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	Mini Gan Izzy (3 & 4 years old) - Registration PART 1 - .................................................................................................................... - Camp Gan Izzy - Jewish Day Camp - Bucks County - Newtown
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ul.orange li {
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#co_body_container #cco_body {
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#co_body_container img {
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/* Search */

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input#topAreaTopSearch_search:-moz-input-placeholder {
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			<h1 class="article-header__title js-article-title js-page-title">Mini Gan Izzy (3 & 4 years old) registration part 1</h1>
		
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","21_description":"","21_readonly":"No","21_name":"input21","21_qid":21,"21_type":"control_textbox","21_order":23,"44_text":"\u003cp\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"color:#ff0000;\"\u003e\u003cstrong\u003ePLEASE READ\u003c/strong\u003e\u003c/span\u003e\u003cbr\u003e\n\u003cbr\u003e\n\u003cstrong\u003eWith to current rise of costs, in order to make camp more affordable for families,\u0026nbsp;Gan Izzy Day Camp will\u0026nbsp;offer\u0026nbsp; two pricing tiers.\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\n\u003cp\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cstrong\u003ePlease choose from the\u0026nbsp;pricing options below\u003c/strong\u003e. Your choice is completely optional.\u003cbr\u003e\n\u003cbr\u003e\n\u003cspan style=\"color:#ff0000;\"\u003e\u003cb\u003eRATE A\u003c/b\u003e\u003c/span\u003e-\u0026nbsp;\u003cstrong\u003eThis rate most accurately accounts for the costs of camp\u003c/strong\u003e. This\u0026nbsp;includes\u0026nbsp;staffing, facility rentals, swimming, programming, camp administration, insurance, utilities, etc.\u003cbr\u003e\n\u003cbr\u003e\nChoosing this tier gives you an opportunity to help us do more each day. You help us stretch our limited scholarship funds further so more children can experience the power of camp.\u0026nbsp;\u003cstrong\u003e\u0026nbsp;If you are able to pay this amount, please do so. Thank you!\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\n\u003cp\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"color:#ff0000;\"\u003e\u003cstrong\u003eRATE B\u003c/strong\u003e\u003c/span\u003e\u0026nbsp;-\u0026nbsp;\u003cstrong\u003eOur SUBSIDIZED rate.\u0026nbsp;\u003c/strong\u003eThis reduced rate is made possible through the funding dollars we receive from individual donors who value the impact that the summer camp experience at Gan Izzy has on children, youth, individuals and families. 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width:182px; padding:0in 7px 0in 7px; height:30px; border-top:none; border-right:1px solid black; border-left:9px double black\" valign=\"top\"\u003e\n\t\t\t\u003cp align=\"center\" style=\"text-align:center\"\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"line-height:normal\"\u003e\u003cb\u003e\u003cspan style=\"color:#004070\"\u003eOptions\u003c/span\u003e\u003c/b\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\t\t\t\u003c/td\u003e\n\t\t\t\u003ctd style=\"border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:30px; border-top:none; border-right:1px solid black; border-left:none\" valign=\"top\"\u003e\n\t\t\t\u003cp align=\"center\" style=\"text-align:center\"\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"line-height:normal\"\u003e\u003cb\u003e\u003cspan style=\"color:#004070\"\u003eRate A\u003c/span\u003e\u003c/b\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\t\t\t\u003c/td\u003e\n\t\t\t\u003ctd style=\"border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:30px; border-top:none; border-right:9px double black; border-left:none\" valign=\"top\"\u003e\n\t\t\t\u003cp align=\"center\" style=\"text-align:center\"\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"line-height:normal\"\u003e\u003cb\u003e\u003cspan style=\"color:#004070\"\u003eRate B\u003c/span\u003e\u003c/b\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\t\t\t\u003c/td\u003e\n\t\t\u003c/tr\u003e\n\t\t\u003ctr\u003e\n\t\t\t\u003ctd style=\"border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:32px; border-top:none; border-right:1px solid black; border-left:9px double black\" valign=\"top\"\u003e\n\t\t\t\u003cp align=\"center\" style=\"text-align:center\"\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"line-height:normal\"\u003e\u003cb\u003e\u003cspan style=\"color:#004070\"\u003eAll Sessions\u003c/span\u003e\u003c/b\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\n\t\t\t\u003cp align=\"center\" style=\"text-align:center\"\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"line-height:normal\"\u003e\u003cb\u003e\u003cspan style=\"color:#004070\"\u003eJune 25\u0026nbsp;- July 24\u003c/span\u003e\u003c/b\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\t\t\t\u003c/td\u003e\n\t\t\t\u003ctd style=\"border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:32px; border-top:none; border-right:1px solid black; border-left:none\" valign=\"top\"\u003e\n\t\t\t\u003cp align=\"center\" style=\"text-align:center\"\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"line-height:normal\"\u003e\u003cb\u003e\u003cspan style=\"color:#004070\"\u003e$1738\u003c/span\u003e\u003c/b\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\t\t\t\u003c/td\u003e\n\t\t\t\u003ctd style=\"border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:32px; border-top:none; border-right:9px double black; border-left:none\" valign=\"top\"\u003e\n\t\t\t\u003cp align=\"center\" style=\"text-align:center\"\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"line-height:normal\"\u003e\u003cb\u003e\u003cspan style=\"color:#004070\"\u003e$1364\u003c/span\u003e\u003c/b\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\t\t\t\u003c/td\u003e\n\t\t\u003c/tr\u003e\n\t\t\u003ctr\u003e\n\t\t\t\u003ctd style=\"border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:34px; border-top:none; border-right:1px solid black; border-left:9px double black\" valign=\"top\"\u003e\n\t\t\t\u003cp align=\"center\" style=\"text-align:center\"\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"line-height:normal\"\u003e\u003cb\u003e\u003cspan style=\"color:#004070\"\u003e1\u003csup\u003est\u003c/sup\u003e Session\u003c/span\u003e\u003c/b\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\n\t\t\t\u003cp