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	Register Now - Young Israel - Chabad of Pinellas County
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<img src="https://w2.chabad.org/media/images/1096/uzON10964998.jpg" alt="Welcome!" />
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<a href="/5474775" style="text-decoration: none;">
Camp Gan Israel</a></div>
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&#160;</div>
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Summer 2026</div>
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<form class="userform-form" action="" method="post" name="form_7340866" id="7340866" accept-charset="utf-8"><input type="hidden" name="formID" value="7340866" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li class="form-line" id="id_64"><div id="cid_64" class="form-input-wide"> <div id="text_64" class="form-html"><p>Camp Gan Israel is a camp dedicated to enriching the lives of children from diverse Jewish backgrounds and affiliations through a stimulating camping experience.  CGI is part of the largest and fastest growing network of day camps, enjoying a reputation as a pioneer in Jewish camping, with innovative ideas and creative activities, to both provide enjoyment and inspire children to try new and exciting things!</p></div> </div></li><li class="form-line" id="id_77"><div id="cid_77" class="form-input-wide"> <div id="text_77" class="form-html"><h3><span style="font-size:18px;"><strong>Camp Rates &amp; Fees</strong></span></h3>

<p><span style="font-size:18px;"><strong>Registration Fee:</strong> $50 (Non-refundable)<br />
<em>This reserves your child's spot, and it goes toward summer camp tuition.</em><br />
All camp tuition will be charged by the first day of camp</span></p>

<p><span style="font-size:18px;"><strong>Camp Tuition (Includes 2 lunches per week):</strong></span></p>

<ul>
        <li><span style="font-size:18px;"><strong>Rate:</strong> $240 per week | $680 for the full summer</span></li>
        <li><span style="font-size:18px;"><strong>Sibling Discount:</strong> 5% off tuition for the additional children</span></li>
</ul>

<p><br />
<span style="font-size:18px;"><strong>Extended Care Options:</strong></span></p>

<ul>
        <li><span style="font-size:18px;"><strong>Pre-Care (8:30 AM - 9:00 AM):</strong> $25 per week</span></li>
</ul>

<p><br />
<span style="font-size:18px;"><strong>Camp T-Shirt:</strong></span></p>

<ul>
        <li><span style="font-size:18px;">$12 for the first shirt | $10 for each additional shirt</span></li>
</ul>

<p><span style="font-size:18px;"><strong>Tuition Assistance</strong>: Financial assistance may be available to your family. Please submit <a href="/article.asp?AID=6819051">THIS APPLICATION </a>to discuss how we can help make camp affordable for you. Your inquiry will be kept confidential. </span></p>
</div> </div></li><li class="form-line" id="id_23"><div class="form-label-left" id="label_23"><label for="input_23"> Parent Filling the Form<span class="form-required">*</span> </label><label class="label-message" for="input_23"> </label></div><div id="cid_23" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q23_mothersInfo[first]" id="first_23" autocomplete="given-name" />  <label class="form-sub-label" for="first_23" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q23_mothersInfo[last]" id="last_23" autocomplete="family-name" />  <label class="form-sub-label" for="last_23" id="sublabel_last">Last Name</label></span> </div></li><li id="cid_9" class="form-input-wide"> <div class="form-header-group"><h2 id="header_9" class="form-header">1. Child/ren’s Information</h2></div> </li><li class="form-line" id="id_98"><div class="form-label-left" id="label_98"><label for="input_98"> Number of Children Attending<span class="form-required">*</span> </label><label class="label-message" for="input_98"> </label></div><div id="cid_98" class="form-input"> <input type="number" class="form-number-input  form-textbox validate[required]" id="input_98" name="q98_number" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="1" data-numbermin="1" max="4" data-numbermax="4" /> </div></li><li class="form-line" id="id_3"><div class="form-label-left" id="label_3"><label for="input_3"> Child 1<span class="form-required">*</span> </label><label class="label-message" for="input_3"> </label></div><div id="cid_3" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q3_child1[first]" id="first_3" autocomplete="given-name" />  <label class="form-sub-label" for="first_3" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q3_child1[middle]" id="middle_3" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_3" id="sublabel_middle">Middle Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q3_child1[last]" id="last_3" autocomplete="family-name" />  <label class="form-sub-label" for="last_3" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_27"><div class="form-label-left" id="label_27"><label for="input_27"> Birth Date<span class="form-required">*</span> </label><label class="label-message" for="input_27"> </label></div><div id="cid_27" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q27_birthDate27[month]" id="input_27_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_27_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q27_birthDate27[day]" id="input_27_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_27_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q27_birthDate27[year]" id="input_27_year"><option></option><option value="2026">2026</option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option><option value="1941">1941</option><option value="1940">1940</option><option value="1939">1939</option><option value="1938">1938</option><option value="1937">1937</option><option value="1936">1936</option><option value="1935">1935</option><option value="1934">1934</option><option value="1933">1933</option><option value="1932">1932</option><option value="1931">1931</option><option value="1930">1930</option><option value="1929">1929</option><option value="1928">1928</option><option value="1927">1927</option><option value="1926">1926</option><option value="1925">1925</option><option value="1924">1924</option><option value="1923">1923</option><option value="1922">1922</option><option value="1921">1921</option><option value="1920">1920</option></select>  <label class="form-sub-label" for="input_27_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_86"><div class="form-label-left" id="label_86"><label for="input_86"> Grade your child just finished:<span class="form-required">*</span> </label><label class="label-message" for="input_86"> </label></div><div id="cid_86" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_86" name="q86_input86" size="20" value="" /> </div></li><li class="form-line" id="id_19"><div class="form-label-left" id="label_19"><label for="input_19"> Gender<span class="form-required">*</span> </label><label class="label-message" for="input_19"> </label></div><div id="cid_19" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_19_0" name="q19_gender" value="Male" /><label id="label_input_19_0" for="input_19_0"><span>Male</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_19_1" name="q19_gender" value="Female" /><label