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<form class="userform-form" action="" method="post" name="form_7007700" id="7007700" accept-charset="utf-8"><input type="hidden" name="formID" value="7007700" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li id="cid_21" class="form-input-wide"> <div class="form-header-group"><h2 id="header_21" class="form-header">Basic Information</h2></div> </li><li class="form-line" id="id_8"><div class="form-label-left" id="label_8"><label for="input_8"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q8_fullName[first]" id="first_8" autocomplete="given-name" />  <label class="form-sub-label" for="first_8" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q8_fullName[last]" id="last_8" autocomplete="family-name" />  <label class="form-sub-label" for="last_8" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_3"><div class="form-label-left" id="label_3"><label for="input_3"> Hebrew Name<span class="form-required">*</span> </label><label class="label-message" for="input_3"> </label></div><div id="cid_3" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_3" name="q3_input3" size="20" value="" /> </div></li><li class="form-line" id="id_9"><div class="form-label-left" id="label_9"><label for="input_9"> Gender<span class="form-required">*</span> </label><label class="label-message" for="input_9"> </label></div><div id="cid_9" class="form-input"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_9_0" name="q9_input9" value="Male" /><label id="label_input_9_0" for="input_9_0"><span>Male</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_9_1" name="q9_input9" value="Female" /><label id="label_input_9_1" for="input_9_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_5"><div class="form-label-left" id="label_5"><label for="input_5"> Age<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_7"><div class="form-label-left" id="label_7"><label for="input_7"> Birth Date<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 autocomplete="nope" 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 autocomplete="nope" 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 autocomplete="nope" class="form-dropdown validate[required]" name="q7_birthDate[year]" id="input_7_year"><option></option><option value="2026">2026</option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option><option value="1941">1941</option><option value="1940">1940</option><option value="1939">1939</option><option value="1938">1938</option><option value="1937">1937</option><option value="1936">1936</option><option value="1935">1935</option><option value="1934">1934</option><option value="1933">1933</option><option value="1932">1932</option><option value="1931">1931</option><option value="1930">1930</option><option value="1929">1929</option><option value="1928">1928</option><option value="1927">1927</option><option value="1926">1926</option><option value="1925">1925</option><option value="1924">1924</option><option value="1923">1923</option><option value="1922">1922</option><option value="1921">1921</option><option value="1920">1920</option></select>  <label class="form-sub-label" for="input_7_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_10"><div class="form-label-left" id="label_10"><label for="input_10"> Grade Entering<span class="form-required">*</span> </label><label class="label-message" for="input_10"> </label></div><div id="cid_10" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_10" name="q10_input10" size="20" value="" /> </div></li><li class="form-line" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> School<span class="form-required">*</span> </label><label class="label-message" for="input_26"> </label></div><div id="cid_26" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_26" name="q26_input26" size="20" value="" /> </div></li><li class="form-line" id="id_11"><div class="form-label-left" id="label_11"><label for="input_11"> Address<span class="form-required">*</span> </label><label class="label-message" for="input_11"> </label></div><div id="cid_11" 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="q11_address[addr_line1]" id="input_11_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_11_addr_line1" id="sublabel_11_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="q11_address[addr_line2]" id="input_11_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_11_addr_line2" id="sublabel_11_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="q11_address[city]" id="input_11_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_11_city" id="sublabel_11_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q11_address[state]" id="input_11_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_11_state" id="sublabel_11_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="q11_address[postal]" id="input_11_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_11_postal" id="sublabel_11_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q11_address[country]" id="input_11_country" autocomplete="country-name"><option value="" selected="selected">Please 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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_11_country" id="sublabel_11_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12"> Father's Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_12"> </label></div><div id="cid_12" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q12_fullName12[first]" id="first_12" autocomplete="given-name" />  <label class="form-sub-label" for="first_12" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q12_fullName12[last]" id="last_12" autocomplete="family-name" />  <label class="form-sub-label" for="last_12" 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"> Father's Hebrew Name </label><label class="label-message" for="input_63"> </label></div><div id="cid_63" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_63" name="q63_input63" size="20" value="" /> </div></li><li class="form-line" id="id_13"><div class="form-label-left" id="label_13"><label