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Camp Gan Israel</div>
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fun forever!</div>
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<a href="/article.asp?aid=7285682" class="parent selected">Registration Form Copy 2</a>
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			<h1 class="article-header__title js-article-title js-page-title">Registration Form Copy 2</h1>
		
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You can also access the medical form \u003ca href=\"http://www.SACJewishLife.org/Article.asp?AID=2661255\"\u003e\u003cspan style=\"color: rgb(0, 0, 255);\"\u003ehere\u003c/span\u003e\u003c/a\u003e\u0026#160;if you would like to fill out a printed copy and mail it to the office.\u0026#160;\u003c/p\u003e","67_name":"doubleclickTo","67_qid":67,"67_type":"control_text","67_order":49,"form_title":"I would like to Donate","form_pagetitle":"Form","form_styles":"nova","form_font":"","form_fontsize":"14","form_fontcolor":"","form_optioncolor":"","form_lineSpacing":"12","form_background":"","form_formWidth":"685","form_labelWidth":"150","form_alignment":"Left","form_thankurl":"","form_thanktext":"","form_highlightLine":"Enabled","form_activeRedirect":"default","form_sendpostdata":"No","form_unique":"None","form_uniqueField":"\u003cField Id\u003e","form_status":"Enabled","form_injectCSS":"","form_hideMailEmptyFields":"disable","form_showProgressBar":"disable","form_formStrings":[{"alphabetic":"This field can only contain letters","alphanumeric":"This field can only contain letters and numbers.","confirmClearForm":"Are you sure you want to clear the form?","confirmEmail":"E-mail does not match","email":"Enter a valid e-mail address","generalError":"There are errors on the form. 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<form class="userform-form" action="" method="post" name="form_7285682" id="7285682" accept-charset="utf-8"><input type="hidden" name="formID" value="7285682" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><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_91"><div id="cid_91" class="form-input-wide"> <div id="text_91" class="form-html"><p>Dates: June 29th - July 17th</p>

<p>Kiddie Camp: Ages 2-5 </p>

<p>Older Camp: Ages 6-13 </p>

<p>Monday-Friday<br />
9:30 am-3:00 pm</p>
</div> </div></li><li class="form-line" id="id_3"><div class="form-label-left" id="label_3"><label for="input_3"> Child 1<span class="form-required">*</span> </label><label class="label-message" for="input_3"> </label></div><div id="cid_3" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q3_child1[first]" id="first_3" autocomplete="given-name" />  <label class="form-sub-label" for="first_3" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q3_child1[middle]" id="middle_3" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_3" id="sublabel_middle">Middle Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q3_child1[last]" id="last_3" autocomplete="family-name" />  <label class="form-sub-label" for="last_3" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_27"><div class="form-label-left" id="label_27"><label for="input_27"> Birth Date<span class="form-required">*</span> </label><label class="label-message" for="input_27"> </label></div><div id="cid_27" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q27_birthDate27[month]" id="input_27_month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_27_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q27_birthDate27[day]" id="input_27_day"><option></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select>  <label class="form-sub-label" for="input_27_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q27_birthDate27[year]" id="input_27_year"><option></option><option value="2026">2026</option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option><option value="1941">1941</option><option value="1940">1940</option><option value="1939">1939</option><option value="1938">1938</option><option value="1937">1937</option><option value="1936">1936</option><option value="1935">1935</option><option value="1934">1934</option><option value="1933">1933</option><option value="1932">1932</option><option value="1931">1931</option><option value="1930">1930</option><option value="1929">1929</option><option value="1928">1928</option><option value="1927">1927</option><option value="1926">1926</option><option value="1925">1925</option><option value="1924">1924</option><option value="1923">1923</option><option value="1922">1922</option><option value="1921">1921</option><option value="1920">1920</option></select>  <label class="form-sub-label" for="input_27_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_72"><div class="form-label-left" id="label_72"><label for="input_72"> Grade Entering<span class="form-required">*</span> </label><label class="label-message" for="input_72"> </label></div><div id="cid_72" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_72" name="q72_input72"><option value=""></option><option value="18 mo (if older sibling is attending kiddie camp)">18 mo (if older sibling is attending kiddie camp)</option><option value="Preschool ">Preschool </option><option value="Pre-K ">Pre-K </option><option value="Kindergarten ">Kindergarten </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></select> </div></li><li class="form-line" id="id_19"><div