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Includes Books, crafts and security fees<br />
For more about CHS including our calendar, location, tuition and curriculum visit our <a href="https://www.jewishbrevard.com/templates/articlecco_cdo/aid/1225186/jewish/About.htm" target="_blank">about</a> page.</p>
</div> </div></li><li class="form-line" id="id_108"><div class="form-label-left" id="label_108"><label for="input_108"> Your Name </label><label class="label-message" for="input_108"> </label></div><div id="cid_108" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q108_fullName108[first]" id="first_108" autocomplete="given-name" />  <label class="form-sub-label" for="first_108" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q108_fullName108[last]" id="last_108" autocomplete="family-name" />  <label class="form-sub-label" for="last_108" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_55"><div class="form-label-left" id="label_55"><label for="input_55"> Your email address<span class="form-required">*</span> </label><label class="label-message" for="input_55"> We'll send registration confirmation to this email</label></div><div id="cid_55" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_55" name="q55_email55" size="30" value="" autocomplete="email" /><br /><input type="email" class="form-textbox validate[required, Email, Email_Confirm]" id="input_55_confirm" style="margin-top:8px;" name="q55_email55[confirm]" size="30" /> </div></li><li id="cid_11" class="form-input-wide"> <div class="form-header-group"><h3 id="header_11" class="form-header">Student Information</h3></div> </li><li class="form-line" id="id_71"><div class="form-label-left" id="label_71"><label for="input_71"> No. of Students registering<span class="form-required">*</span> </label><label class="label-message" for="input_71"> </label></div><div id="cid_71" 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_71_0" name="q71_input71" value="1 child" /><label id="label_input_71_0" for="input_71_0"><span>1 child</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_71_1" name="q71_input71" value="2 children" /><label id="label_input_71_1" for="input_71_1"><span>2 children</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_71_2" name="q71_input71" value="3 children" /><label id="label_input_71_2" for="input_71_2"><span>3 children</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_73" class="form-input-wide"> <div class="form-header-group"><h2 id="header_73" class="form-header">Child 1</h2></div> </li><li class="form-line" id="id_63"><div class="form-label-left" id="label_63"><label for="input_63"> Registration Type<span class="form-required">*</span> </label><label class="label-message" for="input_63"> </label></div><div id="cid_63" 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_63_0" name="q63_input63" value="New student" /><label id="label_input_63_0" for="input_63_0"><span>New student</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_63_1" name="q63_input63" value="Returning student" /><label id="label_input_63_1" for="input_63_1"><span>Returning student</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_1"><div class="form-label-left" id="label_1"><label for="input_1"> Name of child <span class="form-required">*</span> </label><label class="label-message" for="input_1"> </label></div><div id="cid_1" class="form-input"> <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" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q1_fullName[last]" id="last_1" autocomplete="family-name" />  <label class="form-sub-label" for="last_1" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_62"><div class="form-label-left" id="label_62"><label for="input_62"> Hebrew Name<span class="form-required">*</span> </label><label class="label-message" for="input_62"> If unknown / none, write 'unknown' or 'none'</label></div><div id="cid_62" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_62" name="q62_input62" size="20" value="" /> </div></li><li class="form-line" id="id_4"><div class="form-label-left" id="label_4"><label for="input_4"> Date of Birth<span class="form-required">*</span> </label><label class="label-message" for="input_4"> </label></div><div id="cid_4" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox validate[required]" id="month_4" name="q4_input4[month]" type="tel" size="2" maxlength="2" value="" />  <label class="form-sub-label" for="month_4" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="noDefault form-textbox validate[required]" id="day_4" name="q4_input4[day]" type="tel" size="2" maxlength="2" value="" />  <label class="form-sub-label" for="day_4" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox validate[required]" id="year_4" name="q4_input4[year]" type="tel" size="4" maxlength="4" value="" />  <label class="form-sub-label" for="year_4" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_4_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_4_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_5"><div class="form-label-left" id="label_5"><label for="input_5"> School<span class="form-required">*</span> </label><label class="label-message" for="input_5"> </label></div><div id="cid_5" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_5" name="q5_input5" size="20" value="" /> </div></li><li class="form-line" id="id_7"><div class="form-label-left" id="label_7"><label for="input_7"> Grade entering<span class="form-required">*</span> </label><label class="label-message" for="input_7"> </label></div><div id="cid_7" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_7" name="q7_input7"><option value=""></option><option value="Kindergarten ">Kindergarten </option><option value="1st">1st</option><option value="2nd">2nd</option><option value="3rd">3rd</option><option value="4th">4th</option><option value="5th">5th</option><option