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<form class="userform-form" action="" method="post" name="form_6001440" id="6001440" accept-charset="utf-8"><input type="hidden" name="formID" value="6001440" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li class="form-line" id="id_3"><div id="cid_3" class="form-input-wide"> <div id="text_3" class="form-html"><p style="text-align: center;"><span style="font-size:16px;">We are excited for a new year at Chabad Hebrew School of Vernon Hills.  </span></p>

<p style="text-align: center;"><span style="font-size:16px;">This form is for returning students.</span></p>

<p style="text-align: center;"><span style="font-size:16px;">A separate <a href="/article.asp?AID=3707044" target="_blank">New Student Registration Form</a> must be filled out for any siblings joining for the first time.</span></p>

<p style="text-align: center;"><span style="font-size:16px;">We look forward to another wonderful year of learning and growth with your family!</span></p>
</div> </div></li><li id="cid_73" class="form-input-wide"> <div class="form-header-group"><h2 id="header_73" class="form-header">Parent Information</h2></div> </li><li class="form-line" id="id_71"><div class="form-label-top" id="label_71"><label for="input_71"> Father's Name:<span class="form-required">*</span> </label><label class="label-message" for="input_71"> </label></div><div id="cid_71" class="form-input-wide"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q71_fullName71[first]" id="first_71" autocomplete="given-name" />  <label class="form-sub-label" for="first_71" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q71_fullName71[last]" id="last_71" autocomplete="family-name" />  <label class="form-sub-label" for="last_71" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_72"><div class="form-label-top" id="label_72"><label for="input_72"> Father’s Email:<span class="form-required">*</span> </label><label class="label-message" for="input_72"> </label></div><div id="cid_72" class="form-input-wide"> <input type="email" class=" form-textbox validate[required, Email]" id="input_72" name="q72_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_74"><div class="form-label-top" id="label_74"><label for="input_74"> Father’s cell:<span class="form-required">*</span> </label><label class="label-message" for="input_74"> </label></div><div id="cid_74" class="form-input-wide"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q74_phoneNumber[full]" id="input_74_full" autocomplete="tel" />  <label class="form-sub-label" for="input_74_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_75"><div class="form-label-top" id="label_75"><label for="input_75"> Mother's Name:<span class="form-required">*</span> </label><label class="label-message" for="input_75"> </label></div><div id="cid_75" class="form-input-wide"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q75_fullName75[first]" id="first_75" autocomplete="given-name" />  <label class="form-sub-label" for="first_75" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q75_fullName75[last]" id="last_75" autocomplete="family-name" />  <label class="form-sub-label" for="last_75" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_76"><div class="form-label-top" id="label_76"><label for="input_76"> Mother's Email:<span class="form-required">*</span> </label><label class="label-message" for="input_76"> </label></div><div id="cid_76" class="form-input-wide"> <input type="email" class=" form-textbox validate[required, Email]" id="input_76" name="q76_email76" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_77"><div class="form-label-top" id="label_77"><label for="input_77"> Mother's Cell:<span class="form-required">*</span> </label><label class="label-message" for="input_77"> </label></div><div id="cid_77" class="form-input-wide"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q77_phoneNumber77[full]" id="input_77_full" autocomplete="tel" />  <label class="form-sub-label" for="input_77_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_43"><div class="form-label-top" id="label_43"><label for="input_43"> How many children are you registering as returning students?<span class="form-required">*</span> </label><label class="label-message" for="input_43"> </label></div><div id="cid_43" class="form-input-wide"> <input type="number" class="form-number-input  form-textbox validate[required]" id="input_43" name="q43_number" style="width:68px" size="6" value="1" data-type="input-number" autocomplete="nope" min="1" data-numbermin="1" max="3" data-numbermax="3" /> </div></li><li id="cid_4" class="form-input-wide"> <div class="form-header-group"><h2 id="header_4" class="form-header">Student Information - Child 1</h2></div> </li><li class="form-line" id="id_1"><div class="form-label-top" id="label_1"><label for="input_1"> Full Name:<span class="form-required">*</span> </label><label class="label-message" for="input_1"> </label></div><div id="cid_1" class="form-input-wide"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q1_fullName[first]" id="first_1" autocomplete="given-name" />  <label class="form-sub-label" for="first_1" 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for="input_89"> </label></div><div