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	New Student Registration - Chabad of The Woodlands 
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			<h1 class="article-header__title js-article-title js-page-title">New Student Registration</h1>
		
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<div><em><strong>*The Director will interview new families after registration is submitted, before acceptance is finalized.</strong></em></div>

<div><em><strong>** Scholarship applicants must complete Registration and the <a href="https://www.jewishwoodlands.com/templates/articlecco_cdo/aid/3421822/jewish/HS-Scholarship-Application.htm">Scholarship Application</a>. </strong></em></div>

<div><em><strong>*** Please note that there is an additional application process for Bar/Bat Mitzvah, that is distinct from Hebrew School.</strong></em></div>
</div> </div></li><li class="form-line" id="id_78"><div class="form-label-left" id="label_78"><label for="input_78"> Number of students being registered:<span class="form-required">*</span> </label><label class="label-message" for="input_78"> </label></div><div id="cid_78" class="form-input"> <input type="number" class="form-number-input  form-textbox validate[required]" id="input_78" name="q78_number" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" max="5" data-numbermax="5" /> </div></li><li id="cid_40" class="form-input-wide"> <div class="form-header-group"><h2 id="header_40" class="form-header">Parent Information</h2></div> </li><li class="form-line" id="id_45"><div class="form-label-left" id="label_45"><label for="input_45"> Father's Title </label><label class="label-message" for="input_45"> </label></div><div id="cid_45" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_45" name="q45_input45"><option value=""></option><option value="Dr.">Dr.</option><option value="Mr. ">Mr. </option></select> </div></li><li class="form-line" id="id_41"><div class="form-label-left" id="label_41"><label for="input_41"> Father's Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_41"> </label></div><div id="cid_41" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q41_fullName41[first]" id="first_41" autocomplete="given-name" />  <label class="form-sub-label" for="first_41" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q41_fullName41[last]" id="last_41" autocomplete="family-name" />  <label class="form-sub-label" for="last_41" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_42"><div class="form-label-left" id="label_42"><label for="input_42"> Father's Cell Phone Number </label><label class="label-message" for="input_42"> </label></div><div id="cid_42" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q42_phoneNumber[area]" id="input_42_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_42_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q42_phoneNumber[phone]" id="input_42_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_42_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_43"><div class="form-label-left" id="label_43"><label for="input_43"> Father's E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_43"> </label></div><div id="cid_43" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_43" name="q43_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_44"><div class="form-label-left" id="label_44"><label for="input_44"> Father's Employer </label><label class="label-message" for="input_44"> </label></div><div id="cid_44" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_44" name="q44_input44" size="20" value="" /> </div></li><li class="form-line" id="id_120"><div class="form-label-left" id="label_120"><label for="input_120"> Position </label><label class="label-message" for="input_120"> </label></div><div id="cid_120" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_120" name="q120_input120" size="20" value="" /> </div></li><li class="form-line" id="id_79"><div class="form-label-left" id="label_79"><label for="input_79"> Address<span class="form-required">*</span> </label><label class="label-message" for="input_79"> </label></div><div id="cid_79" 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="q79_address79[addr_line1]" id="input_79_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_79_addr_line1" id="sublabel_79_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="q79_address79[addr_line2]" id="input_79_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_79_addr_line2" id="sublabel_79_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="q79_address79[city]" id="input_79_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_79_city" id="sublabel_79_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q79_address79[state]" id="input_79_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_79_state" id="sublabel_79_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="q79_address79[postal]" id="input_79_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_79_postal" id="sublabel_79_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q79_address79[country]" id="input_79_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_79_country" id="sublabel_79_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"> Mother's Title </label><label class="label-message" for="input_47"> </label></div><div id="cid_47" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_47" name="q47_input47"><option value=""></option><option value="Dr.">Dr.</option><option value="Mrs. ">Mrs. </option><option value="Ms. ">Ms. </option></select> </div></li><li class="form-line" id="id_48"><div class="form-label-left" id="label_48"><label for="input_48"> Mother's Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_48"> </label></div><div id="cid_48" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q48_fullName48[first]" id="first_48" autocomplete="given-name" />  <label class="form-sub-label" for="first_48" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q48_fullName48[last]" id="last_48" autocomplete="family-name" />  <label class="form-sub-label" for="last_48" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_49"><div class="form-label-left" id="label_49"><label for="input_49"> Mother's Cell Phone Number </label><label class="label-message" for="input_49"> </label></div><div id="cid_49" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q49_phoneNumber49[area]" id="input_49_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_49_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q49_phoneNumber49[phone]" id="input_49_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_49_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_50"><div class="form-label-left" id="label_50"><label for="input_50"> Mother's E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_50"> </label></div><div id="cid_50" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_50" name="q50_email50" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_51"><div class="form-label-left" id="label_51"><label for="input_51"> Mother's Employer </label><label class="label-message" for="input_51"> </label></div><div id="cid_51" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_51" name="q51_input51" size="20" value="" /> </div></li><li class="form-line" id="id_121"><div class="form-label-left" id="label_121"><label for="input_121"> Position </label><label class="label-message" for="input_121"> </label></div><div id="cid_121" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_121" name="q121_input121" size="20" value="" /> </div></li><li class="form-line" id="id_80"><div class="form-label-left" id="label_80"><label for="input_80"> Mother's Address, if different from above </label><label class="label-message" for="input_80"> </label></div><div id="cid_80" 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 form-address-line" type="text" name="q80_address[addr_line1]" id="input_80_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_80_addr_line1" id="sublabel_80_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="q80_address[addr_line2]" id="input_80_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_80_addr_line2" id="sublabel_80_addr_line2">Street Address Line 2</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q80_address[city]" id="input_80_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_80_city" id="sublabel_80_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q80_address[state]" id="input_80_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_80_state" id="sublabel_80_state">State / Province</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q80_address[postal]" id="input_80_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_80_postal" id="sublabel_80_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q80_address[country]" id="input_80_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_80_country" id="sublabel_80_country">Country</label></span></td></tr></tbody></table> </div></li><li id="cid_3" class="form-input-wide"> <div class="form-header-group"><h2 id="header_3" class="form-header">Student Profile</h2><div id="subHeader_3" class="form-subHeader">Student 1</div></div> </li><li class="form-line" id="id_4"><div class="form-label-left" id="label_4"><label for="input_4"> 1. Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_4"> </label></div><div id="cid_4" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q4_fullName[first]" id="first_4" autocomplete="given-name" />  <label class="form-sub-label" for="first_4" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q4_fullName[last]" id="last_4" autocomplete="family-name" />  <label class="form-sub-label" for="last_4" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_5"><div class="form-label-left" id="label_5"><label for="input_5"> 1. Hebrew Name<span class="form-required">*</span> </label><label class="label-message" for="input_5"> </label></div><div id="cid_5" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_5" name="q5_input5" size="20" value="" /> </div></li><li class="form-line" id="id_6"><div class="form-label-left" id="label_6"><label for="input_6"> 1. Gender<span class="form-required">*</span> </label><label class="label-message" for="input_6"> </label></div><div id="cid_6" 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_6_0" name="q6_input6" value="Male" /><label id="label_input_6_0" for="input_6_0"><span>Male</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_6_1" name="q6_input6" value="Female" /><label id="label_input_6_1" for="input_6_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_7"><div class="form-label-left" id="label_7"><label for="input_7"> 1. Date of Birth<span class="form-required">*</span> </label><label class="label-message" for="input_7"> </label></div><div id="cid_7" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select class="form-dropdown validate[required]" name="q7_birthDate[month]" id="input_7_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_7_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" name="q7_birthDate[day]" id="input_7_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_7_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" name="q7_birthDate[year]" id="input_7_year"><option></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_7_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_8"><div class="form-label-left" id="label_8"><label for="input_8"> 1. School<span class="form-required">*</span> </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_8" name="q8_input8" size="20" value="" /> </div></li><li class="form-line" id="id_9"><div class="form-label-left" id="label_9"><label for="input_9"> 1. Grade<span class="form-required">*</span> </label><label class="label-message" for="input_9"> </label></div><div id="cid_9" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_9" name="q9_input9"><option value=""></option><option value="Pre-K">Pre-K</option><option value="K">K</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_10"><div class="form-label-left" id="label_10"><label for="input_10"> 1. Previous Jewish education?<span class="form-required">*</span> </label><label class="label-message" for="input_10"> </label></div><div id="cid_10" 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_10_0" name="q10_input10" value="Yes" /><label id="label_input_10_0" for="input_10_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_10_1" name="q10_input10" value="No" /><label id="label_input_10_1" for="input_10_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_11"><div class="form-label-left" id="label_11"><label for="input_11"> 1. If Yes please describe </label><label class="label-message" for="input_11"> </label></div><div id="cid_11" class="form-input"> <textarea id="input_11" class="form-textarea" name="q11_input11" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12"> 1. Hebrew Reading Proficiency:<span class="form-required">*</span> </label><label class="label-message" for="input_12"> </label></div><div id="cid_12" 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_12_0" name="q12_input12" value="None" /><label id="label_input_12_0" for="input_12_0"><span>None</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_12_1" name="q12_input12" value="Somewhat" /><label id="label_input_12_1" for="input_12_1"><span>Somewhat</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_12_2" name="q12_input12" value="Well" /><label id="label_input_12_2" for="input_12_2"><span>Well</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_13"><div class="form-label-left" id="label_13"><label for="input_13"> 1. Is the child's mother Jewish by birth?