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<form class="userform-form" action="" method="post" name="form_3348991" id="3348991" accept-charset="utf-8"><input type="hidden" name="formID" value="3348991" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li id="cid_1" class="form-input-wide"> <div class="form-header-group"><h2 id="header_1" class="form-header">Hebrew School Registration 2026/27</h2></div> </li><li class="form-line" id="id_3"><div class="form-label-left" id="label_3"><label for="input_3"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_3"> </label></div><div id="cid_3" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q3_fullName[first]" id="first_3" autocomplete="given-name" />  <label class="form-sub-label" for="first_3" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q3_fullName[last]" id="last_3" autocomplete="family-name" />  <label class="form-sub-label" for="last_3" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_48"><div class="form-label-left" id="label_48"><label for="input_48"> Child's Hebrew Name<span class="form-required">*</span> </label><label class="label-message" for="input_48"> </label></div><div id="cid_48" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_48" name="q48_input48" size="20" value="" /> </div></li><li class="form-line" id="id_52"><div class="form-label-left" id="label_52"><label for="input_52"> Mothers Hebrew Name<span class="form-required">*</span> </label><label class="label-message" for="input_52"> </label></div><div id="cid_52" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_52" name="q52_input52" size="20" value="" /> </div></li><li class="form-line" id="id_4"><div class="form-label-left" id="label_4"><label for="input_4"> Gender<span class="form-required">*</span> </label><label class="label-message" for="input_4"> </label></div><div id="cid_4" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_4_0" name="q4_gender" value="Boy" /><label id="label_input_4_0" for="input_4_0"><span>Boy</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_4_1" name="q4_gender" value="Girl" /><label id="label_input_4_1" for="input_4_1"><span>Girl</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_5"><div class="form-label-left" id="label_5"><label for="input_5"> Birth Date<span class="form-required">*</span> </label><label class="label-message" for="input_5"> </label></div><div id="cid_5" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q5_birthDate[month]" id="input_5_month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_5_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q5_birthDate[day]" id="input_5_day"><option></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select>  <label class="form-sub-label" for="input_5_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q5_birthDate[year]" id="input_5_year"><option></option><option value="2026">2026</option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option><option value="1941">1941</option><option value="1940">1940</option><option value="1939">1939</option><option value="1938">1938</option><option value="1937">1937</option><option value="1936">1936</option><option value="1935">1935</option><option value="1934">1934</option><option value="1933">1933</option><option value="1932">1932</option><option value="1931">1931</option><option value="1930">1930</option><option value="1929">1929</option><option value="1928">1928</option><option value="1927">1927</option><option value="1926">1926</option><option value="1925">1925</option><option value="1924">1924</option><option value="1923">1923</option><option value="1922">1922</option><option value="1921">1921</option><option value="1920">1920</option></select>  <label class="form-sub-label" for="input_5_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_53"><div class="form-label-left" id="label_53"><label for="input_53"> Time of Birth<span class="form-required">*</span> </label><label class="label-message" for="input_53"> </label></div><div id="cid_53" class="form-input"> <span class="dir_ltr inline_block"><span class="form-sub-label-container"><select class="noDefault form-dropdown validate[required]" id="input_53_hourSelect" name="q53_input53[hourSelect]"><option></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option></select>  <label class="form-sub-label" for="input_53_hourSelect" id="sublabel_hour">Hour</label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" id="input_53_minuteSelect" name="q53_input53[minuteSelect]"><option></option><option value="00">00</option><option value="10">10</option><option value="20">20</option><option value="30">30</option><option value="40">40</option><option value="50">50</option></select>  <label class="form-sub-label" for="input_53_minuteSelect" id="sublabel_minutes">Minutes</label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" id="input_53_ampm" name="q53_input53[ampm]"><option></option><option selected="selected" value="AM">AM</option><option value="PM">PM</option></select>  <label class="form-sub-label" for="input_53_ampm"><span> </span></label></span></span> </div></li><li class="form-line" id="id_6"><div class="form-label-left" id="label_6"><label for="input_6"> Address<span class="form-required">*</span> </label><label class="label-message" for="input_6"> </label></div><div id="cid_6" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-line" type="text" name="q6_address[addr_line1]" id="input_6_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_6_addr_line1" id="sublabel_6_addr_line1">Street