id="label_input_19_1" for="input_19_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_91"><div class="form-label-left" id="label_91"><label for="input_91"> T-Shirt Size<span class="form-required">*</span> </label><label class="label-message" for="input_91"> First camp shirt is $12 per child, please specify if an additional shirt is needed </label></div><div id="cid_91" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_91" name="q91_input91"><option value=""></option><option value="Youth Small (6-8)">Youth Small (6-8)</option><option value="Youth Medium (8-10)">Youth Medium (8-10)</option><option value="Youth Large (10-12)">Youth Large (10-12)</option><option value="Youth Extra large (12-14)">Youth Extra large (12-14)</option></select> </div></li><li class="form-line" id="id_107"><div class="form-label-left" id="label_107"><label for="input_107"> Number of Additional Shirts (optional) </label><label class="label-message" for="input_107"> $10/Shirt</label></div><div id="cid_107" class="form-input"> <input type="number" class="form-number-input  form-textbox" id="input_107" name="q107_number107" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" /> </div></li><li class="form-line" id="id_15"><div class="form-label-left" id="label_15"><label for="input_15"> Child 2 </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" type="text" size="10" name="q15_child2[first]" id="first_15" autocomplete="given-name" />  <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" type="text" size="10" name="q15_child2[middle]" id="middle_15" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_15" id="sublabel_middle">Middle Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q15_child2[last]" id="last_15" autocomplete="family-name" />  <label class="form-sub-label" for="last_15" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_28"><div class="form-label-left" id="label_28"><label for="input_28"> Birth Date </label><label class="label-message" for="input_28"> </label></div><div id="cid_28" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q28_birthDate28[month]" id="input_28_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_28_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q28_birthDate28[day]" id="input_28_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_28_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q28_birthDate28[year]" id="input_28_year"><option></option><option value="2026">2026</option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option><option value="1941">1941</option><option value="1940">1940</option><option value="1939">1939</option><option value="1938">1938</option><option value="1937">1937</option><option value="1936">1936</option><option value="1935">1935</option><option value="1934">1934</option><option value="1933">1933</option><option value="1932">1932</option><option value="1931">1931</option><option value="1930">1930</option><option value="1929">1929</option><option value="1928">1928</option><option value="1927">1927</option><option value="1926">1926</option><option value="1925">1925</option><option value="1924">1924</option><option value="1923">1923</option><option value="1922">1922</option><option value="1921">1921</option><option value="1920">1920</option></select>  <label class="form-sub-label" for="input_28_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"> Grade your child just finished: </label><label class="label-message" for="input_87"> </label></div><div id="cid_87" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_87" name="q87_input87" size="20" value="" /> </div></li><li class="form-line" id="id_20"><div class="form-label-left" id="label_20"><label for="input_20"> Gender </label><label class="label-message" for="input_20"> </label></div><div id="cid_20" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_20_0" name="q20_gender20" value="Male" /><label id="label_input_20_0" for="input_20_0"><span>Male</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_20_1" name="q20_gender20" value="Female" /><label id="label_input_20_1" for="input_20_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_109"><div class="form-label-left" id="label_109"><label for="input_109"> T-Shirt Size </label><label class="label-message" for="input_109"> First camp shirt is $12 per child, please specify if an additional shirt is needed </label></div><div id="cid_109" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_109" name="q109_input109"><option value=""></option><option value="Youth Small (6-8)">Youth Small (6-8)</option><option value="Youth Medium (8-10)">Youth Medium (8-10)</option><option value="Youth Large (10-12)">Youth Large (10-12)</option><option value="Youth Extra large (12-14)">Youth Extra large (12-14)</option></select> </div></li><li class="form-line" id="id_104"><div class="form-label-left" id="label_104"><label for="input_104"> Number of Additional Shirts </label><label class="label-message" for="input_104"> $10/Shirt</label></div><div id="cid_104" class="form-input"> <input type="number" class="form-number-input  form-textbox" id="input_104" name="q104_number104" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" /> </div></li><li class="form-line" id="id_14"><div class="form-label-left" id="label_14"><label for="input_14"> Child 3 </label><label class="label-message" for="input_14"> </label></div><div id="cid_14" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q14_child3[first]" id="first_14" autocomplete="given-name" />  <label class="form-sub-label" for="first_14" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q14_child3[middle]" id="middle_14" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_14" id="sublabel_middle">Middle Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q14_child3[last]" id="last_14" autocomplete="family-name" />  <label class="form-sub-label" for="last_14" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_29"><div class="form-label-left" id="label_29"><label for="input_29"> Birth Date </label><label class="label-message" for="input_29"> </label></div><div id="cid_29" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q29_birthDate29[month]" id="input_29_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_29_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q29_birthDate29[day]" id="input_29_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_29_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q29_birthDate29[year]" id="input_29_year"><option></option><option value="2026">2026</option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option><option value="1941">1941</option><option value="1940">1940</option><option value="1939">1939</option><option value="1938">1938</option><option value="1937">1937</option><option value="1936">1936</option><option value="1935">1935</option><option value="1934">1934</option><option value="1933">1933</option><option value="1932">1932</option><option value="1931">1931</option><option value="1930">1930</option><option value="1929">1929</option><option value="1928">1928</option><option value="1927">1927</option><option value="1926">1926</option><option value="1925">1925</option><option