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      Userform.description('input_74', 'For use if we can not reach a parent');
      Userform.description('input_53', 'write \"None\" if your child does not have any allergies');
      Userform.alterTexts({"required":"This field is required","requireOne":"At least one field required","requireEveryRow":"Every row is required","alphabetic":"This field can only contain letters","numeric":"This field can only contain numeric values","alphanumeric":"This field can only contain letters and numbers","incompleteFields":"There are incomplete required fields. Please complete them.","uploadFilesize":"File size cannot be bigger than:","confirmClearForm":"Are you sure you want to clear the form?","lessThan":"Your score should be less than or equal to","email":"Enter a valid e-mail address","uploadExtensions":"You can only upload following files:","pleaseWait":"Please wait...","confirmEmail":"E-mail does not match","submissionLimit":"Sorry! Only one entry is allowed.  Multiple submissions are disabled for this form.","gradingScoreError":"Score total should only be less than or equal to","inputCarretErrorA":"Input should not be less than the minimum value:","inputCarretErrorB":"Input should not be greater than the maximum value:","maxDigitsError":"The maximum digits allowed is","minSelectionsError":"The minimum required number of selections is","maxSelectionsError":"The maximum number of selections allowed is","pastDatesDisallowed":"Date must not be in the past","multipleFileUploads_typeError":"{file} has invalid extension. Only {extensions} are allowed.","multipleFileUploads_sizeError":"{file} is too large, maximum file size is {sizeLimit}.","multipleFileUploads_minSizeError":"{file} is too small, minimum file size is {minSizeLimit}.","multipleFileUploads_emptyError":"{file} is empty, please select files again without it.","multipleFileUploads_onLeave":"The files are being uploaded, if you leave now the upload will be cancelled.","generalError":"There are errors on the form. Please fix them before continuing.","generalPageError":"There are errors on this page. Please fix them before continuing."});
   });
</script>
<style type="text/css" id="GenFormStyles">
    .form-label{
        width:300px !important;
    }
    .form-label-left{
        width:300px !important;
    }
    .form-line{
        padding-top:12px;
        padding-bottom:12px;
    }
    .form-label-right{
        width:300px !important;
    }
    .form-all {
        font-size:14px;
    }
.co_body .content .form-all p {
 font-size:14px;

}
@media screen and (max-width: 750px) {.form-label-left{	float:none;	display:block;}.form-buttons-wrapper.button-align-auto{text-indent: 0!important;}}</style>

<form class="userform-form" action="" method="post" name="form_3403501" id="3403501" accept-charset="utf-8">
  <input type="hidden" name="formID" value="3403501" />
  <div class="form-all dir_ltr" dir="ltr">
    <ul class="form-section">
      <li id="cid_11" class="form-input-wide">
        <div class="form-header-group">
          <h1 id="header_11" class="form-header">
            Teen's Information
          </h1>
        </div>
      </li>
      <li class="form-line" id="id_5">
        <div class="form-label-left" id="label_5">
          <label for="input_5">
            Teen's Full Name<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_5">  </label>
        </div>
        <div id="cid_5" class="form-input"><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q5_childsFull[first]" id="first_5" />
            <label class="form-sub-label" for="first_5" id="sublabel_first"> First Name </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q5_childsFull[last]" id="last_5" />
            <label class="form-sub-label" for="last_5" id="sublabel_last"> Last Name </label></span>
        </div>
      </li>
      <li class="form-line" id="id_21">
        <div class="form-label-left" id="label_21">
          <label for="input_21">
            Teen's Gender<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_21">  </label>
        </div>
        <div id="cid_21" class="form-input">
          <input type="text" class=" form-textbox validate[required, Alphabetic]" data-type="input-textbox" id="input_21" name="q21_childsGender" size="30" value="" />
        </div>
      </li>
      <li class="form-line" id="id_6">
        <div class="form-label-left" id="label_6">
          <label for="input_6">
            Teen's E-mail (Write NONE if your child does not have an email address.)<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_6">  </label>
        </div>
        <div id="cid_6" class="form-input">
          <input type="email" class=" form-textbox validate[required]" id="input_6" name="q6_childsEmail6" size="30" value="" />
        </div>
      </li>
      <li class="form-line" id="id_9">
        <div class="form-label-left" id="label_9">
          <label for="input_9">