Address</label></span></td></tr><tr><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q6_address[addr_line2]" id="input_6_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_6_addr_line2" id="sublabel_6_addr_line2">Street Address Line 2</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-city" type="text" name="q6_address[city]" id="input_6_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_6_city" id="sublabel_6_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q6_address[state]" id="input_6_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_6_state" id="sublabel_6_state">State / Province</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-postal" type="text" name="q6_address[postal]" id="input_6_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_6_postal" id="sublabel_6_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q6_address[country]" id="input_6_country" autocomplete="country-name"><option value="" selected="selected">Please Select</option><option value="United States">United States</option><option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="The Bahamas">The Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Brazil">Brazil</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burundi">Burundi</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cape Verde">Cape Verde</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="People's Republic of China">People's Republic of China</option><option value="Republic of China">Republic of China</option><option value="Christmas Island">Christmas Island</option><option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo">Congo</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Cote d'Ivoire">Cote d'Ivoire</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Eswatini">Eswatini</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Polynesia">French Polynesia</option><option value="Gabon">Gabon</option><option value="The Gambia">The Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jersey">Jersey</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="North Korea">North Korea</option><option value="South Korea">South Korea</option><option value="Kosovo">Kosovo</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Laos">Laos</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macau">Macau</option><option value="Macedonia">Macedonia</option><option value="Madagascar">Madagascar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Myanmar">Myanmar</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="Northern Mariana">Northern Mariana</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn Islands">Pitcairn Islands</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Barthelemy">Saint Barthelemy</option><option value="Saint Helena">Saint Helena</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="Somaliland">Somaliland</option><option value="South Africa">South Africa</option><option value="South Ossetia">South Ossetia</option><option value="Spain">Spain</option><option value="Sri Lanka">Sri Lanka</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Svalbard">Svalbard</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria">Syria</option><option value="Taiwan">Taiwan</option><option value="Tajikistan">Tajikistan</option><option value="Tanzania">Tanzania</option><option value="Thailand">Thailand</option><option value="Timor-Leste">Timor-Leste</option><option value="Togo">Togo</option><option value="Tokelau">Tokelau</option><option value="Tonga">Tonga</option><option value="Trinidad and Tobago">Trinidad and Tobago</option><option value="Tristan da Cunha">Tristan da Cunha</option><option value="Tunisia">Tunisia</option><option value="Turkey">Turkey</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks and Caicos Islands">Turks and Caicos Islands</option><option value="Tuvalu">Tuvalu</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="United Arab Emirates">United Arab Emirates</option><option value="United Kingdom">United Kingdom</option><option value="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Vatican City">Vatican City</option><option value="Venezuela">Venezuela</option><option value="Vietnam">Vietnam</option><option value="British Virgin Islands">British Virgin Islands</option><option value="US Virgin Islands">US Virgin Islands</option><option value="Wallis and Futuna">Wallis and Futuna</option><option value="Western Sahara">Western Sahara</option><option value="Yemen">Yemen</option><option value="Zambia">Zambia</option><option value="Zimbabwe">Zimbabwe</option><option value="other">Other</option></select>  <label class="form-sub-label" for="input_6_country" id="sublabel_6_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_7"><div class="form-label-left" id="label_7"><label for="input_7"> School </label><label class="label-message" for="input_7"> </label></div><div id="cid_7" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_7" name="q7_school" size="20" value="" /> </div></li><li class="form-line" id="id_8"><div class="form-label-left" id="label_8"><label for="input_8"> Grade<span class="form-required">*</span> </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_8" name="q8_grade"><option value=""></option><option value="JK">JK</option><option value="SK">SK</option><option value="Grade 1">Grade 1</option><option value="Grade 2">Grade 2</option><option value="Grade 3">Grade 3</option><option value="Grade 4">Grade 4</option><option value="Grade 5">Grade 5</option><option