value="1924">1924</option><option value="1923">1923</option><option value="1922">1922</option><option value="1921">1921</option><option value="1920">1920</option></select>  <label class="form-sub-label" for="input_29_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_88"><div class="form-label-left" id="label_88"><label for="input_88"> Grade your child just finished: </label><label class="label-message" for="input_88"> </label></div><div id="cid_88" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_88" name="q88_input88" size="20" value="" /> </div></li><li class="form-line" id="id_22"><div class="form-label-left" id="label_22"><label for="input_22"> Gender </label><label class="label-message" for="input_22"> </label></div><div id="cid_22" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_22_0" name="q22_gender22" value="Male" /><label id="label_input_22_0" for="input_22_0"><span>Male</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_22_1" name="q22_gender22" value="Female" /><label id="label_input_22_1" for="input_22_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_110"><div class="form-label-left" id="label_110"><label for="input_110"> T-Shirt Size </label><label class="label-message" for="input_110"> First camp shirt is $12 per child, please specify if an additional shirt is needed </label></div><div id="cid_110" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_110" name="q110_input110"><option value=""></option><option value="Youth Small (6-8)">Youth Small (6-8)</option><option value="Youth Medium (8-10)">Youth Medium (8-10)</option><option value="Youth Large (10-12)">Youth Large (10-12)</option><option value="Youth Extra large (12-14)">Youth Extra large (12-14)</option></select> </div></li><li class="form-line" id="id_106"><div class="form-label-left" id="label_106"><label for="input_106"> Number of Additional Shirts </label><label class="label-message" for="input_106"> $10/Shirt</label></div><div id="cid_106" class="form-input"> <input type="number" class="form-number-input  form-textbox" id="input_106" name="q106_number106" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" /> </div></li><li class="form-line" id="id_16"><div class="form-label-left" id="label_16"><label for="input_16"> Child 4 </label><label class="label-message" for="input_16"> </label></div><div id="cid_16" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q16_child4[first]" id="first_16" autocomplete="given-name" />  <label class="form-sub-label" for="first_16" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q16_child4[middle]" id="middle_16" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_16" id="sublabel_middle">Middle Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q16_child4[last]" id="last_16" autocomplete="family-name" />  <label class="form-sub-label" for="last_16" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_30"><div class="form-label-left" id="label_30"><label for="input_30"> Birth Date </label><label class="label-message" for="input_30"> </label></div><div id="cid_30" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q30_birthDate30[month]" id="input_30_month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_30_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q30_birthDate30[day]" id="input_30_day"><option></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select>  <label class="form-sub-label" for="input_30_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q30_birthDate30[year]" id="input_30_year"><option></option><option value="2026">2026</option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option><option value="1941">1941</option><option value="1940">1940</option><option value="1939">1939</option><option value="1938">1938</option><option value="1937">1937</option><option value="1936">1936</option><option value="1935">1935</option><option value="1934">1934</option><option value="1933">1933</option><option value="1932">1932</option><option value="1931">1931</option><option value="1930">1930</option><option value="1929">1929</option><option value="1928">1928</option><option value="1927">1927</option><option value="1926">1926</option><option value="1925">1925</option><option value="1924">1924</option><option value="1923">1923</option><option value="1922">1922</option><option value="1921">1921</option><option value="1920">1920</option></select>  <label class="form-sub-label" for="input_30_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_89"><div class="form-label-left" id="label_89"><label for="input_89"> Grade your child just finished: </label><label class="label-message" for="input_89"> </label></div><div id="cid_89" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_89" name="q89_input89" size="20" value="" /> </div></li><li class="form-line" id="id_21"><div class="form-label-left" id="label_21"><label for="input_21"> Gender </label><label class="label-message" for="input_21"> </label></div><div id="cid_21" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_21_0" name="q21_gender21" value="Male" /><label id="label_input_21_0" for="input_21_0"><span>Male</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_21_1" name="q21_gender21" value="Female" /><label id="label_input_21_1" for="input_21_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_111"><div class="form-label-left" id="label_111"><label for="input_111"> T-Shirt Size </label><label class="label-message" for="input_111"> First camp shirt is $12 per child, please specify if an additional shirt is needed </label></div><div id="cid_111" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_111" name="q111_input111"><option value=""></option><option value="Youth Small (6-8)">Youth Small (6-8)</option><option value="Youth Medium (8-10)">Youth Medium (8-10)</option><option value="Youth Large (10-12)">Youth Large (10-12)</option><option value="Youth Extra large (12-14)">Youth Extra large (12-14)</option></select> </div></li><li class="form-line" id="id_105"><div class="form-label-left" id="label_105"><label for="input_105"> Number of Additional Shirts </label><label class="label-message" for="input_105"> $10/Shirt</label></div><div id="cid_105" class="form-input"> <input type="number" class="form-number-input  form-textbox" id="input_105" name="q105_number105" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" /> </div></li><li class="form-line" id="id_60"><div id="cid_60" class="form-input-wide"> <div id="text_60" class="form-html"><p>If you have additional children please contact us.