id="cid_89" class="form-input-wide"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q89_birthDate89[month]" id="input_89_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_89_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q89_birthDate89[day]" id="input_89_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_89_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q89_birthDate89[year]" id="input_89_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_89_year" id="sublabel_year">Year</label></span></div> </div></li><li 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class="form-input-wide"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_107" name="q107_input107" size="20" value="" /> </div></li><li class="form-line" id="id_45"><div class="form-label-top" id="label_45"><label for="input_45"> Does this student have any allergies?<span class="form-required">*</span> </label><label class="label-message" for="input_45"> </label></div><div id="cid_45" class="form-input-wide"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_45_0" name="q45_input45" value="Yes" /><label id="label_input_45_0" for="input_45_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_45_1" name="q45_input45" value="No" /><label id="label_input_45_1" for="input_45_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_51"><div class="form-label-top" id="label_51"><label for="input_51"> If yes, please list them:<span class="form-required">*</span> </label><label class="label-message" for="input_51"> </label></div><div id="cid_51" class="form-input-wide"> <textarea id="input_51" class="form-textarea validate[required]" name="q51_input51" cols="40" rows="2"></textarea> </div></li><li class="form-line" id="id_50"><div class="form-label-top" id="label_50"><label for="input_50"> Does this student have an IEP?<span class="form-required">*</span> </label><label class="label-message" for="input_50"> </label></div><div id="cid_50" class="form-input-wide"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_50_0" name="q50_input50" value="Yes" /><label id="label_input_50_0" for="input_50_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_50_1" name="q50_input50" value="No" /><label id="label_input_50_1" for="input_50_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_46"><div class="form-label-top" id="label_46"><label for="input_46"> If yes, please explain:<span class="form-required">*</span> </label><label class="label-message" for="input_46"> </label></div><div id="cid_46" class="form-input-wide"> <textarea id="input_46" class="form-textarea validate[required]" name="q46_input46" cols="40" rows="2"></textarea> </div></li><li id="cid_47" class="form-input-wide"> <div class="form-header-group"><h2 id="header_47" class="form-header">Child 2</h2></div> </li><li class="form-line" id="id_48"><div class="form-label-top" id="label_48"><label for="input_48"> Full Name:<span class="form-required">*</span> </label><label class="label-message" for="input_48"> </label></div><div id="cid_48" class="form-input-wide"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q48_fullName48[first]" id="first_48" autocomplete="given-name" />  <label class="form-sub-label" for="first_48" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q48_fullName48[last]" id="last_48" autocomplete="family-name" />  <label class="form-sub-label" for="last_48" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_88"><div class="form-label-top" id="label_88"><label for="input_88"> Current Age:<span class="form-required">*</span> </label><label class="label-message" for="input_88"> </label></div><div id="cid_88" class="form-input-wide"> <input type="number" class="form-number-input  form-textbox validate[required]" id="input_88" name="q88_number88" 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_87"><div class="form-label-top" id="label_87"><label for="input_87"> Date of birth:<span class="form-required">*</span> </label><label class="label-message" for="input_87"> </label></div><div id="cid_87" class="form-input-wide"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q87_birthDate[month]" id="input_87_month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_87_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q87_birthDate[day]" id="input_87_day"><option></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select>  <label class="form-sub-label" for="input_87_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q87_birthDate[year]" id="input_87_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_87_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_49"><div class="form-label-top" id="label_49"><label for="input_49"> Grade Entering:<span class="form-required">*</span> </label><label class="label-message" for="input_49"> </label></div><div id="cid_49" class="form-input-wide"> <select class="form-dropdown validate[required]" style="width:150px" id="input_49" name="q49_input49"><option value=""></option><option value="Kindergarten">Kindergarten</option><option value="First">First</option><option value="Second">Second</option><option value="Third">Third</option><option value="Fourth">Fourth</option><option value="Fifth">Fifth</option><option value="Sixth">Sixth</option><option value="Seventh">Seventh</option><option value="Eighth">Eighth</option></select> </div></li><li class="form-line" id="id_108"><div class="form-label-top" id="label_108"><label for="input_108"> School Currently Attending:<span class="form-required">*</span> </label><label class="label-message" for="input_108"> </label></div><div id="cid_108" class="form-input-wide"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_108" name="q108_input108" size="20" value="" /> </div></li><li class="form-line" id="id_52"><div class="form-label-top" id="label_52"><label for="input_52"> Does this student have any allergies?