align=\"center\" style=\"text-align:center\"\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"line-height:normal\"\u003e\u003cb\u003e\u003cspan style=\"color:#004070\"\u003eJune 25\u0026nbsp;- July 2\u003c/span\u003e\u003c/b\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\t\t\t\u003c/td\u003e\n\t\t\t\u003ctd style=\"border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:34px; border-top:none; border-right:1px solid black; border-left:none\" valign=\"top\"\u003e\n\t\t\t\u003cp align=\"center\" style=\"text-align:center\"\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"line-height:normal\"\u003e\u003cb\u003e\u003cspan style=\"color:#004070\"\u003e$553\u003c/span\u003e\u003c/b\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\t\t\t\u003c/td\u003e\n\t\t\t\u003ctd style=\"border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:34px; border-top:none; border-right:9px double black; border-left:none\" valign=\"top\"\u003e\n\t\t\t\u003cp align=\"center\" style=\"text-align:center\"\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"line-height:normal\"\u003e\u003cb\u003e\u003cspan style=\"color:#004070\"\u003e$434\u003c/span\u003e\u003c/b\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\t\t\t\u003c/td\u003e\n\t\t\u003c/tr\u003e\n\t\t\u003ctr\u003e\n\t\t\t\u003ctd style=\"border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:32px; border-top:none; border-right:1px solid black; border-left:9px double black\" valign=\"top\"\u003e\n\t\t\t\u003cp align=\"center\" style=\"text-align:center\"\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"line-height:normal\"\u003e\u003cb\u003e\u003cspan style=\"color:#004070\"\u003e2\u003csup\u003end\u003c/sup\u003e Session\u003c/span\u003e\u003c/b\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\n\t\t\t\u003cp align=\"center\" style=\"text-align:center\"\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"line-height:normal\"\u003e\u003cb\u003e\u003cspan style=\"color:#004070\"\u003eJuly 6\u0026nbsp;- July 24\u003c/span\u003e\u003c/b\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\t\t\t\u003c/td\u003e\n\t\t\t\u003ctd style=\"border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:32px; border-top:none; border-right:1px solid black; border-left:none\" valign=\"top\"\u003e\n\t\t\t\u003cp align=\"center\" style=\"text-align:center\"\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"line-height:normal\"\u003e\u003cb\u003e\u003cspan style=\"color:#004070\"\u003e$1185\u003c/span\u003e\u003c/b\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\t\t\t\u003c/td\u003e\n\t\t\t\u003ctd style=\"border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:32px; border-top:none; border-right:9px double black; border-left:none\" valign=\"top\"\u003e\n\t\t\t\u003cp align=\"center\" style=\"text-align:center\"\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"line-height:normal\"\u003e\u003cb\u003e\u003cspan style=\"color:#004070\"\u003e$930\u003c/span\u003e\u003c/b\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\t\t\t\u003c/td\u003e\n\t\t\u003c/tr\u003e\n\t\t\u003ctr\u003e\n\t\t\t\u003ctd style=\"border-bottom:9px double black; width:182px; padding:0in 7px 0in 7px; height:32px; border-top:none; border-right:1px solid black; border-left:9px double black\" valign=\"top\"\u003e\n\t\t\t\u003cp align=\"center\" style=\"text-align:center\"\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"line-height:normal\"\u003e\u003cb\u003e\u003cspan style=\"color:#004070\"\u003eWeekly Option\u003c/span\u003e\u003c/b\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\t\t\t\u003c/td\u003e\n\t\t\t\u003ctd style=\"border-bottom:9px double black; width:182px; padding:0in 7px 0in 7px; height:32px; border-top:none; border-right:1px solid black; border-left:none\" valign=\"top\"\u003e\n\t\t\t\u003cp align=\"center\" style=\"text-align:center\"\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"line-height:normal\"\u003e\u003cb\u003e\u003cspan style=\"color:#004070\"\u003e\u0026nbsp;$395 / week\u003cbr\u003e\n\t\t\t\u003cbr\u003e\n\t\t\t(Week 1 $158)\u003c/span\u003e\u003c/b\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\t\t\t\u003c/td\u003e\n\t\t\t\u003ctd style=\"border-bottom:9px double black; width:182px; padding:0in 7px 0in 7px; height:32px; border-top:none; border-right:9px double black; border-left:none\" valign=\"top\"\u003e\n\t\t\t\u003cp align=\"center\" style=\"text-align:center\"\u003e\u003cspan style=\"font-size:16px;\"\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"line-height:normal\"\u003e\u003cb\u003e\u003cspan style=\"color:#004070\"\u003e\u0026nbsp;$310 / week\u003cbr\u003e\n\t\t\t\u003cbr\u003e\n\t\t\t(Week 1 $124)\u003c/span\u003e\u003c/b\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003cbr\u003e\n\t\t\t\u0026nbsp;\u003c/p\u003e\n\t\t\t\u003c/td\u003e\n\t\t\u003c/tr\u003e\n\t\u003c/tbody\u003e\n\u003c/table\u003e\n","44_name":"doubleclickTo44","44_qid":44,"44_type":"control_text","44_order":24,"45_text":"Please select the rate that works for you","45_message":"","45_labelAlign":"Auto","45_required":"Yes","45_options":"Rate A, This rate most accurately accounts for the costs of camp|Rate B, Our SUBSIDIZED rate","45_special":"None","45_allowOther":"No","45_otherText":"Other","45_calculateOther":"No","45_selected":"","45_spreadCols":"1","45_description":"Please see info about the rate option above","45_name":"input45","45_qid":45,"45_type":"control_radio","45_order":25,"23_text":"Sessions Attending","23_subHeader":"","23_headerType":"Default","23_name":"clickTo23","23_qid":23,"23_type":"control_head","23_order":26,"51_text":"\u003cp\u003eIf\u0026nbsp;you would like to register for the week of July 13 - 17, please reach out to the camp office at\u003cbr\u003e\n2154979925 ext 2 or rl@jewishcenter.info to confirm there is space. Thank you\u003c/p\u003e\n","51_name":"doubleclickTo51","51_qid":51,"51_type":"control_text","51_order":27,"24_text":"Please select which session of camp  your child will be attending.","24_message":"","24_labelAlign":"Auto","24_required":"Yes","24_options":"All Sessions: June 25 - July 24 - $1364|First Session June 25 July 2 - $434|Second Session July 6 - July 24 -  $930|Weekly Option $310 a week","24_special":"None","24_size":0,"24_width":"275","24_selected":"","24_subLabel":"","24_description":"","24_emptyText":"","24_name":"input24","24_qid":24,"24_type":"control_dropdown","24_order":28,"24_pricing":"1364|434|930|0","46_text":"Please select which session of camp  your child will be attending.","46_message":"","46_labelAlign":"Auto","46_required":"Yes","46_options":"All Sessions: June 25 - July 24 - $1738|First Session June 25 - July 2 - $553|Second Session July 6 - July 24 -  $1185|Weekly Option $395 a