value="Grade 6">Grade 6</option><option value="Grade 7">Grade 7</option></select> </div></li><li class="form-line" id="id_9"><div class="form-label-left" id="label_9"><label for="input_9"> Previous Hebrew School Experience <span class="form-required">*</span> </label><label class="label-message" for="input_9"> </label></div><div id="cid_9" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_9" name="q9_previousHebrew" size="20" value="" maxlength="2" /> </div></li><li class="form-line" id="id_10"><div class="form-label-left" id="label_10"><label for="input_10"> Physician Name<span class="form-required">*</span> </label><label class="label-message" for="input_10"> </label></div><div id="cid_10" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_10" name="q10_physicianName" size="20" value="" /> </div></li><li class="form-line" id="id_11"><div class="form-label-left" id="label_11"><label for="input_11"> Allergies<span class="form-required">*</span> </label><label class="label-message" for="input_11"> </label></div><div id="cid_11" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_11" name="q11_allergies" size="20" value="" /> </div></li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12"> Medical Notes </label><label class="label-message" for="input_12"> </label></div><div id="cid_12" class="form-input"> <textarea id="input_12" class="form-textarea" name="q12_medicalNotes" cols="40" rows="6"></textarea> </div></li><li id="cid_13" class="form-input-wide"> <div class="form-header-group"><h2 id="header_13" class="form-header">Parent Information</h2></div> </li><li id="cid_20" class="form-input-wide"> <div class="form-header-group"><h3 id="header_20" class="form-header">Father</h3></div> </li><li class="form-line" id="id_15"><div class="form-label-left" id="label_15"><label for="input_15"> Title<span class="form-required">*</span> </label><label class="label-message" for="input_15"> </label></div><div id="cid_15" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_15" name="q15_title"><option value=""></option><option value="Mr.">Mr.</option><option value="Dr.">Dr.</option></select> </div></li><li class="form-line" id="id_16"><div class="form-label-left" id="label_16"><label for="input_16"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_16"> </label></div><div id="cid_16" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q16_fullName16[first]" id="first_16" autocomplete="given-name" />  <label class="form-sub-label" for="first_16" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q16_fullName16[last]" id="last_16" autocomplete="family-name" />  <label class="form-sub-label" for="last_16" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_18"><div class="form-label-left" id="label_18"><label for="input_18"> Cell Number<span class="form-required">*</span> </label><label class="label-message" for="input_18"> </label></div><div id="cid_18" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q18_cellNumber[area]" id="input_18_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_18_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q18_cellNumber[phone]" id="input_18_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_18_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_19"><div class="form-label-left" id="label_19"><label for="input_19"> Home Number<span class="form-required">*</span> </label><label class="label-message" for="input_19"> </label></div><div id="cid_19" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q19_homeNumber[area]" id="input_19_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_19_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q19_homeNumber[phone]" id="input_19_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_19_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_21"><div class="form-label-left" id="label_21"><label for="input_21"> E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_21"> </label></div><div id="cid_21" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_21" name="q21_email" size="30" value="" autocomplete="email" /> </div></li><li id="cid_23" class="form-input-wide"> <div class="form-header-group"><h3 id="header_23" class="form-header">Mother</h3></div> </li><li class="form-line" id="id_25"><div class="form-label-left" id="label_25"><label for="input_25"> Title<span class="form-required">*</span> </label><label class="label-message" for="input_25"> </label></div><div id="cid_25" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_25" name="q25_title25"><option value=""></option><option value="Mrs.">Mrs.</option><option value="Ms.">Ms.</option><option value="Dr.">Dr.</option></select> </div></li><li class="form-line" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_26"> </label></div><div id="cid_26" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q26_fullName26[first]" id="first_26" autocomplete="given-name" />  <label class="form-sub-label" for="first_26" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q26_fullName26[last]" id="last_26" autocomplete="family-name" />  <label class="form-sub-label" for="last_26" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_27"><div class="form-label-left" id="label_27"><label for="input_27"> Home Number<span class="form-required">*</span> </label><label class="label-message" for="input_27"> </label></div><div