for="input_13"> Father's Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_13"> </label></div><div id="cid_13" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q13_phoneNumber[full]" id="input_13_full" autocomplete="tel" />  <label class="form-sub-label" for="input_13_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_15"><div class="form-label-left" id="label_15"><label for="input_15"> Father's E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_15"> </label></div><div id="cid_15" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_15" name="q15_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_14"><div class="form-label-left" id="label_14"><label for="input_14"> Mother's Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_14"> </label></div><div id="cid_14" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q14_fullName14[first]" id="first_14" autocomplete="given-name" />  <label class="form-sub-label" for="first_14" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q14_fullName14[last]" id="last_14" autocomplete="family-name" />  <label class="form-sub-label" for="last_14" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_64"><div class="form-label-left" id="label_64"><label for="input_64"> Mother's Hebrew Name </label><label class="label-message" for="input_64"> </label></div><div id="cid_64" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_64" name="q64_input64" size="20" value="" /> </div></li><li class="form-line" id="id_16"><div class="form-label-left" id="label_16"><label for="input_16"> Mother's Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_16"> </label></div><div id="cid_16" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q16_phoneNumber16[full]" id="input_16_full" autocomplete="tel" />  <label class="form-sub-label" for="input_16_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_17"><div class="form-label-left" id="label_17"><label for="input_17"> Mother's E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_17"> </label></div><div id="cid_17" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_17" name="q17_email17" 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"> Was the child's mother born Jewish?<span class="form-required">*</span> </label><label class="label-message" for="input_51"> </label></div><div id="cid_51" class="form-input"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_51_0" name="q51_input51" value="Yes" /><label id="label_input_51_0" for="input_51_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_51_1" name="q51_input51" value="No" /><label id="label_input_51_1" for="input_51_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_53"><div class="form-label-left" id="label_53"><label for="input_53"> Was the child's maternal grandmother born Jewish?<span class="form-required">*</span> </label><label class="label-message" for="input_53"> </label></div><div id="cid_53" class="form-input"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_53_0" name="q53_input53" value="Yes" /><label id="label_input_53_0" for="input_53_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_53_1" name="q53_input53" value="No" /><label id="label_input_53_1" for="input_53_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_52"><div class="form-label-left" id="label_52"><label for="input_52"> Is the child's father Jewish?<span class="form-required">*</span> </label><label class="label-message" for="input_52"> </label></div><div id="cid_52" class="form-input"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_52_0" name="q52_input52" value="Yes" /><label id="label_input_52_0" for="input_52_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_52_1" name="q52_input52" value="No" /><label id="label_input_52_1" for="input_52_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_54"><div class="form-label-left" id="label_54"><label for="input_54"> Are there any adoptions in the family?<span class="form-required">*</span> </label><label class="label-message" for="input_54"> </label></div><div id="cid_54" class="form-input"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_54_0" name="q54_input54" value="Yes" /><label id="label_input_54_0" for="input_54_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_54_1" name="q54_input54" value="No" /><label id="label_input_54_1" for="input_54_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_56"><div class="form-label-left" id="label_56"><label for="input_56"> If yes, please explain </label><label class="label-message" for="input_56"> </label></div><div id="cid_56" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_56" name="q56_input56" size="20" value="" /> </div></li><li class="form-line" id="id_55"><div class="form-label-left" id="label_55"><label for="input_55"> Are there any conversions in the family?<span class="form-required">*</span> </label><label class="label-message" for="input_55"> </label></div><div id="cid_55" class="form-input"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_55_0" name="q55_input55" value="Yes" /><label id="label_input_55_0" for="input_55_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_55_1" name="q55_input55" value="No" /><label id="label_input_55_1" for="input_55_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_57"><div class="form-label-left" id="label_57"><label for="input_57"> If yes, please explain </label><label class="label-message" for="input_57"> </label></div><div id="cid_57" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_57" name="q57_input57" size="20" value="" /> </div></li><li class="form-line" id="id_18"><div class="form-label-left" id="label_18"><label for="input_18"> Who should be the primary contact?