value="6th">6th</option><option value="7th">7th</option><option value="8th">8th</option><option value="9th">9th</option></select> </div></li><li class="form-line" id="id_36"><div class="form-label-left" id="label_36"><label for="input_36"> Hebrew Reading Proficiency<span class="form-required">*</span> </label><label class="label-message" for="input_36"> </label></div><div id="cid_36" class="form-input"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_36_0" name="q36_input36" value="None" /><label id="label_input_36_0" for="input_36_0"><span>None</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_36_1" name="q36_input36" value="Somewhat" /><label id="label_input_36_1" for="input_36_1"><span>Somewhat</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_36_2" name="q36_input36" value="Well" /><label id="label_input_36_2" for="input_36_2"><span>Well</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_74"><div class="form-label-left" id="label_74"><label for="input_74"> Previous Jewish Education<span class="form-required">*</span> </label><label class="label-message" for="input_74"> </label></div><div id="cid_74" 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_74_0" name="q74_input74" value="Yes" /><label id="label_input_74_0" for="input_74_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_74_1" name="q74_input74" value="No" /><label id="label_input_74_1" for="input_74_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_6"><div class="form-label-left" id="label_6"><label for="input_6"> Where<span class="form-required">*</span> </label><label class="label-message" for="input_6"> </label></div><div id="cid_6" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_6" name="q6_input6" size="20" value="" /> </div></li><li class="form-line" id="id_80"><div class="form-label-left" id="label_80"><label for="input_80"> Please list any special needs that may require special awareness from our staff </label><label class="label-message" for="input_80"> Special needs including physical, developmental, learning, emotional or behavioral</label></div><div id="cid_80" class="form-input"> <textarea id="input_80" class="form-textarea" name="q80_input80" cols="40" rows="6"></textarea> </div></li><li id="cid_72" class="form-input-wide"> <div class="form-header-group"><h2 id="header_72" class="form-header">Child 2</h2><div id="subHeader_72" class="form-subHeader">If you wish to only register 1 child, scroll to top and change "No. of Students registering"</div></div> </li><li class="form-line" id="id_64"><div class="form-label-left" id="label_64"><label for="input_64"> Registration Type<span class="form-required">*</span> </label><label class="label-message" for="input_64"> </label></div><div id="cid_64" 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_64_0" name="q64_input64" value="New student" /><label id="label_input_64_0" for="input_64_0"><span>New student</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_64_1" name="q64_input64" value="Returning student" /><label id="label_input_64_1" for="input_64_1"><span>Returning student</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_41"><div class="form-label-left" id="label_41"><label for="input_41"> Name (child 2)<span class="form-required">*</span> </label><label class="label-message" for="input_41"> </label></div><div id="cid_41" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q41_fullName41[first]" id="first_41" autocomplete="given-name" />  <label class="form-sub-label" for="first_41" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q41_fullName41[last]" id="last_41" autocomplete="family-name" />  <label class="form-sub-label" for="last_41" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_66"><div class="form-label-left" id="label_66"><label for="input_66"> Hebrew Name (child 2)<span class="form-required">*</span> </label><label class="label-message" for="input_66"> If unknown / none, write 'unknown' or 'none'</label></div><div id="cid_66" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_66" name="q66_input66" size="20" value="" /> </div></li><li class="form-line" id="id_43"><div class="form-label-left" id="label_43"><label for="input_43"> Date of Birth (child 2)<span class="form-required">*</span> </label><label class="label-message" for="input_43"> </label></div><div id="cid_43" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox validate[required]" id="month_43" name="q43_input43[month]" type="tel" size="2" maxlength="2" value="" />  <label class="form-sub-label" for="month_43" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="noDefault form-textbox validate[required]" id="day_43" name="q43_input43[day]" type="tel" size="2" maxlength="2" value="" />  <label class="form-sub-label" for="day_43" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox validate[required]" id="year_43" name="q43_input43[year]" type="tel" size="4" maxlength="4" value="" />  <label class="form-sub-label" for="year_43" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_43_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_43_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_44"><div class="form-label-left" id="label_44"><label for="input_44"> School (child 2)<span class="form-required">*</span> </label><label class="label-message" for="input_44"> </label></div><div id="cid_44" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_44" name="q44_input44" size="20" value="" /> </div></li><li class="form-line" id="id_46"><div class="form-label-left" id="label_46"><label for="input_46"> Grade entering (child 2)<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:150px" id="input_46" name="q46_input46"><option value=""></option><option value="Kindergarten ">Kindergarten </option><option value="1st">1st</option><option value="2nd">2nd</option><option value="3rd">3rd</option><option value="4th">4th</option><option