</p></div> </div></li><li class="form-line" id="id_63"><div class="form-label-left" id="label_63"><label for="input_63"> Child 1 Sessions attending<span class="form-required">*</span> </label><label class="label-message" for="input_63"> 9 am to 3:30 pm</label></div><div id="cid_63" class="form-input"> <div class="form-multiple-column"><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox validate[required]" id="input_63_0" name="q63_sessions63[]" value="Week 1: June 8 - 12" /><label id="label_input_63_0" for="input_63_0"><span>Week 1: June 8 - 12</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox validate[required]" id="input_63_1" name="q63_sessions63[]" value="Week 2: June 15-19" /><label id="label_input_63_1" for="input_63_1"><span>Week 2: June 15-19</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox validate[required]" id="input_63_2" name="q63_sessions63[]" value="Week 3: June 22-26" /><label id="label_input_63_2" for="input_63_2"><span>Week 3: June 22-26</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_63_3" name="q63_sessions63[]" value="Full Session: June 8-26" /><label id="label_input_63_3" for="input_63_3"><span>Full Session: June 8-26</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_97"><div class="form-label-left" id="label_97"><label for="input_97"> Child 2 Sessions attending </label><label class="label-message" for="input_97"> 9 am to 3:30 pm</label></div><div id="cid_97" class="form-input"> <div class="form-multiple-column"><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_97_0" name="q97_sessions97[]" value="Week 1: June 8 - 12" /><label id="label_input_97_0" for="input_97_0"><span>Week 1: June 8 - 12</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_97_1" name="q97_sessions97[]" value="Week 2: June 15-19" /><label id="label_input_97_1" for="input_97_1"><span>Week 2: June 15-19</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_97_2" name="q97_sessions97[]" value="Week 3: June 22-26" /><label id="label_input_97_2" for="input_97_2"><span>Week 3: June 22-26</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_97_3" name="q97_sessions97[]" value="Full Session: June 8-26" /><label id="label_input_97_3" for="input_97_3"><span>Full Session: June 8-26</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_99"><div class="form-label-left" id="label_99"><label for="input_99"> Child 3 Sessions attending </label><label class="label-message" for="input_99"> 9 am to 3:30 pm</label></div><div id="cid_99" class="form-input"> <div class="form-multiple-column"><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_99_0" name="q99_sessions99[]" value="Week 1: June 8 - 12" /><label id="label_input_99_0" for="input_99_0"><span>Week 1: June 8 - 12</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_99_1" name="q99_sessions99[]" value="Week 2: June 15-19" /><label id="label_input_99_1" for="input_99_1"><span>Week 2: June 15-19</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_99_2" name="q99_sessions99[]" value="Week 3: June 22-26" /><label id="label_input_99_2" for="input_99_2"><span>Week 3: June 22-26</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_99_3" name="q99_sessions99[]" value="Full Session: June 8-26" /><label id="label_input_99_3" for="input_99_3"><span>Full Session: June 8-26</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_100"><div class="form-label-left" id="label_100"><label for="input_100"> Child 4 Sessions attending </label><label class="label-message" for="input_100"> 9 am to 3:30 pm</label></div><div id="cid_100" class="form-input"> <div class="form-multiple-column"><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_100_0" name="q100_sessions100[]" value="Week 1: June 8- 12" /><label id="label_input_100_0" for="input_100_0"><span>Week 1: June 8- 12</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_100_1" name="q100_sessions100[]" value="Week 2: June 15-19" /><label id="label_input_100_1" for="input_100_1"><span>Week 2: June 15-19</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_100_2" name="q100_sessions100[]" value="Week 3: June 22-26" /><label id="label_input_100_2" for="input_100_2"><span>Week 3: June 22-26</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_100_3" name="q100_sessions100[]" value="Full Session: June 8-26" /><label id="label_input_100_3" for="input_100_3"><span>Full Session: June 8-26</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_95"><div class="form-label-left" id="label_95"><label for="input_95"> Child 1 Early Care </label><label class="label-message" for="input_95"> 8:30-9 am to 3:30-5:00 pm</label></div><div id="cid_95" class="form-input"> <div class="form-multiple-column"><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_95_0" name="q95_sessions95[]" value="Full Session Early Care" /><label id="label_input_95_0" for="input_95_0"><span>Full Session Early Care</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_95_1" name="q95_sessions95[]" value="Week 1 Early Care" /><label id="label_input_95_1" for="input_95_1"><span>Week 1 Early Care</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_95_2" name="q95_sessions95[]" value="Week 2 Early Care" /><label id="label_input_95_2" for="input_95_2"><span>Week 2 Early Care</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_95_3" name="q95_sessions95[]" value="Week 1 After Care" /><label id="label_input_95_3" for="input_95_3"><span>Week 1 After Care</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_101"><div class="form-label-left" id="label_101"><label for="input_101"> Child 2 Early Care </label><label class="label-message" for="input_101"> 8:30-9 am to 3:30-5:00 pm</label></div><div id="cid_101" class="form-input"> <div class="form-multiple-column"><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_101_0" name="q101_sessions101[]" value="Full Session Early Care" /><label id="label_input_101_0" for="input_101_0"><span>Full Session Early Care</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_101_1" name="q101_sessions101[]" value="Week 1 Early Care" /><label id="label_input_101_1" for="input_101_1"><span>Week 1 Early Care</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_101_2" name="q101_sessions101[]" value="Week 2 Early Care" /><label id="label_input_101_2" for="input_101_2"><span>Week 2 Early Care</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_101_3" name="q101_sessions101[]" value="Week 3 Early Care" /><label id="label_input_101_3" for="input_101_3"><span>Week 3 Early Care</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_102"><div class="form-label-left" id="label_102"><label for="input_102"> Child 3 Early Care </label><label class="label-message" for="input_102"> 8:30-9 am to 3:30-5:00 pm</label></div><div id="cid_102" class="form-input"> <div class="form-multiple-column"><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_102_0" name="q102_sessions102[]" value="Full Session Early Care" /><label id="label_input_102_0" for="input_102_0"><span>Full Session Early Care</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_102_1" name="q102_sessions102[]" value="Week 1 Early Care" /><label id="label_input_102_1" for="input_102_1"><span>Week 1 Early Care</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_102_2" name="q102_sessions102[]" value="Week 2 Early Care" /><label id="label_input_102_2" for="input_102_2"><span>Week 2 Early Care</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_102_3" name="q102_sessions102[]" value="Week 3 Early Care" /><label id="label_input_102_3" for="input_102_3"><span>Week 3 Early Care</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_103"><div class="form-label-left" id="label_103"><label for="input_103"> Child 4 Early Care </label><label class="label-message" for="input_103"> 8:30-9 am to 3:30-5:00 pm</label></div><div id="cid_103" class="form-input"> <div class="form-multiple-column"><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_103_0" name="q103_sessions103[]" value="Full