            Teen's Cell Phone Number (Write 000 in both fields if your child does not have a cell 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 class="form-textbox validate[required]" type="tel" name="q9_childsCell[area]" id="input_9_area" size="3" />
              <label class="form-sub-label" for="input_9_area" id="sublabel_area"> Area Code </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="tel" name="q9_childsCell[phone]" id="input_9_phone" size="8" />
              <label class="form-sub-label" for="input_9_phone" id="sublabel_phone"> Phone Number </label></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_14">
        <div class="form-label-left" id="label_14">
          <label for="input_14">
            Teen's Home Phone Number (Write 000 in both fields if your child/household does not have a home phone number.)<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_14">  </label>
        </div>
        <div id="cid_14" class="form-input">
          <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="tel" name="q14_childsHome14[area]" id="input_14_area" size="3" />
              <label class="form-sub-label" for="input_14_area" id="sublabel_area"> Area Code </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="tel" name="q14_childsHome14[phone]" id="input_14_phone" size="8" />
              <label class="form-sub-label" for="input_14_phone" id="sublabel_phone"> Phone Number </label></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_77">
        <div class="form-label-left" id="label_77">
          <label for="input_77"> Best way to contact your teen </label>
          <label class="label-message" for="input_77">  </label>
        </div>
        <div id="cid_77" class="form-input">
          <select class="form-dropdown" style="width:150px" id="input_77" name="q77_bestWay">
            <option value="">  </option>
            <option value="Phone Call"> Phone Call </option>
            <option value="Text Message"> Text Message </option>
            <option value="Email"> Email </option>
          </select>
        </div>
      </li>
      <li class="form-line" id="id_8">
        <div class="form-label-left" id="label_8">
          <label for="input_8">
            Teen's Home 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_childsHome[addr_line1]" id="input_8_addr_line1" size="46" />
                  <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_childsHome[addr_line2]" id="input_8_addr_line2" size="46" />
                  <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_childsHome[city]" id="input_8_city" size="21" />
                  <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_childsHome[state]" id="input_8_state" size="22" />
                  <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_childsHome[postal]" id="input_8_postal" size="10" />
                  <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_childsHome[country]" id="input_8_country">
                    <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_10">
        <div class="form-label-left" id="label_10">
          <label for="input_10">
            Teen's Birth Date<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_10">  </label>
        </div>
        <div id="cid_10" class="form-input">
          <div class="dir_ltr"><span class="form-sub-label-container"><select class="form-dropdown validate[required]" name="q10_childsBirth[month]" id="input_10_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_10_month" id="sublabel_month"> Month </label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" name="q10_childsBirth[day]" id="input_10_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_10_day" id="sublabel_day"> Day </label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" name="q10_childsBirth[year]" id="input_10_year">
                <option>  </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_10_year" id="sublabel_year"> Year </label></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_87">
        <div class="form-label-left" id="label_87">
          <label for="input_87"> Upcoming Bar/Bat Mitzvah date (if applicable) </label>
          <label class="label-message" for="input_87">  </label>
        </div>
        <div id="cid_87" class="form-input">
          <div class="dir_ltr"><span class="form-sub-label-container"><select class="form-dropdown" name="q87_birthDate[month]" id="input_87_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_87_month" id="sublabel_month"> Month </label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q87_birthDate[day]" id="input_87_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_87_day" id="sublabel_day"> Day </label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q87_birthDate[year]" id="input_87_year">
                <option>  </option>
                <option value="2025"> 2025 </option>
                <option value="2024"> 2024 </option>
                <option value="2023"> 2023 </option>
                <option value="2022"> 2022 </option>
                <option value="2021"> 2021 </option>
                <option value="2020"> 2020 </option>
