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</div> </div></li><li id="cid_61" class="form-input-wide"> <div class="form-header-group"><h2 id="header_61" class="form-header">Student Information:</h2></div> </li><li class="form-line" id="id_4"><div class="form-label-left" id="label_4"><label for="input_4"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_4"> </label></div><div id="cid_4" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q4_fullName[first]" id="first_4" autocomplete="given-name" />  <label class="form-sub-label" for="first_4" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q4_fullName[last]" id="last_4" autocomplete="family-name" />  <label class="form-sub-label" for="last_4" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_5"><div 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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_80_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_10"><div class="form-label-left" id="label_10"><label for="input_10"> Time of Day:<span class="form-required">*</span> </label><label class="label-message" for="input_10"> </label></div><div id="cid_10" class="form-input"> <span class="dir_ltr inline_block"><span class="form-sub-label-container"><select class="noDefault form-dropdown validate[required]" id="input_10_hourSelect" name="q10_timeOf[hourSelect]"><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></select>  <label class="form-sub-label" for="input_10_hourSelect" id="sublabel_hour">Hour</label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" id="input_10_minuteSelect" name="q10_timeOf[minuteSelect]"><option></option><option value="00">00</option><option value="10">10</option><option value="20">20</option><option value="30">30</option><option value="40">40</option><option value="50">50</option></select>  <label class="form-sub-label" for="input_10_minuteSelect" id="sublabel_minutes">Minutes</label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" id="input_10_ampm" name="q10_timeOf[ampm]"><option></option><option value="AM">AM</option><option value="PM">PM</option></select>  <label class="form-sub-label" for="input_10_ampm"><span> </span></label></span></span> </div></li><li class="form-line" id="id_11"><div class="form-label-left" id="label_11"><label for="input_11"> School Currently Attending:<span class="form-required">*</span> </label><label class="label-message" for="input_11"> </label></div><div id="cid_11" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_11" name="q11_schoolCurrently" size="20" value="" /> </div></li><li id="cid_62" class="form-input-wide"> <div class="form-header-group"><h2 id="header_62" class="form-header">Family Information:</h2></div> </li><li class="form-line" id="id_14"><div class="form-label-left" id="label_14"><label for="input_14">   </label><label class="label-message" for="input_14"> </label></div><div id="cid_14" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_14_0" name="q14_input14[]" value="All family information is the same as the first child." /><label id="label_input_14_0" for="input_14_0"><span>All family information is the same as the first child.</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"> Address<span class="form-required">*</span> </label><label class="label-message" for="input_15"> </label></div><div id="cid_15" 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="q15_address[addr_line1]" id="input_15_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_15_addr_line1" id="sublabel_15_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="q15_address[addr_line2]" id="input_15_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_15_addr_line2" id="sublabel_15_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="q15_address[city]" id="input_15_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_15_city" id="sublabel_15_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q15_address[state]" id="input_15_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_15_state" id="sublabel_15_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="q15_address[postal]" id="input_15_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_15_postal" id="sublabel_15_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q15_address[country]" id="input_15_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_15_country" id="sublabel_15_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_16"><div class="form-label-left" id="label_16"><label for="input_16"> Home Phone Number: <span class="form-required">*</span> </label><label class="label-message" for="input_16"> </label></div><div id="cid_16" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q16_homePhone[area]" id="input_16_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_16_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q16_homePhone[phone]" id="input_16_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_16_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_17"><div class="form-label-left" id="label_17"><label for="input_17"> Father's Name:<span class="form-required">*</span> </label><label class="label-message" for="input_17"> </label></div><div id="cid_17" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_17" name="q17_fathersName" size="20" value="" /> </div></li><li class="form-line" id="id_18"><div class="form-label-left" id="label_18"><label for="input_18"> Hebrew Name:<span class="form-required">*</span> </label><label class="label-message" for="input_18"> </label></div><div id="cid_18" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_18" name="q18_hebrewName18" size="20" value="" /> </div></li><li class="form-line" id="id_19"><div class="form-label-left" id="label_19"><label for="input_19"> Work Phone Number: </label><label class="label-message" for="input_19"> </label></div><div id="cid_19" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q19_workPhone19[area]" id="input_19_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_19_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q19_workPhone19[phone]" id="input_19_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_19_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_20"><div class="form-label-left" id="label_20"><label for="input_20"> Cell Phone Number: </label><label class="label-message" for="input_20"> </label></div><div