<span class="form-required">*</span> </label><label class="label-message" for="input_18"> </label></div><div id="cid_18" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxselection="1" id="input_18_0" name="q18_input18[]" value="Father" /><label id="label_input_18_0" for="input_18_0"><span>Father</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxselection="1" id="input_18_1" name="q18_input18[]" value="Mother" /><label id="label_input_18_1" for="input_18_1"><span>Mother</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxselection="1" id="input_18_2" name="q18_input18[]" value="Both" /><label id="label_input_18_2" for="input_18_2"><span>Both</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_19"><div class="form-label-left" id="label_19"><label for="input_19"> Parent's Marital Status<span class="form-required">*</span> </label><label class="label-message" for="input_19"> </label></div><div id="cid_19" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxselection="1" id="input_19_0" name="q19_input19[]" value="Married" /><label id="label_input_19_0" for="input_19_0"><span>Married</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxselection="1" id="input_19_1" name="q19_input19[]" value="Separated" /><label id="label_input_19_1" for="input_19_1"><span>Separated</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxselection="1" id="input_19_2" name="q19_input19[]" value="Divorced" /><label id="label_input_19_2" for="input_19_2"><span>Divorced</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxselection="1" id="input_19_3" name="q19_input19[]" value="Single Parent" /><label id="label_input_19_3" for="input_19_3"><span>Single Parent</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxselection="1" id="input_19_4" name="q19_input19[]" value="Parent Deceased" /><label id="label_input_19_4" for="input_19_4"><span>Parent Deceased</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_20" class="form-input-wide"> <div class="form-header-group"><h2 id="header_20" class="form-header">About Your Child</h2></div> </li><li class="form-line" id="id_22"><div class="form-label-left" id="label_22"><label for="input_22"> Does your child have any difficulties with general studies?<span class="form-required">*</span> </label><label class="label-message" for="input_22"> </label></div><div id="cid_22" class="form-input"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_22_0" name="q22_input22" value="Yes" /><label id="label_input_22_0" for="input_22_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_22_1" name="q22_input22" value="No" /><label id="label_input_22_1" for="input_22_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_24"><div class="form-label-left" id="label_24"><label for="input_24"> If yes, please explain: </label><label class="label-message" for="input_24"> </label></div><div id="cid_24" class="form-input"> <textarea id="input_24" class="form-textarea" name="q24_input24" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_25"><div class="form-label-left" id="label_25"><label for="input_25"> In what way does your child learn best?<span class="form-required">*</span> </label><label class="label-message" for="input_25"> </label></div><div id="cid_25" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_25" name="q25_input25" size="20" value="" /> </div></li><li id="cid_27" class="form-input-wide"> <div class="form-header-group"><h2 id="header_27" class="form-header">Emergency Information</h2></div> </li><li class="form-line" id="id_28"><div class="form-label-left" id="label_28"><label for="input_28"> Emergency Contact Besides Parent<span class="form-required">*</span> </label><label class="label-message" for="input_28"> </label></div><div id="cid_28" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q28_fullName28[first]" id="first_28" autocomplete="given-name" />  <label class="form-sub-label" for="first_28" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q28_fullName28[last]" id="last_28" autocomplete="family-name" />  <label class="form-sub-label" for="last_28" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_29"><div class="form-label-left" id="label_29"><label for="input_29"> Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_29"> </label></div><div id="cid_29" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q29_phoneNumber29[full]" id="input_29_full" autocomplete="tel" />  <label class="form-sub-label" for="input_29_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_30"><div class="form-label-left" id="label_30"><label for="input_30"> Pediatrician<span class="form-required">*</span> </label><label class="label-message" for="input_30"> </label></div><div id="cid_30" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q30_fullName30[first]" id="first_30" autocomplete="given-name" />  <label class="form-sub-label" for="first_30" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q30_fullName30[last]" id="last_30" autocomplete="family-name" />  <label class="form-sub-label" for="last_30" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_31"><div class="form-label-left" id="label_31"><label for="input_31"> Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_31"> </label></div><div id="cid_31" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q31_phoneNumber31[full]" id="input_31_full" autocomplete="tel" />  <label class="form-sub-label" for="input_31_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_32"><div class="form-label-left" id="label_32"><label for="input_32"> Medications<span class="form-required">*</span> </label><label class="label-message" for="input_32"> </label></div><div id="cid_32" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_32" name="q32_input32" size="20" value="" /> </div></li><li class="form-line" id="id_33"><div class="form-label-left" id="label_33"><label for="input_33"> Allergies or Medical Circumstances<span class="form-required">*</span> </label><label class="label-message" for="input_33"> </label></div><div id="cid_33" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_33" name="q33_input33" size="20" value="" /> </div></li><li class="form-line" id="id_34"><div id="cid_34" class="form-input-wide"> <div id="text_34" class="form-html"><p>I authorize Chabad Center for Jewish Life and Learning of London, ON to take my child on school trips. (you will be notified prior to any trips via email, and/or text)</p>

