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			<h1 class="article-header__title js-article-title js-page-title">Chabad Hebrew School Registration Form 2025-2026</h1>
		
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<form class="userform-form" action="" method="post" name="form_7206038" id="7206038" accept-charset="utf-8"><input type="hidden" name="formID" value="7206038" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li id="cid_1" class="form-input-wide"> <div class="form-header-group"><h2 id="header_1" class="form-header">Student Profile</h2></div> </li><li class="form-line" id="id_3"><div class="form-label-left" id="label_3"><label for="input_3"> Family 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_16"><div class="form-label-left" id="label_16"><label for="input_16"> How many children are you registering?<span class="form-required">*</span> </label><label class="label-message" for="input_16"> </label></div><div id="cid_16" class="form-input"> <input type="number" class="form-number-input  form-textbox validate[required]" id="input_16" name="q16_number" style="width:60px" size="5" value="1" data-type="input-number" autocomplete="nope" min="1" data-numbermin="1" max="3" data-numbermax="3" /> </div></li><li class="form-line" id="id_35"><div id="cid_35" class="form-input-wide"> <div id="text_35" class="form-html"><p><u><strong><span style="font-size:18px;">Information For First Child</span></strong></u></p>
</div> </div></li><li class="form-line" id="id_4"><div class="form-label-left" id="label_4"><label for="input_4"> Name of Child<span class="form-required">*</span> </label><label class="label-message" for="input_4"> </label></div><div id="cid_4" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_4" name="q4_input4" size="20" value="" /> </div></li><li class="form-line" id="id_6"><div class="form-label-left" id="label_6"><label for="input_6"> Name Preferred To Be Called<span class="form-required">*</span> </label><label class="label-message" for="input_6"> </label></div><div id="cid_6" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_6" name="q6_input6" size="20" value="" /> </div></li><li class="form-line" id="id_84"><div class="form-label-left" id="label_84"><label for="input_84"> Child's Hebrew Name<span class="form-required">*</span> </label><label class="label-message" for="input_84"> </label></div><div id="cid_84" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_84" name="q84_input84" size="20" value="" /> </div></li><li class="form-line" id="id_17"><div class="form-label-left" id="label_17"><label for="input_17"> Birth Date<span class="form-required">*</span> </label><label class="label-message" for="input_17"> </label></div><div id="cid_17" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q17_birthDate[month]" id="input_17_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_17_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q17_birthDate[day]" id="input_17_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_17_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q17_birthDate[year]" id="input_17_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_17_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_7"><div class="form-label-left" id="label_7"><label for="input_7"> Grade Entering September 2025<span class="form-required">*</span> </label><label class="label-message" for="input_7"> </label></div><div id="cid_7" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_7" name="q7_input7" 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_12"><div class="form-label-left" id="label_12"><label for="input_12"> Does your child have any allergies or other medical condition?<span class="form-required">*</span> </label><label class="label-message" for="input_12"> </label></div><div id="cid_12" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_12" name="q12_input12" size="30" value="" /> </div></li><li class="form-line" id="id_13"><div class="form-label-left" id="label_13"><label for="input_13"> Does your child have any learning challenges or disorders?<span class="form-required">*</span> </label><label class="label-message" for="input_13"> </label></div><div id="cid_13" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_13" name="q13_input13" size="30" value="" /> </div></li><li class="form-line" id="id_26"><div id="cid_26" class="form-input-wide"> <div id="text_26" class="form-html"><p><u><strong><span style="font-size:18px;">Information For Second Child</span></strong></u></p>
</div> </div></li><li class="form-line" id="id_18"><div class="form-label-left" id="label_18"><label for="input_18"> Name of Child<span class="form-required">*</span> </label><label class="label-message" for="input_18"> </label></div><div id="cid_18" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_18" name="q18_input18" size="20" value="" /> </div></li><li class="form-line" id="id_19"><div class="form-label-left" id="label_19"><label for="input_19"> Name Preferred To Be Called<span class="form-required">*</span> </label><label class="label-message" for="input_19"> </label></div><div id="cid_19" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_19" name="q19_input19" size="20" value="" /> </div></li><li class="form-line" id="id_85"><div class="form-label-left" id="label_85"><label for="input_85"> Child's Hebrew Name<span class="form-required">*</span> </label><label class="label-message" for="input_85"> </label></div><div id="cid_85" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_85" name="q85_input85" size="20" value="" /> </div></li><li