Session Early Care" /><label id="label_input_103_0" for="input_103_0"><span>Full Session Early Care</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_103_1" name="q103_sessions103[]" value="Week 1 Early Care" /><label id="label_input_103_1" for="input_103_1"><span>Week 1 Early Care</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_103_2" name="q103_sessions103[]" value="Week 2 Early Care" /><label id="label_input_103_2" for="input_103_2"><span>Week 2 Early Care</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_103_3" name="q103_sessions103[]" value="Week 3 Early Care" /><label id="label_input_103_3" for="input_103_3"><span>Week 3 Early Care</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_25" class="form-input-wide"> <div class="form-header-group"><h2 id="header_25" class="form-header">2. Parent information</h2></div> </li><li class="form-line" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> Home Phone<span class="form-required">*</span> </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 validate[required, Numeric]" type="tel" name="q26_phoneNumber26[area]" id="input_26_area" autocomplete="tel-area-code" maxlength="5" 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 validate[required, Numeric]" type="tel" name="q26_phoneNumber26[phone]" id="input_26_phone" autocomplete="tel-local" 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_24"><div class="form-label-left" id="label_24"><label for="input_24"> Address<span class="form-required">*</span> </label><label class="label-message" for="input_24"> </label></div><div id="cid_24" 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="q24_address24[addr_line1]" id="input_24_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_24_addr_line1" id="sublabel_24_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="q24_address24[addr_line2]" id="input_24_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_24_addr_line2" id="sublabel_24_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="q24_address24[city]" id="input_24_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_24_city" id="sublabel_24_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q24_address24[state]" id="input_24_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_24_state" id="sublabel_24_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="q24_address24[postal]" id="input_24_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_24_postal" id="sublabel_24_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q24_address24[country]" id="input_24_country" autocomplete="country-name"><option value="" selected="selected">Please Select</option><option value="United States">United States</option><option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="The Bahamas">The Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Brazil">Brazil</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burundi">Burundi</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cape Verde">Cape Verde</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="People's Republic of China">People's Republic of China</option><option value="Republic of China">Republic of China</option><option value="Christmas Island">Christmas Island</option><option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo">Congo</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Cote d'Ivoire">Cote d'Ivoire</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Eswatini">Eswatini</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Polynesia">French Polynesia</option><option value="Gabon">Gabon</option><option value="The Gambia">The Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jersey">Jersey</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="North Korea">North Korea</option><option value="South Korea">South Korea</option><option value="Kosovo">Kosovo</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Laos">Laos</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macau">Macau</option><option value="Macedonia">Macedonia</option><option value="Madagascar">Madagascar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Myanmar">Myanmar</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="Northern Mariana">Northern Mariana</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn Islands">Pitcairn Islands</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Barthelemy">Saint Barthelemy</option><option value="Saint Helena">Saint Helena</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="Somaliland">Somaliland</option><option value="South Africa">South Africa</option><option value="South Ossetia">South Ossetia</option><option value="Spain">Spain</option><option value="Sri Lanka">Sri Lanka</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Svalbard">Svalbard</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria">Syria</option><option value="Taiwan">Taiwan</option><option value="Tajikistan">Tajikistan</option><option value="Tanzania">Tanzania</option><option value="Thailand">Thailand</option><option value="Timor-Leste">Timor-Leste</option><option value="Togo">Togo</option><option value="Tokelau">Tokelau</option><option value="Tonga">Tonga</option><option value="Trinidad and Tobago">Trinidad and Tobago</option><option value="Tristan da Cunha">Tristan da Cunha</option><option value="Tunisia">Tunisia</option><option value="Turkey">Turkey</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks and Caicos Islands">Turks and Caicos Islands</option><option value="Tuvalu">Tuvalu</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="United Arab Emirates">United Arab Emirates</option><option value="United Kingdom">United Kingdom</option><option value="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Vatican City">Vatican City</option><option value="Venezuela">Venezuela</option><option value="Vietnam">Vietnam</option><option value="British Virgin Islands">British Virgin Islands</option><option value="US Virgin Islands">US Virgin Islands</option><option value="Wallis and Futuna">Wallis and Futuna</option><option value="Western Sahara">Western Sahara</option><option value="Yemen">Yemen</option><option value="Zambia">Zambia</option><option value="Zimbabwe">Zimbabwe</option><option value="other">Other</option></select>  <label class="form-sub-label" for="input_24_country" id="sublabel_24_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_36"><div class="form-label-left" id="label_36"><label for="input_36"> Cell Phone<span class="form-required">*</span> </label><label class="label-message" for="input_36"> </label></div><div id="cid_36" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q36_cellPhone36[area]" id="input_36_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_36_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q36_cellPhone36[phone]" id="input_36_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_36_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_33"><div class="form-label-left" id="label_33"><label for="input_33"> Work Phone </label><label class="label-message" for="input_33"> </label></div><div