id="cid_27" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q27_homeNumber27[area]" id="input_27_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_27_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q27_homeNumber27[phone]" id="input_27_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_27_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_28"><div class="form-label-left" id="label_28"><label for="input_28"> Cell Number<span class="form-required">*</span> </label><label class="label-message" for="input_28"> </label></div><div id="cid_28" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q28_cellNumber28[area]" id="input_28_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_28_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q28_cellNumber28[phone]" id="input_28_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_28_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_29"><div class="form-label-left" id="label_29"><label for="input_29"> E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_29"> </label></div><div id="cid_29" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_29" name="q29_email29" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_34"><div class="form-label-left" id="label_34"><label for="input_34"> Marital Status<span class="form-required">*</span> </label><label class="label-message" for="input_34"> </label></div><div id="cid_34" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_34" name="q34_maritalStatus"><option value=""></option><option value="Married">Married</option><option value="Divorced">Divorced</option></select> </div></li><li class="form-line" id="id_35"><div class="form-label-left" id="label_35"><label for="input_35"> Shul Affiliation </label><label class="label-message" for="input_35"> </label></div><div id="cid_35" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_35" name="q35_shulAffiliation" size="20" value="" /> </div></li><li class="form-line" id="id_36"><div class="form-label-left" id="label_36"><label for="input_36"> Has there been any adoptions or conversions in the family?<span class="form-required">*</span> </label><label class="label-message" for="input_36"> </label></div><div id="cid_36" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_36_0" name="q36_haveThere[]" value="No" /><label id="label_input_36_0" for="input_36_0"><span>No</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_36_1" name="q36_haveThere[]" value="Yes" /><label id="label_input_36_1" for="input_36_1"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_36_2" name="q36_haveThere[]" value="Option 3" /><label id="label_input_36_2" for="input_36_2"><span>Option 3</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_37"><div class="form-label-left" id="label_37"><label for="input_37"> If yes please explain </label><label class="label-message" for="input_37"> </label></div><div id="cid_37" class="form-input"> <textarea id="input_37" class="form-textarea" name="q37_ifYes" cols="40" rows="6"></textarea> </div></li><li id="cid_38" class="form-input-wide"> <div class="form-header-group"><h2 id="header_38" class="form-header">Payment Information</h2></div> </li><li class="form-line" id="id_39"><div id="cid_39" class="form-input-wide"> <div id="text_39" class="form-html"><p><span style="background-color: rgb(255, 255, 255); font-size: 13px; font-family: Tahoma;">Registration fee is $100 until June 30th, 2026 ($150 after). Registration fee will be charged once this form is submitted and reviewed. Below please choose your payment plan for the tuition fee. </span></p>
</div> </div></li><li class="form-line" id="id_50"><div class="form-label-left" id="label_50"><label for="input_50"> Registration Fee<span class="form-required">*</span> </label><label class="label-message" for="input_50"> </label></div><div id="cid_50" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_50" name="q50_input50"><option value=""></option><option value="$100 Before June 30">$100 Before June 30</option><option value="$150 After June 30">$150 After June 30</option></select> </div></li><li class="form-line" id="id_51"><div id="cid_51" class="form-input-wide"> <div id="text_51" class="form-html"><p><span style="font-family: Tahoma; font-size: 12px; background-color: rgb(255, 255, 255);">Tuition fee is $650. Please choose below your payment preference. For alternative payment plans kindly contact sara, sara@chabadofaurora.com.</span></p>
</div> </div></li><li class="form-line" id="id_40"><div class="form-label-left" id="label_40"><label for="input_40"> Payment Schedule <span class="form-required">*</span> </label><label class="label-message" for="input_40"> </label></div><div id="cid_40" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_40_0" name="q40_paymentSchedule" value="Pay in Full (September 1)" /><label id="label_input_40_0" for="input_40_0"><span>Pay in Full (September 1)</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_40_1" name="q40_paymentSchedule" value="3 equal payments (Oct. 1, Nov. 1, Dec. 1)" /><label id="label_input_40_1" for="input_40_1"><span>3 equal payments (Oct. 1, Nov. 1, Dec. 1)</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_41"><div class="form-label-left" id="label_41"><label for="input_41"> Payment<span class="form-required">*</span> </label><label class="label-message" for="input_41"> </label></div><div id="cid_41" class="form-input"> <div class="form-error form-error--internal">⚠ You have not yet connected a credit card processor.