id="cid_20" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q20_cellPhone[area]" id="input_20_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_20_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q20_cellPhone[phone]" id="input_20_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_20_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_57"><div class="form-label-left" id="label_57"><label for="input_57"> Father's Occupation:<span class="form-required">*</span> </label><label class="label-message" for="input_57"> </label></div><div id="cid_57" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_57" name="q57_input57" size="20" value="" /> </div></li><li class="form-line" id="id_21"><div class="form-label-left" id="label_21"><label for="input_21"> Mother's Name: <span class="form-required">*</span> </label><label class="label-message" for="input_21"> </label></div><div id="cid_21" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_21" name="q21_mothersName" size="20" value="" /> </div></li><li class="form-line" id="id_22"><div class="form-label-left" id="label_22"><label for="input_22"> Hebrew Name:<span class="form-required">*</span> </label><label class="label-message" for="input_22"> </label></div><div id="cid_22" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_22" name="q22_hebrewName22" size="20" value="" /> </div></li><li class="form-line" id="id_23"><div class="form-label-left" id="label_23"><label for="input_23"> Work Phone Number:<span class="form-required">*</span> </label><label class="label-message" for="input_23"> </label></div><div id="cid_23" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q23_workPhone[area]" id="input_23_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_23_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q23_workPhone[phone]" id="input_23_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_23_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"> Cell Phone Number:<span class="form-required">*</span> </label><label class="label-message" for="input_24"> </label></div><div id="cid_24" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q24_cellPhone24[area]" id="input_24_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_24_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q24_cellPhone24[phone]" id="input_24_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_24_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_58"><div class="form-label-left" id="label_58"><label for="input_58"> Mother's Occupation:<span class="form-required">*</span> </label><label class="label-message" for="input_58"> </label></div><div id="cid_58" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_58" name="q58_input58" size="20" value="" /> </div></li><li class="form-line" id="id_25"><div class="form-label-left" id="label_25"><label for="input_25"> Mother's E-mail:<span class="form-required">*</span> </label><label class="label-message" for="input_25"> </label></div><div id="cid_25" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_25" name="q25_mothersEmail" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> Father's E-mail:<span class="form-required">*</span> </label><label class="label-message" for="input_26"> </label></div><div id="cid_26" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_26" name="q26_fathersEmail" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_27"><div class="form-label-left" id="label_27"><label for="input_27"> Which email would you like used for updates and newsletters?<span class="form-required">*</span> </label><label class="label-message" for="input_27"> </label></div><div id="cid_27" 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_27_0" name="q27_whichEmail" value="Mother's" /><label id="label_input_27_0" for="input_27_0"><span>Mother's</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_27_1" name="q27_whichEmail" value="Father's" /><label id="label_input_27_1" for="input_27_1"><span>Father's</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_27_2" name="q27_whichEmail" value="Both" /><label id="label_input_27_2" for="input_27_2"><span>Both</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_28"><div class="form-label-left" id="label_28"><label for="input_28"> Marital Status:<span class="form-required">*</span> </label><label class="label-message" for="input_28"> </label></div><div id="cid_28" 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_28_0" name="q28_maritalStatus" value="Married" /><label id="label_input_28_0" for="input_28_0"><span>Married</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_28_1" name="q28_maritalStatus" value="Single" /><label id="label_input_28_1" for="input_28_1"><span>Single</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_28_2" name="q28_maritalStatus" value="Divorced" /><label id="label_input_28_2" for="input_28_2"><span>Divorced</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_68" class="form-input-wide"> <div class="form-header-group"><h2 id="header_68" class="form-header">Grandparents Information (for Nachas reports):</h2><div id="subHeader_68" class="form-subHeader">We would love to send updates about your child to their grandparents throughout the year.</div></div> </li><li class="form-line" id="id_69"><div class="form-label-left" id="label_69"><label for="input_69"> Paternal Grandparents Full Name: </label><label class="label-message" for="input_69"> </label></div><div id="cid_69" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q69_fullName69[first]" id="first_69" autocomplete="given-name" />  <label class="form-sub-label" for="first_69" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q69_fullName69[last]" id="last_69" autocomplete="family-name" />  <label class="form-sub-label" for="last_69" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_70"><div class="form-label-left" id="label_70"><label for="input_70"> Address: </label><label class="label-message" for="input_70"> </label></div><div id="cid_70" 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 form-address-line" type="text" name="q70_address70[addr_line1]" id="input_70_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_70_addr_line1" id="sublabel_70_addr_line1">Street Address</label></span></td></tr><tr style="display: none;"><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q70_address70[addr_line2]" id="input_70_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_70_addr_line2" id="sublabel_70_addr_line2">Street Address Line 