value="5th">5th</option><option value="6th">6th</option><option value="7th">7th</option><option value="8th">8th</option><option value="9th">9th</option></select> </div></li><li class="form-line" id="id_47"><div class="form-label-left" id="label_47"><label for="input_47"> Hebrew Reading Proficiency (child 2)<span class="form-required">*</span> </label><label class="label-message" for="input_47"> </label></div><div id="cid_47" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_47_0" name="q47_input47" value="None" /><label id="label_input_47_0" for="input_47_0"><span>None</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_47_1" name="q47_input47" value="Somewhat" /><label id="label_input_47_1" for="input_47_1"><span>Somewhat</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_47_2" name="q47_input47" value="Well" /><label id="label_input_47_2" for="input_47_2"><span>Well</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_82"><div class="form-label-left" id="label_82"><label for="input_82"> Previous Jewish Education (child 2)<span class="form-required">*</span> </label><label class="label-message" for="input_82"> </label></div><div id="cid_82" 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_82_0" name="q82_input82" value="Yes" /><label id="label_input_82_0" for="input_82_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_82_1" name="q82_input82" value="No" /><label id="label_input_82_1" for="input_82_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_45"><div class="form-label-left" id="label_45"><label for="input_45"> Where?<span class="form-required">*</span> </label><label class="label-message" for="input_45"> </label></div><div id="cid_45" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_45" name="q45_input45" size="20" value="" /> </div></li><li class="form-line" id="id_87"><div class="form-label-left" id="label_87"><label for="input_87"> Please list any special needs that may require special awareness from our staff </label><label class="label-message" for="input_87"> Special needs including physical, developmental, learning, emotional or behavioral</label></div><div id="cid_87" class="form-input"> <textarea id="input_87" class="form-textarea" name="q87_input87" cols="40" rows="6"></textarea> </div></li><li id="cid_89" class="form-input-wide"> <div class="form-header-group"><h2 id="header_89" class="form-header">Child 3</h2><div id="subHeader_89" class="form-subHeader">If you wish to only register 1 or 2 children, scroll to top and change "No. of Students registering" </div></div> </li><li class="form-line" id="id_92"><div class="form-label-left" id="label_92"><label for="input_92"> Registration Type<span class="form-required">*</span> </label><label class="label-message" for="input_92"> </label></div><div id="cid_92" 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_92_0" name="q92_input92" value="New student" /><label id="label_input_92_0" for="input_92_0"><span>New student</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_92_1" name="q92_input92" value="Returning student" /><label id="label_input_92_1" for="input_92_1"><span>Returning student</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_93"><div class="form-label-left" id="label_93"><label for="input_93"> Name (child 3)<span class="form-required">*</span> </label><label class="label-message" for="input_93"> </label></div><div id="cid_93" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q93_fullName93[first]" id="first_93" autocomplete="given-name" />  <label class="form-sub-label" for="first_93" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q93_fullName93[last]" id="last_93" autocomplete="family-name" />  <label class="form-sub-label" for="last_93" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_94"><div class="form-label-left" id="label_94"><label for="input_94"> Hebrew Name (child 3)<span class="form-required">*</span> </label><label class="label-message" for="input_94"> If unknown / none, write 'unknown' or 'none'</label></div><div id="cid_94" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_94" name="q94_input94" size="20" value="" /> </div></li><li class="form-line" id="id_95"><div class="form-label-left" id="label_95"><label for="input_95"> Date of Birth (child 3)<span class="form-required">*</span> </label><label class="label-message" for="input_95"> </label></div><div id="cid_95" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q95_birthDate[month]" id="input_95_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_95_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q95_birthDate[day]" id="input_95_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_95_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q95_birthDate[year]" id="input_95_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_95_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_96"><div class="form-label-left" id="label_96"><label for="input_96"> School (child 3)<span class="form-required">*</span> </label><label class="label-message" for="input_96"> </label></div><div id="cid_96" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_96" name="q96_input96" size="20" value="" /> </div></li><li class="form-line" id="id_97"><div class="form-label-left" id="label_97"><label for="input_97"> Grade entering (child 3)<span class="form-required">*</span> </label><label class="label-message" for="input_97"> </label></div><div id="cid_97" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_97" name="q97_input97"><option value=""></option><option value="Kindergarten ">Kindergarten </option><option value="1st">1st</option><option value="2nd">2nd</option><option value="3rd">3rd</option><option value="4th">4th</option><option value="5th">5th</option><option value="6th">6th</option><option value="7th">7th</option><option value="8th">8th</option><option value="9th">9th</option></select> </div></li><li