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	Summer Camp Registration - Chabad of Bradenton
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<body class="lang_en dir_ltr cco_body form secure cco_templateless_page section_branch">
	
	
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	.sPromo-wrap .caption,
	[class="widget-"] {
		text-transform: uppercase;
	}
	.large_banner.wrap-image {
		width: 100%;
	}
	.sPromo-wrap {
		display: inline-block;
		margin-left: 4px;
		width: 100%;
		max-height: 250px;
		position: relative;
	}
	.sPromo-wrap:first-child {
		margin-left: 0;
	}
	.sPromo-wrap a {
		position: absolute;
		width: 100%;
		height: 100%;
		left: 0;
		right: 0;
		z-index: 1;
	}
	.sPromo-wrap img {
		height: 100%;
		object-fit: cover;
		opacity: 1;
		display: block;
		width: 100%;
		transition: 0.5s ease;
		backface-visibility: hidden;
	}
	.sPromo-wrap .caption {
		font-family: Oswald, Arimo, sans-serif;
		position: absolute;
		width: 100%;
		bottom: 0;
		height: 38px;
		line-height: 36px;
		font-weight: 400;
		font-size: 15pt;
		overflow: hidden;
		text-overflow: ellipsis;
		white-space: nowrap;
		background: rgba(255, 255, 255, 0.75);
	}
	.sPromo-wrap:hover img {
		opacity: 0.5;
	}
	.sPromo-flex {
		max-height: 250px;
		flex: 1 1 250px;
		min-width: 200px;
		max-width: 500px;
		text-align: center;
		display: inline-block;
		position: relative;
		border: 1px solid #c3c1b8;
	}
	.sPromo-flex a {
		position: absolute;
		width: 100%;
		height: 100%;
		left: 0;
		right: 0;
		z-index: 1;
	}
	.sPromo-flex img {
		height: 100%;
		object-fit: cover;
		opacity: 1;
		display: block;
		width: 100%;
		transition: 0.5s ease;
		backface-visibility: hidden;
	}
	div#chabad_main_content {
		width: 100%;
	}
	.article-header__title {
		font-size: 30px;
		color: #66635b;
		font-family: Montserrat, sans-serif;
	}
	.wrap-image .bannerContainer img {
		opacity: 1;
		display: block;
		width: 100%;
		transition: 0.5s ease;
		backface-visibility: hidden;
	}
	.wrap-image:hover .bannerContainer img {
		opacity: 0.5;
	}
	.wrap-image:hover .wrap-image2 {
		opacity: 1;
	}
	.wrap-image2 {
		transition: 0.5s ease;
		opacity: 0;
		position: absolute;
		top: 50%;
		left: 50%;
		-ms-transform: translate(-50%, -50%);
		-webkit-transform: translate(-50%, -50%);
		transform: translate(-50%, -50%);
	}
	.custom_message {
		margin-bottom: 50px;
	}
	.custom_message .message {
		font-family: Montserrat, sans-serif;
		font-size: 16pt;
		margin: 0 auto;
		text-align: center;
		padding: 25px;
	}
	.photo_title {
		font-size: 20pt;
		text-transform: uppercase;
		text-align: center;
	}
	.co_date {
		font-size: 17pt;
		text-decoration: none;
		line-height: 25px;
		font-family: Oswald, Arimo, sans-serif;
		color: #fff;
		text-transform: uppercase;
	}

	.chabad_header {
		height: 450px;
		text-align: center;
		background-position: right bottom;
		background-repeat: no-repeat;
		background-color: rgba(255, 255, 255, 0.2);
		background-blend-mode: screen;
	}
	.indexsection {
		padding: 0 100px;
	}
	.indexsection .title {
		text-transform: uppercase;
		font-size: 20pt;
		text-align: left;
	}
	.indexsection .read-more_link {
		margin: 25px 0;
		width: 15%;
	}
	.indexsection .custom_message {
		padding: 25px;
	}
	.indexsection .message {
		padding: 20px 0;
		text-align: left;
		font-family: Montserrat, sans-serif !important;
		color: #000;
	}
	.indexsectionImg img {
		width: 40%;
		float: right;
	}
	.custom-mini-banner .banner-box {
		display: inline-block;
	}
	.custom-mini-banner {
		margin: 0px 0px 50px 0px;
		font-family: Montserrat, sans-serif;
		text-transform: uppercase;
		padding-left: 100px;
		padding-right: 100px;
	}
	.custom-mini-banner .mini-banner-1,
	.custom-mini-banner .mini-banner-2 {
		margin: 10px 0 2px;
	}
	.custom-mini-banner .banner-box {
		padding: 20px 35px;
		vertical-align: middle;
		text-align: left;
		box-sizing: border-box;
	}
	.custom-mini-banner .banner-box .title {
		font-weight: 700;
		display: inline-block;
		font-size: 18px;
	}
	.custom-mini-banner .banner-box .desc {
		font-size: 11px;
		line-height: 16px;
		padding-top: 6px;
	}
	.prepResource-title {
		font-size: 20pt;
		text-align: center;
		text-transform: uppercase;
	}
	.mobile div#chabad_head .chabad_navigator_bar ul li {
		background-color: inherit;
	}

