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<form class="userform-form" action="" method="post" name="form_5069190" id="5069190" accept-charset="utf-8"><input type="hidden" name="formID" value="5069190" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li class="form-line" id="id_64"><div id="cid_64" class="form-input-wide"> <div id="text_64" class="form-html"><p>Camp Gan Israel is a camp dedicated to enriching the lives of children from diverse Jewish backgrounds and affiliations through a stimulating camping experience with innovative ideas and creative activities, to both provide enjoyment and inspire children!</p><p><a href="http://www.CGIDayton.com/Article.asp?AID=283563">For dates &amp; rates, click here. </a></p></div> </div></li><li id="cid_9" class="form-input-wide"> <div class="form-header-group"><h2 id="header_9" class="form-header">1. Child/ren’s Information</h2></div> </li><li class="form-line" id="id_3"><div class="form-label-left" id="label_3"><label for="input_3"> Child 1<span class="form-required">*</span> </label><label class="label-message" for="input_3"> </label></div><div id="cid_3" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q3_child1[first]" id="first_3" autocomplete="given-name" />  <label class="form-sub-label" for="first_3" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q3_child1[middle]" id="middle_3" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_3" id="sublabel_middle">Middle Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q3_child1[last]" id="last_3" autocomplete="family-name" />  <label class="form-sub-label" for="last_3" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_27"><div class="form-label-left" id="label_27"><label for="input_27"> Birth Date<span class="form-required">*</span> </label><label class="label-message" for="input_27"> </label></div><div id="cid_27" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q27_birthDate27[month]" id="input_27_month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_27_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q27_birthDate27[day]" id="input_27_day"><option></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select>  <label class="form-sub-label" for="input_27_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q27_birthDate27[year]" id="input_27_year"><option></option><option value="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></select>  <label class="form-sub-label" for="input_27_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_19"><div class="form-label-left" id="label_19"><label for="input_19"> Gender<span class="form-required">*</span> </label><label class="label-message" for="input_19"> </label></div><div id="cid_19" class="form-input"> <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_19_0" name="q19_gender" value="Male" /><label id="label_input_19_0" for="input_19_0"><span>Male</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_19_1" name="q19_gender" value="Female" /><label id="label_input_19_1" for="input_19_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_54"><div class="form-label-left" id="label_54"><label for="input_54"> Sessions ($250 per session)<span class="form-required">*</span> </label><label class="label-message" for="input_54"> $225/week early bird</label></div><div id="cid_54" class="form-input"> <div class="form-multiple-column"><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox validate[required]" id="input_54_0" name="q54_sessions200[]" value="Week 1 (July 20)" /><label id="label_input_54_0" for="input_54_0"><span>Week 1 (July 20)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox validate[required]" id="input_54_1" name="q54_sessions200[]" value="Week 2 (July 27)" /><label id="label_input_54_1" for="input_54_1"><span>Week 2 (July 27)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox validate[required]" id="input_54_2" name="q54_sessions200[]" value="Week 3 (Aug. 3)" /><label id="label_input_54_2" for="input_54_2"><span>Week 3 (Aug. 3)</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_15"><div class="form-label-left" id="label_15"><label for="input_15"> Child 2 </label><label class="label-message" for="input_15"> </label></div><div id="cid_15" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q15_child2[first]" id="first_15" autocomplete="given-name" />  <label class="form-sub-label" for="first_15" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q15_child2[middle]" id="middle_15" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_15" id="sublabel_middle">Middle Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q15_child2[last]" id="last_15" autocomplete="family-name" />  <label class="form-sub-label" for="last_15" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_28"><div class="form-label-left" id="label_28"><label for="input_28"> Birth Date </label><label class="label-message" for="input_28"> </label></div><div id="cid_28" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q28_birthDate28[month]" id="input_28_month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_28_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q28_birthDate28[day]" id="input_28_day"><option></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select>  <label class="form-sub-label" for="input_28_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q28_birthDate28[year]" id="input_28_year"><option></option><option value="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></select>  <label class="form-sub-label" for="input_28_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_20"><div class="form-label-left" id="label_20"><label for="input_20"> Gender </label><label class="label-message" for="input_20"> </label></div><div id="cid_20" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_20_0" name="q20_gender20" value="Male" /><label id="label_input_20_0" for="input_20_0"><span>Male</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_20_1" name="q20_gender20" value="Female" /><label id="label_input_20_1" for="input_20_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_61"><div class="form-label-left" id="label_61"><label for="input_61"> Sessions ($250 per session) </label><label class="label-message" for="input_61"> $225/week early bird</label></div><div