class="form-label-left" id="label_19"><label for="input_19"> Gender<span class="form-required">*</span> </label><label class="label-message" for="input_19"> </label></div><div id="cid_19" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_19_0" name="q19_gender" value="Male" /><label id="label_input_19_0" for="input_19_0"><span>Male</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_19_1" name="q19_gender" value="Female" /><label id="label_input_19_1" for="input_19_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_61"><div class="form-label-left" id="label_61"><label for="input_61"> Weeks Attending ($250/week)<span class="form-required">*</span> </label><label class="label-message" for="input_61"> </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 validate[required]" 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 validate[required]" 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 validate[required]" 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_88"><div class="form-label-left" id="label_88"><label for="input_88"> Camp t-shirt size<span class="form-required">*</span> </label><label class="label-message" for="input_88"> </label></div><div id="cid_88" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_88" name="q88_input88"><option value=""></option><option value="Youth XS">Youth XS</option><option value="Youth S">Youth S</option><option value="Youth M">Youth M</option><option value="Youth L">Youth L</option><option value="Youth XL">Youth XL</option><option value="Adult XS">Adult XS</option><option value="Adult S">Adult S</option><option value="Adult M">Adult M</option><option value="Adult L">Adult L</option><option value="Adult XL">Adult XL</option></select> </div></li><li class="form-line" id="id_15"><div class="form-label-left" id="label_15"><label for="input_15"> Child 2 </label><label class="label-message" for="input_15"> </label></div><div id="cid_15" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q15_child2[first]" id="first_15" autocomplete="given-name" />  <label class="form-sub-label" for="first_15" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q15_child2[middle]" id="middle_15" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_15" id="sublabel_middle">Middle Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q15_child2[last]" id="last_15" autocomplete="family-name" />  <label class="form-sub-label" for="last_15" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_28"><div class="form-label-left" id="label_28"><label for="input_28"> Birth Date </label><label class="label-message" for="input_28"> </label></div><div id="cid_28" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q28_birthDate28[month]" id="input_28_month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_28_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q28_birthDate28[day]" id="input_28_day"><option></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select>  <label class="form-sub-label" for="input_28_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q28_birthDate28[year]" id="input_28_year"><option></option><option value="2026">2026</option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option><option value="1941">1941</option><option value="1940">1940</option><option value="1939">1939</option><option value="1938">1938</option><option value="1937">1937</option><option value="1936">1936</option><option value="1935">1935</option><option value="1934">1934</option><option value="1933">1933</option><option value="1932">1932</option><option value="1931">1931</option><option value="1930">1930</option><option value="1929">1929</option><option value="1928">1928</option><option value="1927">1927</option><option value="1926">1926</option><option value="1925">1925</option><option value="1924">1924</option><option value="1923">1923</option><option value="1922">1922</option><option value="1921">1921</option><option value="1920">1920</option></select>  <label class="form-sub-label" for="input_28_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_73"><div class="form-label-left" id="label_73"><label for="input_73"> Grade Entering </label><label class="label-message" for="input_73"> </label></div><div id="cid_73" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_73" name="q73_input73"><option value=""></option><option value="18 mo (if older sibling is attending kiddie camp)">18 mo (if older sibling is attending kiddie camp)</option><option value="Preschool ">Preschool </option><option value="Pre-K">Pre-K</option><option value="Kindergarten ">Kindergarten </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></select> </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_68"><div class="form-label-left" id="label_68"><label for="input_68"> Weeks Attending ($250/week) </label><label class="label-message" for="input_68"> </label></div><div id="cid_68" class="form-input"> <div class="form-multiple-column"><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_68_0" name="q68_sessions68[]" value="Week 1" /><label id="label_input_68_0" for="input_68_0"><span>Week 1</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_68_1" name="q68_sessions68[]" value="Week 2" /><label id="label_input_68_1" for="input_68_1"><span>Week 2</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_68_2" name="q68_sessions68[]" value="Week 3" /><label