id="cid_33" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q33_workPhone[area]" id="input_33_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_33_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q33_workPhone[phone]" id="input_33_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_33_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_4"><div class="form-label-left" id="label_4"><label for="input_4"> E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_4"> Primary email</label></div><div id="cid_4" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_4" name="q4_email4" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_32"><div class="form-label-left" id="label_32"><label for="input_32"> Other Parent </label><label class="label-message" for="input_32"> </label></div><div id="cid_32" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q32_fathersInfo[first]" id="first_32" autocomplete="given-name" />  <label class="form-sub-label" for="first_32" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q32_fathersInfo[last]" id="last_32" autocomplete="family-name" />  <label class="form-sub-label" for="last_32" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_34"><div class="form-label-left" id="label_34"><label for="input_34"> Work Phone </label><label class="label-message" for="input_34"> </label></div><div id="cid_34" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q34_workPhone34[area]" id="input_34_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_34_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q34_workPhone34[phone]" id="input_34_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_34_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_35"><div class="form-label-left" id="label_35"><label for="input_35"> E-mail </label><label class="label-message" for="input_35"> </label></div><div id="cid_35" class="form-input"> <input type="email" class=" form-textbox validate[Email]" id="input_35" name="q35_email35" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_31"><div class="form-label-left" id="label_31"><label for="input_31"> Cell Phone </label><label class="label-message" for="input_31"> </label></div><div id="cid_31" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q31_cellPhone[area]" id="input_31_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_31_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q31_cellPhone[phone]" id="input_31_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_31_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_45"><div class="form-label-left" id="label_45"><label for="input_45"> How did you hear of Camp Gan Israel? </label><label class="label-message" for="input_45"> </label></div><div id="cid_45" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_45" name="q45_howDid"><option value=""></option><option value="Mailer">Mailer</option><option value="Email">Email</option><option value="Facebook">Facebook</option><option value="Newspaper Ad">Newspaper Ad</option><option value="Internet Search">Internet Search</option><option value="Attended Previously">Attended Previously</option><option value="Other">Other</option></select> </div></li><li class="form-line" id="id_108"><div class="form-label-left" id="label_108"><label for="input_108"> Explain Please </label><label class="label-message" for="input_108"> </label></div><div id="cid_108" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_108" name="q108_input108" size="20" value="" /> </div></li><li id="cid_37" class="form-input-wide"> <div class="form-header-group"><h2 id="header_37" class="form-header">3. Emergency Information</h2></div> </li><li class="form-line" id="id_38"><div class="form-label-left" id="label_38"><label for="input_38"> Emergency Contact (if Parents cannot be reached<span class="form-required">*</span> </label><label class="label-message" for="input_38"> </label></div><div id="cid_38" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q38_emergencyContact[first]" id="first_38" autocomplete="given-name" />  <label class="form-sub-label" for="first_38" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q38_emergencyContact[last]" id="last_38" autocomplete="family-name" />  <label class="form-sub-label" for="last_38" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_39"><div class="form-label-left" id="label_39"><label for="input_39"> Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_39"> </label></div><div id="cid_39" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q39_phoneNumber39[area]" id="input_39_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_39_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q39_phoneNumber39[phone]" id="input_39_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_39_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_40"><div class="form-label-left" id="label_40"><label for="input_40"> Relationship<span class="form-required">*</span> </label><label class="label-message" for="input_40"> </label></div><div id="cid_40" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_40" name="q40_relationship" size="20" value="" /> </div></li><li class="form-line" id="id_41"><div class="form-label-left" id="label_41"><label for="input_41"> Pediatrician <span class="form-required">*</span> </label><label class="label-message" for="input_41"> </label></div><div id="cid_41" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q41_pediatricianamp[first]" id="first_41" autocomplete="given-name" />  <label class="form-sub-label" for="first_41" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q41_pediatricianamp[last]" id="last_41" autocomplete="family-name" />  <label class="form-sub-label" for="last_41" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_42"><div class="form-label-left" id="label_42"><label for="input_42"> Dr. Office Phone Number </label><label class="label-message" for="input_42"> </label></div><div id="cid_42" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q42_phoneNumber42[area]" id="input_42_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_42_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q42_phoneNumber42[phone]" id="input_42_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_42_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_84"><div class="form-label-left" id="label_84"><label for="input_84"> If this form is for multiple siblings and they have different Doctors, please specify over here. </label><label class="label-message" for="input_84"> </label></div><div id="cid_84" class="form-input"> <textarea id="input_84" class="form-textarea" name="q84_input84" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_67"><div class="form-label-left" id="label_67"><label for="input_67"> The child/ren may be picked up from camp by: </label><label class="label-message" for="input_67"> </label></div><div id="cid_67" class="form-input"> <span class="form-sub-label-container"><input type="text" class=" form-textbox" data-type="input-textbox" id="input_67" name="q67_input67" size="60" value="" />  <label class="form-sub-label" for="input_67">Names</label></span> </div></li><li class="form-line" id="id_83"><div class="form-label-left" id="label_83"><label for="input_83"> Does your child(ren) have any medical condition or allergies<span class="form-required">*</span> </label><label