week","46_special":"None","46_size":0,"46_width":"275","46_selected":"","46_subLabel":"","46_description":"","46_emptyText":"","46_name":"input46","46_qid":46,"46_type":"control_dropdown","46_order":29,"46_pricing":"1738|553|1185|0","47_text":"Please Select the weeks your child will be attending","47_message":"","47_labelAlign":"Auto","47_required":"No","47_options":"Week 1 June 25- June 26|Week 2 June 29 - July 2|Week 3 July 6 -July 10|Week 4 July 13 - July 17|Week 5 July 20 - July 24","47_special":"None","47_allowOther":"No","47_otherText":"Other","47_calculateOther":"No","47_spreadCols":"1","47_selected":"","47_minSelection":"","47_maxSelection":"","47_description":"","47_name":"input47","47_qid":47,"47_type":"control_checkbox","47_order":30,"47_pricing":"158|395|395|395|395","48_text":"Please select the weeks your child will be attending","48_message":"","48_labelAlign":"Auto","48_required":"No","48_options":"Week 1 June 25 - June 26|Week 2 June 29 - July 2|Week 3 July 6 - July 10|Week 4 July 13 - July 17|Week 5 July 20 - July 24","48_special":"None","48_allowOther":"No","48_otherText":"Other","48_calculateOther":"No","48_spreadCols":"1","48_selected":"","48_minSelection":"","48_maxSelection":"","48_description":"","48_name":"input48","48_qid":48,"48_type":"control_checkbox","48_order":31,"48_pricing":"124|310|310|310|310","25_text":"Payment","25_subHeader":"","25_headerType":"Default","25_name":"clickTo25","25_qid":25,"25_type":"control_head","25_order":32,"37_text":"\u003cp\u003eA $60 registration fee will be charge in additional to the camp tuition.\u0026#160;\u0026#160;\u003c/p\u003e","37_name":"doubleclickTo37","37_qid":37,"37_type":"control_text","37_order":33,"41_text":"Please choose how you would like to pay","41_message":"","41_labelAlign":"Auto","41_required":"Yes","41_options":"Charge my credit card in full now","41_special":"None","41_allowOther":"No","41_otherText":"Other","41_calculateOther":"No","41_selected":"","41_spreadCols":"1","41_description":"","41_name":"input41","41_qid":41,"41_type":"control_radio","41_order":34,"41_pricing":"60|60|60|60","39_text":"\u003cp\u003eTotal includes -\u003cbr\u003e\nCamp Tuition\u003cbr\u003e\n$60 Registration Fee\u003cbr\u003e\n5% Early Bird Discount - when registered for a full session\u0026#160;before February 15th.\u003c/p\u003e\n","39_name":"doubleclickTo39","39_qid":39,"39_type":"control_text","39_order":35,"27_labelAlign":"Auto","27_text":"Total","27_partialPayEnabled":"No","27_partialPayType":"dollar","27_partialPayMinimum":0,"27_required":"No","27_offsetGiftEnabled":"No","27_offsetGift":3,"27_name":"total","27_qid":27,"27_type":"control_totalamount","27_order":36,"33_text":"\u003cp\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"font-size:14px;\"\u003e1)\u0026nbsp;Please note the credit credit will be charged manually so it might take a couple of days to see the charge on your credit card.\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\n\u003cp\u003e\u003cspan style=\"font-family:Arial,Helvetica Neue,Helvetica,sans-serif;\"\u003e\u003cspan style=\"font-size:14px;\"\u003e2) \u003cu\u003ePart 2 registration -\u0026nbsp;\u003c/u\u003e\u003c/span\u003e\u003cspan style=\"font-size:14px;\"\u003e\u003cstrong\u003ePlease fill out part 2 registration before May 15th.\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n","33_name":"doubleclickTo33","33_qid":33,"33_type":"control_text","33_order":37,"30_text":"Payment","30_message":"","30_labelAlign":"Auto","30_required":"Yes","30_duplicatable":false,"30_selectedCountry":"","30_description":"","30_sublabels":{"cc_firstName":"First Name","cc_lastName":"Last Name","cc_type":"Credit Card Type","cc_number":"Credit Card Number","cc_ccv":"Security Code","cc_nameOnCard":"Name on Card","cc_IdNumber":"Israel Identity Number","cc_exp_month":"Expiration Month","cc_exp_year":"Expiration Year","eCheck_bankName":"Bank Name","eCheck_routingNumber":"Routing Number","eCheck_accountNumber":"Account Number","eCheck_accountType":"Account Type","addr_line1":"Street Address","addr_line2":"Street Address Line 2","city":"City","state":"State / Province","postal":"Postal / Zip Code","country":"Country"},"30_name":"payment","30_qid":30,"30_type":"control_payform","30_order":38,"30_options":{"currency":"default","creditCard":{"value":"Credit Card","enabled":true,"fields":[{"name":"ccv","value":"CCV","enabled":true},{"name":"nameOnCard","value":"Name on Card","enabled":true},{"name":"billingAddress","value":"Billing Address","enabled":true},{"name":"israelIdentityNumber","value":"Israel Identity Number","enabled":true}],"processorIndex":-1,"type":[{"name":"Visa","value":"Visa","enabled":true},{"name":"Mastercard","value":"MasterCard","enabled":true},{"name":"Amex","value":"American Express","enabled":true},{"name":"Discover","value":"Discover","enabled":true},{"name":"Isracard","value":"Isracard","enabled":false}],"payMe":false},"paypal":{"value":"Paypal","enabled":false,"processorIndex":null},"eCheck":{"value":"eCheck","enabled":false},"other":{"value":"Other","enabled":false,"altText":"","message":""}},"34_text":"Security Code","34_message":"","34_labelAlign":"Auto","34_required":"Yes","34_cols":"5","34_rows":"1","34_validation":"None","34_entryLimit":"None-0","34_maxsize":"","34_defaultValue":"","34_subLabel":"","34_hint":"","34_description":"","34_readonly":"No","34_wysiwyg":"Disable","34_name":"input34","34_qid":34,"34_type":"control_textarea","34_order":39,"form_title":"Gan Izzy Day Camp Registration - Part One Gan Izzy Day Camp - We build Jewish Pride!","form_pagetitle":"Form","form_styles":"nova","form_font":"","form_fontsize":"14","form_fontcolor":"","form_optioncolor":"","form_lineSpacing":"12","form_background":"","form_formWidth":"685","form_labelWidth":"150","form_alignment":"Left","form_thankurl":"","form_thanktext":"","form_highlightLine":"Enabled","form_activeRedirect":"default","form_sendpostdata":"No","form_unique":"None","form_uniqueField":"\u003cField Id\u003e","form_status":"Enabled","form_injectCSS":"","form_hideMailEmptyFields":"disable","form_showProgressBar":"disable","form_formStrings":[{"alphabetic":"This field can only contain letters","alphanumeric":"This field can only contain letters and numbers.","confirmClearForm":"Are you sure you want to clear the form?","confirmEmail":"E-mail does not match","email":"Enter a valid e-mail address","generalError":"There are errors on the form. Please fix them before continuing.","generalPageError":"There are errors on this page. Please fix them before continuing.","gradingScoreError":"Score total should only be less than or equal to","incompleteFields":"There are incomplete required fields. 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<form class="userform-form" action="" method="post" name="form_7246818" id="7246818" accept-charset="utf-8"><input type="hidden" name="formID" value="7246818" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li id="cid_1" class="form-input-wide"> <div class="form-header-group"><h1 id="header_1" class="form-header">Mini Gan Izzy Day Camp Registration (3 &amp; 4 years old) - Part One</h1></div> </li><li class="form-line" id="id_2"><div id="cid_2" class="form-input-wide"> <div id="text_2" class="form-html"><h2><span style="color:#000066;"><span style="font-size:22px;"><strong>A day camp for Jewish children, celebrating our traditions.</strong></span></span></h2>