	/* End of desktop CSS */

	/* Start of Media Queries */

	@media only screen and (min-width: 651px) {
		#co_calendar .item {
			min-height: 175px;
		}
		.co_calendar_text {
			padding-left: 52px;
			padding-right: 52px;
		}
	}
	@media only screen and (min-width: 1025px) {
		#co_calendar .item.small-width {
			width: 160px;
		}
		#co_calendar .item.normal-width {
			width: 25%;
		}
		#co_calendar .item.medium-width {
			width: 267px;
		}
		#co_calendar .item.large-width {
			width: 400px;
		}
	}
	@media only screen and (min-width: 1024px) and (max-width: 1366px) and (orientation: landscape) {
		.co_calendar_text {
			padding-left: 52px;
			padding-right: 52px;
		}
	}
	@media only screen and (min-width: 768px) and (max-width: 1024px) and (orientation: landscape) {
		.co_calendar_text {
			padding-left: 62px;
			padding-right: 62px;
		}
	}
	@media only screen and (min-width: 768px) and (max-width: 1024px) and (orientation: portrait) {
		.co_calendar_text {
			padding-left: 53px;
			padding-right: 52px;
		}
	}
	@media only screen and (min-width: 1024px) and (max-width: 1366px) and (orientation: portrait) {
		.co_calendar_text {
			padding-left: 62px;
			padding-right: 62px;
		}
	}
	@media only screen and (max-width: 650px) and (max-width: 650px) {
		.small_promos {
			flex-wrap: wrap;
			justify-content: center;
		}
	}
	@media only screen and (max-width: 650px) {
		.bannerCta,
		.textWrapper .wrapper-message {
			display: none;
		}
		.co_photo_gallery_head,
		.textWrapper span {
			text-align: center;
		}
		.textWrapper {
			background: rgba(255, 255, 255, 0.75);
		}
		.textWrapper .big {
			color: #000;
			margin: 0;
		}
		.cco_templateless_template a {
			padding-left: 0;
		}
		div.chabad_left_column {
			padding-top: 10px;
		}
		.chabad_header {
			background-image: none;
			height: 250px;
			display: block !important;
		}
		.chabad_header img {
			background-size: cover;
			background-position: center 0;
			background-attachment: inherit;
			height: 250px;
		}
		.headerTitle {
			padding-top: 50px;
		}
		.headerSubTitle,
		.header-desc {
			font-size: 20pt;
		}
		.header-desc {
			padding-bottom: 60px;
		}
		div#chabad_head .chabad_navigator_bar ul li a {
			border-right: none;
			line-height: 45px;
		}
		body.mobile #navigation.chabad_navigator_bar #menu {
			width: 100%;
			height: 45px;
		}
		body.mobile .g960.footer {
			padding: 10px;
		}
		.textWrapper {
			padding: 5px;
			float: none;
			left: 0;
			height: auto !important;
		}
		.sPromo-wrap {
			margin: 8px 8px 8px auto;
		}
		.small_promos img {
			width: 75%;
			display: initial;
		}
		.custom_message .title {
			font-size: 25pt;
		}
		.custom_message .message {
			width: 100%;
			font-size: 13pt;
			padding: 10px;
		}
		#co_calendar {
			display: block;
			clear: both;
		}
		#co_calendar .item {
			float: none;
			width: 100% !important;
			height: auto;
		}
		.co_features,
		.photo {
			display: inline-block;
			margin: 0 auto;
			width: 45%;
			padding-bottom: 15px;
		}
		.feature_caption a {
			font-size: 10pt;
		}
		.chabad_header div.headerTitle {
			font-size: 43px;
			line-height: 70px;
			padding-top: initial;
		}
		.indexsection,
		.indexsection .custom_message {
			padding: 10px;
		}
		.indexsection .message,
		.indexsection .title {
			text-align: center;
		}
		.indexsection .read-more_link {
			width: 100%;
		}
		.indexsectionImg img {
			float: none;
			width: 75%;
		}
		.sPromo-wrap {
			margin: 8px auto;
		}
		.textWrapper {
			background: rgba(255, 255, 255, 0.75);
		}
		.textWrapper .big {
			color: #000;
		}
		.custom-mini-banner .banner-box .desc {
			width: 100%;
		}
		.custom-mini-banner .banner-box {
			display: block;
			width: 100%;
			padding: 10px;
		}
		.custom-mini-banner {
			padding-left: 0px;
			padding-right: 0px;
		}
	}
	@media only screen and (max-width: 1024px) {
		#co_calendar .item .calendar-width,
		.calendar-width {
			max-width: 936px;
		}
		#co_calendar .item .normal-width {
			width: 300px;
		}
		#co_calendar .item .normal-width.last {
			width: 600px;
		}
		#co_calendar .item.medium-width,
		#co_calendar .item.small-width {
			width: 203px;
		}
		#co_calendar .item.normal-width {
			width: 25%;
		}
		#co_calendar .item.large-width {
			width: 300px;
		}
		div#chabad_body_content {
			background-color: #fff;
		}
		body.mobile #navigation.chabad_navigator_bar #menu li:not(.heading) {
			padding: 0;
		}
		div#chabad_head .chabad_navigator_bar ul li a {
			border-right: 0 !important;
		}
		body.cco_templateless_page.mobile #navigation.chabad_navigator_bar #menu {
			margin-top: 10px;
			height: 45px;
		}
		body.mobile .chabad_navigator_bar #menu .item.heading a {
			background: url("https://w2.chabad.org/images/shluchim/minisites/down_triangle_white.gif") no-repeat right center;
		}
		body.mobile .chabad_navigator_bar .sub_menu_toggle {
			background: url(https://w2.chabad.org/images/shluchim/minisites/down_triangle_white.gif) no-repeat center;
		}
		body.mobile div.chabad_navigator_bar #menu .sub_menu ul {
			border-left: 3px solid #fff;
		}
		body.mobile #navigation.chabad_navigator_bar #menu li:not(.heading) {
			padding-left: 0;
		}
		div#chabad_head .chabad_navigator_bar ul li ul li {
			min-height: 0;
		}
		body.mobile #navigation.chabad_navigator_bar #menu {
			width: 100%;
		}
		/*.cco_templateless_page #chabad_main_content {
			background-image: url(https://w2.chabad.org/images/Shluchim/minisites/themes/Generic_New/abstract2.jpg);
			background-blend-mode: screen;
			background-size: contain;
			background-color: rgba(255, 255, 255, 0.7);
		}*/
		.bannerCta button {
			margin-top: 0;
		}
		.small_promos {
			margin-top: 10px;
		}
		.co_features {
			width: 25%;
		}
		.co_photo_gallery_head {
			text-align: center;
		}
		.g960.footer {
			padding: 20px;
			width: 100%;
		}
		.arrow:hover {
			background: 0 0;
		}
		.sPromo-wrap .caption {
			max-width: 100%;
		}
		.custom_message .message {
			width: 100%;
		}
		.co_content {
			width: 100%;
		}
		.chabad_header {
			background-position: bottom center;
			background-attachment: inherit;
		}
		.chabad_header .headerTitle {
			padding-top: 100px;
		}
		.header-desc {
			padding-bottom: 75px;
		}
		.cco_templateless_page .chabad_header,
		.chabad_header {
			background-blend-mode: screen;
			background-position: left bottom;
			background-color: rgba(255, 255, 255, 0.3);
		}
		.header-desc {
			padding-bottom: 50px;
		}
	}
	#RegisterSinglePage {
		text-align: left;
		.form-label {
			width: 250px !important;
		}
		.form-label-left {
			width: 250px !important;
		}
		.form-line {
			padding-top: 12px;
			padding-bottom: 12px;
		}
		.form-label-right {
			width: 250px !important;
		}
		.form-all {
			font-size: 14px;
		}
		.co_body .content .form-all p {
			font-size: 14px;
		}
	}
	.co_photo_gallery {
		display: flex;
		flex-wrap: wrap;
	}