<span class="form-required">*</span> </label><label class="label-message" for="input_52"> </label></div><div id="cid_52" class="form-input-wide"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_52_0" name="q52_input52" value="Yes" /><label id="label_input_52_0" for="input_52_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_52_1" name="q52_input52" value="No" /><label id="label_input_52_1" for="input_52_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_53"><div class="form-label-top" id="label_53"><label for="input_53"> If yes, please list them:<span class="form-required">*</span> </label><label class="label-message" for="input_53"> </label></div><div id="cid_53" class="form-input-wide"> <textarea id="input_53" class="form-textarea validate[required]" name="q53_input53" cols="40" rows="2"></textarea> </div></li><li class="form-line" id="id_54"><div class="form-label-top" id="label_54"><label for="input_54"> Does this student have an IEP?<span class="form-required">*</span> </label><label class="label-message" for="input_54"> </label></div><div id="cid_54" class="form-input-wide"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_54_0" name="q54_input54" value="Yes" /><label id="label_input_54_0" for="input_54_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_54_1" name="q54_input54" value="No" /><label id="label_input_54_1" for="input_54_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_55"><div class="form-label-top" id="label_55"><label for="input_55"> If yes, please explain:<span class="form-required">*</span> </label><label class="label-message" for="input_55"> </label></div><div id="cid_55" class="form-input-wide"> <textarea id="input_55" class="form-textarea validate[required]" name="q55_input55" cols="40" rows="2"></textarea> </div></li><li id="cid_56" class="form-input-wide"> <div class="form-header-group"><h2 id="header_56" class="form-header">Child 3</h2></div> </li><li class="form-line" id="id_57"><div class="form-label-top" id="label_57"><label for="input_57"> Full Name:<span class="form-required">*</span> </label><label class="label-message" for="input_57"> </label></div><div id="cid_57" class="form-input-wide"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q57_fullName57[first]" id="first_57" autocomplete="given-name" />  <label class="form-sub-label" for="first_57" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q57_fullName57[last]" id="last_57" autocomplete="family-name" />  <label class="form-sub-label" for="last_57" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_90"><div class="form-label-top" id="label_90"><label for="input_90"> Current Age:<span class="form-required">*</span> </label><label class="label-message" for="input_90"> </label></div><div id="cid_90" class="form-input-wide"> <input type="number" class="form-number-input  form-textbox validate[required]" id="input_90" name="q90_number90" 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_91"><div class="form-label-top" id="label_91"><label for="input_91"> Date of birth:<span class="form-required">*</span> </label><label class="label-message" for="input_91"> </label></div><div id="cid_91" class="form-input-wide"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q91_birthDate91[month]" id="input_91_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_91_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q91_birthDate91[day]" id="input_91_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_91_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q91_birthDate91[year]" id="input_91_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_91_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_58"><div class="form-label-top" id="label_58"><label for="input_58"> Grade Entering:<span class="form-required">*</span> </label><label class="label-message" for="input_58"> </label></div><div id="cid_58" class="form-input-wide"> <select class="form-dropdown validate[required]" style="width:150px" id="input_58" name="q58_input58"><option value=""></option><option value="Kindergarten">Kindergarten</option><option value="First">First</option><option value="Second">Second</option><option value="Third">Third</option><option value="Fourth">Fourth</option><option value="Fifth">Fifth</option><option value="Sixth">Sixth</option><option value="Seventh">Seventh</option><option value="Eighth">Eighth</option></select> </div></li><li class="form-line" id="id_109"><div class="form-label-top" id="label_109"><label for="input_109"> School Currently Attending:<span class="form-required">*</span> </label><label class="label-message" for="input_109"> </label></div><div id="cid_109" class="form-input-wide"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_109" name="q109_input109" size="20" value="" /> </div></li><li class="form-line" id="id_59"><div class="form-label-top" id="label_59"><label for="input_59"> Does this student have any allergies?