<p>I authorize Chabad Center for Jewish Life and Learning of London, ON to take pictures/video of my child and use them for publicity purposes (i.e., Brochures, Websites)</p>

<p>In the event I cannot be reached, I hereby grant permission to the staff of Chabad Center for Jewish Life and Learning of London, ON to treat and/or provide a physician or hospital to give emergency treatment to my child. </p>
</div> </div></li><li class="form-line" id="id_35"><div class="form-label-left" id="label_35"><label for="input_35">  <span class="form-required">*</span> </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-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_35_0" name="q35_input35[]" value="I have read &amp; agree to all the above." /><label id="label_input_35_0" for="input_35_0"><span>I have read &amp; agree to all the above.</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"> Signature<span class="form-required">*</span> </label><label class="label-message" for="input_36"> </label></div><div id="cid_36" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_36" name="q36_input36" size="20" value="" /> </div></li><li class="form-line" id="id_38"><div class="form-label-left" id="label_38"><label for="input_38"> Date<span class="form-required">*</span> </label><label class="label-message" for="input_38"> </label></div><div id="cid_38" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q38_birthDate38[month]" id="input_38_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_38_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q38_birthDate38[day]" id="input_38_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_38_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q38_birthDate38[year]" id="input_38_year"><option></option><option value="2026">2026</option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option><option value="1941">1941</option><option value="1940">1940</option><option value="1939">1939</option><option value="1938">1938</option><option value="1937">1937</option><option value="1936">1936</option><option value="1935">1935</option><option value="1934">1934</option><option value="1933">1933</option><option value="1932">1932</option><option value="1931">1931</option><option value="1930">1930</option><option value="1929">1929</option><option value="1928">1928</option><option value="1927">1927</option><option value="1926">1926</option><option value="1925">1925</option><option value="1924">1924</option><option value="1923">1923</option><option value="1922">1922</option><option value="1921">1921</option><option value="1920">1920</option></select>  <label class="form-sub-label" for="input_38_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_39"><div class="form-label-left" id="label_39"><label for="input_39"> How did you hear about JUDA? </label><label class="label-message" for="input_39"> </label></div><div id="cid_39" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_39" name="q39_input39" size="20" value="" /> </div></li><li id="cid_40" class="form-input-wide"> <div class="form-header-group"><h2 id="header_40" class="form-header">Tuition and Dates</h2></div> </li><li class="form-line" id="id_42"><div id="cid_42" class="form-input-wide"> <div id="text_42" class="form-html"><p><b>Session 1 </b>October 20, 2025 - November 21, 2025</p>