id="label_input_68_2" for="input_68_2"><span>Week 3</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_89"><div class="form-label-left" id="label_89"><label for="input_89"> Camp t-shirt size </label><label class="label-message" for="input_89"> </label></div><div id="cid_89" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_89" name="q89_input89"><option value=""></option><option value="Youth XS">Youth XS</option><option value="Youth S">Youth S</option><option value="Youth M">Youth M</option><option value="Youth L">Youth L</option><option value="Youth XL">Youth XL</option><option value="Adult XS">Adult XS</option><option value="Adult S">Adult S</option><option value="Adult M">Adult M</option><option value="Adult L">Adult L</option><option value="Adult XL">Adult XL</option></select> </div></li><li class="form-line" id="id_14"><div class="form-label-left" id="label_14"><label for="input_14"> Child 3 </label><label class="label-message" for="input_14"> </label></div><div id="cid_14" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q14_child3[first]" id="first_14" autocomplete="given-name" />  <label class="form-sub-label" for="first_14" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q14_child3[middle]" id="middle_14" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_14" id="sublabel_middle">Middle Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q14_child3[last]" id="last_14" autocomplete="family-name" />  <label class="form-sub-label" for="last_14" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_29"><div class="form-label-left" id="label_29"><label for="input_29"> Birth Date </label><label class="label-message" for="input_29"> </label></div><div id="cid_29" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q29_birthDate29[month]" id="input_29_month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_29_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q29_birthDate29[day]" id="input_29_day"><option></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select>  <label class="form-sub-label" for="input_29_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q29_birthDate29[year]" id="input_29_year"><option></option><option value="2026">2026</option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option><option value="1941">1941</option><option value="1940">1940</option><option value="1939">1939</option><option value="1938">1938</option><option value="1937">1937</option><option value="1936">1936</option><option value="1935">1935</option><option value="1934">1934</option><option value="1933">1933</option><option value="1932">1932</option><option value="1931">1931</option><option value="1930">1930</option><option value="1929">1929</option><option value="1928">1928</option><option value="1927">1927</option><option value="1926">1926</option><option value="1925">1925</option><option value="1924">1924</option><option value="1923">1923</option><option value="1922">1922</option><option value="1921">1921</option><option value="1920">1920</option></select>  <label class="form-sub-label" for="input_29_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_74"><div class="form-label-left" id="label_74"><label for="input_74"> Grade Entering </label><label class="label-message" for="input_74"> </label></div><div id="cid_74" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_74" name="q74_input74"><option value=""></option><option value="18 mo (if older sibling is attending kiddie camp)">18 mo (if older sibling is attending kiddie camp)</option><option value="Preschool ">Preschool </option><option value="Pre-K ">Pre-K </option><option value="Kindergarten">Kindergarten</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></select> </div></li><li class="form-line" id="id_62"><div class="form-label-left" id="label_62"><label for="input_62"> Weeks Attending ($250/week) </label><label class="label-message" for="input_62"> </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_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_90"><div class="form-label-left" id="label_90"><label for="input_90"> Camp t-shirt size </label><label class="label-message" for="input_90"> </label></div><div id="cid_90" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_90" name="q90_input90"><option value=""></option><option value="Youth XS">Youth XS</option><option value="Youth S">Youth S</option><option value="Youth M">Youth M</option><option value="Youth L">Youth L</option><option value="Youth XL">Youth XL</option><option value="Adult XS">Adult XS</option><option value="Adult S">Adult S</option><option value="Adult M">Adult M</option><option value="Adult L">Adult L</option><option value="Adult XL">Adult XL</option></select> </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_24"><div class="form-label-left" id="label_24"><label for="input_24"> Address<span class="form-required">*</span> </label><label class="label-message" for="input_24"> </label></div><div id="cid_24" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-line" type="text" name="q24_address24[addr_line1]" id="input_24_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_24_addr_line1" id="sublabel_24_addr_line1">Street Address</label></span></td></tr><tr><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q24_address24[addr_line2]" id="input_24_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_24_addr_line2" id="sublabel_24_addr_line2">Street