<p>To secure a spot for your child, a $60 non-refundable registration fee is required per camper.</p>
</div> </div></li><li id="cid_3" class="form-input-wide"> <div class="form-header-group"><h2 id="header_3" class="form-header">Parent Information</h2></div> </li><li class="form-line" id="id_4"><div id="cid_4" class="form-input-wide"> <div id="text_4" class="form-html"><p>Please fill out all parent information. If Parent is a single parent please enter NA.</p></div> </div></li><li class="form-line" id="id_5"><div class="form-label-left" id="label_5"><label for="input_5"> Mother's Name<span class="form-required">*</span> </label><label class="label-message" for="input_5"> </label></div><div id="cid_5" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q5_fullName[first]" id="first_5" autocomplete="given-name" />  <label class="form-sub-label" for="first_5" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q5_fullName[last]" id="last_5" autocomplete="family-name" />  <label class="form-sub-label" for="last_5" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_6"><div class="form-label-left" id="label_6"><label for="input_6"> Mother's Cell Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_6"> </label></div><div id="cid_6" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q6_phoneNumber[area]" id="input_6_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_6_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q6_phoneNumber[phone]" id="input_6_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_6_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_10"><div class="form-label-left" id="label_10"><label for="input_10"> Mother's Work Phone Number </label><label class="label-message" for="input_10"> </label></div><div id="cid_10" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q10_phoneNumber10[area]" id="input_10_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_10_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q10_phoneNumber10[phone]" id="input_10_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_10_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_7"><div class="form-label-left" id="label_7"><label for="input_7"> Mother's Email<span class="form-required">*</span> </label><label class="label-message" for="input_7"> </label></div><div id="cid_7" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_7" name="q7_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_8"><div class="form-label-left" id="label_8"><label for="input_8"> Father's Name<span class="form-required">*</span> </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q8_fullName8[first]" id="first_8" autocomplete="given-name" />  <label class="form-sub-label" for="first_8" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q8_fullName8[last]" id="last_8" autocomplete="family-name" />  <label class="form-sub-label" for="last_8" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_9"><div class="form-label-left" id="label_9"><label for="input_9"> Father's Cell Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_9"> </label></div><div id="cid_9" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q9_phoneNumber9[area]" id="input_9_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_9_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q9_phoneNumber9[phone]" id="input_9_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_9_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_11"><div class="form-label-left" id="label_11"><label for="input_11"> Father's Work Phone Number </label><label class="label-message" for="input_11"> </label></div><div id="cid_11" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q11_phoneNumber11[area]" id="input_11_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_11_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q11_phoneNumber11[phone]" id="input_11_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_11_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12"> Father's Email<span class="form-required">*</span> </label><label class="label-message" for="input_12"> </label></div><div id="cid_12" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_12" name="q12_email12" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_38"><div class="form-label-left" id="label_38"><label for="input_38"> Are the natural parents of the child Jewish?<span class="form-required">*</span> </label><label class="label-message" for="input_38"> </label></div><div id="cid_38" 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_38_0" name="q38_input38" value="Both Parents" /><label id="label_input_38_0" for="input_38_0"><span>Both Parents</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_38_1" name="q38_input38" value="Mother Only" /><label id="label_input_38_1" for="input_38_1"><span>Mother Only</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_38_2" name="q38_input38" value="Father Only" /><label id="label_input_38_2" for="input_38_2"><span>Father Only</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_13" class="form-input-wide"> <div class="form-header-group"><h2 id="header_13" class="form-header">Camper's information</h2></div> </li><li class="form-line" id="id_14"><div class="form-label-left" id="label_14"><label for="input_14"> Camper's Full Name<span class="form-required">*</span> </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 validate[required]" type="text" size="10" name="q14_fullName14[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 validate[required]" type="text" size="15" name="q14_fullName14[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_35"><div class="form-label-left" id="label_35"><label for="input_35"> Camper's Jewish Name </label><label class="label-message" for="input_35"> </label></div><div id="cid_35" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_35" name="q35_input35" size="20" value="" /> </div></li><li class="form-line" id="id_16"><div class="form-label-left" id="label_16"><label for="input_16"> Camper's