<span class="form-required">*</span> </label><label class="label-message" for="input_59"> </label></div><div id="cid_59" class="form-input-wide"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_59_0" name="q59_input59" value="Yes" /><label id="label_input_59_0" for="input_59_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_59_1" name="q59_input59" value="No" /><label id="label_input_59_1" for="input_59_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_60"><div class="form-label-top" id="label_60"><label for="input_60"> If yes, please list them:<span class="form-required">*</span> </label><label class="label-message" for="input_60"> </label></div><div id="cid_60" class="form-input-wide"> <textarea id="input_60" class="form-textarea validate[required]" name="q60_input60" cols="40" rows="2"></textarea> </div></li><li class="form-line" id="id_61"><div class="form-label-top" id="label_61"><label for="input_61"> Does this student have an IEP?<span class="form-required">*</span> </label><label class="label-message" for="input_61"> </label></div><div id="cid_61" class="form-input-wide"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_61_0" name="q61_input61" value="Yes" /><label id="label_input_61_0" for="input_61_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_61_1" name="q61_input61" value="No" /><label id="label_input_61_1" for="input_61_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_62"><div class="form-label-top" id="label_62"><label for="input_62"> If yes, please explain:<span class="form-required">*</span> </label><label class="label-message" for="input_62"> </label></div><div id="cid_62" class="form-input-wide"> <textarea id="input_62" class="form-textarea validate[required]" name="q62_input62" cols="40" rows="2"></textarea> </div></li><li class="form-line" id="id_78"><div class="form-label-top" id="label_78"><label for="input_78"> What school does your child attend?<span class="form-required">*</span> </label><label class="label-message" for="input_78"> </label></div><div id="cid_78" class="form-input-wide"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_78" name="q78_input78" size="20" value="" /> </div></li><li class="form-line" id="id_79"><div class="form-label-top" id="label_79"><label for="input_79"> What are your child’s special interests, likes or dislikes?<span class="form-required">*</span> </label><label class="label-message" for="input_79"> </label></div><div id="cid_79" class="form-input-wide"> <textarea id="input_79" class="form-textarea validate[required]" name="q79_input79" cols="40" rows="6"></textarea> </div></li><li id="cid_63" class="form-input-wide"> <div class="form-header-group"><h2 id="header_63" class="form-header">Other Information</h2></div> </li><li class="form-line" id="id_35"><div class="form-label-top" id="label_35"><label for="input_35"> As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of the Chabad Hebrew School to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, the Chabad Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in the Chabad Hebrew School activities and that these pictures may be used for marketing purposes.<span class="form-required">*</span> </label><label class="label-message" for="input_35"> </label></div><div id="cid_35" class="form-input-wide"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_35_0" name="q35_input35" value="I accept" /><label id="label_input_35_0" for="input_35_0"><span>I accept</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_36"><div class="form-label-top" id="label_36"><label for="input_36"> Name and Initials:<span class="form-required">*</span> </label><label class="label-message" for="input_36"> </label></div><div id="cid_36" class="form-input-wide"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q36_fullName36[first]" id="first_36" autocomplete="given-name" />  <label class="form-sub-label" for="first_36" id="sublabel_first">Name:</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q36_fullName36[last]" id="last_36" autocomplete="family-name" />  <label class="form-sub-label" for="last_36" id="sublabel_last">Initials:</label></span> </div></li><li id="cid_64" class="form-input-wide"> <div class="form-header-group"><h2 id="header_64" class="form-header">Payment Information</h2></div> </li><li class="form-line" id="id_37"><div id="cid_37" class="form-input-wide"> <div id="text_37" class="form-html"><p><span style="font-size:16px;"><strong>Sundays, 10:00 AM – 12:00PM - September 2025 through May 2026</strong></span></p>

<p><span style="font-size:16px;">Open for all children,  Ages 5-13</span><br />
<span style="font-size:12px;"><em><strong>Includes: Books, Supplies and Snack Fee</strong></em></span></p>

<hr />
<p><span style="font-size:16px;"><strong>Tuition Tiers</strong></span></p>

<p><span style="font-size:16px;">Our goal is to provide every child with a warm, engaging Hebrew School experience. To help meet increasing operating costs, tuition has been adjusted this year. We invite families who are able, to consider selecting the Supporter Tuition option to help support our program. Thank you for being a valued part of our Hebrew School family.</span></p>