<p><strong>Session 2* </strong>November 24, 2025 - December 19, 2025 </p>

<p>*dates subject to change</p>

<p><strong>Mondays - Thursdays 4:30 -5:30</strong></p>

<p><strong>Pricing</strong></p>

<table>
	<thead>
		<tr>
			<th>                 </th>
			<th>Per Session            </th>
			<th>Full Year  </th>
		</tr>
	</thead>
	<tbody>
		<tr>
			<td>1 Day</td>
			<td>$140</td>
			<td>$833</td>
		</tr>
		<tr>
			<td>2 Days</td>
			<td>$240</td>
			<td>$1,428</td>
		</tr>
		<tr>
			<td>3 Days</td>
			<td>$330</td>
			<td>$1,963</td>
		</tr>
		<tr>
			<td>4 Days</td>
			<td>$400</td>
			<td>$2,380</td>
		</tr>
	</tbody>
</table>

<p>Juda Afterschool is divided into seven sessions. Most sessions will flow continuously. </p>

<p>A 10% early bird discount is available up to one month before each session.</p>

<p>Alternatively, a 15% discount applies to full-year commitments (full-year commitments do not need to be paid up front).</p>

<p>Day school students are eligible for a 40% discount.</p>

<p><strong>Monday </strong>Juda</p>

<p>In each session, we will explore a different area of Jewish knowledge. At the end of every session, your child will bring home a meaningful, beautifully crafted takeaway that reinforces and extends what they learned.</p>

<p><strong>Tuesday </strong>Hebrew Reading</p>

<p>Whether or not your child already knows the Alef-Bet, they are warmly welcome! Each child will receive a personalized reading curriculum tailored to their level, making learning both effective and enjoyable.</p>

<p><strong>Wednesday </strong>Clubs</p>

<p>In each session, we will introduce two exciting new clubs, and your child can choose which one to join! Options may include Kids in the Kitchen, Chess, Sports, Woodworking, and more.</p>

<p><strong>Thursday </strong>JewQ</p>

<p><em>JewQ</em> - the International Torah Championship. Where children become experts in the fundamentals of Judaism, while competing with children from around the world.</p>
</div> </div></li><li class="form-line" id="id_43"><div class="form-label-left" id="label_43"><label for="input_43"> Please select the days your child will be attending </label><label class="label-message" for="input_43"> </label></div><div id="cid_43" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_43_0" name="q43_input43[]" value="Monday" /><label id="label_input_43_0" for="input_43_0"><span>Monday</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_43_1" name="q43_input43[]" value="Tuesday" /><label id="label_input_43_1" for="input_43_1"><span>Tuesday</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_43_2" name="q43_input43[]" value="Wednesday" /><label id="label_input_43_2" for="input_43_2"><span>Wednesday</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_43_3" name="q43_input43[]" value="Thursday" /><label id="label_input_43_3" for="input_43_3"><span>Thursday</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_45" class="form-input-wide"> <div class="form-header-group"><h2 id="header_45" class="form-header">Payment Options</h2></div> </li><li class="form-line" id="id_58"><div class="form-label-left" id="label_58"><label for="input_58"> I would like to apply for one session: </label><label class="label-message" for="input_58"> </label></div><div id="cid_58" class="form-input"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_58_0" name="q58_input58" value="1 Day a Week" /><label id="label_input_58_0" for="input_58_0"><span>1 Day a Week</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_58_1" name="q58_input58" value="2 Days a Week" /><label id="label_input_58_1" for="input_58_1"><span>2 Days a Week</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_58_2" name="q58_input58" value="3 Days a Week" /><label id="label_input_58_2" for="input_58_2"><span>3 Days a Week</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_58_3" name="q58_input58" value="4 Days a Week" /><label id="label_input_58_3" for="input_58_3"><span>4 Days a Week</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_59"><div class="form-label-left" id="label_59"><label for="input_59"> I would like to apply for a full year: </label><label class="label-message" for="input_59"> </label></div><div id="cid_59" class="form-input"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_59_0" name="q59_input59" value="1 Day a Week" /><label id="label_input_59_0" for="input_59_0"><span>1 Day a Week</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_59_1" name="q59_input59" value="2 Days a Week" /><label id="label_input_59_1" for="input_59_1"><span>2 Days a Week</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_59_2" name="q59_input59" value="3 Days a Week" /><label id="label_input_59_2" for="input_59_2"><span>3 Days a Week</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_59_3" name="q59_input59" value="4 Days a Week" /><label id="label_input_59_3" for="input_59_3"><span>4 Days a Week</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_46"><div class="form-label-left" id="label_46"><label for="input_46"> I would like to pay the Tuition by: please select. </label><label class="label-message" for="input_46"> </label></div><div id="cid_46" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_46_0" name="q46_input46" value="Full Tuition by card" /><label id="label_input_46_0" for="input_46_0"><span>Full Tuition by card</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_46_1" name="q46_input46" value="Monthly Charge*" /><label id="label_input_46_1" for="input_46_1"><span>Monthly Charge*</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_46_2" name="q46_input46" value="Checks" /><label id="label_input_46_2" for="input_46_2"><span>Checks</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_46_3" name="q46_input46" value="ETransfer - chabadlondonon@gmail.com" /><label id="label_input_46_3" for="input_46_3"><span>ETransfer - chabadlondonon@gmail.com</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_65"><div id="cid_65" class="form-input-wide"> <div id="text_65" class="form-html"><p>*Only applicable to full year applicants.</p>