class="form-line" id="id_20"><div class="form-label-left" id="label_20"><label for="input_20"> Birth Date<span class="form-required">*</span> </label><label class="label-message" for="input_20"> </label></div><div id="cid_20" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q20_birthDate20[month]" id="input_20_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_20_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q20_birthDate20[day]" id="input_20_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_20_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q20_birthDate20[year]" id="input_20_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_20_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_22"><div class="form-label-left" id="label_22"><label for="input_22"> Grade Entering September 2025<span class="form-required">*</span> </label><label class="label-message" for="input_22"> </label></div><div id="cid_22" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_22" name="q22_input22" size="20" value="" /> </div></li><li class="form-line" id="id_23"><div class="form-label-left" id="label_23"><label for="input_23"> Gender<span class="form-required">*</span> </label><label class="label-message" for="input_23"> </label></div><div id="cid_23" class="form-input"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_23_0" name="q23_input23" value="Male" /><label id="label_input_23_0" for="input_23_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_23_1" name="q23_input23" value="Female" /><label id="label_input_23_1" for="input_23_1"><span>Female</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"> Does your child have any allergies or other medical condition?<span class="form-required">*</span> </label><label class="label-message" for="input_24"> </label></div><div id="cid_24" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_24" name="q24_input24" size="30" value="" /> </div></li><li class="form-line" id="id_25"><div class="form-label-left" id="label_25"><label for="input_25"> Does your child have any learning challenges or disorders?<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="30" value="" /> </div></li><li class="form-line" id="id_27"><div id="cid_27" class="form-input-wide"> <div id="text_27" class="form-html"><p><u><strong><span style="font-size:18px;">Information For Third Child</span></strong></u></p>
</div> </div></li><li class="form-line" id="id_28"><div class="form-label-left" id="label_28"><label for="input_28"> Name of Child<span class="form-required">*</span> </label><label class="label-message" for="input_28"> </label></div><div id="cid_28" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_28" name="q28_input28" size="20" value="" /> </div></li><li class="form-line" id="id_29"><div class="form-label-left" id="label_29"><label for="input_29"> Name Preferred To Be Called<span class="form-required">*</span> </label><label class="label-message" for="input_29"> </label></div><div id="cid_29" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_29" name="q29_input29" size="20" value="" /> </div></li><li class="form-line" id="id_86"><div class="form-label-left" id="label_86"><label for="input_86"> Child's Hebrew Name<span class="form-required">*</span> </label><label class="label-message" for="input_86"> </label></div><div id="cid_86" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_86" name="q86_input86" size="20" value="" /> </div></li><li class="form-line" id="id_30"><div class="form-label-left" id="label_30"><label for="input_30"> Birth Date<span class="form-required">*</span> </label><label class="label-message" for="input_30"> </label></div><div id="cid_30" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q30_birthDate30[month]" id="input_30_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_30_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q30_birthDate30[day]" id="input_30_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_30_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q30_birthDate30[year]" id="input_30_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_30_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_31"><div class="form-label-left" id="label_31"><label for="input_31"> Grade Entering September 2025<span class="form-required">*</span> </label><label class="label-message" for="input_31"> </label></div><div id="cid_31" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_31" name="q31_input31" size="20" value="" /> </div></li><li class="form-line" id="id_32"><div class="form-label-left" id="label_32"><label for="input_32"> Gender<span class="form-required">*</span> </label><label class="label-message" for="input_32"> </label></div><div id="cid_32" class="form-input"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_32_0" name="q32_input32" value="Male" /><label id="label_input_32_0" for="input_32_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_32_1" name="q32_input32" value="Female" /><label id="label_input_32_1" for="input_32_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_33"><div class="form-label-left" id="label_33"><label for="input_33"> Does your child have any allergies or other medical condition?<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="30" value="" /> </div></li><li class="form-line" id="id_34"><div class="form-label-left" id="label_34"><label for="input_34"> Does your child have any learning challenges or disorders?