</div><table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2" class="form-payment-methods form-multiple-column"></td></tr><tr class="credit_card "><th colspan="2">Credit Card</th></tr><tr class="credit_card "><td colspan="2" style="padding:0"><table cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container">  <label class="form-sub-label">We accept Visa, MasterCard, American Express</label></span><div class="cc-icons"><div class="cc-icon visa-icon"></div><div class="cc-icon mastercard-icon"></div><div class="cc-icon amex-icon"></div></div><input type="hidden" name="q41_payment[cc_type]" id="input_41_cc_type" value="" /></td></tr><tr><td><div class="cc-field-wrapper"><span class="form-sub-label-container"><input class="form-textbox form-creditcard js-cc-number validate[required, visible, creditcard]" type="text" name="q41_payment[cc_number]" id="input_41_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_41_cc_number" id="sublabel_cc_number">Credit Card Number</label></span></div></td><td class="cc_ccv hide"><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q41_payment[cc_ccv]" id="input_41_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_41_cc_ccv" id="sublabel_cc_ccv">Security Code</label></span></td></tr><tr><td colspan="2" class="cc_name_on_card "><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q41_payment[cc_nameOnCard]" id="input_41_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_41_cc_nameOnCard" id="sublabel_cc_nameOnCard">Name on Card</label></span></td></tr><tr class="credit_card "><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q41_payment[cc_exp_month]" id="input_41_cc_exp_month" autocomplete="cc-exp-month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_41_cc_exp_month" id="sublabel_cc_exp_month">Expiration Month</label></span></td><td><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q41_payment[cc_exp_year]" id="input_41_cc_exp_year" autocomplete="cc-exp-year"><option></option><option value="2026">2026</option><option value="2027">2027</option><option value="2028">2028</option><option value="2029">2029</option><option value="2030">2030</option><option value="2031">2031</option><option value="2032">2032</option><option value="2033">2033</option><option value="2034">2034</option><option value="2035">2035</option></select>  <label class="form-sub-label" for="input_41_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="billing_address "><th colspan="2">Billing Address</th></tr><tr class="billing_address "><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-line" type="text" name="q41_payment[addr_line1]" id="input_41_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_41_addr_line1" id="sublabel_41_addr_line1">Street Address</label></span></td></tr><tr class="billing_address "><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-city" type="text" name="q41_payment[city]" id="input_41_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_41_city" id="sublabel_41_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q41_payment[state]" id="input_41_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_41_state" id="sublabel_41_state">State / Province</label></span></td></tr><tr class="billing_address "><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-postal" type="text" name="q41_payment[postal]" id="input_41_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_41_postal" id="sublabel_41_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q41_payment[country]" id="input_41_country" autocomplete="billing country-name"><option value="" selected="selected">Please Select</option><option value="United States">United States</option><option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="The Bahamas">The Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Brazil">Brazil</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burundi">Burundi</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cape Verde">Cape Verde</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="People's Republic of China">People's Republic of China</option><option value="Republic of China">Republic of China</option><option value="Christmas Island">Christmas Island</option><option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo">Congo</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Cote d'Ivoire">Cote d'Ivoire</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Eswatini">Eswatini</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Polynesia">French Polynesia</option><option value="Gabon">Gabon</option><option value="The Gambia">The Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jersey">Jersey</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="North Korea">North Korea</option><option value="South Korea">South Korea</option><option value="Kosovo">Kosovo</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Laos">Laos</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macau">Macau</option><option value="Macedonia">Macedonia</option><option value="Madagascar">Madagascar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Myanmar">Myanmar</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="Northern Mariana">Northern Mariana</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn Islands">Pitcairn Islands</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Barthelemy">Saint Barthelemy</option><option value="Saint Helena">Saint Helena</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="Somaliland">Somaliland</option><option value="South Africa">South Africa</option><option value="South Ossetia">South Ossetia</option><option value="Spain">Spain</option><option value="Sri Lanka">Sri