Address Line 2</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-city" type="text" name="q24_address24[city]" id="input_24_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_24_city" id="sublabel_24_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q24_address24[state]" id="input_24_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_24_state" id="sublabel_24_state">State / Province</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-postal" type="text" name="q24_address24[postal]" id="input_24_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_24_postal" id="sublabel_24_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q24_address24[country]" id="input_24_country" autocomplete="country-name"><option value="" selected="selected">Please Select</option><option value="United States">United States</option><option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="The Bahamas">The Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Brazil">Brazil</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burundi">Burundi</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cape Verde">Cape Verde</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="People's Republic of China">People's Republic of China</option><option value="Republic of China">Republic of China</option><option value="Christmas Island">Christmas Island</option><option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo">Congo</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Cote d'Ivoire">Cote d'Ivoire</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Eswatini">Eswatini</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Polynesia">French Polynesia</option><option value="Gabon">Gabon</option><option value="The Gambia">The Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jersey">Jersey</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="North Korea">North Korea</option><option value="South Korea">South Korea</option><option value="Kosovo">Kosovo</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Laos">Laos</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macau">Macau</option><option value="Macedonia">Macedonia</option><option value="Madagascar">Madagascar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Myanmar">Myanmar</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="Northern Mariana">Northern Mariana</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn Islands">Pitcairn Islands</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Barthelemy">Saint Barthelemy</option><option value="Saint Helena">Saint Helena</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="Somaliland">Somaliland</option><option value="South Africa">South Africa</option><option value="South Ossetia">South Ossetia</option><option value="Spain">Spain</option><option value="Sri Lanka">Sri Lanka</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Svalbard">Svalbard</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria">Syria</option><option value="Taiwan">Taiwan</option><option value="Tajikistan">Tajikistan</option><option value="Tanzania">Tanzania</option><option value="Thailand">Thailand</option><option value="Timor-Leste">Timor-Leste</option><option value="Togo">Togo</option><option value="Tokelau">Tokelau</option><option value="Tonga">Tonga</option><option value="Trinidad and Tobago">Trinidad and Tobago</option><option value="Tristan da Cunha">Tristan da Cunha</option><option value="Tunisia">Tunisia</option><option value="Turkey">Turkey</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks and Caicos Islands">Turks and Caicos Islands</option><option value="Tuvalu">Tuvalu</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="United Arab Emirates">United Arab Emirates</option><option value="United Kingdom">United Kingdom</option><option value="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Vatican City">Vatican City</option><option value="Venezuela">Venezuela</option><option value="Vietnam">Vietnam</option><option value="British Virgin Islands">British Virgin Islands</option><option value="US Virgin Islands">US Virgin Islands</option><option value="Wallis and Futuna">Wallis and Futuna</option><option value="Western Sahara">Western Sahara</option><option value="Yemen">Yemen</option><option value="Zambia">Zambia</option><option value="Zimbabwe">Zimbabwe</option><option value="other">Other</option></select>  <label class="form-sub-label" for="input_24_country" id="sublabel_24_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_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_33"><div class="form-label-left" id="label_33"><label for="input_33"> Work Phone </label><label class="label-message" for="input_33"> </label></div><div id="cid_33" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q33_workPhone[area]" id="input_33_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_33_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q33_workPhone[phone]" id="input_33_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_33_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_4"><div class="form-label-left" id="label_4"><label for="input_4"> E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_4"> Primary email</label></div><div id="cid_4" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_4" name="q4_email4" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_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_34"><div