<span class="form-required">*</span> </label><label class="label-message" for="input_34"> </label></div><div id="cid_34" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_34" name="q34_input34" size="30" value="" /> </div></li><li id="cid_36" class="form-input-wide"> <div class="form-header-group"><h2 id="header_36" class="form-header">Family Information</h2></div> </li><li class="form-line" id="id_37"><div class="form-label-left" id="label_37"><label for="input_37"> Do Both Parents Live In The Same House?<span class="form-required">*</span> </label><label class="label-message" for="input_37"> </label></div><div id="cid_37" class="form-input"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" 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"><input type="radio" class="form-radio validate[required]" 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_38"><div class="form-label-left" id="label_38"><label for="input_38"> Home Address<span class="form-required">*</span> </label><label class="label-message" for="input_38"> </label></div><div id="cid_38" 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="q38_address[addr_line1]" id="input_38_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_38_addr_line1" id="sublabel_38_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="q38_address[addr_line2]" id="input_38_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_38_addr_line2" id="sublabel_38_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="q38_address[city]" id="input_38_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_38_city" id="sublabel_38_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q38_address[state]" id="input_38_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_38_state" id="sublabel_38_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="q38_address[postal]" id="input_38_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_38_postal" id="sublabel_38_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q38_address[country]" id="input_38_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_38_country" id="sublabel_38_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_39"><div class="form-label-left" id="label_39"><label for="input_39"> Home Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_39"> </label></div><div id="cid_39" 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="q39_phoneNumber[full]" id="input_39_full" autocomplete="tel" />  <label class="form-sub-label" for="input_39_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_40"><div id="cid_40" class="form-input-wide"> <div id="text_40" class="form-html"><p><u><strong><span style="font-size:18px;">Mother's Information</span></strong></u></p>
</div> </div></li><li class="form-line" id="id_41"><div class="form-label-left" id="label_41"><label for="input_41"> Mother'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_fullName[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_fullName[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_43"><div class="form-label-left" id="label_43"><label for="input_43"> Mother's Home Address<span class="form-required">*</span> </label><label class="label-message" for="input_43"> </label></div><div id="cid_43" 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="q43_address43[addr_line1]" id="input_43_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_43_addr_line1" id="sublabel_43_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="q43_address43[addr_line2]" id="input_43_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_43_addr_line2" id="sublabel_43_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="q43_address43[city]" id="input_43_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_43_city" id="sublabel_43_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q43_address43[state]" id="input_43_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_43_state" id="sublabel_43_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="q43_address43[postal]" id="input_43_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_43_postal" id="sublabel_43_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q43_address43[country]" id="input_43_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_43_country" id="sublabel_43_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_42"><div class="form-label-left" id="label_42"><label for="input_42"> Mother's Home Phone<span class="form-required">*</span> </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 data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q42_phoneNumber42[full]" id="input_42_full" autocomplete="tel" />  <label class="form-sub-label" for="input_42_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_44"><div class="form-label-left" id="label_44"><label for="input_44"> Mother's Cell<span class="form-required">*</span> </label><label class="label-message" for="input_44"> </label></div><div id="cid_44" 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="q44_phoneNumber44[full]" id="input_44_full" autocomplete="tel" />  <label class="form-sub-label" for="input_44_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_45"><div class="form-label-left" id="label_45"><label for="input_45"> Mother's E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_45"> </label></div><div id="cid_45" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_45" name="q45_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_47"><div id="cid_47" class="form-input-wide"> <div id="text_47" class="form-html"><p><u><strong><span style="font-size:18px;">Father's Information</span></strong></u></p>