	.co_photo_gallery a img {
		aspect-ratio: 1;
		object-fit: cover;
	}
.co_photo_gallery a {
  flex: 1 1 220px;
gap: 5px;
}
</style>


<div id="chabad_body_page">
<div id="chabad_main_content">
<div id="chabad_head">


<div class="chabad_header">

<img src="https://chabadofbradenton.com/media/images/1358/UQCw13583974.png" alt="Welcome!" />
<div class="headerTitle">
<a href="/7254282" style="text-decoration: none;">
</a>
</div>
<div class="headerSubTitle"></div>
<div class="header-desc"></div>
</div>

<div id="navigation" class="chabad_navigator_bar">
<div class="chabad_menu_content">
<ul id="menu" class="navi">
<li class="item parent">
<a href="/article.asp?aid=7254282" class="parent">Home</a>
|
</li>
<li class="item parent arrow selected">
<a href="/article.asp?aid=7244200" class="parent arrow selected">Summer Camp Registration</a>
<div class="sub_menu">
<ul>
<li class="item first">
<a href="/article.asp?aid=7245545">Camp Scholarship Form</a>
</li>
<li class="item last">
<a href="/article.asp?aid=7245550">Terms & Conditions</a>
</li>
</ul>
</div>
|
</li>
<li class="item parent">
<a href="/article.asp?aid=7265939" class="parent">About</a>
|
</li>
<li class="item parent">
<a href="/article.asp?aid=7266257" class="parent">Dates & Rates</a>
|
</li>
<li class="item parent">
<a href="/article.asp?aid=7266291" class="parent">Schedule</a>
|
</li>
<li class="item parent">
<a href="/article.asp?aid=7266298" class="parent">Photos</a>
</li>

</ul>
</div>
</div>


</div>
<div id="chabad_body_content">
<div class="chabad_left_column">
<div detached="true" type="static" id="ContentArea" name="content_area" actions="edit,delete" class="chabad_left_column"><div id="content_page" class="content_page"><!-- END HEADER -->
			
			
			<div class="clearfix bh mobile-only align_right">ב"ה</div>
			
				<div class="master-content-wrapper " >
					

<header class="article-header cf ">
	
	
			<h1 class="article-header__title js-article-title js-page-title">Summer Camp Registration</h1>
		
			<div>
				
			</div>
		
</header>
				</div>
			
			<div class="body_wrapper clearfix co_body">
				<div class="" id="co_body_container">
					
					<div id="ContentBody">
						
						
							<div class="content-area-parent no_margin">
								
	<div id="cco_body">
		<div class="content  no_margin no_overflow" id="co_content_container">
			
			
	

	<article class="content js-content" >
	

<div id="formContainer"><script type="text/javascript">var defaultCurrency = { value: 'USD', symbol: '$'};
$j(function(){
window.multiplier = 0;
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<form class="userform-form" action="" method="post" name="form_7244200" id="7244200" accept-charset="utf-8"><input type="hidden" name="formID" value="7244200" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li class="form-line" id="id_1"><div id="cid_1" class="form-input-wide"> <div style="text-align:center;"><img alt="" class="form-image" border="0" src="https://w2.chabad.org/media/images/1359/uiZq13593106.png" height="292.6" width="665" /></div> </div></li><li class="form-line" id="id_4"><div id="cid_4" class="form-input-wide"> <div id="text_4" class="form-html"><p><strong><em>Limited availability, first come first serve basis.  </em></strong> </p>