Lanka</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Svalbard">Svalbard</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria">Syria</option><option value="Taiwan">Taiwan</option><option value="Tajikistan">Tajikistan</option><option value="Tanzania">Tanzania</option><option value="Thailand">Thailand</option><option value="Timor-Leste">Timor-Leste</option><option value="Togo">Togo</option><option value="Tokelau">Tokelau</option><option value="Tonga">Tonga</option><option value="Trinidad and Tobago">Trinidad and Tobago</option><option value="Tristan da Cunha">Tristan da Cunha</option><option value="Tunisia">Tunisia</option><option value="Turkey">Turkey</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks and Caicos Islands">Turks and Caicos Islands</option><option value="Tuvalu">Tuvalu</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="United Arab Emirates">United Arab Emirates</option><option value="United Kingdom">United Kingdom</option><option value="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Vatican City">Vatican City</option><option value="Venezuela">Venezuela</option><option value="Vietnam">Vietnam</option><option value="British Virgin Islands">British Virgin Islands</option><option value="US Virgin Islands">US Virgin Islands</option><option value="Wallis and Futuna">Wallis and Futuna</option><option value="Western Sahara">Western Sahara</option><option value="Yemen">Yemen</option><option value="Zambia">Zambia</option><option value="Zimbabwe">Zimbabwe</option><option value="other">Other</option></select>  <label class="form-sub-label" for="input_41_country" id="sublabel_41_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_47"><div class="form-label-left" id="label_47"><label for="input_47"> Credit Card CVV<span class="form-required">*</span> </label><label class="label-message" for="input_47"> </label></div><div id="cid_47" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_47" name="q47_input47" size="20" value="" /> </div></li><li class="form-line" id="id_42"><div id="cid_42" class="form-input-wide"> <div id="text_42" class="form-html"><p class="MsoNormal"><span style="font-size: 9px;"><span style="font-family: Arial;">As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Alef Bet Hebrew School to hospitalize or secure treatment for my/our child, I/we further agree to pay all charges for that care and/or treatment.  It is understood that if time and circumstances reasonably permit, Alef Bet Hebrew School personnel will try, but are not required, to communicate with me/us prior to such treatment.  I/we hereby give permission for my/our child to participate in all school activities, join in class and school trips on and beyond school properties and allow my/our child to be photographed while participating in Hebrew School activities which will be posted on the School's website.  I/we also understand that all liability and costs resulting from damage to property and/or personal injury caused or attributable to my/our child/children will be my/our responsibility and I/we agree to fully indemnify and save Alef Bet Hebrew School and its associates, teachers and agents harmless therefrom.  I/we consent to Alef Bet Hebrew School’s use of our personal information and of our child/children at its discretion in pursuit of school activities.</span></span></p></div> </div></li><li class="form-line" id="id_43"><div class="form-label-left" id="label_43"><label for="input_43"> I agree to the terms and conditions above<span class="form-required">*</span> </label><label class="label-message" for="input_43"> </label></div><div id="cid_43" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_43_0" name="q43_iAgree[]" value="Agree" /><label id="label_input_43_0" for="input_43_0"><span>Agree</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_44"><div id="cid_44" class="form-input-wide"> <div id="text_44" class="form-html"><p><span style="font-family: Arial; font-size: 13px;">Once submitted we will contact you to confirm your registration. Registration fee will be charged once your child has been accepted.</span></p></div> </div></li><li class="form-line" id="id_45"><div class="form-label-left" id="label_45"><label for="input_45"> Comments: </label><label class="label-message" for="input_45"> </label></div><div id="cid_45" class="form-input"> <textarea id="input_45" class="form-textarea" name="q45_comments" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_46"><div class="form-label-left" id="label_46"><label for="input_46"> How did you hear about our Hebrew School? </label><label class="label-message" for="input_46"> </label></div><div id="cid_46" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_46" name="q46_input46"><option value=""></option><option value="A friend referral ">A friend referral </option><option value="Mailing">Mailing</option><option value="Other">Other</option></select> </div></li><li class="form-line" id="id_2"><div id="cid_2" class="form-input-wide"> <div style="text-align: center; text-indent:156px;" class="form-buttons-wrapper button-align-auto"><button id="input_2" type="submit" class="form-submit-button  form-submit-button-none;">Submit</button></div> </div></li><li style="display:none">Should be Empty: <input type="text" name="website" value="" /></li></ul></div><input type="hidden" id="simple_spc" name="simple_spc" value="3348991" /><script type="text/javascript">document.getElementById("si"+"mple"+"_spc").value = "3348991-3348991";</script><div>


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