class="form-line" id="id_98"><div class="form-label-left" id="label_98"><label for="input_98"> Hebrew Reading Proficiency (child 3)<span class="form-required">*</span> </label><label class="label-message" for="input_98"> </label></div><div id="cid_98" 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_98_0" name="q98_input98" value="None" /><label id="label_input_98_0" for="input_98_0"><span>None</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_98_1" name="q98_input98" value="Somewhat" /><label id="label_input_98_1" for="input_98_1"><span>Somewhat</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_98_2" name="q98_input98" value="Well" /><label id="label_input_98_2" for="input_98_2"><span>Well</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_99"><div class="form-label-left" id="label_99"><label for="input_99"> Previous Jewish Education (child 3)<span class="form-required">*</span> </label><label class="label-message" for="input_99"> </label></div><div id="cid_99" 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_99_0" name="q99_input99" value="Yes" /><label id="label_input_99_0" for="input_99_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_99_1" name="q99_input99" value="No" /><label id="label_input_99_1" for="input_99_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_100"><div class="form-label-left" id="label_100"><label for="input_100"> Where<span class="form-required">*</span> </label><label class="label-message" for="input_100"> </label></div><div id="cid_100" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_100" name="q100_input100" size="20" value="" /> </div></li><li class="form-line" id="id_101"><div class="form-label-left" id="label_101"><label for="input_101"> Please list any special needs that may require special awareness from our staff </label><label class="label-message" for="input_101"> Special needs including physical, developmental, learning, emotional or behavioral</label></div><div id="cid_101" class="form-input"> <textarea id="input_101" class="form-textarea" name="q101_input101" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_8"><div class="form-label-left" id="label_8"><label for="input_8"> Home address<span class="form-required">*</span> </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-line" type="text" name="q8_address[addr_line1]" id="input_8_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_8_addr_line1" id="sublabel_8_addr_line1">Street Address</label></span></td></tr><tr><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q8_address[addr_line2]" id="input_8_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_8_addr_line2" id="sublabel_8_addr_line2">Street Address Line 2</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-city" type="text" name="q8_address[city]" id="input_8_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_8_city" id="sublabel_8_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q8_address[state]" id="input_8_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_8_state" id="sublabel_8_state">State / Province</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-postal" type="text" name="q8_address[postal]" id="input_8_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_8_postal" id="sublabel_8_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q8_address[country]" id="input_8_country" autocomplete="country-name"><option value="" selected="selected">Please Select</option><option value="United States">United States</option><option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="The Bahamas">The Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Brazil">Brazil</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burundi">Burundi</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cape Verde">Cape Verde</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="People's Republic of China">People's Republic of China</option><option value="Republic of China">Republic of China</option><option value="Christmas Island">Christmas Island</option><option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo">Congo</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Cote d'Ivoire">Cote d'Ivoire</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Eswatini">Eswatini</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Polynesia">French Polynesia</option><option value="Gabon">Gabon</option><option value="The Gambia">The Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jersey">Jersey</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="North Korea">North Korea</option><option value="South Korea">South Korea</option><option value="Kosovo">Kosovo</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Laos">Laos</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macau">Macau</option><option value="Macedonia">Macedonia</option><option value="Madagascar">Madagascar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Myanmar">Myanmar</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="Northern Mariana">Northern Mariana</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn Islands">Pitcairn Islands</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Barthelemy">Saint Barthelemy</option><option value="Saint Helena">Saint Helena</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="Somaliland">Somaliland</option><option value="South Africa">South Africa</option><option value="South Ossetia">South Ossetia</option><option value="Spain">Spain</option><option value="Sri Lanka">Sri Lanka</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Svalbard">Svalbard</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria">Syria</option><option value="Taiwan">Taiwan</option><option value="Tajikistan">Tajikistan</option><option value="Tanzania">Tanzania</option><option value="Thailand">Thailand</option><option value="Timor-Leste">Timor-Leste</option><option