<table border="0" width="600">
	<tbody>
		<tr>
			<td><strong>Dates:</strong></td>
			<td>
			<p>Monday, June 1 - Friday, June 19, 2026<br />
			9:00 am - 3:00 pm</p>

			<p><br />
			Optional Extended Care<br />
			After Care: Monday - Thursday 3:00 - 5:00 pm- $25 per week</p>

			<p>PLEASE NOTE: THERE IS NO AFTER CARE ON FRIDAY AFTERNOON.</p>
			</td>
		</tr>
	</tbody>
</table>
</div> </div></li><li class="form-line" id="id_5"><div id="cid_5" class="form-input-wide"> <div id="text_5" class="form-html"><table border="0">
	<tbody>
		<tr>
			<td>
			<table border="5">
				<tbody>
					<tr>
						<td>
						<p><strong>Division</strong></p>
						</td>
						<td><strong>Weekly Rate</strong></td>
						<td><strong>Full Summer (3 Weeks)</strong></td>
					</tr>
					<tr>
						<td>
						<p><strong>Explorers (Grades K–1)*          </strong></p>
						</td>
						<td>$225 <em>(Early Bird: $200)          </em></td>
						<td>$675 <em>(Early Bird: $600)</em></td>
					</tr>
					<tr>
						<td>
						<p><strong>Trailblazers (Grades 2–4)</strong></p>
						</td>
						<td>$225 <em>(Early Bird: $200)</em></td>
						<td>$675 <em>(Early Bird: $600)</em></td>
					</tr>
					<tr>
						<td>
						<p><strong>Pioneers (Grades 5–7)</strong></p>
						</td>
						<td>$275 <em>(Early Bird: $250)</em></td>
						<td>$825 <em>(Early Bird: $750</em></td>
					</tr>
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</table>

<p><strong>*Limited Availability for Explorers: Grades K - 1.</strong> Contact Chanie for more information. </p>