class="form-label-left" id="label_34"><label for="input_34"> Work Phone </label><label class="label-message" for="input_34"> </label></div><div id="cid_34" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q34_workPhone34[area]" id="input_34_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_34_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q34_workPhone34[phone]" id="input_34_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_34_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_35"><div class="form-label-left" id="label_35"><label for="input_35"> E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_35"> </label></div><div id="cid_35" class="form-input"> <input type="email" class=" form-textbox validate[required, 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="Email">Email</option><option value="Facebook">Facebook</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_78"><div id="cid_78" class="form-input-wide"> <div id="text_78" class="form-html"><p>Additional authorized persons to pick up my child:</p></div> </div></li><li class="form-line" id="id_79"><div class="form-label-left" id="label_79"><label for="input_79"> Full Name </label><label class="label-message" for="input_79"> </label></div><div id="cid_79" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q79_fullName[first]" id="first_79" autocomplete="given-name" />  <label class="form-sub-label" for="first_79" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q79_fullName[last]" id="last_79" autocomplete="family-name" />  <label class="form-sub-label" for="last_79" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_80"><div class="form-label-left" id="label_80"><label for="input_80"> Cell Phone </label><label class="label-message" for="input_80"> </label></div><div id="cid_80" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q80_phoneNumber[area]" id="input_80_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_80_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q80_phoneNumber[phone]" id="input_80_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_80_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_81"><div class="form-label-left" id="label_81"><label for="input_81"> Full Name </label><label class="label-message" for="input_81"> </label></div><div id="cid_81" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q81_fullName81[first]" id="first_81" autocomplete="given-name" />  <label class="form-sub-label" for="first_81" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q81_fullName81[last]" id="last_81" autocomplete="family-name" />  <label class="form-sub-label" for="last_81" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_82"><div class="form-label-left" id="label_82"><label for="input_82"> Cell Phone </label><label class="label-message" for="input_82"> </label></div><div id="cid_82" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q82_phoneNumber82[area]" id="input_82_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_82_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q82_phoneNumber82[phone]" id="input_82_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_82_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_83"><div id="cid_83" class="form-input-wide"> <div id="text_83" class="form-html"><p><strong>*This is on the Medical Form as well*</strong><br />In case of an accident or serious illness involving my child whenever the child is in attendance at Camp Gan Israel, I request The Camp to telephone me at the above listed telephone. If in the judgment of The Camp, delay entailed in telephoning me or other persons named above would not be in the best interest of my child, I hereby authorize The Camp before telephoning me to take my child to any physician or surgeon selected by The Camp and licensed under the provision of the California Medical Practice Act, to any physician or surgeon selected by the director for such action as such physician or surgeon deems necessary or advisable in the circumstances. I hereby consent to any and all diagnostic procedures, examinations, care and treatment (including without limitation, X-ray examination, anesthetic and emergency surgical intervention) as any such physician or surgeon may deem necessary or advisable, whether such diagnostic procedure, examination, care or treatment is rendered at the office of such physician, surgeon or dentist or at a hospital or clinic. I understand that this authorization is given in advance of any specific diagnosis, examination, care or treatment being rendered and is given to provide authority and power on the part of any such physician or surgeon to render any and all such diagnostic procedures, examinations, care or treatment that he or she may deem necessary or advisable. I certify that no information concerning the health of this counselor/camper has been withheld or misrepresented. I authorize our physician to provide further medical history should it be deemed necessary. This completed form may be photocopied for trips out of camp. I hereby give permission, for my child registered in any of the Monday – Friday programs of Camp Gan Israel, to be taken by school bus on all outings and trips. I give permission to Camp Gan Israel to use camp photos of my child/ren in any camp publicity. I understand that refund of payment is subject to Camp Gan Israel refund policies, as written in the parent handbook.