Address<span class="form-required">*</span> </label><label class="label-message" for="input_16"> </label></div><div id="cid_16" 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="q16_address[addr_line1]" id="input_16_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_16_addr_line1" id="sublabel_16_addr_line1">Street Address</label></span></td></tr><tr style="display: none;"><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q16_address[addr_line2]" id="input_16_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_16_addr_line2" id="sublabel_16_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="q16_address[city]" id="input_16_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_16_city" id="sublabel_16_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q16_address[state]" id="input_16_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_16_state" id="sublabel_16_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="q16_address[postal]" id="input_16_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_16_postal" id="sublabel_16_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q16_address[country]" id="input_16_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 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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_16_country" id="sublabel_16_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_17"><div class="form-label-left" id="label_17"><label for="input_17"> Camper's Home Phone Number </label><label class="label-message" for="input_17"> </label></div><div id="cid_17" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q17_phoneNumber17[area]" id="input_17_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_17_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q17_phoneNumber17[phone]" id="input_17_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_17_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_40"><div class="form-label-left" id="label_40"><label for="input_40"> Gender<span class="form-required">*</span> </label><label class="label-message" for="input_40"> </label></div><div id="cid_40" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_40_0" name="q40_input40" value="Male" /><label id="label_input_40_0" for="input_40_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_40_1" name="q40_input40" value="Female" /><label id="label_input_40_1" for="input_40_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_19"><div class="form-label-left" id="label_19"><label for="input_19"> Camper's Age.<span class="form-required">*</span> </label><label class="label-message" for="input_19"> </label></div><div id="cid_19" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_19" name="q19_input19"><option value=""></option><option value="3 years old">3 years old</option><option value="4 years old">4 years old</option><option value="5 years old">5 years old</option></select> </div></li><li class="form-line" id="id_18"><div class="form-label-left" id="label_18"><label for="input_18"> Camper's Birth Date<span class="form-required">*</span> </label><label class="label-message" for="input_18"> </label></div><div id="cid_18" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q18_birthDate[month]" id="input_18_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_18_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q18_birthDate[day]" id="input_18_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_18_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q18_birthDate[year]" id="input_18_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_18_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_49"><div class="form-label-left" id="label_49"><label for="input_49"> Is your child in preschool or daycare center </label><label class="label-message" for="input_49"> </label></div><div id="cid_49" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_49_0" name="q49_input49" value="Yes" /><label id="label_input_49_0" for="input_49_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_49_1" name="q49_input49" value="No" /><label id="label_input_49_1" for="input_49_1"><span>No</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_49_2" name="q49_input49" value="Part time" /><label id="label_input_49_2" for="input_49_2"><span>Part time</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_21"><div class="form-label-left" id="label_21"><label for="input_21"> Name Preschool or Daycare </label><label class="label-message" for="input_21"> </label></div><div id="cid_21" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_21" name="q21_input21" size="20" value="" /> </div></li><li class="form-line" id="id_44"><div id="cid_44" class="form-input-wide"> <div id="text_44" class="form-html"><p><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="color:#ff0000;"><strong>PLEASE READ</strong></span><br />
<br />
<strong>With to current rise of costs, in order to make camp more affordable for families, Gan Izzy Day Camp will offer  two pricing tiers.</strong></span></span></p>

<p><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><strong>Please choose from the pricing options below</strong>. Your choice is completely optional.<br />
<br />
<span style="color:#ff0000;"><b>RATE A</b></span>- <strong>This rate most accurately accounts for the costs of camp</strong>. This includes staffing, facility rentals, swimming, programming, camp administration, insurance, utilities, etc.<br />
<br />
Choosing this tier gives you an opportunity to help us do more each day. You help us stretch our limited scholarship funds further so more children can experience the power of camp. <strong> If you are able to pay this amount, please do so. Thank you! </strong></span></span></p>

<p><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="color:#ff0000;"><strong>RATE B</strong></span> - <strong>Our SUBSIDIZED rate. </strong>This reduced rate is made possible through the funding dollars we receive from individual donors who value the impact that the summer camp experience at Gan Izzy has on children, youth, individuals and families. This rate makes the camp experience available to more families. <strong>Please, choose this rate if you feel this is right for your family.</strong><br />
<br />
<strong>If you cannot afford either of the rates and need additional assistance</strong>, register using Rate B and then please fill out a scholarship application at <a href="https://www.ganizzy.info/scholarship">www.ganizzy.info/scholarship</a></span></span></p>

<table class="MsoTableGrid" style="width:546px; border-collapse:collapse; border:none" width="546">
	<tbody>