<p><span style="font-size:16px;"><em><strong>❗NOTE: All billing for Hebrew School will begin in October</strong></em></span></p>

<p><span style="font-size:16px;">⌛<em><strong> $100 off Early Bird Discount until August 1</strong></em></span><br />
<em>       The discount will be automatically deducted and reflected in your total below.</em></p>

<p><span style="font-size:16px;">🏷️<strong><em> $50 off Sibling Discount<br />
 </em></strong></span><span style="font-size:14px;"><em>     </em></span><span style="font-size:12px;"><em>The discount will be automatically deducted and reflected in your total below.</em></span></p>
</div> </div></li><li class="form-line" id="id_93"><div class="form-label-top" id="label_93"><label for="input_93"> Tuition Tiers </label><label class="label-message" for="input_93"> </label></div><div id="cid_93" class="form-input-wide"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_93_0" name="q93_input93" value="$1,600 - Supporter Tuition" /><label id="label_input_93_0" for="input_93_0"><span>$1,600 - Supporter Tuition</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_93_1" name="q93_input93" value="$1,395 - Standard Tuition" /><label id="label_input_93_1" for="input_93_1"><span>$1,395 - Standard Tuition</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_95"><div class="form-label-top" id="label_95"><label for="input_95"> Supporter Payment Options:<span class="form-required">*</span> </label><label class="label-message" for="input_95"> All billing for Hebrew School tuition will begin in October.</label></div><div id="cid_95" class="form-input-wide"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_95_0" name="q95_input95" value="Entire payment in full with a check, cash or credit card" /><label id="label_input_95_0" for="input_95_0"><span>Entire payment in full with a check, cash or credit card</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_95_1" name="q95_input95" value="I would like to pay 50% billed in October, and 50% by January 1, 2026 credit card (please include your card information below)" /><label id="label_input_95_1" for="input_95_1"><span>I would like to pay 50% billed in October, and 50% by January 1, 2026 credit card (please include your card information below)</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_95_2" name="q95_input95" value="I would like to pay my tuition over a 5 month school period (please include your card information below)" /><label id="label_input_95_2" for="input_95_2"><span>I would like to pay my tuition over a 5 month school period (please include your card information below)</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_104"><div class="form-label-top" id="label_104"><label for="input_104"> Standard Payment Options:<span class="form-required">*</span> </label><label class="label-message" for="input_104"> All billing for Hebrew School tuition will begin in October.</label></div><div id="cid_104" class="form-input-wide"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_104_0" name="q104_input104" value="Entire payment in full with a check, cash or credit card" /><label id="label_input_104_0" for="input_104_0"><span>Entire payment in full with a check, cash or credit card</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_104_1" name="q104_input104" value="I would like to pay 50% billed in October, and 50% by January 1, 2026 credit card (please include your card information below)" /><label id="label_input_104_1" for="input_104_1"><span>I would like to pay 50% billed in October, and 50% by January 1, 2026 credit card (please include your card information below)</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_104_2" name="q104_input104" value="I would like to pay my tuition over a 5 month school period (please include your card information below)" /><label id="label_input_104_2" for="input_104_2"><span>I would like to pay my tuition over a 5 month school period (please include your card information below)</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_98"><div class="form-label-top" id="label_98"><label for="input_98"> Child 2 Tuition Tiers </label><label class="label-message" for="input_98"> $50 off - Sibling Discount</label></div><div id="cid_98" class="form-input-wide"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_98_0" name="q98_input98" value="$1,600 - Supporter Tuition" /><label id="label_input_98_0" for="input_98_0"><span>$1,600 - Supporter Tuition</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_98_1" name="q98_input98" value="$1,395 - Standard Tuition" /><label id="label_input_98_1" for="input_98_1"><span>$1,395 - Standard Tuition</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_100"><div class="form-label-top" id="label_100"><label for="input_100"> Child 2 Supporter Payment Options:<span class="form-required">*</span> </label><label class="label-message" for="input_100"> All billing for Hebrew School tuition will begin in October.