value="Togo">Togo</option><option value="Tokelau">Tokelau</option><option value="Tonga">Tonga</option><option value="Trinidad and Tobago">Trinidad and Tobago</option><option value="Tristan da Cunha">Tristan da Cunha</option><option value="Tunisia">Tunisia</option><option value="Turkey">Turkey</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks and Caicos Islands">Turks and Caicos Islands</option><option value="Tuvalu">Tuvalu</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="United Arab Emirates">United Arab Emirates</option><option value="United Kingdom">United Kingdom</option><option value="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Vatican City">Vatican City</option><option value="Venezuela">Venezuela</option><option value="Vietnam">Vietnam</option><option value="British Virgin Islands">British Virgin Islands</option><option value="US Virgin Islands">US Virgin Islands</option><option value="Wallis and Futuna">Wallis and Futuna</option><option value="Western Sahara">Western Sahara</option><option value="Yemen">Yemen</option><option value="Zambia">Zambia</option><option value="Zimbabwe">Zimbabwe</option><option value="other">Other</option></select>  <label class="form-sub-label" for="input_8_country" id="sublabel_8_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_75"><div class="form-label-left" id="label_75"><label for="input_75"> Does your child/ren have allergies?<span class="form-required">*</span> </label><label class="label-message" for="input_75"> Food or medication</label></div><div id="cid_75" 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_75_0" name="q75_input75" value="Yes" /><label id="label_input_75_0" for="input_75_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_75_1" name="q75_input75" value="No" /><label id="label_input_75_1" for="input_75_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_78"><div class="form-label-left" id="label_78"><label for="input_78"> Please describe allergies<span class="form-required">*</span> </label><label class="label-message" for="input_78"> Specify which child/ren</label></div><div id="cid_78" class="form-input"> <textarea id="input_78" class="form-textarea validate[required]" name="q78_input78" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_77"><div class="form-label-left" id="label_77"><label for="input_77"> Does your child/ren take medication regularly?<span class="form-required">*</span> </label><label class="label-message" for="input_77"> </label></div><div id="cid_77" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_77_0" name="q77_input77" value="Yes" /><label id="label_input_77_0" for="input_77_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_77_1" name="q77_input77" value="No" /><label id="label_input_77_1" for="input_77_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_79"><div class="form-label-left" id="label_79"><label for="input_79"> Please outline medication<span class="form-required">*</span> </label><label class="label-message" for="input_79"> Specify which child/ren</label></div><div id="cid_79" class="form-input"> <textarea id="input_79" class="form-textarea validate[required]" name="q79_input79" cols="40" rows="6"></textarea> </div></li><li id="cid_30" class="form-input-wide"> <div class="form-header-group"><h3 id="header_30" class="form-header">Parents Information</h3></div> </li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12"> Father's Name<span class="form-required">*</span> </label><label class="label-message" for="input_12"> </label></div><div id="cid_12" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q12_fullName12[first]" id="first_12" autocomplete="given-name" />  <label class="form-sub-label" for="first_12" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q12_fullName12[last]" id="last_12" autocomplete="family-name" />  <label class="form-sub-label" for="last_12" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_13"><div class="form-label-left" id="label_13"><label for="input_13"> Father's Cell </label><label class="label-message" for="input_13"> </label></div><div id="cid_13" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox" type="tel" name="q13_phoneNumber[full]" id="input_13_full" autocomplete="tel" />  <label class="form-sub-label" for="input_13_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_53"><div class="form-label-left" id="label_53"><label for="input_53"> Father's E-mail </label><label class="label-message" for="input_53"> </label></div><div id="cid_53" class="form-input"> <input type="email" class=" form-textbox validate[Email]" id="input_53" name="q53_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_14"><div class="form-label-left" id="label_14"><label for="input_14"> Mother's 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_15"><div class="form-label-left" id="label_15"><label for="input_15"> Mother's Cell<span class="form-required">*</span> </label><label class="label-message" for="input_15"> </label></div><div id="cid_15" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q15_phoneNumber15[full]" id="input_15_full" autocomplete="tel" />  <label class="form-sub-label" for="input_15_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_67"><div class="form-label-left" id="label_67"><label for="input_67"> Mother's E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_67"> </label></div><div id="cid_67" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_67" name="q67_email67" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_59"><div class="form-label-left" id="label_59"><label for="input_59"> Mother's Hebrew Name </label><label class="label-message" for="input_59"> </label></div><div id="cid_59" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_59" name="q59_input59" size="20" value="" /> </div></li><li class="form-line" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> Mother born Jewish?