<span class="form-required">*</span> </label><label class="label-message" for="input_13"> </label></div><div id="cid_13" 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_13_0" name="q13_input13" value="Yes" /><label id="label_input_13_0" for="input_13_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_13_1" name="q13_input13" value="No" /><label id="label_input_13_1" for="input_13_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_14"><div class="form-label-left" id="label_14"><label for="input_14"> 1. Have there been any conversions or adoptions in the family? <span class="form-required">*</span> </label><label class="label-message" for="input_14"> </label></div><div id="cid_14" 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_14_0" name="q14_input14" value="Yes" /><label id="label_input_14_0" for="input_14_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_14_1" name="q14_input14" value="No" /><label id="label_input_14_1" for="input_14_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_15"><div class="form-label-left" id="label_15"><label for="input_15"> 1. If yes, please explain </label><label class="label-message" for="input_15"> </label></div><div id="cid_15" class="form-input"> <textarea id="input_15" class="form-textarea" name="q15_input15" cols="40" rows="6"></textarea> </div></li><li id="cid_75" class="form-input-wide"> <div class="form-header-group"><h2 id="header_75" class="form-header"></h2><div id="subHeader_75" class="form-subHeader">Student 2</div></div> </li><li class="form-line" id="id_16"><div class="form-label-left" id="label_16"><label for="input_16"> 2. Full Name </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" 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" 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"> 2. Hebrew Name </label><label class="label-message" for="input_18"> </label></div><div id="cid_18" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_18" name="q18_input18" size="20" value="" /> </div></li><li class="form-line" id="id_20"><div class="form-label-left" id="label_20"><label for="input_20"> 2. Gender </label><label class="label-message" for="input_20"> </label></div><div id="cid_20" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_20_0" name="q20_input20" value="Male" /><label id="label_input_20_0" for="input_20_0"><span>Male</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_20_1" name="q20_input20" value="Female" /><label id="label_input_20_1" for="input_20_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_22"><div class="form-label-left" id="label_22"><label for="input_22"> 2. Date of Birth </label><label class="label-message" for="input_22"> </label></div><div id="cid_22" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select class="form-dropdown" name="q22_birthDate22[month]" id="input_22_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_22_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q22_birthDate22[day]" id="input_22_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_22_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q22_birthDate22[year]" id="input_22_year"><option></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_22_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_24"><div class="form-label-left" id="label_24"><label for="input_24"> 2. School </label><label class="label-message" for="input_24"> </label></div><div id="cid_24" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_24" name="q24_input24" size="20" value="" /> </div></li><li class="form-line" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> 2. Grade </label><label class="label-message" for="input_26"> </label></div><div id="cid_26" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_26" name="q26_input26"><option value=""></option><option value="Pre-K">Pre-K</option><option value="K">K</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><option value="Grade 8">Grade 8</option></select> </div></li><li class="form-line" id="id_28"><div class="form-label-left" id="label_28"><label for="input_28"> 2. Previous Jewish education? </label><label class="label-message" for="input_28"> </label></div><div id="cid_28" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_28_0" name="q28_input28" value="Yes" /><label id="label_input_28_0" for="input_28_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_28_1" name="q28_input28" value="No" /><label id="label_input_28_1" for="input_28_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_30"><div class="form-label-left" id="label_30"><label for="input_30"> 2. If Yes please describe </label><label class="label-message" for="input_30"> </label></div><div id="cid_30" class="form-input"> <textarea id="input_30" class="form-textarea" name="q30_input30" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_32"><div class="form-label-left" id="label_32"><label for="input_32"> 2. Hebrew Reading Proficiency: </label><label class="label-message" for="input_32"> </label></div><div id="cid_32" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_32_0" name="q32_input32" value="None" /><label id="label_input_32_0" for="input_32_0"><span>None</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_32_1" name="q32_input32" value="Somewhat" /><label id="label_input_32_1" for="input_32_1"><span>Somewhat</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_32_2" name="q32_input32" value="Well" /><label id="label_input_32_2" for="input_32_2"><span>Well</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_34"><div class="form-label-left" id="label_34"><label for="input_34"> 2. Is the child's mother Jewish by birth? </label><label class="label-message" for="input_34"> </label></div><div id="cid_34" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_34_0" name="q34_input34" value="Yes" /><label id="label_input_34_0" for="input_34_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_34_1" name="q34_input34" value="No" /><label id="label_input_34_1" for="input_34_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_36"><div class="form-label-left" id="label_36"><label for="input_36"> 2. Have there been any conversions or adoptions in the family? </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-radio-item clear-left"><input type="radio" class="form-radio" id="input_36_0" name="q36_input36" value="Yes" /><label id="label_input_36_0" for="input_36_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_36_1" name="q36_input36" value="No" /><label id="label_input_36_1" for="input_36_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_38"><div class="form-label-left" id="label_38"><label for="input_38"> 2. If yes, please explain </label><label class="label-message" for="input_38"> </label></div><div id="cid_38" class="form-input"> <textarea id="input_38" class="form-textarea" name="q38_input38" cols="40" rows="6"></textarea> </div></li><li id="cid_76" class="form-input-wide"> <div class="form-header-group"><h2 id="header_76" class="form-header"></h2><div id="subHeader_76" class="form-subHeader">Student 3</div></div> </li><li class="form-line" id="id_17"><div class="form-label-left" id="label_17"><label for="input_17"> 3. Full Name </label><label class="label-message" for="input_17"> </label></div><div id="cid_17" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q17_fullName17[first]" id="first_17" autocomplete="given-name" />  <label