</label></div><div id="cid_100" class="form-input-wide"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_100_0" name="q100_input100" value="Entire payment in full with a check, cash or credit card" /><label id="label_input_100_0" for="input_100_0"><span>Entire payment in full with a check, cash or credit card</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_100_1" name="q100_input100" value="I would like to pay 50% billed in October, and 50% by January 1, 2026 credit card (please include your card information below)" /><label id="label_input_100_1" for="input_100_1"><span>I would like to pay 50% billed in October, and 50% by January 1, 2026 credit card (please include your card information below)</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_100_2" name="q100_input100" value="I would like to pay my tuition over a 5 month school period (please include your card information below)" /><label id="label_input_100_2" for="input_100_2"><span>I would like to pay my tuition over a 5 month school period (please include your card information below)</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_105"><div class="form-label-top" id="label_105"><label for="input_105"> Child 2 Standard Payment Options:<span class="form-required">*</span> </label><label class="label-message" for="input_105"> All billing for Hebrew School tuition will begin in October.</label></div><div id="cid_105" class="form-input-wide"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_105_0" name="q105_input105" value="Entire payment in full with a check, cash or credit card" /><label id="label_input_105_0" for="input_105_0"><span>Entire payment in full with a check, cash or credit card</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_105_1" name="q105_input105" value="I would like to pay 50% billed in October, and 50% by January 1, 2026 credit card (please include your card information below)" /><label id="label_input_105_1" for="input_105_1"><span>I would like to pay 50% billed in October, and 50% by January 1, 2026 credit card (please include your card information below)</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_105_2" name="q105_input105" value="I would like to pay my tuition over a 5 month school period (please include your card information below)" /><label id="label_input_105_2" for="input_105_2"><span>I would like to pay my tuition over a 5 month school period (please include your card information below)</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_99"><div class="form-label-top" id="label_99"><label for="input_99"> Child 3 Tuition Tier </label><label class="label-message" for="input_99"> $50 off - Sibling Discount</label></div><div id="cid_99" class="form-input-wide"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_99_0" name="q99_input99" value="$1,600 - Supporter Tuition" /><label id="label_input_99_0" for="input_99_0"><span>$1,600 - Supporter Tuition</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_99_1" name="q99_input99" value="$1.395 - Standard Tuition" /><label id="label_input_99_1" for="input_99_1"><span>$1.395 - Standard Tuition</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_101"><div class="form-label-top" id="label_101"><label for="input_101"> Child 3 Supporter Payment Options:<span class="form-required">*</span> </label><label class="label-message" for="input_101"> All billing for Hebrew School tuition will begin in October.</label></div><div id="cid_101" class="form-input-wide"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_101_0" name="q101_input101" value="Entire payment in full with a check, cash or credit card" /><label id="label_input_101_0" for="input_101_0"><span>Entire payment in full with a check, cash or credit card</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_101_1" name="q101_input101" value="I would like to pay 50% billed in October, and 50% by January 1, 2026 credit card (please include your card information below)" /><label id="label_input_101_1" for="input_101_1"><span>I would like to pay 50% billed in October, and 50% by January 1, 2026 credit card (please include your card information below)</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_101_2" name="q101_input101" value="I would like to pay my tuition over a 5 month school period (please include your card information below)" /><label id="label_input_101_2" for="input_101_2"><span>I would like to pay my tuition over a 5 month school period (please include your card information below)</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_106"><div class="form-label-top" id="label_106"><label for="input_106"> Child 3 Standard Payment Options:<span class="form-required">*</span> </label><label class="label-message" for="input_106"> All billing for Hebrew School tuition will begin in October.