class="label-message" for="input_83"> </label></div><div id="cid_83" class="form-input"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_83_0" name="q83_input83" value="No" /><label id="label_input_83_0" for="input_83_0"><span>No</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_83_1" name="q83_input83" value="Yes" /><label id="label_input_83_1" for="input_83_1"><span>Yes</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_82"><div class="form-label-left" id="label_82"><label for="input_82"> Please note the name of the child and any allergies or medical conditions we would need to know about your child/ren </label><label class="label-message" for="input_82"> </label></div><div id="cid_82" class="form-input"> <textarea id="input_82" class="form-textarea" name="q82_input82" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_79"><div class="form-label-left" id="label_79"><label for="input_79"> Please feel free to add anything else which you consider important to your child's success: (Fears, naps, difficulties, passion etc) </label><label class="label-message" for="input_79"> </label></div><div id="cid_79" class="form-input"> <textarea id="input_79" class="form-textarea" name="q79_input79" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_51"><div class="form-label-left" id="label_51"><label for="input_51"> Permission for emergency medical treatment<span class="form-required">*</span> </label><label class="label-message" for="input_51"> </label></div><div id="cid_51" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_51_0" name="q51_agreement[]" value="In case of any medical emergency whereby parents or legal guardians cannot be reached, I hereby authorize Camp Gan Israel to take appropiate medical action. If at any time the above information must be changed, I will notify the camp." /><label id="label_input_51_0" for="input_51_0"><span>In case of any medical emergency whereby parents or legal guardians cannot be reached, I hereby authorize Camp Gan Israel to take appropiate medical action. If at any time the above information must be changed, I will notify the camp.</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line always-hidden" id="id_80"><div class="form-label-left" id="label_80"><label for="input_80"> Date and time this form was filled out </label><label class="label-message" for="input_80"> </label></div><div id="cid_80" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="month_80" name="q80_input80[month]" type="tel" size="2" maxlength="2" value="04" />  <label class="form-sub-label" for="month_80" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="day_80" name="q80_input80[day]" type="tel" size="2" maxlength="2" value="29" />  <label class="form-sub-label" for="day_80" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="year_80" name="q80_input80[year]" type="tel" size="4" maxlength="4" value="2026" />  <label class="form-sub-label" for="year_80" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_80_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_80_pick"><span> </span></label></span></div><span class="dir_ltr inline_block time-fields" style="white-space: nowrap;"><span class="form-sub-label-container"><span id="at_80" class="form-control-static at-label">at</span>  <label class="form-sub-label" for="at_80"><span> </span></label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" id="hour_80" name="q80_input80[hour]"><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 selected="selected" value="12">12</option></select>  <label class="form-sub-label" for="hour_80" id="sublabel_hour">Hour</label></span><span class="form-sub-label-container"><select class="form-dropdown" id="min_80" name="q80_input80[min]"><option></option><option value="00">00</option><option value="01">01</option><option value="02">02</option><option value="03">03</option><option value="04">04</option><option value="05">05</option><option value="06">06</option><option value="07">07</option><option value="08">08</option><option value="09">09</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 selected="selected" 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><option value="32">32</option><option value="33">33</option><option value="34">34</option><option value="35">35</option><option value="36">36</option><option value="37">37</option><option value="38">38</option><option value="39">39</option><option value="40">40</option><option value="41">41</option><option value="42">42</option><option value="43">43</option><option value="44">44</option><option value="45">45</option><option value="46">46</option><option value="47">47</option><option value="48">48</option><option value="49">49</option><option value="50">50</option><option value="51">51</option><option value="52">52</option><option value="53">53</option><option value="54">54</option><option value="55">55</option><option value="56">56</option><option value="57">57</option><option value="58">58</option><option value="59">59</option></select>  <label class="form-sub-label" for="min_80" id="sublabel_minutes">Minutes</label></span><span class="form-sub-label-container"><select class="form-dropdown" id="ampm_80" name="q80_input80[ampm]"><option value="AM">AM</option><option selected="selected" value="PM">PM</option></select>  <label class="form-sub-label" for="ampm_80"><span> </span></label></span></span></div> </div></li><li id="cid_52" class="form-input-wide"> <div class="form-header-group"><h2 id="header_52" class="form-header">4. Payment Information</h2></div> </li><li class="form-line" id="id_113"><div class="form-label-left" id="label_113"><label for="input_113"> Optional Security Donation to Help Cover Security for your children's Safety </label><label class="label-message" for="input_113"> </label></div><div id="cid_113" class="form-input"> <div class="form-multiple-column" data-columns="3"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_113_0" name="q113_input113" value="50" /><label for="input_113_0"><span>$50</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_113_1" name="q113_input113" value="75" /><label for="input_113_1"><span>$75</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_113_2" name="q113_input113" value="100" /><label for="input_113_2"><span>$100</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio-other form-radio" name="q113_input113" id="other_113" value="" /><span><input type="number" min="1" class="form-radio-other-input form-textbox" onkeypress="validateNumber(event)" name="q113_input113[other]" data-otherhint="Other" size="15" id="input_113" disabled="disabled" /></span><br /></span></div> </div></li><li class="form-line" id="id_112"><div id="cid_112" class="form-input-wide"> <div id="text_112" class="form-html"><p>Registration is $50 per child. You must adjust your minimum payment amount to reflect the number of children you are registering to hold their spot &amp; receive the early bird discount. (IE: 2 children, $100)</p>