</div> </div></li><li class="form-line" id="id_48"><div class="form-label-left" id="label_48"><label for="input_48"> Father'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"> Father's Home Address<span class="form-required">*</span> </label><label class="label-message" for="input_49"> </label></div><div id="cid_49" 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="q49_address49[addr_line1]" id="input_49_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_49_addr_line1" id="sublabel_49_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="q49_address49[addr_line2]" id="input_49_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_49_addr_line2" id="sublabel_49_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="q49_address49[city]" id="input_49_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_49_city" id="sublabel_49_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q49_address49[state]" id="input_49_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_49_state" id="sublabel_49_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="q49_address49[postal]" id="input_49_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_49_postal" id="sublabel_49_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q49_address49[country]" id="input_49_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_49_country" id="sublabel_49_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_50"><div class="form-label-left" id="label_50"><label for="input_50"> Father's Home Phone<span class="form-required">*</span> </label><label class="label-message" for="input_50"> </label></div><div id="cid_50" 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="q50_phoneNumber50[full]" id="input_50_full" autocomplete="tel" />  <label class="form-sub-label" for="input_50_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_51"><div class="form-label-left" id="label_51"><label for="input_51"> Father's Cell<span class="form-required">*</span> </label><label class="label-message" for="input_51"> </label></div><div id="cid_51" 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="q51_phoneNumber51[full]" id="input_51_full" autocomplete="tel" />  <label class="form-sub-label" for="input_51_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_52"><div class="form-label-left" id="label_52"><label for="input_52"> Father's E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_52"> </label></div><div id="cid_52" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_52" name="q52_email52" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_53"><div id="cid_53" class="form-input-wide"> <div id="text_53" class="form-html"><p><u><strong><span style="font-size:18px;">Additional Family Information</span></strong></u></p>
</div> </div></li><li class="form-line" id="id_54"><div class="form-label-left" id="label_54"><label for="input_54"> Please Mark Each Family Member That Is Jewish<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-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_54_0" name="q54_input54[]" value="Mother" /><label id="label_input_54_0" for="input_54_0"><span>Mother</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_54_1" name="q54_input54[]" value="Father" /><label id="label_input_54_1" for="input_54_1"><span>Father</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_54_2" name="q54_input54[]" value="Maternal Grandmother" /><label id="label_input_54_2" for="input_54_2"><span>Maternal Grandmother</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_54_3" name="q54_input54[]" value="Maternal Grandfather" /><label id="label_input_54_3" for="input_54_3"><span>Maternal Grandfather</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_54_4" name="q54_input54[]" value="Paternal Grandmother" /><label id="label_input_54_4" for="input_54_4"><span>Paternal Grandmother</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_54_5" name="q54_input54[]" value="Paternal Grandfather" /><label id="label_input_54_5" for="input_54_5"><span>Paternal Grandfather</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"> Are There Any Conversions or Adoptions In The Family?<span class="form-required">*</span> </label><label class="label-message" for="input_56"> </label></div><div id="cid_56" class="form-input"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_56_0" name="q56_input56" value="Yes" /><label id="label_input_56_0" for="input_56_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_56_1" name="q56_input56" value="No" /><label id="label_input_56_1" for="input_56_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_83"><div class="form-label-left" id="label_83"><label for="input_83"> Please Specify Who<span class="form-required">*</span> </label><label class="label-message" for="input_83"> please e-mail all information and documentation of the conversion to the director at Rochi@ChabadMinneapolis.com</label></div><div id="cid_83" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_83" name="q83_input83" size="20" value="" /> </div></li><li class="form-line" id="id_87"><div class="form-label-left" id="label_87"><label for="input_87"> There are no Conversions in our Family  (including grandparents and great-grandparents)<span class="form-required">*</span> </label><label class="label-message" for="input_87"> </label></div><div id="cid_87" 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_87_0" name="q87_input87[]" value="I certify this statment is true to the best of my knoweledge" /><label id="label_input_87_0" for="input_87_0"><span>I certify this statment is true to the best of my knoweledge</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_88"><div class="form-label-left" id="label_88"><label