class="form-sub-label" for="first_17" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q17_fullName17[last]" id="last_17" autocomplete="family-name" />  <label class="form-sub-label" for="last_17" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_19"><div class="form-label-left" id="label_19"><label for="input_19"> 3. Hebrew Name </label><label class="label-message" for="input_19"> </label></div><div id="cid_19" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_19" name="q19_input19" size="20" value="" /> </div></li><li class="form-line" id="id_21"><div class="form-label-left" id="label_21"><label for="input_21"> 3. Gender </label><label class="label-message" for="input_21"> </label></div><div id="cid_21" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_21_0" name="q21_input21" value="Male" /><label id="label_input_21_0" for="input_21_0"><span>Male</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_21_1" name="q21_input21" value="Female" /><label id="label_input_21_1" for="input_21_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_23"><div class="form-label-left" id="label_23"><label for="input_23"> 3. Date of Birth </label><label class="label-message" for="input_23"> </label></div><div id="cid_23" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select class="form-dropdown" name="q23_birthDate23[month]" id="input_23_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_23_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q23_birthDate23[day]" id="input_23_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_23_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q23_birthDate23[year]" id="input_23_year"><option></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_23_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_25"><div class="form-label-left" id="label_25"><label for="input_25"> 3. School </label><label class="label-message" for="input_25"> </label></div><div id="cid_25" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_25" name="q25_input25" size="20" value="" /> </div></li><li class="form-line" id="id_27"><div class="form-label-left" id="label_27"><label for="input_27"> 3. Grade </label><label class="label-message" for="input_27"> </label></div><div id="cid_27" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_27" name="q27_input27"><option value=""></option><option value="Pre-K">Pre-K</option><option value="K">K</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><option value="Grade 8">Grade 8</option></select> </div></li><li class="form-line" id="id_29"><div class="form-label-left" id="label_29"><label for="input_29"> 3. Previous Jewish education? </label><label class="label-message" for="input_29"> </label></div><div id="cid_29" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_29_0" name="q29_input29" value="Yes" /><label id="label_input_29_0" for="input_29_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_29_1" name="q29_input29" value="No" /><label id="label_input_29_1" for="input_29_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_31"><div class="form-label-left" id="label_31"><label for="input_31"> 3. If Yes please describe </label><label class="label-message" for="input_31"> </label></div><div id="cid_31" class="form-input"> <textarea id="input_31" class="form-textarea" name="q31_input31" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_33"><div class="form-label-left" id="label_33"><label for="input_33"> 3. Hebrew Reading Proficiency: </label><label class="label-message" for="input_33"> </label></div><div id="cid_33" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_33_0" name="q33_input33" value="None" /><label id="label_input_33_0" for="input_33_0"><span>None</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_33_1" name="q33_input33" value="Somewhat" /><label id="label_input_33_1" for="input_33_1"><span>Somewhat</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_33_2" name="q33_input33" value="Well" /><label id="label_input_33_2" for="input_33_2"><span>Well</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_35"><div class="form-label-left" id="label_35"><label for="input_35"> 3. Is the child's mother Jewish by birth? </label><label class="label-message" for="input_35"> </label></div><div id="cid_35" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_35_0" name="q35_input35" value="Yes" /><label id="label_input_35_0" for="input_35_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_35_1" name="q35_input35" value="No" /><label id="label_input_35_1" for="input_35_1"><span>No</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"> 3. Have there been any conversions or adoptions in the family? </label><label class="label-message" for="input_37"> </label></div><div id="cid_37" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_37_0" name="q37_input37" value="Yes" /><label id="label_input_37_0" for="input_37_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_37_1" name="q37_input37" value="No" /><label id="label_input_37_1" for="input_37_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_39"><div class="form-label-left" id="label_39"><label for="input_39"> 3. If yes, please explain </label><label class="label-message" for="input_39"> </label></div><div id="cid_39" class="form-input"> <textarea id="input_39" class="form-textarea" name="q39_input39" cols="40" rows="6"></textarea> </div></li><li id="cid_93" class="form-input-wide"> <div class="form-header-group"><h2 id="header_93" class="form-header"></h2><div id="subHeader_93" class="form-subHeader">Student 4</div></div> </li><li class="form-line" id="id_97"><div class="form-label-left" id="label_97"><label for="input_97"> 4. Full Name </label><label class="label-message" for="input_97"> </label></div><div id="cid_97" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q97_fullName97[first]" id="first_97" autocomplete="given-name" />  <label class="form-sub-label" for="first_97" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q97_fullName97[last]" id="last_97" autocomplete="family-name" />  <label class="form-sub-label" for="last_97" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_98"><div class="form-label-left" id="label_98"><label for="input_98"> 4. Hebrew Name </label><label class="label-message" for="input_98"> </label></div><div id="cid_98" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_98" name="q98_input98" size="20" value="" /> </div></li><li class="form-line" id="id_99"><div class="form-label-left" id="label_99"><label for="input_99"> 4. Gender </label><label class="label-message" for="input_99"> </label></div><div id="cid_99" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_99_0" name="q99_input99" value="Male" /><label id="label_input_99_0" for="input_99_0"><span>Male</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_99_1" name="q99_input99" value="Female" /><label id="label_input_99_1" for="input_99_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_100"><div class="form-label-left" id="label_100"><label for="input_100"> 