<p>LIMITED SCHOLARSHIPS ARE AVAILABLE UPON REQUEST <strong>. For those requesting a scholarship, please complete<a href="/article.asp?AID=7245545"> this form.</a> For more information, please email <a href="mailto:Info@chabadofbradenton.com?subject=Re-Scholarship%20Form%20for%20Camp">Info@chabadofbradenton.com</a><br />
Early bird pricing ends March 31st.</strong></p>
</div> </div></li><li id="cid_6" class="form-input-wide"> <div class="form-header-group"><h2 id="header_6" class="form-header">Family Information:</h2></div> </li><li class="form-line" id="id_27"><div class="form-label-left" id="label_27"><label for="input_27"> Family Name<span class="form-required">*</span> </label><label class="label-message" for="input_27"> </label></div><div id="cid_27" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_27" name="q27_input27" size="20" value="" /> </div></li><li class="form-line" id="id_8"><div class="form-label-left" id="label_8"><label for="input_8"> Address<span class="form-required">*</span> </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" 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="q8_address[addr_line1]" id="input_8_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_8_addr_line1" id="sublabel_8_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="q8_address[addr_line2]" id="input_8_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_8_addr_line2" id="sublabel_8_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="q8_address[city]" id="input_8_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_8_city" id="sublabel_8_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q8_address[state]" id="input_8_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_8_state" id="sublabel_8_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="q8_address[postal]" id="input_8_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_8_postal" id="sublabel_8_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q8_address[country]" id="input_8_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_8_country" id="sublabel_8_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_9"><div class="form-label-left" id="label_9"><label for="input_9"> Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_9"> </label></div><div id="cid_9" 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="q9_phoneNumber[full]" id="input_9_full" autocomplete="tel" />  <label class="form-sub-label" for="input_9_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_10"><div class="form-label-left" id="label_10"><label for="input_10"> Father's E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_10"> </label></div><div id="cid_10" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_10" name="q10_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12"> Mother's E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_12"> </label></div><div id="cid_12" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_12" name="q12_email12" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_13"><div class="form-label-left" id="label_13"><label for="input_13"> Mother's Name<span class="form-required">*</span> </label><label class="label-message" for="input_13"> </label></div><div id="cid_13" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q13_fullName13[first]" id="first_13" autocomplete="given-name" />  <label class="form-sub-label" for="first_13" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q13_fullName13[last]" id="last_13" autocomplete="family-name" />  <label class="form-sub-label" for="last_13" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_14"><div class="form-label-left" id="label_14"><label for="input_14"> Mother's Hebrew Name<span class="form-required">*</span> </label><label class="label-message" for="input_14"> </label></div><div id="cid_14" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_14" name="q14_input14" size="20" value="" /> </div></li><li class="form-line" id="id_15"><div class="form-label-left" id="label_15"><label for="input_15"> Mother's Work Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_15"> </label></div><div id="cid_15" 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="q15_phoneNumber15[full]" id="input_15_full" autocomplete="tel" />  <label class="form-sub-label" for="input_15_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_16"><div class="form-label-left" id="label_16"><label for="input_16"> Mother's Cell Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_16"> </label></div><div id="cid_16" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q16_phoneNumber16[full]" id="input_16_full" autocomplete="tel" />  <label class="form-sub-label" for="input_16_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_17"><div class="form-label-left" id="label_17"><label for="input_17"> Father's Name<span class="form-required">*</span> </label><label class="label-message" for="input_17"> </label></div><div id="cid_17" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q17_fullName17[first]" id="first_17" autocomplete="given-name" />  <label class="form-sub-label" for="first_17" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q17_fullName17[last]" id="last_17" autocomplete="family-name" />  <label class="form-sub-label" for="last_17" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_18"><div class="form-label-left" id="label_18"><label for="input_18"> Father's Hebrew Name<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"> Father's Work Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_19"> </label></div><div id="cid_19" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q19_phoneNumber19[full]" id="input_19_full" autocomplete="tel" />  <label class="form-sub-label" for="input_19_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_20"><div class="form-label-left" id="label_20"><label for="input_20"> Father's Cell Phone Number<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"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q20_phoneNumber20[full]" id="input_20_full" autocomplete="tel" />  <label class="form-sub-label" for="input_20_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_68"><div class="form-label-left" id="label_68"><label for="input_68"> Emergency Contact Person One:<span class="form-required">*</span> </label><label class="label-message" for="input_68"> </label></div><div id="cid_68" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q68_fullName68[first]" id="first_68" autocomplete="given-name" />  <label class="form-sub-label" for="first_68" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q68_fullName68[last]" id="last_68" autocomplete="family-name" />  <label class="form-sub-label" for="last_68" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_22"><div class="form-label-left" id="label_22"><label for="input_22"> Emergency Contact One: Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_22"> </label></div><div id="cid_22" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q22_phoneNumber22[full]" id="input_22_full" autocomplete="tel" />  <label class="form-sub-label" for="input_22_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_23"><div class="form-label-left" id="label_23"><label for="input_23"> Relationship<span class="form-required">*</span> </label><label class="label-message" for="input_23"> </label></div><div id="cid_23" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_23" name="q23_input23" size="20" value="" /> </div></li><li class="form-line" id="id_21"><div class="form-label-left" id="label_21"><label for="input_21"> Emergency Contact Person Two:<span class="form-required">*</span> </label><label class="label-message" for="input_21"> </label></div><div id="cid_21" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q21_fullName21[first]" id="first_21" autocomplete="given-name" />  <label class="form-sub-label" for="first_21" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q21_fullName21[last]" id="last_21" autocomplete="family-name" />  <label class="form-sub-label" for="last_21" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_69"><div class="form-label-left" id="label_69"><label for="input_69"> Emergency Contact Two: Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_69"> </label></div><div id="cid_69" 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="q69_phoneNumber69[full]" id="input_69_full" autocomplete="tel" />  <label class="form-sub-label" for="input_69_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_70"><div class="form-label-left" id="label_70"><label for="input_70"> Relationship<span class="form-required">*</span> </label><label