</p></div> </div></li><li class="form-line" id="id_84"><div class="form-label-left" id="label_84"><label for="input_84"> Agreement<span class="form-required">*</span> </label><label class="label-message" for="input_84"> </label></div><div id="cid_84" 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_84_0" name="q84_input84[]" value="I agree" /><label id="label_input_84_0" for="input_84_0"><span>I agree</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_86"><div class="form-label-left" id="label_86"><label for="input_86"> Name<span class="form-required">*</span> </label><label class="label-message" for="input_86"> </label></div><div id="cid_86" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_86" name="q86_input86" size="20" value="" /> </div></li><li class="form-line" id="id_87"><div class="form-label-left" id="label_87"><label for="input_87"> Initials<span class="form-required">*</span> </label><label class="label-message" for="input_87"> </label></div><div id="cid_87" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_87" name="q87_input87" size="20" value="" /> </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_56"><div class="form-label-left" id="label_56"><label for="input_56"> Total </label></div><div id="cid_56" class="form-input"> <div id="total_amount">$0.00 </div> </div></li><li class="form-line" id="id_49"><div class="form-label-left" id="label_49"><label for="input_49"> Payment<span class="form-required">*</span> </label><label class="label-message" for="input_49"> </label></div><div id="cid_49" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2" class="form-payment-methods form-multiple-column"><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_49_creditCard" name="q49_payment49[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_49_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_49_paypal" name="q49_payment49[payment_method]" value="paypal" onclick="BuildSource.paypal(this)" /><label for="input_49_paypal">Paypal</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, 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[required, visible, creditcard]" type="text" name="q49_payment49[cc_number]" id="input_49_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_49_cc_number" id="sublabel_cc_number">Credit Card Number</label></span></div></td><td class="cc_ccv "><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q49_payment49[cc_ccv]" id="input_49_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_49_cc_ccv" id="sublabel_cc_ccv">Security Code</label></span></td></tr><tr><td colspan="2" class="cc_name_on_card "><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q49_payment49[cc_nameOnCard]" id="input_49_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_49_cc_nameOnCard" id="sublabel_cc_nameOnCard">Name on Card</label></span></td></tr><tr class="credit_card hide"><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q49_payment49[cc_exp_month]" id="input_49_cc_exp_month" autocomplete="cc-exp-month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_49_cc_exp_month" id="sublabel_cc_exp_month">Expiration Month</label></span></td><td><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q49_payment49[cc_exp_year]" id="input_49_cc_exp_year" autocomplete="cc-exp-year"><option></option><option value="2026">2026</option><option value="2027">2027</option><option value="2028">2028</option><option value="2029">2029</option><option value="2030">2030</option><option value="2031">2031</option><option value="2032">2032</option><option value="2033">2033</option><option value="2034">2034</option><option value="2035">2035</option></select>  <label class="form-sub-label" for="input_49_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="paypal hide"><td colspan="2">Paypal has been selected. Payment will take place on the next page.</td></tr><tr class="other hide"><td colspan="2"></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"> Any notes or additional info: </label><label class="label-message" for="input_66"> </label></div><div id="cid_66" class="form-input"> <textarea id="input_66" class="form-textarea" name="q66_generalComments66" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_67"><div id="cid_67" class="form-input-wide"> <div id="text_67" class="form-html"><p>Registration is not complete until the medical form is filled out for each child. </p><p>A form will be emailed to you via DocHub to fill out online. You can also access the medical form <a href="http://www.SACJewishLife.org/Article.asp?AID=2661255"><span style="color: rgb(0, 0, 255);">here</span></a> if you would like to fill out a printed copy and mail it to the office. </p></div> </div></li><li style="display:none">Should be Empty: <input type="text" name="website" value="" /></li><li class="form-line" id="id_92"><div id="cid_92" class="form-input-wide"><div style="text-align:center" class="form-buttons-wrapper"><button id="input_92" 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="7285682" /><script type="text/javascript">document.getElementById("si"+"mple"+"_spc").value = "7285682-7285682";</script><div>


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<u>SUMMER 2025:</u></span></div>
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