<span class="form-required">*</span> </label><label class="label-message" for="input_26"> </label></div><div id="cid_26" class="form-input"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_26_0" name="q26_input26" value="Yes" /><label id="label_input_26_0" for="input_26_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_26_1" name="q26_input26" value="No" /><label id="label_input_26_1" for="input_26_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_39"><div class="form-label-left" id="label_39"><label for="input_39"> If there's conversions or adoptions in the family, please provide details. </label><label class="label-message" for="input_39"> </label></div><div id="cid_39" class="form-input"> <textarea id="input_39" class="form-textarea" name="q39_input39" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_20"><div class="form-label-left" id="label_20"><label for="input_20"> Best way to send Hebrew School updates:<span class="form-required">*</span> </label><label class="label-message" for="input_20"> </label></div><div id="cid_20" class="form-input"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_20_0" name="q20_input20" value="Cell Phone" /><label id="label_input_20_0" for="input_20_0"><span>Cell Phone</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_20_1" name="q20_input20" value="Email" /><label id="label_input_20_1" for="input_20_1"><span>Email</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_20_2" name="q20_input20" value="Handout" /><label id="label_input_20_2" for="input_20_2"><span>Handout</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"> Volunteer </label><label class="label-message" for="input_21"> </label></div><div id="cid_21" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_21_0" name="q21_input21[]" value="I am willing to assist in school activities, please contact me" /><label id="label_input_21_0" for="input_21_0"><span>I am willing to assist in school activities, please contact me</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_19" class="form-input-wide"> <div class="form-header-group"><h3 id="header_19" class="form-header">Emergency Information</h3></div> </li><li class="form-line" id="id_50"><div class="form-label-left" id="label_50"><label for="input_50"> Emergency Contact 	<span class="form-required">*</span> </label><label class="label-message" for="input_50"> </label></div><div id="cid_50" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_50" name="q50_input50" size="20" value="" /> </div></li><li class="form-line" id="id_52"><div class="form-label-left" id="label_52"><label for="input_52"> Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_52"> </label></div><div id="cid_52" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q52_phoneNumber52[full]" id="input_52_full" autocomplete="tel" />  <label class="form-sub-label" for="input_52_full"><span> </span></label></span></div> </div></li><li id="cid_48" class="form-input-wide"> <div class="form-header-group"><h3 id="header_48" class="form-header">Payment</h3></div> </li><li class="form-line" id="id_40"><div class="form-label-left" id="label_40"><label for="input_40"> Tuition Payment plan:<span class="form-required">*</span> </label><label class="label-message" for="input_40"> Tuition for the year is $950 per child. Tuition PAID IN FULL before Hebrew School begins will receive a 5% discount.</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="Plan A - Pay in full before HS starts" /><label id="label_input_40_0" for="input_40_0"><span>Plan A - Pay in full before HS starts</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="Plan B - 50% before HS starts and 50% Jan. 1st" /><label id="label_input_40_1" for="input_40_1"><span>Plan B - 50% before HS starts and 50% Jan. 1st</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_2" name="q40_input40" value="Plan C - Ten month payment plan - $95/student/month beginning Sep. 1st" /><label id="label_input_40_2" for="input_40_2"><span>Plan C - Ten month payment plan - $95/student/month beginning Sep. 1st</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_35"><div class="form-label-left" id="label_35"><label for="input_35"> Tuition agreement<span class="form-required">*</span> </label><label class="label-message" for="input_35"> </label></div><div id="cid_35" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_35_0" name="q35_input35[]" value="I have reviewed the tuition rates listed above and agree to pay the amount for my child/ren to attend Chabad Hebrew School." /><label id="label_input_35_0" for="input_35_0"><span>I have reviewed the tuition rates listed above and agree to pay the amount for my child/ren to attend Chabad Hebrew School.</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_107"><div class="form-label-left" id="label_107"><label for="input_107"> Credit Card Autopay<span class="form-required">*</span> </label><label class="label-message" for="input_107"> A CC is required on file. Unless you make arrangement for a different method of payment, your CC will be used for tuition</label></div><div id="cid_107" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_107_0" name="q107_input107[]" value="I hereby agree that my CC be kept on file and charged automatically according to my selected payment plan" /><label id="label_input_107_0" for="input_107_0"><span>I hereby agree that my CC be kept on file and charged automatically according to my selected payment plan</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_31"><div id="cid_31" class="form-input-wide"> <div id="text_31" class="form-html"><p>Registration for Book/Craft &amp; Security Guard fees:</p>