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			<td colspan="3" style="border-bottom:1px solid black; width:546px; padding:0in 7px 0in 7px; height:22px; background-color:yellow; border-top:9px double black; border-right:9px double black; border-left:9px double black" valign="top">
			<p align="center" style="text-align:center"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="line-height:normal"><b><span style="color:#004070">Summer 2026 Rates</span></b></span></span></span></p>
			</td>
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			<td style="border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:30px; border-top:none; border-right:1px solid black; border-left:9px double black" valign="top">
			<p align="center" style="text-align:center"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="line-height:normal"><b><span style="color:#004070">Options</span></b></span></span></span></p>
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			<td style="border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:30px; border-top:none; border-right:1px solid black; border-left:none" valign="top">
			<p align="center" style="text-align:center"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="line-height:normal"><b><span style="color:#004070">Rate A</span></b></span></span></span></p>
			</td>
			<td style="border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:30px; border-top:none; border-right:9px double black; border-left:none" valign="top">
			<p align="center" style="text-align:center"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="line-height:normal"><b><span style="color:#004070">Rate B</span></b></span></span></span></p>
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			<td style="border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:32px; border-top:none; border-right:1px solid black; border-left:9px double black" valign="top">
			<p align="center" style="text-align:center"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="line-height:normal"><b><span style="color:#004070">All Sessions</span></b></span></span></span></p>

			<p align="center" style="text-align:center"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="line-height:normal"><b><span style="color:#004070">June 25 - July 24</span></b></span></span></span></p>
			</td>
			<td style="border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:32px; border-top:none; border-right:1px solid black; border-left:none" valign="top">
			<p align="center" style="text-align:center"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="line-height:normal"><b><span style="color:#004070">$1738</span></b></span></span></span></p>
			</td>
			<td style="border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:32px; border-top:none; border-right:9px double black; border-left:none" valign="top">
			<p align="center" style="text-align:center"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="line-height:normal"><b><span style="color:#004070">$1364</span></b></span></span></span></p>
			</td>
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			<td style="border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:34px; border-top:none; border-right:1px solid black; border-left:9px double black" valign="top">
			<p align="center" style="text-align:center"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="line-height:normal"><b><span style="color:#004070">1<sup>st</sup> Session</span></b></span></span></span></p>

			<p align="center" style="text-align:center"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="line-height:normal"><b><span style="color:#004070">June 25 - July 2</span></b></span></span></span></p>
			</td>
			<td style="border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:34px; border-top:none; border-right:1px solid black; border-left:none" valign="top">
			<p align="center" style="text-align:center"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="line-height:normal"><b><span style="color:#004070">$553</span></b></span></span></span></p>
			</td>
			<td style="border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:34px; border-top:none; border-right:9px double black; border-left:none" valign="top">
			<p align="center" style="text-align:center"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="line-height:normal"><b><span style="color:#004070">$434</span></b></span></span></span></p>
			</td>
		</tr>
		<tr>
			<td style="border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:32px; border-top:none; border-right:1px solid black; border-left:9px double black" valign="top">
			<p align="center" style="text-align:center"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="line-height:normal"><b><span style="color:#004070">2<sup>nd</sup> Session</span></b></span></span></span></p>

			<p align="center" style="text-align:center"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="line-height:normal"><b><span style="color:#004070">July 6 - July 24</span></b></span></span></span></p>
			</td>
			<td style="border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:32px; border-top:none; border-right:1px solid black; border-left:none" valign="top">
			<p align="center" style="text-align:center"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="line-height:normal"><b><span style="color:#004070">$1185</span></b></span></span></span></p>
			</td>
			<td style="border-bottom:1px solid black; width:182px; padding:0in 7px 0in 7px; height:32px; border-top:none; border-right:9px double black; border-left:none" valign="top">
			<p align="center" style="text-align:center"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="line-height:normal"><b><span style="color:#004070">$930</span></b></span></span></span></p>
			</td>
		</tr>
		<tr>
			<td style="border-bottom:9px double black; width:182px; padding:0in 7px 0in 7px; height:32px; border-top:none; border-right:1px solid black; border-left:9px double black" valign="top">
			<p align="center" style="text-align:center"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="line-height:normal"><b><span style="color:#004070">Weekly Option</span></b></span></span></span></p>
			</td>
			<td style="border-bottom:9px double black; width:182px; padding:0in 7px 0in 7px; height:32px; border-top:none; border-right:1px solid black; border-left:none" valign="top">
			<p align="center" style="text-align:center"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="line-height:normal"><b><span style="color:#004070"> $395 / week<br />
			<br />
			(Week 1 $158)</span></b></span></span></span></p>
			</td>
			<td style="border-bottom:9px double black; width:182px; padding:0in 7px 0in 7px; height:32px; border-top:none; border-right:9px double black; border-left:none" valign="top">