class="label-message" for="input_70"> </label></div><div id="cid_70" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_70" name="q70_input70" size="20" value="" /> </div></li><li class="form-line" id="id_24"><div class="form-label-left" id="label_24"><label for="input_24"> Pediatrician Name<span class="form-required">*</span> </label><label class="label-message" for="input_24"> </label></div><div id="cid_24" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q24_fullName24[first]" id="first_24" autocomplete="given-name" />  <label class="form-sub-label" for="first_24" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q24_fullName24[last]" id="last_24" autocomplete="family-name" />  <label class="form-sub-label" for="last_24" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_25"><div class="form-label-left" id="label_25"><label for="input_25"> Pediatrician Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_25"> </label></div><div id="cid_25" 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="q25_phoneNumber25[full]" id="input_25_full" autocomplete="tel" />  <label class="form-sub-label" for="input_25_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_78"><div class="form-label-left" id="label_78"><label for="input_78"> Insurance Policy Number </label><label class="label-message" for="input_78"> </label></div><div id="cid_78" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_78" name="q78_input78" size="20" value="" /> </div></li><li class="form-line" id="id_79"><div class="form-label-left" id="label_79"><label for="input_79"> Group Number </label><label class="label-message" for="input_79"> </label></div><div id="cid_79" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_79" name="q79_input79" size="20" value="" /> </div></li><li class="form-line" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> Who can we thank for referring you? </label><label class="label-message" for="input_26"> </label></div><div id="cid_26" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_26" name="q26_input26" size="20" value="" /> </div></li><li class="form-line" id="id_29"><div class="form-label-left" id="label_29"><label for="input_29"> Number of children being registered:<span class="form-required">*</span> </label><label class="label-message" for="input_29"> </label></div><div id="cid_29" class="form-input"> <input type="number" class="form-number-input  form-textbox validate[required]" id="input_29" name="q29_number" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="1" data-numbermin="1" /> </div></li><li id="cid_30" class="form-input-wide"> <div class="form-header-group"><h2 id="header_30" class="form-header">Camper One Information</h2></div> </li><li class="form-line" id="id_46"><div class="form-label-left" id="label_46"><label for="input_46"> Name<span class="form-required">*</span> </label><label class="label-message" for="input_46"> </label></div><div id="cid_46" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_46" name="q46_input46" size="20" value="" /> </div></li><li class="form-line" id="id_34"><div class="form-label-left" id="label_34"><label for="input_34"> Gender<span class="form-required">*</span> </label><label class="label-message" for="input_34"> </label></div><div id="cid_34" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_34_0" name="q34_input34" value="Male" /><label id="label_input_34_0" for="input_34_0"><span>Male</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_34_1" name="q34_input34" value="Female" /><label id="label_input_34_1" for="input_34_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_48"><div class="form-label-left" id="label_48"><label for="input_48"> Date of Birth<span class="form-required">*</span> </label><label class="label-message" for="input_48"> </label></div><div id="cid_48" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q48_birthDate48[month]" id="input_48_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_48_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q48_birthDate48[day]" id="input_48_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_48_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q48_birthDate48[year]" id="input_48_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_48_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_35"><div class="form-label-left" id="label_35"><label for="input_35"> School<span class="form-required">*</span> </label><label class="label-message" for="input_35"> </label></div><div id="cid_35" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_35" name="q35_input35" size="20" value="" /> </div></li><li class="form-line" id="id_50"><div class="form-label-left" id="label_50"><label for="input_50"> Entering Grade:<span class="form-required">*</span> </label><label class="label-message" for="input_50"> </label></div><div id="cid_50" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_50" name="q50_input50" size="20" value="" /> </div></li><li class="form-line" id="id_37"><div class="form-label-left" id="label_37"><label for="input_37"> Medication<span class="form-required">*</span> </label><label class="label-message" for="input_37"> </label></div><div id="cid_37" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_37" name="q37_input37" size="20" value="" /> </div></li><li class="form-line" id="id_52"><div class="form-label-left" id="label_52"><label for="input_52"> Allergies<span class="form-required">*</span> </label><label class="label-message" for="input_52"> </label></div><div id="cid_52" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_52" name="q52_input52" size="20" value="" /> </div></li><li class="form-line" id="id_53"><div class="form-label-left" id="label_53"><label for="input_53"> Health Issues, Disabilities, or Special Needs of child:<span class="form-required">*</span> </label><label class="label-message" for="input_53"> </label></div><div id="cid_53" class="form-input"> <textarea id="input_53" class="form-textarea validate[required]" name="q53_input53" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_73"><div class="form-label-left" id="label_73"><label for="input_73"> I would like to order the following amount of tshirts<span class="form-required">*</span> </label><label class="label-message" for="input_73"> </label></div><div id="cid_73" class="form-input"> <span class="form-sub-label-container"><input type="number" class="form-number-input  form-textbox validate[required]" id="input_73" name="q73_number73" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" />  <label class="form-sub-label" for="input_73">$12 each</label></span> </div></li><li class="form-line" id="id_72"><div class="form-label-left" id="label_72"><label for="input_72"> T-shirt size (New Color This Summer) </label><label class="label-message" for="input_72"> </label></div><div id="cid_72" class="form-input"> <span class="form-sub-label-container"><select class="form-dropdown" style="width:150px" id="input_72" name="q72_input72"><option value=""></option><option value="S (6-8)">S (6-8)</option><option value="M (10-12)">M (10-12)</option><option value="L (12-14)">L (12-14)</option><option value="XL (14-16)">XL (14-16)</option><option value="(A) S">(A) S</option><option value="(A) M">(A) M</option><option value="(A) L">(A) L</option><option value="(A) XL">(A) XL</option><option value="(A) 2X">(A) 2X</option></select>  <label class="form-sub-label" for="input_72">(A) implies Adult Sizes</label></span> </div></li><li class="form-line" id="id_54"><div class="form-label-left" id="label_54"><label for="input_54"> Age Group<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-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_54_0" name="q54_input54" value="Explorers: Grades K - 1" /><label id="label_input_54_0" for="input_54_0"><span>Explorers: Grades K - 1</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_54_1" name="q54_input54" value="Trailblazers: Grades 2 - 4" /><label id="label_input_54_1" for="input_54_1"><span>Trailblazers: Grades 2 - 4</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_54_2" name="q54_input54" value="Pioneers: Grades 5 – 7" /><label id="label_input_54_2" for="input_54_2"><span>Pioneers: Grades 5 – 7</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_41"><div class="form-label-left" id="label_41"><label for="input_41"> Explorers/Trailblazers attending: </label><label class="label-message" for="input_41"> </label></div><div id="cid_41" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_41_0" name="q41_input41[]" value="Full Session" /><label id="label_input_41_0" for="input_41_0"><span>Full