                <option value="2019"> 2019 </option>
              </select>
              <label class="form-sub-label" for="input_87_year" id="sublabel_year"> Year </label></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_80">
        <div class="form-label-left" id="label_80">
          <label for="input_80">
            School (Write NONE if it is not applicable)<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_80">  </label>
        </div>
        <div id="cid_80" class="form-input">
          <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_80" name="q80_school" size="30" value="" />
        </div>
      </li>
      <li class="form-line" id="id_83">
        <div class="form-label-left" id="label_83">
          <label for="input_83">
            High School Graduating Year<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_83">  </label>
        </div>
        <div id="cid_83" class="form-input">
          <input type="text" class=" form-textbox validate[required, Numeric]" data-type="input-textbox" id="input_83" name="q83_highSchool" size="20" value="" />
        </div>
      </li>
      <li class="form-line" id="id_28">
        <div class="form-label-left" id="label_28">
          <label for="input_28"> Synagogue Affiliation (if applicable) </label>
          <label class="label-message" for="input_28">  </label>
        </div>
        <div id="cid_28" class="form-input">
          <input type="text" class=" form-textbox" data-type="input-textbox" id="input_28" name="q28_synagogueAffiliation" size="30" value="" />
        </div>
      </li>
      <li id="cid_67" class="form-input-wide">
        <div class="form-header-group">
          <h1 id="header_67" class="form-header">
            Parent/Guardian Information
          </h1>
        </div>
      </li>
      <li class="form-line" id="id_15">
        <div class="form-label-left" id="label_15">
          <label for="input_15">
            Parent/Guardian 1 Full Name<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_15">  </label>
        </div>
        <div id="cid_15" class="form-input"><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q15_parentguardian1[first]" id="first_15" />
            <label class="form-sub-label" for="first_15" id="sublabel_first"> First Name </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q15_parentguardian1[last]" id="last_15" />
            <label class="form-sub-label" for="last_15" id="sublabel_last"> Last Name </label></span>
        </div>
      </li>
      <li class="form-line" id="id_30">
        <div class="form-label-left" id="label_30">
          <label for="input_30">
            Parent/Guardian 1 Gender<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_30">  </label>
        </div>
        <div id="cid_30" class="form-input">
          <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_30" name="q30_parentguardian130" size="30" value="" />
        </div>
      </li>
      <li class="form-line" id="id_16">
        <div class="form-label-left" id="label_16">
          <label for="input_16">
            Parent/Guardian 1 E-mail<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_16">  </label>
        </div>
        <div id="cid_16" class="form-input">
          <input type="email" class=" form-textbox validate[required]" id="input_16" name="q16_parentguardian116" size="30" value="" />
        </div>
      </li>
      <li class="form-line" id="id_17">
        <div class="form-label-left" id="label_17">
          <label for="input_17">
            Parent/Guardian 1 Cell Phone Number<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"><input class="form-textbox validate[required, Numeric]" type="tel" name="q17_parentguardian117[area]" id="input_17_area" size="3" />
              <label class="form-sub-label" for="input_17_area" id="sublabel_area"> Area Code </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q17_parentguardian117[phone]" id="input_17_phone" size="8" />
              <label class="form-sub-label" for="input_17_phone" id="sublabel_phone"> Phone Number </label></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_24">
        <div class="form-label-left" id="label_24">
          <label for="input_24"> Parent/Guardian 1 Home Phone Number (Complete IF DIFFERENT than child's home phone number) </label>
          <label class="label-message" for="input_24">  </label>
        </div>
        <div id="cid_24" class="form-input">
          <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox" type="tel" name="q24_parentguardian124[area]" id="input_24_area" size="3" />
              <label class="form-sub-label" for="input_24_area" id="sublabel_area"> Area Code </label></span><span class="form-sub-label-container"><input class="form-textbox" type="tel" name="q24_parentguardian124[phone]" id="input_24_phone" size="8" />
              <label class="form-sub-label" for="input_24_phone" id="sublabel_phone"> Phone Number </label></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_78">