2</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q70_address70[city]" id="input_70_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_70_city" id="sublabel_70_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q70_address70[state]" id="input_70_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_70_state" id="sublabel_70_state">State / Province</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q70_address70[postal]" id="input_70_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_70_postal" id="sublabel_70_postal">Postal / Zip Code</label></span></td><td style="display: none;"><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q70_address70[country]" id="input_70_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_70_country" id="sublabel_70_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_72"><div class="form-label-left" id="label_72"><label for="input_72"> E-mail: </label><label class="label-message" for="input_72"> </label></div><div id="cid_72" class="form-input"> <input type="email" class=" form-textbox validate[Email]" id="input_72" name="q72_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_73"><div class="form-label-left" id="label_73"><label for="input_73"> Maternal Grandparents Full Name: </label><label class="label-message" for="input_73"> </label></div><div id="cid_73" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q73_fullName73[first]" id="first_73" autocomplete="given-name" />  <label class="form-sub-label" for="first_73" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q73_fullName73[last]" id="last_73" autocomplete="family-name" />  <label class="form-sub-label" for="last_73" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_74"><div class="form-label-left" id="label_74"><label for="input_74"> Address: </label><label class="label-message" for="input_74"> </label></div><div id="cid_74" 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 form-address-line" type="text" name="q74_address74[addr_line1]" id="input_74_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_74_addr_line1" id="sublabel_74_addr_line1">Street Address</label></span></td></tr><tr style="display: none;"><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q74_address74[addr_line2]" id="input_74_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_74_addr_line2" id="sublabel_74_addr_line2">Street Address Line 2</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q74_address74[city]" id="input_74_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_74_city" id="sublabel_74_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q74_address74[state]" id="input_74_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_74_state" id="sublabel_74_state">State / Province</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q74_address74[postal]" id="input_74_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_74_postal" id="sublabel_74_postal">Postal / Zip Code</label></span></td><td style="display: none;"><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q74_address74[country]" id="input_74_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 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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_74_country" id="sublabel_74_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_76"><div class="form-label-left" id="label_76"><label for="input_76"> E-mail: </label><label class="label-message" for="input_76"> </label></div><div id="cid_76" class="form-input"> <input type="email" class=" form-textbox validate[Email]" id="input_76" name="q76_email76" size="30" value="" autocomplete="email" /> </div></li><li id="cid_63" class="form-input-wide"> <div class="form-header-group"><h2 id="header_63" class="form-header">Religious &amp; Educational:</h2></div> </li><li class="form-line" id="id_30"><div class="form-label-left" id="label_30"><label for="input_30"> Previous Jewish Education:<span class="form-required">*</span> </label><label class="label-message" for="input_30"> </label></div><div id="cid_30" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_30" name="q30_previousJewish" size="20" value="" /> </div></li><li class="form-line" id="id_32"><div class="form-label-left" id="label_32"><label for="input_32"> Does your child have any learning difficulties with General Studies?<span class="form-required">*</span> </label><label class="label-message" for="input_32"> </label></div><div id="cid_32" 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_32_0" name="q32_doesYour32" value="Yes" /><label id="label_input_32_0" for="input_32_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_32_1" name="q32_doesYour32" value="No" /><label id="label_input_32_1" for="input_32_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_33"><div class="form-label-left" id="label_33"><label for="input_33"> If yes, please describe: </label><label class="label-message" for="input_33"> </label></div><div id="cid_33" class="form-input"> <textarea id="input_33" class="form-textarea" name="q33_ifYes33" cols="35" rows="3"></textarea> </div></li><li class="form-line" id="id_59"><div class="form-label-left" id="label_59"><label for="input_59"> Does your child have an IEP?<span class="form-required">*</span> </label><label class="label-message" for="input_59"> </label></div><div id="cid_59" 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_59_0" name="q59_input59" value="Yes" /><label id="label_input_59_0" for="input_59_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_59_1" name="q59_input59" value="No" /><label id="label_input_59_1" for="input_59_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_60"><div id="cid_60" class="form-input-wide"> <div id="text_60" class="form-html"><p style="text-align: center;"><em>*If yes, please submit a copy with the registration form.</em></p></div> </div></li><li class="form-line" id="id_34"><div class="form-label-left" id="label_34"><label for="input_34"> Is the natural mother of the child Jewish?<span class="form-required">*</span> </label><label class="label-message" for="input_34"> </label></div><div id="cid_34" 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_34_0" name="q34_isThe34" value="Yes" /><label id="label_input_34_0" for="input_34_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_34_1" name="q34_isThe34" value="No" /><label id="label_input_34_1" for="input_34_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_35"><div class="form-label-left" id="label_35"><label for="input_35"> Is the natural father of the child Jewish?