			<p align="center" style="text-align:center"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="line-height:normal"><b><span style="color:#004070"> $310 / week<br />
			<br />
			(Week 1 $124)</span></b></span></span></span><br />
			 </p>
			</td>
		</tr>
	</tbody>
</table>
</div> </div></li><li class="form-line" id="id_45"><div class="form-label-left" id="label_45"><label for="input_45"> Please select the rate that works for you<span class="form-required">*</span> </label><label class="label-message" for="input_45"> </label></div><div id="cid_45" 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_45_0" name="q45_input45" value="Rate A, This rate most accurately accounts for the costs of camp" /><label id="label_input_45_0" for="input_45_0"><span>Rate A, This rate most accurately accounts for the costs of camp</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_45_1" name="q45_input45" value="Rate B, Our SUBSIDIZED rate" /><label id="label_input_45_1" for="input_45_1"><span>Rate B, Our SUBSIDIZED rate</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_23" class="form-input-wide"> <div class="form-header-group"><h2 id="header_23" class="form-header">Sessions Attending</h2></div> </li><li class="form-line" id="id_51"><div id="cid_51" class="form-input-wide"> <div id="text_51" class="form-html"><p>If you would like to register for the week of July 13 - 17, please reach out to the camp office at<br />
2154979925 ext 2 or rl@jewishcenter.info to confirm there is space. Thank you</p>
</div> </div></li><li class="form-line" id="id_24"><div class="form-label-left" id="label_24"><label for="input_24"> Please select which session of camp  your child will be attending.<span class="form-required">*</span> </label><label class="label-message" for="input_24"> </label></div><div id="cid_24" class="form-input"> <select class="form-dropdown validate[required]" style="width:275px" id="input_24" name="q24_input24"><option value=""></option><option value="All Sessions: June 25 - July 24 - $1364">All Sessions: June 25 - July 24 - $1364</option><option value="First Session June 25 July 2 - $434">First Session June 25 July 2 - $434</option><option value="Second Session July 6 - July 24 -  $930">Second Session July 6 - July 24 -  $930</option><option value="Weekly Option $310 a week">Weekly Option $310 a week</option></select> </div></li><li class="form-line" id="id_46"><div class="form-label-left" id="label_46"><label for="input_46"> Please select which session of camp  your child will be attending.<span class="form-required">*</span> </label><label class="label-message" for="input_46"> </label></div><div id="cid_46" class="form-input"> <select class="form-dropdown validate[required]" style="width:275px" id="input_46" name="q46_input46"><option value=""></option><option value="All Sessions: June 25 - July 24 - $1738">All Sessions: June 25 - July 24 - $1738</option><option value="First Session June 25 - July 2 - $553">First Session June 25 - July 2 - $553</option><option value="Second Session July 6 - July 24 -  $1185">Second Session July 6 - July 24 -  $1185</option><option value="Weekly Option $395 a week">Weekly Option $395 a week</option></select> </div></li><li class="form-line" id="id_47"><div class="form-label-left" id="label_47"><label for="input_47"> Please Select the weeks your child will be attending </label><label class="label-message" for="input_47"> </label></div><div id="cid_47" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_47_0" name="q47_input47[]" value="Week 1 June 25- June 26" /><label id="label_input_47_0" for="input_47_0"><span>Week 1 June 25- June 26</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_47_1" name="q47_input47[]" value="Week 2 June 29 - July 2" /><label id="label_input_47_1" for="input_47_1"><span>Week 2 June 29 - July 2</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_47_2" name="q47_input47[]" value="Week 3 July 6 -July 10" /><label id="label_input_47_2" for="input_47_2"><span>Week 3 July 6 -July 10</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_47_3" name="q47_input47[]" value="Week 4 July 13 - July 17" /><label id="label_input_47_3" for="input_47_3"><span>Week 4 July 13 - July 17</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_47_4" name="q47_input47[]" value="Week 5 July 20 - July 24" /><label id="label_input_47_4" for="input_47_4"><span>Week 5 July 20 - July 24</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_48"><div class="form-label-left" id="label_48"><label for="input_48"> Please select the weeks your child will be attending </label><label class="label-message" for="input_48"> </label></div><div id="cid_48" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_48_0" name="q48_input48[]" value="Week 1 June 25 - June 26" /><label id="label_input_48_0" for="input_48_0"><span>Week 1 June 25 - June 26</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_48_1" name="q48_input48[]" value="Week 2 June 29 - July 2" /><label id="label_input_48_1" for="input_48_1"><span>Week 2 June 29 - July 2</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_48_2" name="q48_input48[]" value="Week 3 July 6 - July 10" /><label id="label_input_48_2" for="input_48_2"><span>Week 3 July 6 - July 10</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_48_3" name="q48_input48[]" value="Week 4 July 13 - July 17" /><label id="label_input_48_3" for="input_48_3"><span>Week 4 July 13 - July 17</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_48_4" name="q48_input48[]" value="Week 5 July 20 - July 24" /><label id="label_input_48_4" for="input_48_4"><span>Week 5 July 20 - July 24</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">Payment</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>A $60 registration fee will be charge in additional to the camp tuition.  </p></div> </div></li><li class="form-line" id="id_41"><div class="form-label-left" id="label_41"><label for="input_41"> Please choose how you would like to pay<span class="form-required">*</span> </label><label class="label-message" for="input_41"> </label></div><div id="cid_41" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_41_0" name="q41_input41" value="Charge my credit card in full now" /><label id="label_input_41_0" for="input_41_0"><span>Charge my credit card in full now</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_39"><div id="cid_39" class="form-input-wide"> <div id="text_39" class="form-html"><p>Total includes -<br />
Camp Tuition<br />
$60 Registration Fee<br />
5% Early Bird Discount - when registered for a full session before February 15th.</p>