4. Date of Birth </label><label class="label-message" for="input_100"> </label></div><div id="cid_100" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select class="form-dropdown" name="q100_birthDate100[month]" id="input_100_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_100_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q100_birthDate100[day]" id="input_100_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_100_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q100_birthDate100[year]" id="input_100_year"><option></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_100_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_101"><div class="form-label-left" id="label_101"><label for="input_101"> 4. School  </label><label class="label-message" for="input_101"> </label></div><div id="cid_101" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_101" name="q101_input101" size="20" value="" /> </div></li><li class="form-line" id="id_103"><div class="form-label-left" id="label_103"><label for="input_103"> 4. Grade </label><label class="label-message" for="input_103"> </label></div><div id="cid_103" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_103" name="q103_input103"><option value=""></option><option value="Pre-K">Pre-K</option><option value="K">K</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><option value="Grade 8">Grade 8</option></select> </div></li><li class="form-line" id="id_104"><div class="form-label-left" id="label_104"><label for="input_104"> 4. Previous Jewish education? </label><label class="label-message" for="input_104"> </label></div><div id="cid_104" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_104_0" name="q104_input104" value="Yes" /><label id="label_input_104_0" for="input_104_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_104_1" name="q104_input104" value="No" /><label id="label_input_104_1" for="input_104_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_105"><div class="form-label-left" id="label_105"><label for="input_105"> 4. If Yes please describe </label><label class="label-message" for="input_105"> </label></div><div id="cid_105" class="form-input"> <textarea id="input_105" class="form-textarea" name="q105_input105" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_106"><div class="form-label-left" id="label_106"><label for="input_106"> 4. Hebrew Reading Proficiency </label><label class="label-message" for="input_106"> </label></div><div id="cid_106" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_106_0" name="q106_input106" value="None" /><label id="label_input_106_0" for="input_106_0"><span>None</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_106_1" name="q106_input106" value="Somewhat" /><label id="label_input_106_1" for="input_106_1"><span>Somewhat</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_106_2" name="q106_input106" value="Well" /><label id="label_input_106_2" for="input_106_2"><span>Well</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_96"><div class="form-label-left" id="label_96"><label for="input_96"> 4. Is the child's mother Jewish by birth? </label><label class="label-message" for="input_96"> </label></div><div id="cid_96" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_96_0" name="q96_input96" value="Yes" /><label id="label_input_96_0" for="input_96_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_96_1" name="q96_input96" value="No" /><label id="label_input_96_1" for="input_96_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_95"><div class="form-label-left" id="label_95"><label for="input_95"> 4. Have there been any conversions or adoptions in the family? </label><label class="label-message" for="input_95"> </label></div><div id="cid_95" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_95_0" name="q95_input95" value="Yes" /><label id="label_input_95_0" for="input_95_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_95_1" name="q95_input95" value="No" /><label id="label_input_95_1" for="input_95_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_94"><div class="form-label-left" id="label_94"><label for="input_94"> 4. If yes, please explain </label><label class="label-message" for="input_94"> </label></div><div id="cid_94" class="form-input"> <textarea id="input_94" class="form-textarea" name="q94_input94" cols="40" rows="6"></textarea> </div></li><li id="cid_108" class="form-input-wide"> <div class="form-header-group"><h2 id="header_108" class="form-header"></h2><div id="subHeader_108" class="form-subHeader">Student 5</div></div> </li><li class="form-line" id="id_107"><div class="form-label-left" id="label_107"><label for="input_107"> 5. Full Name </label><label class="label-message" for="input_107"> </label></div><div id="cid_107" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q107_fullName107[first]" id="first_107" autocomplete="given-name" />  <label class="form-sub-label" for="first_107" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q107_fullName107[last]" id="last_107" autocomplete="family-name" />  <label class="form-sub-label" for="last_107" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_109"><div class="form-label-left" id="label_109"><label for="input_109"> 5. Hebrew Name </label><label class="label-message" for="input_109"> </label></div><div id="cid_109" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_109" name="q109_input109" size="20" value="" /> </div></li><li class="form-line" id="id_110"><div class="form-label-left" id="label_110"><label for="input_110"> 5. Gender </label><label class="label-message" for="input_110"> </label></div><div id="cid_110" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_110_0" name="q110_input110" value="Male" /><label id="label_input_110_0" for="input_110_0"><span>Male</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_110_1" name="q110_input110" value="Female" /><label id="label_input_110_1" for="input_110_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_113"><div class="form-label-left" id="label_113"><label for="input_113"> 5. Date of Birth </label><label class="label-message" for="input_113"> </label></div><div id="cid_113" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select class="form-dropdown" name="q113_birthDate113[month]" id="input_113_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_113_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q113_birthDate113[day]" id="input_113_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_113_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q113_birthDate113[year]" id="input_113_year"><option></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_113_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_112"><div class="form-label-left" id="label_112"><label for="input_112"> 5. School  </label><label class="label-message" for="input_112"> </label></div><div id="cid_112" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_112" name="q112_input112" size="20" value="" /> </div></li><li