id="cid_61" class="form-input"> <div class="form-multiple-column"><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_61_0" name="q61_sessions61[]" value="Week 1" /><label id="label_input_61_0" for="input_61_0"><span>Week 1</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_61_1" name="q61_sessions61[]" value="Week 2" /><label id="label_input_61_1" for="input_61_1"><span>Week 2</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_61_2" name="q61_sessions61[]" value="Week 3" /><label id="label_input_61_2" for="input_61_2"><span>Week 3</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_14"><div class="form-label-left" id="label_14"><label for="input_14"> Child 3 </label><label class="label-message" for="input_14"> </label></div><div id="cid_14" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q14_child3[first]" id="first_14" autocomplete="given-name" />  <label class="form-sub-label" for="first_14" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q14_child3[middle]" id="middle_14" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_14" id="sublabel_middle">Middle Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q14_child3[last]" id="last_14" autocomplete="family-name" />  <label class="form-sub-label" for="last_14" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_29"><div class="form-label-left" id="label_29"><label for="input_29"> Birth Date </label><label class="label-message" for="input_29"> </label></div><div id="cid_29" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q29_birthDate29[month]" id="input_29_month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_29_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q29_birthDate29[day]" id="input_29_day"><option></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select>  <label class="form-sub-label" for="input_29_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q29_birthDate29[year]" id="input_29_year"><option></option><option value="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></select>  <label class="form-sub-label" for="input_29_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_22"><div class="form-label-left" id="label_22"><label for="input_22"> Gender </label><label class="label-message" for="input_22"> </label></div><div id="cid_22" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_22_0" name="q22_gender22" value="Male" /><label id="label_input_22_0" for="input_22_0"><span>Male</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_22_1" name="q22_gender22" value="Female" /><label id="label_input_22_1" for="input_22_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_62"><div class="form-label-left" id="label_62"><label for="input_62"> Sessions ($250 per session) </label><label class="label-message" for="input_62"> $225/week early bird</label></div><div id="cid_62" class="form-input"> <div class="form-multiple-column"><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_62_0" name="q62_sessions62[]" value="Week 1" /><label id="label_input_62_0" for="input_62_0"><span>Week 1</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_62_1" name="q62_sessions62[]" value="Week 2" /><label id="label_input_62_1" for="input_62_1"><span>Week 2</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_62_2" name="q62_sessions62[]" value="Week 3" /><label id="label_input_62_2" for="input_62_2"><span>Week 3</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_16"><div class="form-label-left" id="label_16"><label for="input_16"> Child 4 </label><label class="label-message" for="input_16"> </label></div><div id="cid_16" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q16_child4[first]" id="first_16" autocomplete="given-name" />  <label class="form-sub-label" for="first_16" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q16_child4[middle]" id="middle_16" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_16" id="sublabel_middle">Middle Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q16_child4[last]" id="last_16" autocomplete="family-name" />  <label class="form-sub-label" for="last_16" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_30"><div class="form-label-left" id="label_30"><label for="input_30"> Birth Date </label><label class="label-message" for="input_30"> </label></div><div id="cid_30" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q30_birthDate30[month]" id="input_30_month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_30_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q30_birthDate30[day]" id="input_30_day"><option></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select>  <label class="form-sub-label" for="input_30_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q30_birthDate30[year]" id="input_30_year"><option></option><option value="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></select>  <label class="form-sub-label" for="input_30_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_21"><div class="form-label-left" id="label_21"><label for="input_21"> Gender </label><label class="label-message" for="input_21"> </label></div><div id="cid_21" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_21_0" name="q21_gender21" value="Male" /><label id="label_input_21_0" for="input_21_0"><span>Male</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_21_1" name="q21_gender21" value="Female" /><label id="label_input_21_1" for="input_21_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_63"><div class="form-label-left" id="label_63"><label for="input_63"> Sessions ($250 per session) </label><label class="label-message" for="input_63"> $225/week early bird</label></div><div id="cid_63" class="form-input"> <div class="form-multiple-column"><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_63_0" name="q63_sessions63[]" value="Week 1" /><label id="label_input_63_0" for="input_63_0"><span>Week 1</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_63_1" name="q63_sessions63[]" value="Week 2" /><label id="label_input_63_1" for="input_63_1"><span>Week 2</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_63_2" name="q63_sessions63[]" value="Week 3" /><label id="label_input_63_2" for="input_63_2"><span>Week 3</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_25" class="form-input-wide"> <div