</div> </div></li><li class="form-line" id="id_96"><div class="form-label-left" id="label_96"><label for="input_96"> Total (You can choose to pay the full tuition today, or $50 Registration PER CHILD) </label></div><div id="cid_96" class="form-input"> <div id="total_amount">$0.00 </div><br /><div class="clearfix form-single-column top_padding" id="payformWrapper"><label class="form-header form-label-left">I would like to pay today:</label><span class="form-radio-item"><label><input type="radio" class="form-radio validate[partialPayment]" value="full" name="partial" checked="checked" id="input_partial_1" />Full amount</label></span><span class="form-radio-item"><input type="radio" class="form-radio validate[partialPayment]" value="minimum" name="partial" id="input_partial_2" /><label for="input_partial_2"><span>$<span id="payformMin">50.00</span>  minimum</span></label></span><span class="form-radio-item"><label><input type="radio" class="form-other form-radio validate[partialPayment]" value="custom" name="partial" id="other_partial" />$<input type="text" onclick="document.getElementById('other_partial').checked = true" class="form-radio-other-input validate[customPartial]" id="input_partial" name="partialamount" data-otherhint="Other" onkeypress="validateNumber(event)" /> </label></span></div> </div></li><li class="form-line" id="id_49"><div class="form-label-left" id="label_49"><label for="input_49"> Payment<span class="form-required">*</span> </label><label class="label-message" for="input_49"> If Paying just registration today, we will contact you to set up the rest of tuition payments.</label></div><div id="cid_49" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2" class="form-payment-methods form-multiple-column"><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_49_creditCard" name="q49_payment49[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_49_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_49_paypal" name="q49_payment49[payment_method]" value="paypal" onclick="BuildSource.paypal(this)" /><label for="input_49_paypal">Paypal</label> </span></td></tr><tr class="credit_card hide"><th colspan="2">Credit Card</th></tr><tr class="credit_card hide"><td colspan="2" style="padding:0"><table cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container">  <label class="form-sub-label">We accept Visa, MasterCard, American Express, Discover</label></span><div class="cc-icons"><div class="cc-icon visa-icon"></div><div class="cc-icon mastercard-icon"></div><div class="cc-icon amex-icon"></div><div class="cc-icon discover-icon"></div></div><input type="hidden" name="q49_payment49[cc_type]" id="input_49_cc_type" value="" /></td></tr><tr><td><div class="cc-field-wrapper"><span class="form-sub-label-container"><input class="form-textbox form-creditcard js-cc-number validate[required, visible, creditcard]" type="text" name="q49_payment49[cc_number]" id="input_49_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_49_cc_number" id="sublabel_cc_number">Credit Card Number</label></span></div></td><td class="cc_ccv "><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q49_payment49[cc_ccv]" id="input_49_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_49_cc_ccv" id="sublabel_cc_ccv">Security Code</label></span></td></tr><tr><td colspan="2" class="cc_name_on_card "><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q49_payment49[cc_nameOnCard]" id="input_49_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_49_cc_nameOnCard" id="sublabel_cc_nameOnCard">Name on Card</label></span></td></tr><tr class="credit_card hide"><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q49_payment49[cc_exp_month]" id="input_49_cc_exp_month" autocomplete="cc-exp-month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_49_cc_exp_month" id="sublabel_cc_exp_month">Expiration Month</label></span></td><td><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q49_payment49[cc_exp_year]" id="input_49_cc_exp_year" autocomplete="cc-exp-year"><option></option><option value="2026">2026</option><option value="2027">2027</option><option value="2028">2028</option><option value="2029">2029</option><option value="2030">2030</option><option value="2031">2031</option><option value="2032">2032</option><option value="2033">2033</option><option value="2034">2034</option><option value="2035">2035</option></select>  <label class="form-sub-label" for="input_49_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="paypal hide"><td colspan="2">Paypal has been selected. Payment will take place on the next page.</td></tr></tbody></table> </div></li><li class="form-line" id="id_66"><div class="form-label-left" id="label_66"><label for="input_66"> General comments </label><label class="label-message" for="input_66"> </label></div><div id="cid_66" class="form-input"> <textarea id="input_66" class="form-textarea" name="q66_generalComments66" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_78"><div class="form-label-left" id="label_78"><label for="input_78"> Agreement:<span class="form-required">*</span> </label><label class="label-message" for="input_78"> </label></div><div id="cid_78" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_78_0" name="q78_agreement78[]" value="I hereby permit my child(ren) to be transported with camp transportation and to obtain medical emergency care as the situation mandates. I allow Camp Gan Israel to use my child(ren)'s photographs and videos for promotional purposes. I understand that my deposit is non refundable and that refunds will not be made for incomplete attendance. The parent signing this registration form acknowledges that he/she has the full authority to so and is responsible for all camp fees. I further release and agree to indemnify and hold harmless Camp Gan Israel and its officers, counselors or assigns from any liability concerning our child’s involvement in CGI and further agree that the use of any premises during the CGI camp day is made at the risk of the registrant" /><label id="label_input_78_0" for="input_78_0"><span>I hereby permit my child(ren) to be transported with camp transportation and to obtain medical emergency care as the situation mandates. I allow Camp Gan Israel to use my child(ren)'s photographs and videos for promotional purposes. I understand that my deposit is non refundable and that refunds will not be made for incomplete attendance. The parent signing this registration form acknowledges that he/she has the full authority to so and is responsible for all camp fees. I further release and agree to indemnify and hold harmless Camp Gan Israel and its officers, counselors or assigns from any liability concerning our child’s involvement in CGI and further agree that the use of any premises during the CGI camp day is made at the risk of the registrant</span></label></span><span class="clearfix"></span></div> </div></li><li style="display:none">Should be Empty: <input type="text" name="website" value="" /></li><li class="form-line" id="id_114"><div id="cid_114" class="form-input-wide"><div style="text-align:center" class="form-buttons-wrapper"><button id="input_114" type="submit" class="form-submit-button form-submit-button-none;">Submit</button></div></div></li></ul></div><input type="hidden" id="simple_spc" name="simple_spc" value="7340866" /><script type="text/javascript">document.getElementById("si"+"mple"+"_spc").value = "7340866-7340866";</script><div>


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