class="form-line" id="id_111"><div class="form-label-left" id="label_111"><label for="input_111"> 5. Grade </label><label class="label-message" for="input_111"> </label></div><div id="cid_111" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_111" name="q111_input111"><option value=""></option><option value="Pre-K">Pre-K</option><option value="K">K</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><option value="Grade 8">Grade 8</option></select> </div></li><li class="form-line" id="id_114"><div class="form-label-left" id="label_114"><label for="input_114"> 5. Previous Jewish education? </label><label class="label-message" for="input_114"> </label></div><div id="cid_114" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_114_0" name="q114_input114" value="Yes" /><label id="label_input_114_0" for="input_114_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_114_1" name="q114_input114" value="No" /><label id="label_input_114_1" for="input_114_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_115"><div class="form-label-left" id="label_115"><label for="input_115"> 5. If Yes please describe </label><label class="label-message" for="input_115"> </label></div><div id="cid_115" class="form-input"> <textarea id="input_115" class="form-textarea" name="q115_input115" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_116"><div class="form-label-left" id="label_116"><label for="input_116"> 5. Hebrew Reading Proficiency </label><label class="label-message" for="input_116"> </label></div><div id="cid_116" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_116_0" name="q116_input116" value="None" /><label id="label_input_116_0" for="input_116_0"><span>None</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_116_1" name="q116_input116" value="Somewhat" /><label id="label_input_116_1" for="input_116_1"><span>Somewhat</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_116_2" name="q116_input116" value="Well" /><label id="label_input_116_2" for="input_116_2"><span>Well</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_117"><div class="form-label-left" id="label_117"><label for="input_117"> 5. Is the child's mother Jewish by birth? </label><label class="label-message" for="input_117"> </label></div><div id="cid_117" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_117_0" name="q117_input117" value="Yes" /><label id="label_input_117_0" for="input_117_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_117_1" name="q117_input117" value="No" /><label id="label_input_117_1" for="input_117_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_118"><div class="form-label-left" id="label_118"><label for="input_118"> 5. Have there been any conversions or adoptions in the family? </label><label class="label-message" for="input_118"> </label></div><div id="cid_118" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_118_0" name="q118_input118" value="Yes" /><label id="label_input_118_0" for="input_118_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_118_1" name="q118_input118" value="No" /><label id="label_input_118_1" for="input_118_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_119"><div class="form-label-left" id="label_119"><label for="input_119"> 5. If yes, please explain </label><label class="label-message" for="input_119"> </label></div><div id="cid_119" class="form-input"> <textarea id="input_119" class="form-textarea" name="q119_input119" cols="40" rows="6"></textarea> </div></li><li id="cid_53" class="form-input-wide"> <div class="form-header-group"><h2 id="header_53" class="form-header">Emergency Information</h2></div> </li><li class="form-line" id="id_54"><div class="form-label-left" id="label_54"><label for="input_54"> 1. Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_54"> </label></div><div id="cid_54" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q54_fullName54[first]" id="first_54" autocomplete="given-name" />  <label class="form-sub-label" for="first_54" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q54_fullName54[last]" id="last_54" autocomplete="family-name" />  <label class="form-sub-label" for="last_54" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_55"><div class="form-label-left" id="label_55"><label for="input_55"> 1. Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_55"> </label></div><div id="cid_55" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q55_phoneNumber55[area]" id="input_55_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_55_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q55_phoneNumber55[phone]" id="input_55_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_55_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_60"><div class="form-label-left" id="label_60"><label for="input_60"> 1. Relation<span class="form-required">*</span> </label><label class="label-message" for="input_60"> </label></div><div id="cid_60" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_60" name="q60_input60" size="20" value="" /> </div></li><li class="form-line" id="id_57"><div class="form-label-left" id="label_57"><label for="input_57"> 2. Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_57"> </label></div><div id="cid_57" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q57_fullName57[first]" id="first_57" autocomplete="given-name" />  <label class="form-sub-label" for="first_57" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q57_fullName57[last]" id="last_57" autocomplete="family-name" />  <label class="form-sub-label" for="last_57" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_58"><div class="form-label-left" id="label_58"><label for="input_58"> 2. Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_58"> </label></div><div id="cid_58" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q58_phoneNumber58[area]" id="input_58_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_58_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q58_phoneNumber58[phone]" id="input_58_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_58_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_59"><div class="form-label-left" id="label_59"><label for="input_59"> 2. Relation<span class="form-required">*</span> </label><label class="label-message" for="input_59"> </label></div><div id="cid_59" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_59" name="q59_input59" size="20" value="" /> </div></li><li class="form-line" id="id_61"><div class="form-label-left" id="label_61"><label for="input_61"> Family Physician's Name<span class="form-required">*</span> </label><label class="label-message" for="input_61"> </label></div><div id="cid_61" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q61_fullName61[first]" id="first_61" autocomplete="given-name" />  <label class="form-sub-label" for="first_61" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q61_fullName61[last]" id="last_61" autocomplete="family-name" />  <label class="form-sub-label" for="last_61" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_63"><div