class="form-header-group"><h2 id="header_25" class="form-header">2. Parent information</h2></div> </li><li class="form-line" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> Phone Number </label><label class="label-message" for="input_26"> </label></div><div id="cid_26" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q26_phoneNumber26[area]" id="input_26_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_26_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q26_phoneNumber26[phone]" id="input_26_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_26_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_24"><div class="form-label-left" id="label_24"><label for="input_24"> Address<span class="form-required">*</span> </label><label class="label-message" for="input_24"> </label></div><div id="cid_24" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-line" type="text" name="q24_address24[addr_line1]" id="input_24_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_24_addr_line1" id="sublabel_24_addr_line1">Street Address</label></span></td></tr><tr><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q24_address24[addr_line2]" id="input_24_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_24_addr_line2" id="sublabel_24_addr_line2">Street Address Line 2</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-city" type="text" name="q24_address24[city]" id="input_24_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_24_city" id="sublabel_24_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q24_address24[state]" id="input_24_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_24_state" id="sublabel_24_state">State / Province</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-postal" type="text" name="q24_address24[postal]" id="input_24_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_24_postal" id="sublabel_24_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q24_address24[country]" id="input_24_country" autocomplete="country-name"><option value="" selected="selected">Please Select</option><option selected="selected" value="United States">United States</option><option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="The Bahamas">The Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Brazil">Brazil</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burundi">Burundi</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cape Verde">Cape Verde</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="People's Republic of China">People's Republic of China</option><option value="Republic of China">Republic of China</option><option value="Christmas Island">Christmas Island</option><option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo">Congo</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Cote d'Ivoire">Cote d'Ivoire</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Eswatini">Eswatini</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Polynesia">French Polynesia</option><option value="Gabon">Gabon</option><option value="The Gambia">The Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jersey">Jersey</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="North Korea">North Korea</option><option value="South Korea">South Korea</option><option value="Kosovo">Kosovo</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Laos">Laos</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macau">Macau</option><option value="Macedonia">Macedonia</option><option value="Madagascar">Madagascar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Myanmar">Myanmar</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="Northern Mariana">Northern Mariana</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn Islands">Pitcairn Islands</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Barthelemy">Saint Barthelemy</option><option value="Saint Helena">Saint Helena</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="Somaliland">Somaliland</option><option value="South Africa">South Africa</option><option value="South Ossetia">South Ossetia</option><option value="Spain">Spain</option><option value="Sri Lanka">Sri Lanka</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Svalbard">Svalbard</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria">Syria</option><option value="Taiwan">Taiwan</option><option value="Tajikistan">Tajikistan</option><option value="Tanzania">Tanzania</option><option value="Thailand">Thailand</option><option value="Timor-Leste">Timor-Leste</option><option value="Togo">Togo</option><option value="Tokelau">Tokelau</option><option value="Tonga">Tonga</option><option value="Trinidad and Tobago">Trinidad and Tobago</option><option value="Tristan da Cunha">Tristan da Cunha</option><option value="Tunisia">Tunisia</option><option value="Turkey">Turkey</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks and Caicos Islands">Turks and Caicos Islands</option><option value="Tuvalu">Tuvalu</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="United Arab Emirates">United Arab Emirates</option><option value="United Kingdom">United Kingdom</option><option value="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Vatican City">Vatican City</option><option value="Venezuela">Venezuela</option><option value="Vietnam">Vietnam</option><option value="British Virgin Islands">British Virgin Islands</option><option value="US Virgin Islands">US Virgin Islands</option><option value="Wallis and Futuna">Wallis and Futuna</option><option value="Western Sahara">Western Sahara</option><option value="Yemen">Yemen</option><option value="Zambia">Zambia</option><option value="Zimbabwe">Zimbabwe</option><option value="other">Other</option></select>  <label class="form-sub-label" for="input_24_country" id="sublabel_24_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_23"><div class="form-label-left" id="label_23"><label for="input_23"> Mother's info </label><label class="label-message" for="input_23"> </label></div><div id="cid_23" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q23_mothersInfo[first]" id="first_23" autocomplete="given-name" />  <label class="form-sub-label" for="first_23" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q23_mothersInfo[last]" id="last_23" autocomplete="family-name" />  <label class="form-sub-label" for="last_23" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_4"><div class="form-label-left" id="label_4"><label for="input_4"> E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_4"> Primary email</label></div><div id="cid_4" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_4" name="q4_email4" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_36"><div class="form-label-left" id="label_36"><label for="input_36"> Cell Phone </label><label class="label-message" for="input_36"> </label></div><div id="cid_36" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q36_cellPhone36[area]" id="input_36_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_36_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q36_cellPhone36[phone]" id="input_36_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_36_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_32"><div class="form-label-left" id="label_32"><label for="input_32"> Father's info </label><label class="label-message" for="input_32"> </label></div><div id="cid_32" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q32_fathersInfo[first]" id="first_32" autocomplete="given-name" />  <label class="form-sub-label" for="first_32" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q32_fathersInfo[last]" id="last_32" autocomplete="family-name" />  <label class="form-sub-label" for="last_32" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_35"><div class="form-label-left" id="label_35"><label for="input_35"> E-mail </label><label class="label-message" for="input_35"> </label></div><div id="cid_35" class="form-input"> <input type="email" class=" form-textbox validate[Email]" id="input_35" name="q35_email35" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_31"><div class="form-label-left" id="label_31"><label for="input_31"> Cell Phone </label><label class="label-message" for="input_31"> </label></div><div id="cid_31" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q31_cellPhone[area]" id="input_31_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_31_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q31_cellPhone[phone]" id="input_31_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_31_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_45"><div class="form-label-left" id="label_45"><label for="input_45"> How did you hear of us? </label><label class="label-message" for="input_45"> </label></div><div id="cid_45" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_45" name="q45_howDid"><option value=""></option><option value="Mailer">Mailer</option><option value="Email">Email</option><option value="Facebook">Facebook</option><option value="Newspaper Ad">Newspaper Ad</option><option value="Internet Search">Internet Search</option><option value="Attended Previously">Attended Previously</option><option value="Other">Other</option></select> </div></li><li id="cid_37" class="form-input-wide"> <div class="form-header-group"><h2 id="header_37" class="form-header">3. Emergency Information</h2></div> </li><li class="form-line" id="id_38"><div class="form-label-left" id="label_38"><label for="input_38"> Emergency Contact<span class="form-required">*</span> </label><label class="label-message" for="input_38"> </label></div><div id="cid_38" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q38_emergencyContact[first]" id="first_38" autocomplete="given-name" />  <label class="form-sub-label" for="first_38" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q38_emergencyContact[last]" id="last_38" autocomplete="family-name" />  <label class="form-sub-label" for="last_38" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_39"><div class="form-label-left" id="label_39"><label for="input_39"> Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_39"> </label></div><div id="cid_39" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q39_phoneNumber39[area]" id="input_39_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_39_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q39_phoneNumber39[phone]" id="input_39_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_39_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_40"><div class="form-label-left" id="label_40"><label for="input_40"> Relationship<span class="form-required">*</span> </label><label class="label-message" for="input_40"> </label></div><div id="cid_40" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_40" name="q40_relationship" size="20" value="" /> </div></li><li class="form-line" id="id_41"><div class="form-label-left" id="label_41"><label for="input_41"> Pediatrician &amp; Insurance </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" type="text" size="10" name="q41_pediatricianamp[first]" id="first_41" autocomplete="given-name" />  <label class="form-sub-label" for="first_41" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q41_pediatricianamp[last]" id="last_41" autocomplete="family-name" />  <label class="form-sub-label" for="last_41" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_42"><div class="form-label-left" id="label_42"><label for="input_42"> Phone Number </label><label class="label-message" for="input_42"> </label></div><div id="cid_42" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q42_phoneNumber42[area]" id="input_42_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_42_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q42_phoneNumber42[phone]" id="input_42_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_42_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_43"><div class="form-label-left" id="label_43"><label for="input_43"> Insurance </label><label class="label-message" for="input_43"> </label></div><div id="cid_43" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_43" name="q43_insurance" size="20" value="" /> </div></li><li class="form-line" id="id_44"><div class="form-label-left" id="label_44"><label for="input_44">  Policy # </label><label class="label-message" for="input_44"> </label></div><div id="cid_44" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_44" name="q44_Policy" size="20" value="" /> </div></li><li class="form-line" id="id_51"><div class="form-label-left" id="label_51"><label for="input_51"> Agreement<span class="form-required">*</span> </label><label class="label-message" for="input_51"> </label></div><div id="cid_51" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_51_0" name="q51_agreement[]" value="I am signing up my child for camp. I give my child permission to attend all trips and receive medical care in the case of emergency, G-d forbid.   