<span class="form-required">*</span> </label><label class="label-message" for="input_35"> </label></div><div id="cid_35" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_35_0" name="q35_isThe" value="Yes" /><label id="label_input_35_0" for="input_35_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_35_1" name="q35_isThe" value="No" /><label id="label_input_35_1" for="input_35_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_36"><div class="form-label-left" id="label_36"><label for="input_36"> Is the maternal grandmother of the child Jewish?<span class="form-required">*</span> </label><label class="label-message" for="input_36"> </label></div><div id="cid_36" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_36_0" name="q36_isThe36" value="Yes" /><label id="label_input_36_0" for="input_36_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_36_1" name="q36_isThe36" value="No" /><label id="label_input_36_1" for="input_36_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_37"><div class="form-label-left" id="label_37"><label for="input_37"> Are there any conversions and/or adoptions in the family?<span class="form-required">*</span> </label><label class="label-message" for="input_37"> </label></div><div id="cid_37" 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_37_0" name="q37_areThere" value="Yes" /><label id="label_input_37_0" for="input_37_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_37_1" name="q37_areThere" value="No" /><label id="label_input_37_1" for="input_37_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_64" class="form-input-wide"> <div class="form-header-group"><h2 id="header_64" class="form-header">Medical Information:</h2></div> </li><li class="form-line" id="id_39"><div class="form-label-left" id="label_39"><label for="input_39"> Is there any special medical or other information that we should be aware of?<span class="form-required">*</span> </label><label class="label-message" for="input_39"> </label></div><div id="cid_39" 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_39_0" name="q39_isThere" value="Yes" /><label id="label_input_39_0" for="input_39_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_39_1" name="q39_isThere" value="No" /><label id="label_input_39_1" for="input_39_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_40"><div class="form-label-left" id="label_40"><label for="input_40"> If yes, please describe: </label><label class="label-message" for="input_40"> </label></div><div id="cid_40" class="form-input"> <textarea id="input_40" class="form-textarea" name="q40_ifYes40" cols="35" rows="3"></textarea> </div></li><li class="form-line" id="id_41"><div class="form-label-left" id="label_41"><label for="input_41"> Does your child have any allergies?<span class="form-required">*</span> </label><label class="label-message" for="input_41"> </label></div><div id="cid_41" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_41_0" name="q41_doesYour41" value="Yes" /><label id="label_input_41_0" for="input_41_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_41_1" name="q41_doesYour41" value="No" /><label id="label_input_41_1" for="input_41_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_42"><div class="form-label-left" id="label_42"><label for="input_42"> Is your child currently taking any medication?<span class="form-required">*</span> </label><label class="label-message" for="input_42"> </label></div><div id="cid_42" 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_42_0" name="q42_isYour" value="Yes" /><label id="label_input_42_0" for="input_42_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_42_1" name="q42_isYour" value="No" /><label id="label_input_42_1" for="input_42_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_47"><div class="form-label-left" id="label_47"><label for="input_47"> Emergency Contact #1:<span class="form-required">*</span> </label><label class="label-message" for="input_47"> </label></div><div id="cid_47" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_47" name="q47_emergencyContact" size="20" value="" /> </div></li><li class="form-line" id="id_48"><div class="form-label-left" id="label_48"><label for="input_48"> Relation: <span class="form-required">*</span> </label><label class="label-message" for="input_48"> </label></div><div id="cid_48" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_48" name="q48_relation" size="20" value="" /> </div></li><li class="form-line" id="id_49"><div class="form-label-left" id="label_49"><label for="input_49"> Phone Number:<span class="form-required">*</span> </label><label class="label-message" for="input_49"> </label></div><div id="cid_49" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q49_phoneNumber49[area]" id="input_49_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_49_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q49_phoneNumber49[phone]" id="input_49_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_49_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_50"><div class="form-label-left" id="label_50"><label for="input_50"> Emergency Contact #2:<span class="form-required">*</span> </label><label class="label-message" for="input_50"> </label></div><div id="cid_50" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_50" name="q50_emergencyContact50" size="20" value="" /> </div></li><li class="form-line" id="id_51"><div class="form-label-left" id="label_51"><label for="input_51"> Relation: <span class="form-required">*</span> </label><label class="label-message" for="input_51"> </label></div><div id="cid_51" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_51" name="q51_relation51" size="20" value="" /> </div></li><li class="form-line" id="id_52"><div class="form-label-left" id="label_52"><label for="input_52"> Phone Number:<span class="form-required">*</span> </label><label class="label-message" for="input_52"> </label></div><div id="cid_52" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q52_phoneNumber52[area]" id="input_52_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_52_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q52_phoneNumber52[phone]" id="input_52_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_52_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_54"><div 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