Session</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_41_1" name="q41_input41[]" value="Week 1" /><label id="label_input_41_1" for="input_41_1"><span>Week 1</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_41_2" name="q41_input41[]" value="Week 2" /><label id="label_input_41_2" for="input_41_2"><span>Week 2</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_41_3" name="q41_input41[]" value="Week 3" /><label id="label_input_41_3" for="input_41_3"><span>Week 3</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_42"><div class="form-label-left" id="label_42"><label for="input_42"> Pioneers attending: </label><label class="label-message" for="input_42"> </label></div><div id="cid_42" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_42_0" name="q42_input42[]" value="Full Session" /><label id="label_input_42_0" for="input_42_0"><span>Full Session</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_42_1" name="q42_input42[]" value="Week 1" /><label id="label_input_42_1" for="input_42_1"><span>Week 1</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_42_2" name="q42_input42[]" value="Week 2" /><label id="label_input_42_2" for="input_42_2"><span>Week 2</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_42_3" name="q42_input42[]" value="Week 3" /><label id="label_input_42_3" for="input_42_3"><span>Week 3</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_44"><div class="form-label-left" id="label_44"><label for="input_44"> I will need the following amount of weeks of after care ($25/week) </label><label class="label-message" for="input_44"> </label></div><div id="cid_44" class="form-input"> <input type="number" class="form-number-input  form-textbox" id="input_44" name="q44_number44" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" /> </div></li><li id="cid_45" class="form-input-wide"> <div class="form-header-group"><h2 id="header_45" class="form-header">Camper Two Information</h2></div> </li><li class="form-line" id="id_31"><div class="form-label-left" id="label_31"><label for="input_31"> Name </label><label class="label-message" for="input_31"> </label></div><div id="cid_31" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_31" name="q31_input31" size="20" value="" /> </div></li><li class="form-line" id="id_47"><div class="form-label-left" id="label_47"><label for="input_47"> Gender </label><label class="label-message" for="input_47"> </label></div><div id="cid_47" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_47_0" name="q47_input47" value="Male" /><label id="label_input_47_0" for="input_47_0"><span>Male</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_47_1" name="q47_input47" value="Female" /><label id="label_input_47_1" for="input_47_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"> Date of Birth </label><label class="label-message" for="input_33"> </label></div><div id="cid_33" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q33_birthDate[month]" id="input_33_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_33_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q33_birthDate[day]" id="input_33_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_33_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q33_birthDate[year]" id="input_33_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_33_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_49"><div class="form-label-left" id="label_49"><label for="input_49"> School </label><label class="label-message" for="input_49"> </label></div><div id="cid_49" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_49" name="q49_input49" size="20" value="" /> </div></li><li class="form-line" id="id_36"><div class="form-label-left" id="label_36"><label for="input_36"> Entering Grade: </label><label class="label-message" for="input_36"> </label></div><div id="cid_36" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_36" name="q36_input36" size="20" value="" /> </div></li><li class="form-line" id="id_51"><div class="form-label-left" id="label_51"><label for="input_51"> Medication </label><label class="label-message" for="input_51"> </label></div><div id="cid_51" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_51" name="q51_input51" size="20" value="" /> </div></li><li class="form-line" id="id_38"><div class="form-label-left" id="label_38"><label for="input_38"> Allergies </label><label class="label-message" for="input_38"> </label></div><div id="cid_38" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_38" name="q38_input38" size="20" value="" /> </div></li><li class="form-line" id="id_39"><div class="form-label-left" id="label_39"><label for="input_39"> Health Issues, Disabilities, or Special Needs of child: </label><label class="label-message" for="input_39"> </label></div><div id="cid_39" class="form-input"> <textarea id="input_39" class="form-textarea" name="q39_input39" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_71"><div class="form-label-left" id="label_71"><label for="input_71"> I would like to order the following amount of tshirts </label><label class="label-message" for="input_71"> </label></div><div id="cid_71" class="form-input"> <span class="form-sub-label-container"><input type="number" class="form-number-input  form-textbox" id="input_71" name="q71_number71" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" />  <label class="form-sub-label" for="input_71">$12 each</label></span> </div></li><li class="form-line" id="id_74"><div class="form-label-left" id="label_74"><label for="input_74"> T-shirt size (New Color This Summer) </label><label class="label-message" for="input_74"> </label></div><div id="cid_74" class="form-input"> <span class="form-sub-label-container"><select class="form-dropdown" style="width:150px" id="input_74" name="q74_input74"><option value=""></option><option value="S (6-8)">S (6-8)</option><option value="M (10-12)">M (10-12)</option><option value="L (12-14)">L (12-14)</option><option value="XL (14-16)">XL (14-16)</option><option value="(A) S">(A) S</option><option value="(A) M">(A) M</option><option value="(A) L">(A) L</option><option value="(A) XL">(A) XL</option><option value="(A) 2X">(A) 2X</option></select>  <label class="form-sub-label" for="input_74">(A) implies Adult Sizes</label></span> </div></li><li class="form-line" id="id_40"><div class="form-label-left" id="label_40"><label for="input_40"> Age Group </label><label class="label-message" for="input_40"> </label></div><div id="cid_40" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_40_0" name="q40_input40" value="Explorers: Grades K - 1" /><label id="label_input_40_0" for="input_40_0"><span>Explorers: Grades K - 1</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_40_1" name="q40_input40" value="Trailblazers: Grades 2 - 4" /><label id="label_input_40_1" for="input_40_1"><span>Trailblazers: Grades 2 - 4</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_40_2" name="q40_input40" value="Pioneers: Grades 5 – 7" /><label id="label_input_40_2" for="input_40_2"><span>Pioneers: Grades 5 – 7</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_55"><div class="form-label-left" id="label_55"><label for="input_55"> Explorers/Trailblazers attending: </label><label class="label-message" for="input_55"> </label></div><div id="cid_55" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_55_0" name="q55_input55[]" value="Full Session" /><label id="label_input_55_0" for="input_55_0"><span>Full Session</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_55_1" name="q55_input55[]" value="Week 1" /><label id="label_input_55_1" for="input_55_1"><span>Week 1</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_55_2" name="q55_input55[]" value="Week 2" /><label id="label_input_55_2" for="input_55_2"><span>Week 2</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_55_3" name="q55_input55[]" value="Week 3" /><label id="label_input_55_3" for="input_55_3"><span>Week 3</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"> Pioneers attending: </label><label class="label-message" for="input_56"> </label></div><div id="cid_56" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_56_0" name="q56_input56[]" value="Full Session" /><label id="label_input_56_0" for="input_56_0"><span>Full Session</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_56_1" name="q56_input56[]" value="Week 1" /><label id="label_input_56_1" for="input_56_1"><span>Week 1</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_56_2" name="q56_input56[]" value="Week 2" /><label id="label_input_56_2" for="input_56_2"><span>Week 2</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_56_3" name="q56_input56[]" value="Week 3" /><label id="label_input_56_3" for="input_56_3"><span>Week 3</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_58"><div class="form-label-left" id="label_58"><label for="input_58"> I will need the following amount of weeks of after care ($25/week) </label><label class="label-message" for="input_58"> </label></div><div id="cid_58" class="form-input"> <input type="number" class="form-number-input  form-textbox" id="input_58" name="q58_number58" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" /> </div></li><li id="cid_59" class="form-input-wide"> <div class="form-header-group"><h2 id="header_59" class="form-header">IMPORTANT</h2></div> </li><li class="form-line" id="id_60"><div id="cid_60" class="form-input-wide"> <div id="text_60" class="form-html"><p><strong>All forms must be completed and submitted before your child begins camp.</strong></p>
