\/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\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/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\" >Heard Island and McDonald Islands<\/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 (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/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 (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/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\" >Macao<\/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\" >Marshall Islands<\/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 (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/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\" >Netherlands<\/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\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/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\" >Philippines<\/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\" >Russian Federation<\/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 and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/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\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/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\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-324-field_43-country\" class=\"wpforms-field-sublabel after\">Country<\/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 (Identifying the health level of adult PID patients)<\/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 (Please state your PID Type)<\/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 (A-T)<\/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\">Autoimmune Lymphoproliferative Syndrome (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\">Bruton's Agammaglobulinemia (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\">Chronic Granulomatous Disease (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\">Combined Variable Immunodeficiency (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\">Hyper IgE Syndrome (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\">Hyper IgM Syndrome (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\">Hypoagammaglobulinemia Syndrome<\/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\">Immunoglobulin A Deficiency (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\">Primary Hemophagocytic LymphoHistiocytosis (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\">Severe Combined Immunodeficiency (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\">Severe Congenital Neutropenia (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\">Wiskott-Aldrich Syndrome (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\">Other<\/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\">Layout<\/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. (Where are you getting your treatment? Please state your treating hospital)<\/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. (Where are you getting your clinical consultation? Please state your clinical hospital)<\/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\">Assoc. Prof. 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\">Other<\/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\">Layout<\/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 mendapatkan rawatan atau telah meninggal dunia?  (Is your child still receiving treatment or deceased?)<\/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 (no, my child has deceased)<\/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\">Berapakah bilangan anak yang meninggal dunia? (Total No of Children Deceased)<\/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\">More than 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?  (How many child is PID patient?)<\/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\">More than 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 (Information of PID Child)<\/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 (Please state your PID Type) - 1st Child<\/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 (A-T)<\/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\">Autoimmune Lymphoproliferative Syndrome (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\">Bruton's Agammaglobulinemia (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\">Chronic Granulomatous Disease (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\">Combined Variable Immunodeficiency (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\">Hyper IgE Syndrome (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\">Hyper IgM Syndrome (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\">Hypoagammaglobulinemia Syndrome<\/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\">Immunoglobulin A Deficiency (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\">Primary Hemophagocytic LymphoHistiocytosis (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\">Severe Combined Immunodeficiency (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\">Severe Congenital Neutropenia (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\">Wiskott-Aldrich Syndrome (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\">Other<\/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 (Please state your PID Type) - 2nd Child <\/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 (A-T)<\/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\">Autoimmune Lymphoproliferative Syndrome (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\">Bruton's Agammaglobulinemia (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\">Chronic Granulomatous Disease (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\">Combined Variable Immunodeficiency (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\">Hyper IgE Syndrome (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\">Hyper IgM Syndrome (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\">Hypoagammaglobulinemia Syndrome<\/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\">Immunoglobulin A Deficiency (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\">Primary Hemophagocytic LymphoHistiocytosis (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\">Severe Combined Immunodeficiency (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\">Severe Congenital Neutropenia (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\">Wiskott-Aldrich Syndrome (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\">Other<\/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 (Please state your PID Type) - 3rd Child <\/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 (A-T)<\/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\">Autoimmune Lymphoproliferative Syndrome (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\">Bruton's Agammaglobulinemia (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\">Chronic Granulomatous Disease (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\">Combined Variable Immunodeficiency (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\">Hyper IgE Syndrome (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\">Hyper IgM Syndrome (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\">Hypoagammaglobulinemia Syndrome<\/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\">Immunoglobulin A Deficiency (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\">Primary Hemophagocytic LymphoHistiocytosis (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\">Severe Combined Immunodeficiency (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\">Severe Congenital Neutropenia (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\">Wiskott-Aldrich Syndrome (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\">Other<\/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 (Please state your PID Type) - 4th Child <\/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 (A-T)<\/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\">Autoimmune Lymphoproliferative Syndrome (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\">Bruton's Agammaglobulinemia (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\">Chronic Granulomatous Disease (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\">Combined Variable Immunodeficiency (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\">Hyper IgE Syndrome (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\">Hyper IgM Syndrome (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\">Hypoagammaglobulinemia Syndrome<\/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\">Immunoglobulin A Deficiency (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\">Primary Hemophagocytic LymphoHistiocytosis (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\">Severe Combined Immunodeficiency (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\">Severe Congenital Neutropenia (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\">Wiskott-Aldrich Syndrome (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\">Other<\/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\">Layout<\/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\">Apakah hubungan anda dengan pesakit PID?  (What is your relationship to the PID patient?)<\/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 (Siblings)<\/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 (Cousin)<\/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\">Other<\/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 (PID Patiend Name)<\/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 ataupun sanak saudara pesakit PID. Saya berumur >18 tahun\r\n(I am not a PID patient or a relative of a PID patient. I am >18 years old)\r\nNota: Ahli Bersekutu tidak mempunyai hak mengundi <br>\r\n(Note: Associate Member do not have voting rights)<\/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\">Layout<\/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..(I want to be a member of MYPOPI because ...)<\/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 menyebar lebih kesedaran kepada orang awam  (I wish to raise awareness among general public)<\/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 (I wish to support MYPOPI activities)<\/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\">Other<\/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? (How did you get to know 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\">\u0b9a\u0bae\u0bc2\u0b95 \u0b8a\u0b9f\u0b95\u0b99\u0bcd\u0b95\u0bb3\u0bcd (MYPOPI Facebook \/ \u0b87\u0ba3\u0bc8\u0baf\u0ba4\u0bb3\u0bae\u0bcd)<\/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 (Newspaper &amp; Magazines)<\/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\">\u0b9a\u0bbe\u0bb2\u0bc2\u0bb0\u0ba9\u0bcd \u0baa\u0bc6\u0bb0\u0bbf\u0b9f\u0bbe \u0b9f\u0bbf\u0bb5\u0bbf (\u0b9f\u0bbf\u0bb5\u0bbf \u0b9a\u0bc6\u0baf\u0bcd\u0ba4\u0bbf \u0b9a\u0bc7\u0ba9\u0bb2\u0bcd)<\/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\">\u0bb0\u0bcb\u0b9f\u0bcd\u0bb7\u0bcb, \u0baa\u0bbe\u0bae\u0bb0\u0ba9\u0bcd \u0bae\u0bb1\u0bcd\u0bb1\u0bc1\u0bae\u0bcd \u0ba8\u0bc7\u0bb7\u0ba9\u0bb2\u0bcd \u0bb5\u0bbe\u0b95\u0bcd-\u0b85\u0baa\u0bcc\u0b9f\u0bcd<\/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 (Fundraising Activities)<\/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\">Other<\/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 (Registration Fees)<\/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? (which one do you prefer to be a member of 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 (New Ordinary Member) - Yuran Pendaftaran RM1 (Registration Fee - 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 (Existing Ordinary Member) - Yuran Tahunan RM1 (Yearly Membership Fee 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\">\u0b9a\u0bae\u0bb0\u0bcd\u0baa\u0bcd\u0baa\u0bbf\u0b95\u0bcd\u0b95\u0bb5\u0bc1\u0bae\u0bcd<\/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=\"ta\"\/><\/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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