</div> </div></li><li class="form-line" id="id_27"><div class="form-label-left" id="label_27"><label for="input_27"> Total </label></div><div id="cid_27" class="form-input"> <div id="total_amount">$0.00 </div> </div></li><li class="form-line" id="id_33"><div id="cid_33" class="form-input-wide"> <div id="text_33" class="form-html"><p><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="font-size:14px;">1) Please note the credit credit will be charged manually so it might take a couple of days to see the charge on your credit card. </span></span></p>

<p><span style="font-family:Arial,Helvetica Neue,Helvetica,sans-serif;"><span style="font-size:14px;">2) <u>Part 2 registration - </u></span><span style="font-size:14px;"><strong>Please fill out part 2 registration before May 15th.</strong></span></span></p>
</div> </div></li><li class="form-line" id="id_30"><div class="form-label-left" id="label_30"><label for="input_30"> Payment<span class="form-required">*</span> </label><label class="label-message" for="input_30"> </label></div><div id="cid_30" class="form-input"> <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"></td></tr><tr class="credit_card "><th colspan="2">Credit Card</th></tr><tr class="credit_card "><td colspan="2" style="padding:0"><table cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container">  <label class="form-sub-label">We accept Visa, MasterCard, American Express, Discover</label></span><div class="cc-icons"><div class="cc-icon visa-icon"></div><div class="cc-icon mastercard-icon"></div><div class="cc-icon amex-icon"></div><div class="cc-icon discover-icon"></div></div><input type="hidden" name="q30_payment[cc_type]" id="input_30_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="q30_payment[cc_number]" id="input_30_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_30_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="q30_payment[cc_ccv]" id="input_30_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_30_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="q30_payment[cc_nameOnCard]" id="input_30_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_30_cc_nameOnCard" id="sublabel_cc_nameOnCard">Name on Card</label></span></td></tr><tr class="credit_card "><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q30_payment[cc_exp_month]" id="input_30_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_30_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="q30_payment[cc_exp_year]" id="input_30_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_30_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="billing_address "><th colspan="2">Billing Address</th></tr><tr class="billing_address "><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-line" type="text" name="q30_payment[addr_line1]" id="input_30_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_30_addr_line1" id="sublabel_30_addr_line1">Street Address</label></span></td></tr><tr class="billing_address "><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-city" type="text" name="q30_payment[city]" id="input_30_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_30_city" id="sublabel_30_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q30_payment[state]" id="input_30_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_30_state" id="sublabel_30_state">State / Province</label></span></td></tr><tr class="billing_address "><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-postal" type="text" name="q30_payment[postal]" id="input_30_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_30_postal" id="sublabel_30_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q30_payment[country]" id="input_30_country" autocomplete="billing country-name"><option value="" selected="selected">Please Select</option><option value="United States">United States</option><option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="The Bahamas">The Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Brazil">Brazil</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burundi">Burundi</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cape Verde">Cape Verde</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="People's Republic of China">People's Republic of China</option><option value="Republic of China">Republic of China</option><option value="Christmas Island">Christmas Island</option><option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo">Congo</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Cote d'Ivoire">Cote d'Ivoire</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Eswatini">Eswatini</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Polynesia">French Polynesia</option><option value="Gabon">Gabon</option><option value="The Gambia">The Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jersey">Jersey</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="North Korea">North Korea</option><option value="South Korea">South Korea</option><option value="Kosovo">Kosovo</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Laos">Laos</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macau">Macau</option><option value="Macedonia">Macedonia</option><option value="Madagascar">Madagascar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Myanmar">Myanmar</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="Northern Mariana">Northern Mariana</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn Islands">Pitcairn Islands</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Barthelemy">Saint Barthelemy</option><option value="Saint Helena">Saint Helena</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="Somaliland">Somaliland</option><option value="South Africa">South Africa</option><option value="South Ossetia">South Ossetia</option><option 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_30_country" id="sublabel_30_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_34"><div class="form-label-left" id="label_34"><label for="input_34"> Security Code<span class="form-required">*</span> </label><label class="label-message" for="input_34"> </label></div><div id="cid_34" class="form-input"> <textarea id="input_34" class="form-textarea validate[required]" name="q34_input34" cols="5" rows="1"></textarea> </div></li><li style="display:none">Should be Empty: <input type="text" name="website" value="" /></li><li class="form-line" id="id_52"><div id="cid_52" class="form-input-wide"><div style="text-align:center" class="form-buttons-wrapper"><button id="input_52" 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="7246818" /><script type="text/javascript">document.getElementById("si"+"mple"+"_spc").value = "7246818-7246818";</script><div>


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