        <div class="form-label-left" id="label_78">
          <label for="input_78"> Best way to contact Parent/Guardian 1 </label>
          <label class="label-message" for="input_78">  </label>
        </div>
        <div id="cid_78" class="form-input">
          <select class="form-dropdown" style="width:150px" id="input_78" name="q78_bestWay78">
            <option value="">  </option>
            <option value="Phone Call"> Phone Call </option>
            <option value="Text Message"> Text Message </option>
            <option value="Email"> Email </option>
          </select>
        </div>
      </li>
      <li class="form-line" id="id_84">
        <div class="form-label-left" id="label_84">
          <label for="input_84">
            Is Parent/Guardian 1 Address Different than child's address?<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_84">  </label>
        </div>
        <div id="cid_84" class="form-input">
          <select class="form-dropdown validate[required]" style="width:150px" id="input_84" name="q84_isParentguardian84">
            <option value="">  </option>
            <option value="YES, has different address than child"> YES, has different address than child </option>
            <option value="NO, has same address as child"> NO, has same address as child </option>
          </select>
        </div>
      </li>
      <li class="form-line" id="id_23">
        <div class="form-label-left" id="label_23">
          <label for="input_23"> Parent/Guardian 1 Address </label>
          <label class="label-message" for="input_23">  </label>
        </div>
        <div id="cid_23" class="form-input">
          <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0">
            <tbody><tr>
              <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line" type="text" name="q23_parentguardian123[addr_line1]" id="input_23_addr_line1" size="46" />
                  <label class="form-sub-label" for="input_23_addr_line1" id="sublabel_23_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="q23_parentguardian123[addr_line2]" id="input_23_addr_line2" size="46" />
                  <label class="form-sub-label" for="input_23_addr_line2" id="sublabel_23_addr_line2"> Street Address Line 2 </label></span>
              </td>
            </tr>
            <tr>
              <td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q23_parentguardian123[city]" id="input_23_city" size="21" />
                  <label class="form-sub-label" for="input_23_city" id="sublabel_23_city"> City </label></span>
              </td>
              <td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q23_parentguardian123[state]" id="input_23_state" size="22" />
                  <label class="form-sub-label" for="input_23_state" id="sublabel_23_state"> State / Province </label></span>
              </td>
            </tr>
            <tr>
              <td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q23_parentguardian123[postal]" id="input_23_postal" size="10" />
                  <label class="form-sub-label" for="input_23_postal" id="sublabel_23_postal"> Postal / Zip Code </label></span>
              </td>
              <td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q23_parentguardian123[country]" id="input_23_country">
                    <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_23_country" id="sublabel_23_country"> Country </label></span>
              </td>
            </tr>
          </tbody></table>
        </div>
      </li>
      <li class="form-line" id="id_18">
        <div class="form-label-left" id="label_18">
          <label for="input_18"> Parent/Guardian 2 Full Name </label>
          <label class="label-message" for="input_18">  </label>
        </div>
        <div id="cid_18" class="form-input"><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q18_parentguardian2[first]" id="first_18" />
            <label class="form-sub-label" for="first_18" id="sublabel_first"> First Name </label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q18_parentguardian2[last]" id="last_18" />
            <label class="form-sub-label" for="last_18" id="sublabel_last"> Last Name </label></span>
        </div>
      </li>
      <li class="form-line" id="id_29">
        <div class="form-label-left" id="label_29">
          <label for="input_29"> Parent/Guardian 2 Gender </label>
          <label class="label-message" for="input_29">  </label>
        </div>
        <div id="cid_29" class="form-input">
          <input type="text" class=" form-textbox" data-type="input-textbox" id="input_29" name="q29_parentguardian229" size="30" value="" />
        </div>
      </li>
      <li class="form-line" id="id_19">
        <div class="form-label-left" id="label_19">
          <label for="input_19"> Parent/Guardian 2 E-mail </label>
          <label class="label-message" for="input_19">  </label>
        </div>
        <div id="cid_19" class="form-input">
          <input type="email" class=" form-textbox" id="input_19" name="q19_parentguardian219" size="30" value="" />