I give Gan Israel permission to photograph and videotape my children and use the photos and videos (without their names) for whatever the camp sees fit." /><label id="label_input_51_0" for="input_51_0"><span>I am signing up my child for camp. I give my child permission to attend all trips and receive medical care in the case of emergency, G-d forbid.   I give Gan Israel permission to photograph and videotape my children and use the photos and videos (without their names) for whatever the camp sees fit.</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_52" class="form-input-wide"> <div class="form-header-group"><h2 id="header_52" class="form-header">4. Payment Information</h2></div> </li><li class="form-line" id="id_68"><div id="cid_68" class="form-input-wide"> <div id="text_68" class="form-html"><p>Full payment is NOT required at registration. <br />Please put an amount in the other field for partial payment.</p></div> </div></li><li class="form-line" id="id_67"><div class="form-label-left" id="label_67"><label for="input_67"> Total: 5% discount for multiple campers </label></div><div id="cid_67" class="form-input"> <div id="total_amount">$0.00 </div><br /><div class="clearfix form-single-column top_padding" id="payformWrapper"><label class="form-header form-label-left">I would like to pay today:</label><span class="form-radio-item"><label><input type="radio" class="form-radio validate[partialPayment]" value="full" name="partial" checked="checked" id="input_partial_1" />Full amount</label></span><span class="form-radio-item"><input type="radio" class="form-radio validate[partialPayment]" value="minimum" name="partial" id="input_partial_2" /><label for="input_partial_2"><span>$<span id="payformMin">0.00</span>  minimum</span></label></span><span class="form-radio-item"><label><input type="radio" class="form-other form-radio validate[partialPayment]" value="custom" name="partial" id="other_partial" />$<input type="text" onclick="document.getElementById('other_partial').checked = true" class="form-radio-other-input validate[customPartial]" id="input_partial" name="partialamount" data-otherhint="Other" onkeypress="validateNumber(event)" /> </label></span></div> </div></li><li class="form-line" id="id_49"><div class="form-label-left" id="label_49"><label for="input_49"> Payment </label><label class="label-message" for="input_49"> </label></div><div id="cid_49" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2" class="form-payment-methods form-multiple-column"><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_49_creditCard" name="q49_payment49[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_49_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_49_other" name="q49_payment49[payment_method]" value="other" onclick="BuildSource.other(this)" /><label for="input_49_other">Check</label> </span></td></tr><tr class="credit_card hide"><th colspan="2">Credit Card</th></tr><tr class="credit_card hide"><td colspan="2" style="padding:0"><table cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container">  <label class="form-sub-label">We accept Visa, MasterCard, American Express, Discover</label></span><div class="cc-icons"><div class="cc-icon visa-icon"></div><div class="cc-icon mastercard-icon"></div><div class="cc-icon amex-icon"></div><div class="cc-icon discover-icon"></div></div><input type="hidden" name="q49_payment49[cc_type]" id="input_49_cc_type" value="" /></td></tr><tr><td><div class="cc-field-wrapper"><span class="form-sub-label-container"><input class="form-textbox form-creditcard js-cc-number validate[visible, creditcard]" type="text" name="q49_payment49[cc_number]" id="input_49_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_49_cc_number" id="sublabel_cc_number">Credit Card Number</label></span></div></td><td class="cc_ccv "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q49_payment49[cc_ccv]" id="input_49_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_49_cc_ccv" id="sublabel_cc_ccv">Security Code</label></span></td></tr><tr><td colspan="2" class="cc_name_on_card "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q49_payment49[cc_nameOnCard]" id="input_49_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_49_cc_nameOnCard" id="sublabel_cc_nameOnCard">Name on Card</label></span></td></tr><tr class="credit_card hide"><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q49_payment49[cc_exp_month]" id="input_49_cc_exp_month" autocomplete="cc-exp-month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_49_cc_exp_month" id="sublabel_cc_exp_month">Expiration Month</label></span></td><td><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q49_payment49[cc_exp_year]" id="input_49_cc_exp_year" autocomplete="cc-exp-year"><option></option><option value="2025">2025</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></select>  <label class="form-sub-label" for="input_49_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="other hide"><td colspan="2">Please mail check payable to Chabad of Greater Dayton, 2001 Far Hills Ave., Dayton, OH 45419</td></tr></tbody></table> </div></li><li class="form-line" id="id_66"><div class="form-label-left" id="label_66"><label for="input_66"> General comments </label><label class="label-message" for="input_66"> </label></div><div id="cid_66" class="form-input"> <textarea id="input_66" class="form-textarea" name="q66_generalComments66" cols="40" rows="6"></textarea> </div></li><li style="display:none">Should be Empty: <input type="text" name="website" value="" /></li><li class="form-line" id="id_69"><div id="cid_69" class="form-input-wide"><div style="text-align:center" class="form-buttons-wrapper"><button id="input_69" 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="5069190" /><script type="text/javascript">document.getElementById("si"+"mple"+"_spc").value = "5069190-5069190";</script><div>


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