for="input_88"> Beyond the above person/people specified, there are no other conversions in our family (including grandparents and great-grandparents)<span class="form-required">*</span> </label><label class="label-message" for="input_88"> </label></div><div id="cid_88" 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_88_0" name="q88_input88[]" value="I certify this statment is true to the best of my knoweledge" /><label id="label_input_88_0" for="input_88_0"><span>I certify this statment is true to the best of my knoweledge</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_57" class="form-input-wide"> <div class="form-header-group"><h2 id="header_57" class="form-header">Emergency Information</h2></div> </li><li class="form-line" id="id_58"><div class="form-label-left" id="label_58"><label for="input_58"> Emergency Contact 1<span class="form-required">*</span> </label><label class="label-message" for="input_58"> </label></div><div id="cid_58" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q58_fullName58[first]" id="first_58" autocomplete="given-name" />  <label class="form-sub-label" for="first_58" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q58_fullName58[last]" id="last_58" autocomplete="family-name" />  <label class="form-sub-label" for="last_58" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_59"><div class="form-label-left" id="label_59"><label for="input_59"> Emergency Contact 1 Phone<span class="form-required">*</span> </label><label class="label-message" for="input_59"> </label></div><div id="cid_59" 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="q59_phoneNumber59[full]" id="input_59_full" autocomplete="tel" />  <label class="form-sub-label" for="input_59_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_60"><div class="form-label-left" id="label_60"><label for="input_60"> Emergency Contact 2<span class="form-required">*</span> </label><label class="label-message" for="input_60"> </label></div><div id="cid_60" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q60_fullName60[first]" id="first_60" autocomplete="given-name" />  <label class="form-sub-label" for="first_60" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q60_fullName60[last]" id="last_60" autocomplete="family-name" />  <label class="form-sub-label" for="last_60" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_61"><div class="form-label-left" id="label_61"><label for="input_61"> Emergency Contact 2 Phone<span class="form-required">*</span> </label><label class="label-message" for="input_61"> </label></div><div id="cid_61" 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="q61_phoneNumber61[full]" id="input_61_full" autocomplete="tel" />  <label class="form-sub-label" for="input_61_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_62"><div class="form-label-left" id="label_62"><label for="input_62"> Doctor's Name<span class="form-required">*</span> </label><label class="label-message" for="input_62"> </label></div><div id="cid_62" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q62_fullName62[first]" id="first_62" autocomplete="given-name" />  <label class="form-sub-label" for="first_62" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q62_fullName62[last]" id="last_62" autocomplete="family-name" />  <label class="form-sub-label" for="last_62" 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"> Doctor's Phone<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 data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q63_phoneNumber63[full]" id="input_63_full" autocomplete="tel" />  <label class="form-sub-label" for="input_63_full"><span> </span></label></span></div> </div></li><li id="cid_64" class="form-input-wide"> <div class="form-header-group"><h2 id="header_64" class="form-header">Tuition Agreement</h2></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>Hebrew School Tuition Kindergarden - 8th Grade: $800</p>

<p>Sibling Discount: $50 off for each additional student.</p>

<p>Limited scholarships available; <a href="/article.asp?AID=5523947">CLICK HERE</a> to apply for scholarship.</p>
</div> </div></li><li class="form-line" id="id_66"><div class="form-label-left" id="label_66"><label for="input_66"> Please Select A Payment Plan<span class="form-required">*</span> </label><label class="label-message" for="input_66"> </label></div><div id="cid_66" 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_66_0" name="q66_input66" value="Payment in full before September." /><label id="label_input_66_0" for="input_66_0"><span>Payment in full before September.</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_66_1" name="q66_input66" value="Pay half before September and half on January 15." /><label id="label_input_66_1" for="input_66_1"><span>Pay half before September and half on January 15.</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_66_2" name="q66_input66" value="Total cost split in 9 equal monthly payments. September 2025 - May 2026" /><label id="label_input_66_2" for="input_66_2"><span>Total cost split in 9 equal monthly payments. September 2025 - May 2026</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"> Method of payment:<span class="form-required">*</span> </label><label class="label-message" for="input_67"> </label></div><div id="cid_67" class="form-input"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_67_0" name="q67_input67" value="Check" /><label id="label_input_67_0" for="input_67_0"><span>Check</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_67_1" name="q67_input67" value="Credit Card" /><label id="label_input_67_1" for="input_67_1"><span>Credit Card</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_75"><div id="cid_75" class="form-input-wide"> <div id="text_75" class="form-html"><p>Please mail checks to Chabad Minneapolis: 2845 Hedberg Dr., Minnetonka, MN 55305</p>