        </div>
      </li>
      <li class="form-line" id="id_20">
        <div class="form-label-left" id="label_20">
          <label for="input_20"> Parent/Guardian 2 Cell Phone Number </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 class="form-textbox validate[Numeric]" type="tel" name="q20_parentguardian220[area]" id="input_20_area" size="3" />
              <label class="form-sub-label" for="input_20_area" id="sublabel_area"> Area Code </label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q20_parentguardian220[phone]" id="input_20_phone" size="8" />
              <label class="form-sub-label" for="input_20_phone" id="sublabel_phone"> Phone Number </label></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_26">
        <div class="form-label-left" id="label_26">
          <label for="input_26"> Parent/Guardian 2 Home Phone Number (Complete IF DIFFERENT than child's home phone number.) </label>
          <label class="label-message" for="input_26">  </label>
        </div>
        <div id="cid_26" class="form-input">
          <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox" type="tel" name="q26_parentguardian226[area]" id="input_26_area" size="3" />
              <label class="form-sub-label" for="input_26_area" id="sublabel_area"> Area Code </label></span><span class="form-sub-label-container"><input class="form-textbox" type="tel" name="q26_parentguardian226[phone]" id="input_26_phone" size="8" />
              <label class="form-sub-label" for="input_26_phone" id="sublabel_phone"> Phone Number </label></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_79">
        <div class="form-label-left" id="label_79">
          <label for="input_79"> Best way to contact Parent/Guardian 2 </label>
          <label class="label-message" for="input_79">  </label>
        </div>
        <div id="cid_79" class="form-input">
          <select class="form-dropdown" style="width:150px" id="input_79" name="q79_bestWay79">
            <option value="">  </option>
            <option value="Phone Call"> Phone Call </option>
            <option value="Text Message"> Text Message </option>
            <option value="Email"> Email </option>
          </select>
        </div>
      </li>
      <li class="form-line" id="id_85">
        <div class="form-label-left" id="label_85">
          <label for="input_85"> Is Parent/Guardian 2 Address DIFFERENT than child's address? </label>
          <label class="label-message" for="input_85">  </label>
        </div>
        <div id="cid_85" class="form-input">
          <select class="form-dropdown" style="width:150px" id="input_85" name="q85_isParentguardian85">
            <option value="">  </option>
            <option value="YES, has different address than child"> YES, has different address than child </option>
            <option value="NO, has same address as child"> NO, has same address as child </option>
          </select>
        </div>
      </li>
      <li class="form-line" id="id_25">
        <div class="form-label-left" id="label_25">
          <label for="input_25"> Parent/Guardian 2 Address </label>
          <label class="label-message" for="input_25">  </label>
        </div>
        <div id="cid_25" class="form-input">
          <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0">
            <tbody><tr>
              <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line" type="text" name="q25_parentguardian225[addr_line1]" id="input_25_addr_line1" size="46" />
                  <label class="form-sub-label" for="input_25_addr_line1" id="sublabel_25_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="q25_parentguardian225[addr_line2]" id="input_25_addr_line2" size="46" />
                  <label class="form-sub-label" for="input_25_addr_line2" id="sublabel_25_addr_line2"> Street Address Line 2 </label></span>
              </td>
            </tr>
            <tr>
              <td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q25_parentguardian225[city]" id="input_25_city" size="21" />
                  <label class="form-sub-label" for="input_25_city" id="sublabel_25_city"> City </label></span>
              </td>
              <td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q25_parentguardian225[state]" id="input_25_state" size="22" />
                  <label class="form-sub-label" for="input_25_state" id="sublabel_25_state"> State / Province </label></span>
              </td>
            </tr>
            <tr>
              <td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q25_parentguardian225[postal]" id="input_25_postal" size="10" />
                  <label class="form-sub-label" for="input_25_postal" id="sublabel_25_postal"> Postal / Zip Code </label></span>
              </td>
              <td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q25_parentguardian225[country]" id="input_25_country">
                    <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_25_country" id="sublabel_25_country"> Country </label></span>