</div> </div></li><li class="form-line" id="id_18"><div class="form-label-left" id="label_18"><label for="input_18"> $150 due now </label><label class="label-message" for="input_18"> </label></div><div id="cid_18" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_18_0" name="q18_input18" checked="checked" value="$150 - 1 Child" /><label id="label_input_18_0" for="input_18_0"><span>$150 - 1 Child</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_68"><div class="form-label-left" id="label_68"><label for="input_68"> $300 due now </label><label class="label-message" for="input_68"> </label></div><div id="cid_68" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_68_0" name="q68_input68" checked="checked" value="$300 - 2 Children" /><label id="label_input_68_0" for="input_68_0"><span>$300 - 2 Children</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_88"><div class="form-label-left" id="label_88"><label for="input_88"> $450 due now </label><label class="label-message" for="input_88"> </label></div><div id="cid_88" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_88_0" name="q88_input88" checked="checked" value="$450 - 3 Children" /><label id="label_input_88_0" for="input_88_0"><span>$450 - 3 Children</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_70"><div class="form-label-left" id="label_70"><label for="input_70"> $200 due now </label><label class="label-message" for="input_70"> </label></div><div id="cid_70" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_70_0" name="q70_input70" checked="checked" value="$200 - 1 Child" /><label id="label_input_70_0" for="input_70_0"><span>$200 - 1 Child</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_69"><div class="form-label-left" id="label_69"><label for="input_69"> $400 due now </label><label class="label-message" for="input_69"> </label></div><div id="cid_69" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_69_0" name="q69_input69" checked="checked" value="$400 - 2 Children" /><label id="label_input_69_0" for="input_69_0"><span>$400 - 2 Children</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_90"><div class="form-label-left" id="label_90"><label for="input_90"> $600 due now </label><label class="label-message" for="input_90"> </label></div><div id="cid_90" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_90_0" name="q90_input90" checked="checked" value="$600 - 3 Children" /><label id="label_input_90_0" for="input_90_0"><span>$600 - 3 Children</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line always-hidden" id="id_61"><div class="form-label-left" id="label_61"><label for="input_61"> Date </label><label class="label-message" for="input_61"> </label></div><div id="cid_61" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="month_61" name="q61_input61[month]" type="tel" size="2" maxlength="2" value="08" />  <label class="form-sub-label" for="month_61" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="day_61" name="q61_input61[day]" type="tel" size="2" maxlength="2" value="12" />  <label class="form-sub-label" for="day_61" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="year_61" name="q61_input61[year]" type="tel" size="4" maxlength="4" value="2026" />  <label class="form-sub-label" for="year_61" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_61_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_61_pick"><span> </span></label></span></div><span class="dir_ltr inline_block time-fields" style="white-space: nowrap;"><span class="form-sub-label-container"><span id="at_61" class="form-control-static at-label">at</span>  <label class="form-sub-label" for="at_61"><span> </span></label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" id="hour_61" name="q61_input61[hour]"><option></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option selected="selected" value="12">12</option></select>  <label class="form-sub-label" for="hour_61" id="sublabel_hour">Hour</label></span><span class="form-sub-label-container"><select class="form-dropdown" id="min_61" name="q61_input61[min]"><option></option><option value="00">00</option><option selected="selected" value="10">10</option><option value="20">20</option><option value="30">30</option><option value="40">40</option><option value="50">50</option></select>  <label class="form-sub-label" for="min_61" id="sublabel_minutes">Minutes</label></span><span class="form-sub-label-container"><select class="form-dropdown" id="ampm_61" name="q61_input61[ampm]"><option value="AM">AM</option><option selected="selected" value="PM">PM</option></select>  <label class="form-sub-label" for="ampm_61"><span> </span></label></span></span></div> </div></li><li class="form-line" id="id_106"><div class="form-label-left" id="label_106"><label for="input_106"> Amount of tuition I want to pay now (in addition to registration)* </label><label class="label-message" for="input_106"> Full tuition or enrollement in a payment plan will be required prior to attending CHS</label></div><div id="cid_106" class="form-input"> <div class="form-multiple-column" data-columns="3"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_106_0" name="q106_input106" value="0" /><label for="input_106_0"><span>$0</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio-other form-radio" name="q106_input106" id="other_106" value="" /><span><input type="number" min="1" class="form-radio-other-input form-textbox" onkeypress="validateNumber(event)" name="q106_input106[other]" data-otherhint="Other" size="15" id="input_106" disabled="disabled" /></span><br /></span></div> </div></li><li class="form-line" id="id_29"><div class="form-label-left" id="label_29"><label for="input_29"> Payment </label><label class="label-message" for="input_29"> </label></div><div id="cid_29" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2" class="form-payment-methods form-multiple-column"></td></tr><tr class="credit_card "><th colspan="2">Credit Card</th></tr><tr class="credit_card "><td colspan="2" style="padding:0"><table cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container">  <label class="form-sub-label">We accept Visa, MasterCard, American Express, Discover</label></span><div class="cc-icons"><div class="cc-icon visa-icon"></div><div class="cc-icon mastercard-icon"></div><div class="cc-icon amex-icon"></div><div class="cc-icon discover-icon"></div></div><input type="hidden" name="q29_payment[cc_type]" id="input_29_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[visible, creditcard]" type="text" name="q29_payment[cc_number]" id="input_29_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_29_cc_number" id="sublabel_cc_number">Credit Card Number</label></span></div></td><td class="cc_ccv "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q29_payment[cc_ccv]" id="input_29_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_29_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[visible]" type="text" name="q29_payment[cc_nameOnCard]" id="input_29_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_29_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[visible]" name="q29_payment[cc_exp_month]" id="input_29_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_29_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[visible]" name="q29_payment[cc_exp_year]" id="input_29_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_29_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 form-address-line" type="text" name="q29_payment[addr_line1]" id="input_29_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_29_addr_line1" id="sublabel_29_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 form-address-city" type="text" name="q29_payment[city]" id="input_29_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_29_city" id="sublabel_29_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q29_payment[state]" id="input_29_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_29_state" id="sublabel_29_state">State / Province</label></span></td></tr><tr class="billing_address "><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q29_payment[postal]" id="input_29_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_29_postal" id="sublabel_29_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q29_payment[country]" id="input_29_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 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It is understood that if time and circumstances reasonably permit, 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 Chabad Hebrew School activities and that these pictures may be used for marketing purposes." /><label id="label_input_58_0" for="input_58_0"><span>As the parent(s) or legal guardian of the above child(ren), I/we authorize any adult acting on behalf of 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, 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 Chabad Hebrew School activities and that these pictures may be used for marketing purposes.</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_102"><div class="form-label-left" id="label_102"><label for="input_102"> Promo Code </label><label class="label-message" for="input_102"> </label></div><div id="cid_102" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_102" name="q102_input102" size="20" value="" /> </div></li><li class="form-line" id="id_103"><div class="form-label-left" id="label_103"><label for="input_103"> $50 Promo </label><label class="label-message" for="input_103"> </label></div><div id="cid_103" class="form-input"> <input type="number" readonly="readonly" class="form-number-input form-readonly  form-textbox" id="input_103" name="q103_number" style="width:60px" size="5" value="-50" data-type="input-number" autocomplete="nope" min="-50" data-numbermin="-50" max="-50" data-numbermax="-50" /> </div></li><li class="form-line" id="id_104"><div class="form-label-left" id="label_104"><label for="input_104"> $100 Promo ($50 per child) </label><label class="label-message" for="input_104"> </label></div><div id="cid_104" class="form-input"> <input type="number" readonly="readonly" class="form-number-input form-readonly  form-textbox" id="input_104" name="q104_number104" style="width:68px" size="6" value="-100" data-type="input-number" autocomplete="nope" min="-100" data-numbermin="-100" max="-100" data-numbermax="-100" /> </div></li><li class="form-line" id="id_105"><div class="form-label-left" id="label_105"><label for="input_105"> $150 Promo ($50 per child) </label><label class="label-message" for="input_105"> </label></div><div id="cid_105" class="form-input"> <input type="number" readonly="readonly" class="form-number-input form-readonly  form-textbox" id="input_105" name="q105_number105" style="width:68px" size="6" value="-150" data-type="input-number" autocomplete="nope" min="-150" data-numbermin="-150" max="-150" data-numbermax="-150" /> </div></li><li class="form-line" id="id_17"><div class="form-label-left" id="label_17"><label for="input_17"> Your card will be charged </label></div><div id="cid_17" class="form-input"> <div id="total_amount">$0.00 </div> </div></li><li class="form-line" id="id_2"><div id="cid_2" class="form-input-wide"> <div style="text-align: center; text-indent:156px;" class="form-buttons-wrapper button-align-auto"><button id="input_2" type="submit" class="form-submit-button  form-submit-button-none;">Submit</button></div> </div></li><li class="form-line" id="id_56"><div id="cid_56" class="form-input-wide"> <div id="text_56" class="form-html"><p style="text-align: center;">We look forward to a wonderful year of learning and growth!</p></div> </div></li><li style="display:none">Should be Empty: <input type="text" name="website" value="" /></li></ul></div><input type="hidden" id="simple_spc" name="simple_spc" value="4871035" /><script type="text/javascript">document.getElementById("si"+"mple"+"_spc").value = "4871035-4871035";</script><div>


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