class="form-label-left" id="label_63"><label for="input_63"> Family Physician's Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_63"> </label></div><div id="cid_63" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q63_phoneNumber63[area]" id="input_63_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_63_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q63_phoneNumber63[phone]" id="input_63_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_63_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_62"><div class="form-label-left" id="label_62"><label for="input_62"> Family Physician's Address<span class="form-required">*</span> </label><label class="label-message" for="input_62"> </label></div><div id="cid_62" 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="q62_address62[addr_line1]" id="input_62_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_62_addr_line1" id="sublabel_62_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="q62_address62[addr_line2]" id="input_62_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_62_addr_line2" id="sublabel_62_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="q62_address62[city]" id="input_62_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_62_city" id="sublabel_62_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q62_address62[state]" id="input_62_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_62_state" id="sublabel_62_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="q62_address62[postal]" id="input_62_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_62_postal" id="sublabel_62_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q62_address62[country]" id="input_62_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_62_country" id="sublabel_62_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_64"><div class="form-label-left" id="label_64"><label for="input_64"> CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed. </label><label class="label-message" for="input_64"> </label></div><div id="cid_64" class="form-input"> <textarea id="input_64" class="form-textarea" name="q64_input64" cols="40" rows="6"></textarea> </div></li><li id="cid_65" class="form-input-wide"> <div class="form-header-group"><h2 id="header_65" class="form-header">Tuition</h2><div id="subHeader_65" class="form-subHeader">Supply fee $50/child. Tution: $800/per child <br />If applicable, your balance will be charged in 6 monthly installments beginning on 9/15</div></div> </li><li class="form-line always-hidden" id="id_77"><div class="form-label-left" id="label_77"><label for="input_77"> Total to be paid today: </label><label class="label-message" for="input_77"> </label></div><div id="cid_77" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_77_0" name="q77_input77[]" value="1 Child Full Tuition: $700" /><label id="label_input_77_0" for="input_77_0"><span>1 Child Full Tuition: $700</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_77_1" name="q77_input77[]" value="2 Children Full Tuition: $1,330" /><label id="label_input_77_1" for="input_77_1"><span>2 Children Full Tuition: $1,330</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_77_2" name="q77_input77[]" value="3 Children Full Tuition: $1960" /><label id="label_input_77_2" for="input_77_2"><span>3 Children Full Tuition: $1960</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_77_3" name="q77_input77[]" value="Please charge my balance in 5 monthly installments." /><label id="label_input_77_3" for="input_77_3"><span>Please charge my balance in 5 monthly installments.</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line always-hidden" id="id_86"><div class="form-label-left" id="label_86"><label for="input_86"> Total to be paid today: </label><label class="label-message" for="input_86"> Early bird discount automatically applied</label></div><div id="cid_86" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_86_0" name="q86_input86" value="1 Child Judaica Program Full Tuition: $600" /><label id="label_input_86_0" for="input_86_0"><span>1 Child Judaica Program Full Tuition: $600</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_86_1" name="q86_input86" value="2 Children Judaica Program Full Tuition: $1,140" /><label id="label_input_86_1" for="input_86_1"><span>2 Children Judaica Program Full Tuition: $1,140</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_86_2" name="q86_input86" value="3 Children Judaica Program  Full Tuition: $1,680" /><label id="label_input_86_2" for="input_86_2"><span>3 Children Judaica Program  Full Tuition: $1,680</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line always-hidden" id="id_91"><div class="form-label-left" id="label_91"><label for="input_91"> Total to be paid today: </label><label class="label-message" for="input_91"> </label></div><div id="cid_91" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_91_0" name="q91_input91" value="1 Child Hebrew Reading Program Full Tuition: $180" /><label id="label_input_91_0" for="input_91_0"><span>1 Child Hebrew Reading Program Full Tuition: $180</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_91_1" name="q91_input91" value="2 Children Hebrew Reading Program Full Tuition: $360" /><label id="label_input_91_1" for="input_91_1"><span>2 Children Hebrew Reading Program Full Tuition: $360</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_91_2" name="q91_input91" value="3 Children Hebrew Reading Program Full Tuition: $540" /><label id="label_input_91_2" for="input_91_2"><span>3 Children Hebrew Reading Program Full Tuition: $540</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_92"><div class="form-label-left" id="label_92"><label for="input_92"> Total Registration:<span class="form-required">*</span> </label><label class="label-message" for="input_92"> Please select all that apply:</label></div><div id="cid_92" 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_92_0" name="q92_input92[]" value="Child 1: $800" /><label id="label_input_92_0" for="input_92_0"><span>Child 1: $800</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_92_1" name="q92_input92[]" value="Child 2: $740 (sibling discount applied)" /><label id="label_input_92_1" for="input_92_1"><span>Child 2: $740 (sibling discount applied)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_92_2" name="q92_input92[]" value="Child 3: $740 (sibling discount applied)" /><label id="label_input_92_2" for="input_92_2"><span>Child 3: $740 (sibling discount applied)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_92_3" name="q92_input92[]" value="Child 4: $740 (sibling discount applied)" /><label id="label_input_92_3" for="input_92_3"><span>Child 4: $740 (sibling discount applied)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_92_4" name="q92_input92[]" value="Child 5: $740 (sibling discount applied)" /><label id="label_input_92_4" for="input_92_4"><span>Child 5: $740 (sibling discount applied)</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_67"><div