</div> </div></li><li class="form-line" id="id_47"><div class="form-label-left" id="label_47"><label for="input_47"> We would like to join the Chai Club Family by partnering in all of Chabad Youth programming. </label><label class="label-message" for="input_47"> </label></div><div id="cid_47" class="form-input"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_47_0" name="q47_input47" value="Yes" /><label id="label_input_47_0" for="input_47_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_47_1" name="q47_input47" value="No" /><label id="label_input_47_1" for="input_47_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_48"><div class="form-label-left" id="label_48"><label for="input_48"> Monthly Opportunities </label><label class="label-message" for="input_48"> </label></div><div id="cid_48" class="form-input"> <div class="form-multiple-column" data-columns="2"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_48_0" name="q48_input48" value="36" /><label for="input_48_0"><span>$36 CAD</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_48_1" name="q48_input48" value="72" /><label for="input_48_1"><span>$72 CAD</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_48_2" name="q48_input48" value="180" /><label for="input_48_2"><span>$180 CAD</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio-other form-radio" name="q48_input48" id="other_48" value="" /><span><input type="number" min="1" class="form-radio-other-input form-textbox" onkeypress="validateNumber(event)" name="q48_input48[other]" data-otherhint="Other" size="15" id="input_48" disabled="disabled" /></span><br /></span></div> </div></li><li class="form-line" id="id_60"><div class="form-label-left form-label-hidden" id="label_60"></div><div id="cid_60" class="form-input"> <div class="form-single-column form-checkbox-item">		<input type="checkbox" id="input_60" class="form-checkbox" name="q60_paymentrecurrence" value="Monthly" />		<label id="label_60" for="input_60">Yes, I'd like to make this a monthly recurring payment.</label>		<div class="clearfix"></div>		</div> </div></li><li class="form-line" id="id_66"><div class="form-label-left" id="label_66"><label for="input_66"> Payment </label><label class="label-message" for="input_66"> </label></div><div id="cid_66" 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"></td></tr><tr class="credit_card "><th colspan="2">Credit Card</th></tr><tr class="credit_card "><td colspan="2" style="padding:0"><table cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container">  <label class="form-sub-label">We accept Visa, MasterCard, American Express, 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="q66_payment[cc_type]" id="input_66_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="q66_payment[cc_number]" id="input_66_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_66_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="q66_payment[cc_ccv]" id="input_66_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_66_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="q66_payment[cc_nameOnCard]" id="input_66_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_66_cc_nameOnCard" id="sublabel_cc_nameOnCard">Name on Card</label></span></td></tr><tr class="credit_card "><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q66_payment[cc_exp_month]" id="input_66_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_66_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="q66_payment[cc_exp_year]" id="input_66_cc_exp_year" autocomplete="cc-exp-year"><option></option><option value="2026">2026</option><option value="2027">2027</option><option value="2028">2028</option><option value="2029">2029</option><option value="2030">2030</option><option value="2031">2031</option><option value="2032">2032</option><option value="2033">2033</option><option value="2034">2034</option><option value="2035">2035</option></select>  <label class="form-sub-label" for="input_66_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="billing_address "><th colspan="2">Billing Address</th></tr><tr class="billing_address "><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line" type="text" name="q66_payment[addr_line1]" id="input_66_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_66_addr_line1" id="sublabel_66_addr_line1">Street Address</label></span></td></tr><tr class="billing_address "><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q66_payment[city]" id="input_66_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_66_city" id="sublabel_66_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q66_payment[state]" id="input_66_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_66_state" id="sublabel_66_state">State / Province</label></span></td></tr><tr class="billing_address "><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q66_payment[postal]" id="input_66_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_66_postal" id="sublabel_66_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q66_payment[country]" id="input_66_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 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