</label></div><div id="cid_106" class="form-input-wide"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_106_0" name="q106_input106" value="Entire payment in full with a check, cash or credit card" /><label id="label_input_106_0" for="input_106_0"><span>Entire payment in full with a check, cash or credit card</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_106_1" name="q106_input106" value="I would like to pay 50% billed in October, and 50% by January 1, 2026 credit card (please include your card information below)" /><label id="label_input_106_1" for="input_106_1"><span>I would like to pay 50% billed in October, and 50% by January 1, 2026 credit card (please include your card information below)</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_106_2" name="q106_input106" value="I would like to pay my tuition over a 5 month school period (please include your card information below)" /><label id="label_input_106_2" for="input_106_2"><span>I would like to pay my tuition over a 5 month school period (please include your card information below)</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_102" class="form-input-wide"> <div class="form-header-group"><h2 id="header_102" class="form-header">Optional Sponsorship</h2></div> </li><li class="form-line" id="id_83"><div class="form-label-top" id="label_83"><label for="input_83"> Please consider sponsoring a Jewish holiday program at Chabad Hebrew School to bring the Jewish holidays to life for our students. </label><label class="label-message" for="input_83"> </label></div><div id="cid_83" class="form-input-wide"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_83_0" name="q83_input83" value="Rosh Hashana Fun Day" /><label id="label_input_83_0" for="input_83_0"><span>Rosh Hashana Fun Day</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_83_1" name="q83_input83" value="Sukkot Experience" /><label id="label_input_83_1" for="input_83_1"><span>Sukkot Experience</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_83_2" name="q83_input83" value="Chanukah Celebration" /><label id="label_input_83_2" for="input_83_2"><span>Chanukah Celebration</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_83_3" name="q83_input83" value="Purim Festivities" /><label id="label_input_83_3" for="input_83_3"><span>Purim Festivities</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_83_4" name="q83_input83" value="Passover Experience" /><label id="label_input_83_4" for="input_83_4"><span>Passover Experience</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_83_5" name="q83_input83" value="Shavuot Sundaes" /><label id="label_input_83_5" for="input_83_5"><span>Shavuot Sundaes</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_84"><div class="form-label-top" id="label_84"><label for="input_84"> Amount Sponsored:   </label><label class="label-message" for="input_84"> The sponsorship will be added to the total cost of tuition. We appreciate your support</label></div><div id="cid_84" class="form-input-wide"> <div class="form-single-column"><span class="form-radio-item simple-mode"><label id="label_input_84" for="input_84"><span>$</span></label><input type="number" class="form-textbox" id="input_84" name="q84_input84" value="" onkeypress="validateNumber(event)" /></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_68"><div class="form-label-top" id="label_68"><label for="input_68"> Optional: I'm aware that there are students on scholarship. I'd like to contribute this additional amount towards the tuition of a fellow student in need. </label><label class="label-message" for="input_68"> </label></div><div id="cid_68" class="form-input-wide"> <div class="form-single-column"><span class="form-radio-item simple-mode"><label id="label_input_68" for="input_68"><span>$</span></label><input type="number" class="form-textbox" id="input_68" name="q68_input68" value="" onkeypress="validateNumber(event)" /></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_69"><div class="form-label-top" id="label_69"><label for="input_69"> Total: </label></div><div id="cid_69" class="form-input-wide"> <div id="total_amount">$0.00 </div> </div></li><li class="form-line" id="id_38"><div class="form-label-top" id="label_38"><label for="input_38"> Payment:<span class="form-required">*</span> </label><label class="label-message" for="input_38"> </label></div><div id="cid_38" class="form-input-wide"> <div class="form-error form-error--internal">⚠ You have not yet connected a credit card processor.</div><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_38_creditCard" name="q38_payment[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_38_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_38_other" name="q38_payment[payment_method]" value="other" onclick="BuildSource.other(this)" /><label for="input_38_other">Check, Cash, etc</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="q38_payment[cc_type]" id="input_38_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="q38_payment[cc_number]" id="input_38_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_38_cc_number" id="sublabel_cc_number">Credit Card Number</label></span></div></td><td class="cc_ccv hide"><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q38_payment[cc_ccv]" id="input_38_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_38_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="q38_payment[cc_nameOnCard]" id="input_38_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_38_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="q38_payment[cc_exp_month]" id="input_38_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_38_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="q38_payment[cc_exp_year]" id="input_38_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" 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