</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><a href="/article.asp?AID=7245545" target="_blank">Click here</a> to access the scholarship form.</p>
</div> </div></li><li class="form-line" id="id_61"><div class="form-label-left" id="label_61"><label for="input_61"> Agreement:<span class="form-required">*</span> </label><label class="label-message" for="input_61"> </label></div><div id="cid_61" 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_61_0" name="q61_input61" value="I authorize Camp Gan Israel to charge my card the full tuition amount once accepted." /><label id="label_input_61_0" for="input_61_0"><span>I authorize Camp Gan Israel to charge my card the full tuition amount once accepted.</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_76" class="form-input-wide"> <div class="form-header-group"><h2 id="header_76" class="form-header">Camp Security:</h2></div> </li><li class="form-line always-hidden" id="id_77"><div class="form-label-left" id="label_77"><label for="input_77"> We have employed full time security during camp hours. Please consider a donation to the security fund to help cover the large increase in our budget: </label><label class="label-message" for="input_77"> </label></div><div id="cid_77" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_77_0" name="q77_input77" value="$180" /><label id="label_input_77_0" for="input_77_0"><span>$180</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_77_1" name="q77_input77" value="$360" /><label id="label_input_77_1" for="input_77_1"><span>$360</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_77_2" name="q77_input77" value="$540" /><label id="label_input_77_2" for="input_77_2"><span>$540</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_77_3" name="q77_input77" value="$1000" /><label id="label_input_77_3" for="input_77_3"><span>$1000</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_62"><div class="form-label-left" id="label_62"><label for="input_62"> Questions/Comments: </label><label class="label-message" for="input_62"> </label></div><div id="cid_62" class="form-input"> <textarea id="input_62" class="form-textarea" name="q62_input62" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_63"><div class="form-label-left" id="label_63"><label for="input_63"> Total </label></div><div id="cid_63" class="form-input"> <div id="total_amount">$0.00 </div> </div></li><li class="form-line" id="id_64"><div class="form-label-left" id="label_64"><label for="input_64"> Payment<span class="form-required">*</span> </label><label class="label-message" for="input_64"> </label></div><div id="cid_64" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2" class="form-payment-methods form-multiple-column"></td></tr><tr class="credit_card "><th colspan="2">Credit Card</th></tr><tr class="credit_card "><td colspan="2" style="padding:0"><table cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container">  <label class="form-sub-label">We accept Visa, MasterCard, American Express, Discover</label></span><div class="cc-icons"><div class="cc-icon visa-icon"></div><div class="cc-icon mastercard-icon"></div><div class="cc-icon amex-icon"></div><div class="cc-icon discover-icon"></div></div><input type="hidden" name="q64_payment[cc_type]" id="input_64_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="q64_payment[cc_number]" id="input_64_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_64_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="q64_payment[cc_ccv]" id="input_64_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_64_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="q64_payment[cc_nameOnCard]" id="input_64_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_64_cc_nameOnCard" id="sublabel_cc_nameOnCard">Name on Card</label></span></td></tr><tr class="credit_card "><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q64_payment[cc_exp_month]" id="input_64_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_64_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="q64_payment[cc_exp_year]" id="input_64_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_64_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="billing_address "><th colspan="2">Billing Address</th></tr><tr class="billing_address "><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-line" type="text" name="q64_payment[addr_line1]" id="input_64_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_64_addr_line1" id="sublabel_64_addr_line1">Street Address</label></span></td></tr><tr class="billing_address "><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-city" type="text" name="q64_payment[city]" id="input_64_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_64_city" id="sublabel_64_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q64_payment[state]" id="input_64_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_64_state" id="sublabel_64_state">State / Province</label></span></td></tr><tr class="billing_address "><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-postal" type="text" name="q64_payment[postal]" id="input_64_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_64_postal" id="sublabel_64_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q64_payment[country]" id="input_64_country" autocomplete="billing country-name"><option value="" selected="selected">Please Select</option><option value="United States">United States</option><option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="The Bahamas">The Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Brazil">Brazil</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burundi">Burundi</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cape Verde">Cape Verde</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="People's Republic of China">People's Republic of China</option><option value="Republic of China">Republic of China</option><option value="Christmas Island">Christmas Island</option><option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo">Congo</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Cote d'Ivoire">Cote d'Ivoire</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Eswatini">Eswatini</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Polynesia">French Polynesia</option><option value="Gabon">Gabon</option><option value="The Gambia">The Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jersey">Jersey</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="North Korea">North Korea</option><option value="South Korea">South Korea</option><option value="Kosovo">Kosovo</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Laos">Laos</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macau">Macau</option><option value="Macedonia">Macedonia</option><option value="Madagascar">Madagascar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Myanmar">Myanmar</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="Northern Mariana">Northern Mariana</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn Islands">Pitcairn Islands</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Barthelemy">Saint Barthelemy</option><option value="Saint Helena">Saint Helena</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="Somaliland">Somaliland</option><option value="South Africa">South Africa</option><option value="South Ossetia">South Ossetia</option><option 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I authorize Camp Gan Israel to have my child treated in case of emergency by a physician in the manner such person deems necessary. I further give permission for my child to attend and be transported on camp trips. </p>
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