</div> </div></li><li class="form-line" id="id_70"><div id="cid_70" class="form-input-wide"> <div id="text_70" class="form-html"><p><span style="font-size:14px;">Please submit the credit card information to use for tuition payment.</span></p>

<p><span style="font-size:14px;"><em>This card will only be charged (according to your selected payment plan) once your child has been accepted to Hebrew School.</em> </span></p>
</div> </div></li><li class="form-line" id="id_69"><div class="form-label-left" id="label_69"><label for="input_69"> Name on Card<span class="form-required">*</span> </label><label class="label-message" for="input_69"> </label></div><div id="cid_69" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_69" name="q69_input69" size="20" value="" /> </div></li><li class="form-line" id="id_71"><div class="form-label-left" id="label_71"><label for="input_71"> Card Number<span class="form-required">*</span> </label><label class="label-message" for="input_71"> </label></div><div id="cid_71" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_71" name="q71_input71" size="20" value="" /> </div></li><li class="form-line" id="id_72"><div class="form-label-left" id="label_72"><label for="input_72"> Expiration Date<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_74"><div class="form-label-left" id="label_74"><label for="input_74"> CVV<span class="form-required">*</span> </label><label class="label-message" for="input_74"> </label></div><div id="cid_74" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_74" name="q74_input74" size="20" value="" /> </div></li><li class="form-line" id="id_73"><div class="form-label-left" id="label_73"><label for="input_73"> Billing Address<span class="form-required">*</span> </label><label class="label-message" for="input_73"> </label></div><div id="cid_73" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_73" name="q73_input73" size="20" value="" /> </div></li><li id="cid_76" class="form-input-wide"> <div class="form-header-group"><h2 id="header_76" class="form-header">Registration Payment of $50</h2></div> </li><li class="form-line" id="id_77"><div id="cid_77" class="form-input-wide"> <div id="text_77" class="form-html"><p>A $50 registration fee will be charged upon submission of your application.</p>

<p>If the application is not accepted, the $50 fee will be reimbursed.</p>
</div> </div></li><li class="form-line" id="id_78"><div class="form-label-left" id="label_78"><label for="input_78"> Total Amount To Be Charged Today </label></div><div id="cid_78" class="form-input"> <div id="total_amount">$0.00 </div> </div></li><li class="form-line" id="id_79"><div class="form-label-left" id="label_79"><label for="input_79"> Payment<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" class="form-payment-methods form-multiple-column"><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_79_creditCard" name="q79_payment[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_79_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_79_other" name="q79_payment[payment_method]" value="other" onclick="BuildSource.other(this)" /><label for="input_79_other">Other</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="q79_payment[cc_type]" id="input_79_cc_type" value="" /></td></tr><tr><td><div class="cc-field-wrapper"><span class="form-sub-label-container"><input class="form-textbox form-creditcard js-cc-number validate[required, visible, creditcard]" type="text" name="q79_payment[cc_number]" id="input_79_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_79_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[required, visible]" type="text" name="q79_payment[cc_ccv]" id="input_79_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_79_cc_ccv" id="sublabel_cc_ccv">Security Code</label></span></td></tr><tr><td colspan="2" class="cc_name_on_card "><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q79_payment[cc_nameOnCard]" id="input_79_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_79_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[required, visible]" name="q79_payment[cc_exp_month]" id="input_79_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_79_cc_exp_month" id="sublabel_cc_exp_month">Expiration Month</label></span></td><td><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q79_payment[cc_exp_year]" id="input_79_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_79_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="other hide"><td colspan="2">Please mail payment to Chabad Minneapolis: 2845 Hedberg Dr. Minnetonka, MN 55305</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 validate[required] form-address-line" type="text" name="q79_payment[addr_line1]" id="input_79_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_79_addr_line1" id="sublabel_79_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 validate[required] form-address-city" type="text" name="q79_payment[city]" id="input_79_city" autocomplete="billing 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_payment[state]" id="input_79_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_79_state" id="sublabel_79_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 validate[required] form-address-postal" 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