class="form-label-left" id="label_67"><label for="input_67"> Total (including registration fee): </label></div><div id="cid_67" class="form-input"> <div id="total_amount">$0.00 </div><br /><div class="clearfix form-single-column top_padding" id="payformWrapper"><label class="form-header form-label-left">I would like to pay today:</label><span class="form-radio-item"><label><input type="radio" class="form-radio validate[partialPayment]" value="full" name="partial" checked="checked" id="input_partial_1" />Full amount</label></span><span class="form-radio-item"><input type="radio" class="form-radio validate[partialPayment]" value="minimum" name="partial" id="input_partial_2" /><label for="input_partial_2"><span>$<span id="payformMin">100.00</span>  minimum</span></label></span><span class="form-radio-item"><label><input type="radio" class="form-other form-radio validate[partialPayment]" value="custom" name="partial" id="other_partial" />$<input type="text" onclick="document.getElementById('other_partial').checked = true" class="form-radio-other-input validate[customPartial]" id="input_partial" name="partialamount" data-otherhint="Other" onkeypress="validateNumber(event)" /> </label></span></div><div class="form-single-column form-checkbox-item" id="div_offset_gift_67" style="padding-top: 10px">		<input type="checkbox" id="input_67" class="form-checkbox" name="q67_offsetGiftPercent" value="3" />		<label id="label_67" for="input_67">Yes, I'd like to donate the cost of processing this transaction by adding 3%</label>		<input type="hidden" id="hidden_67" name="q67_offsetGiftAmount" />		<div class="clearfix"></div>		</div> </div></li><li class="form-line" id="id_68"><div class="form-label-left" id="label_68"><label for="input_68"> Payment </label><label class="label-message" for="input_68"> </label></div><div id="cid_68" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2" class="form-payment-methods form-multiple-column"><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_68_creditCard" name="q68_payment[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_68_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_68_paypal" name="q68_payment[payment_method]" value="paypal" onclick="BuildSource.paypal(this)" /><label for="input_68_paypal">Paypal</label> </span></td></tr><tr class="credit_card hide"><th colspan="2">Credit Card</th></tr><tr class="credit_card hide"><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, Discover</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 class="cc-icon discover-icon"></div></div><input type="hidden" name="q68_payment[cc_type]" id="input_68_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[visible, creditcard]" type="text" name="q68_payment[cc_number]" id="input_68_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_68_cc_number" id="sublabel_cc_number">Credit Card Number</label></span></div></td><td class="cc_ccv "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q68_payment[cc_ccv]" id="input_68_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_68_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[visible]" type="text" name="q68_payment[cc_nameOnCard]" id="input_68_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_68_cc_nameOnCard" id="sublabel_cc_nameOnCard">Name on Card</label></span></td></tr><tr class="credit_card hide"><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q68_payment[cc_exp_month]" id="input_68_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_68_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[visible]" name="q68_payment[cc_exp_year]" id="input_68_cc_exp_year" autocomplete="cc-exp-year"><option></option><option value="2025">2025</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></select>  <label class="form-sub-label" for="input_68_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="paypal hide"><td colspan="2">Paypal has been selected. Payment will take place on the next page.</td></tr><tr class="billing_address hide"><th colspan="2">Billing Address</th></tr><tr class="billing_address hide"><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line" type="text" name="q68_payment[addr_line1]" id="input_68_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_68_addr_line1" id="sublabel_68_addr_line1">Street Address</label></span></td></tr><tr class="billing_address hide"><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q68_payment[city]" id="input_68_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_68_city" id="sublabel_68_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q68_payment[state]" id="input_68_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_68_state" id="sublabel_68_state">State / Province</label></span></td></tr><tr class="billing_address hide"><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q68_payment[postal]" id="input_68_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_68_postal" id="sublabel_68_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q68_payment[country]" id="input_68_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_68_country" id="sublabel_68_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_84"><div id="cid_84" class="form-input-wide"> <div id="text_84" class="form-html"><p><em><strong>DISCLAIMER<br /></strong></em>As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad Hebrew School to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in Chabad Hebrew School activities and that these pictures may be used for marketing purposes.</p></div> </div></li><li class="form-line" id="id_70"><div class="form-label-left" id="label_70"><label for="input_70"> <span class="form-required">*</span> </label><label class="label-message" for="input_70"> </label></div><div id="cid_70" 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_70_0" name="q70_input70[]" value="I accept" /><label id="label_input_70_0" for="input_70_0"><span>I accept</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_72"><div class="form-label-left" id="label_72"><label for="input_72"> Initials<span class="form-required">*</span> </label><label class="label-message" for="input_72"> </label></div><div id="cid_72" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_72" name="q72_input72" size="20" value="" /> </div></li><li class="form-line" id="id_2"><div id="cid_2" class="form-input-wide"> <div style="text-align: center;" class="form-buttons-wrapper button-align-center"><button id="input_2" type="submit" class="form-submit-button  form-submit-button-none;">Submit</button></div> </div></li><li class="form-line" id="id_85"><div id="cid_85" class="form-input-wide"> <div id="text_85" class="form-html"><p style="text-align: center;"><em>100% of the proceeds of this donation or payment benefit Chabad of The Woodlands.</em></p></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="4824828" /><script type="text/javascript">document.getElementById("si"+"mple"+"_spc").value = "4824828-4824828";</script><div>


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