              </td>
            </tr>
          </tbody></table>
        </div>
      </li>
      <li class="form-line" id="id_31">
        <div class="form-label-left" id="label_31">
          <label for="input_31">
            Marital Status of Parent/Guardian(s):<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_maritalStatus" size="30" value="" />
        </div>
      </li>
      <li id="cid_68" class="form-input-wide">
        <div class="form-header-group">
          <h1 id="header_68" class="form-header">
            Reference Information
          </h1>
          <div id="subHeader_68" class="form-subHeader">
            We will contact references as background check for your child( We recommend teachers, coaches, employers)
          </div>
        </div>
      </li>
      <li class="form-line" id="id_60">
        <div class="form-label-left" id="label_60">
          <label for="input_60">
            Reference Full Name (Reference can NOT be a Parent or FC Staff Member)<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_60">  </label>
        </div>
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              </label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxselection="7" id="input_34_5" name="q34_whichPrograms[]" value="Inclusive Birthright Israel trip (over 18)" />
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              </label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[maxSelection]" data-maxselection="10" id="input_64_1" name="q64_howDid[]" value="Internet" />
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              </label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[maxSelection]" data-maxselection="10" id="input_64_2" name="q64_howDid[]" value="Synagogue" />
              <label id="label_input_64_2" for="input_64_2"><span>Synagogue</span>
              </label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[maxSelection]" data-maxselection="10" id="input_64_3" name="q64_howDid[]" value="School" />
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              </label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[maxSelection]" data-maxselection="10" id="input_64_4" name="q64_howDid[]" value="Health Care Professional" />
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              </label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[maxSelection]" data-maxselection="10" id="input_64_5" name="q64_howDid[]" value="Other" />
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          <label for="input_86"> If you selected "Friend" above, please share the name of your friend. </label>
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            Service Agreement
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            <p>
              I(Parent/Guardian) hereby give permission to the staff of The Friendship Circle to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible.
            </p>
            <p>
              I(Parent/Guardian) hereby release The Friendship Circle, its providers and administrators, from all Liability for any incident which affects the health, welfare, or safety of (Child)   in the provision of such service. 
            </p>
            <p>
              I(Parent/Guardian) permit Friendship Circle to use my contact information for phone, text and email communications. Msg &amp; data rates apply - please contact Friendship Circle staff to be removed from messaging lists
            </p>
            <p>
              I(Parent/Guardian) permit my child's photograph and video to be used for publicity purposes - please contact Friendship Circle staff to be removed from publicity lists
            </p>
            <p>
              I(Parent/Guardian) permit my child's name to be printed on select Friendship Circle materials - please contact Friendship Circle staff to be removed from print lists
            </p>
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            Parent/Guardian Signature<span class="form-required">*</span>
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					<div class="block-title">Philly Friendship Circle</div>
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						The Friendship Circle Philadelphia Region South - A registered 501c3 organization serving Philadelphia, Montgomery, Chester and Delaware Counties.     754 South 9th Street Philadelphia, PA 19147  Founded by Chabad- Lubavich			
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							<li><a href="#">Families</a></li>
							<li><a href="#">Volunteers</a></li>
							<li><a href="#">Schools</a></li>
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			Copyright © 2026 Friendship Circle
			


	<div class="footer3"><b>The Friendship Circle Philadelphia Region South - A registered 501c3 organization serving Philadelphia, Montgomery, Chester and Delaware Counties.     754 South 9th Street Philadelphia, PA 19147  Founded by Chabad- Lubavich</b></div>
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