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	Camp Registration form - Chabad of Weston
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			<h1 class="article-header__title js-article-title js-page-title">Camp Registration form</h1>
		
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Without a payment schedule registrations are not saved and your place is not confirmed. Refund policy: Camp Gan Israel offers complete refunds of all fees up until one week before your program start date minus a $75 cancellation fee. To cancel a session please contact our office. Other cancellations: no refunds available from 7 days before program start date. Please note: We are unable to offer any refunds for illness of a camper that prevents him/​her from attending our program. If Camp Gan Israel is forced to cancel or temporarily close a program due to an infection, Camp Gan Israel will offer a full refund for unused days (prorated) to all campers affected. 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<form class="userform-form" action="" method="post" name="form_6814208" id="6814208" accept-charset="utf-8"><input type="hidden" name="formID" value="6814208" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li class="form-line" id="id_1"><div id="cid_1" class="form-input-wide"> <div id="text_1" class="form-html"><p style="text-align: center;"><span style="font-size:16px;">Rates</span></p>

<p style="text-align: center;"><span style="font-size:16px;"><strong>Early Bird Weekly Rate</strong>: $320 Members |  $340 Non Members</span></p>

<p style="text-align: center;"><span style="font-size:16px;"><strong>After April 1: </strong>$340 Members |  $360 Non Members</span></p>

<p style="text-align: center;"><span style="font-size:16px;">$100 Registration fee per family</span></p>

<p style="text-align: center;"><span style="font-size:16px;">5% Sibling Discount</span></p>



<p style="text-align: center;"><span style="font-size:16px;">Your bill will be sent to you via email after your child is accepted to camp</span></p>
</div> </div></li><li id="cid_3" class="form-input-wide"> <div class="form-header-group"><h2 id="header_3" class="form-header">Camp Gan Israel Registration- Summer 2026</h2></div> </li><li class="form-line" id="id_76"><div class="form-label-left" id="label_76"><label for="input_76"> How many children will we be signing up today?<span class="form-required">*</span> </label><label class="label-message" for="input_76"> </label></div><div id="cid_76" class="form-input"> <input type="number" class="form-number-input  form-textbox validate[required]" id="input_76" name="q76_number" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" /> </div></li><li class="form-line" id="id_84"><div class="form-label-left" id="label_84"><label for="input_84">  </label><label class="label-message" for="input_84"> </label></div><div id="cid_84" class="form-input"> <textarea id="input_84" class="form-textarea" name="q84_input84" cols="40" rows="6"></textarea> </div></li><li id="cid_5" class="form-input-wide"> <div class="form-header-group"><h2 id="header_5" class="form-header">Parent Information</h2></div> </li><li class="form-line" id="id_6"><div class="form-label-left" id="label_6"><label for="input_6"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_6"> </label></div><div id="cid_6" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q6_fullName[first]" id="first_6" autocomplete="given-name" />  <label class="form-sub-label" for="first_6" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q6_fullName[last]" id="last_6" autocomplete="family-name" />  <label class="form-sub-label" for="last_6" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_7"><div 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id="label_10"><label for="input_10"> Address<span class="form-required">*</span> </label><label class="label-message" for="input_10"> </label></div><div id="cid_10" 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="q10_address[addr_line1]" id="input_10_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_10_addr_line1" id="sublabel_10_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="q10_address[addr_line2]" id="input_10_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_10_addr_line2" id="sublabel_10_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="q10_address[city]" id="input_10_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_10_city" id="sublabel_10_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q10_address[state]" id="input_10_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_10_state" id="sublabel_10_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="q10_address[postal]" id="input_10_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_10_postal" id="sublabel_10_postal">Postal / Zip 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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_10_country" id="sublabel_10_country">Country</label></span></td></tr></tbody></table> </div></li><li id="cid_11" class="form-input-wide"> <div class="form-header-group"><h2 id="header_11" class="form-header">Child Information</h2></div> </li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_12"> </label></div><div id="cid_12" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q12_fullName12[first]" id="first_12" autocomplete="given-name" />  <label class="form-sub-label" for="first_12" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q12_fullName12[last]" id="last_12" autocomplete="family-name" />  <label class="form-sub-label" for="last_12" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_13"><div class="form-label-left" id="label_13"><label for="input_13"> Gender<span class="form-required">*</span> </label><label class="label-message" for="input_13"> </label></div><div id="cid_13" 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_13_0" name="q13_input13" value="Male" /><label id="label_input_13_0" for="input_13_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_13_1" name="q13_input13" value="Female" /><label id="label_input_13_1" for="input_13_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_14"><div class="form-label-left" id="label_14"><label for="input_14"> Birth Date<span class="form-required">*</span> </label><label class="label-message" for="input_14"> </label></div><div id="cid_14" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q14_birthDate[month]" id="input_14_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_14_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q14_birthDate[day]" id="input_14_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_14_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q14_birthDate[year]" id="input_14_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_14_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_15"><div class="form-label-left" id="label_15"><label for="input_15"> School Attending<span class="form-required">*</span> </label><label class="label-message" for="input_15"> </label></div><div id="cid_15" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_15" name="q15_input15" size="20" value="" /> </div></li><li class="form-line" id="id_83"><div class="form-label-left" id="label_83"><label for="input_83"> I'd like to sign my child up for<span class="form-required">*</span> </label><label class="label-message" for="input_83"> </label></div><div id="cid_83" 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_83_0" name="q83_input83[]" value="Week 1 (June 15- 19)  *Only Mini Gan" /><label id="label_input_83_0" for="input_83_0"><span>Week 1 (June 15- 19)  *Only Mini Gan</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_83_1" name="q83_input83[]" value="Week 2 (June 22- 26)" /><label id="label_input_83_1" for="input_83_1"><span>Week 2 (June 22- 26)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_83_2" name="q83_input83[]" value="Week 3 (June 29- July 3)" /><label id="label_input_83_2" for="input_83_2"><span>Week 3 (June 29- July 3)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_83_3" name="q83_input83[]" value="Week 4 (July 6- 10)" /><label id="label_input_83_3" for="input_83_3"><span>Week 4 (July 6- 10)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_83_4" name="q83_input83[]" value="Week 5 (July 13-17)" /><label id="label_input_83_4" for="input_83_4"><span>Week 5 (July 13-17)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_83_5" name="q83_input83[]" value="Week 6 (July 20- 24)" /><label id="label_input_83_5" for="input_83_5"><span>Week 6 (July 20- 24)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_83_6" name="q83_input83[]" value="Week 7 (July 27- 31)" /><label id="label_input_83_6" for="input_83_6"><span>Week 7 (July 27- 31)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_83_7" name="q83_input83[]" value="Full Mini Gan Summer (7 Weeks: June 15- July 31)" /><label id="label_input_83_7" for="input_83_7"><span>Full Mini Gan Summer (7 Weeks: June 15- July 31)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_83_8" name="q83_input83[]" value="Full Main Camp Summer (6 Weeks: June 22- July 31)" /><label id="label_input_83_8" for="input_83_8"><span>Full Main Camp Summer (6 Weeks: June 22- July 31)</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_17" class="form-input-wide"> <div class="form-header-group"><h2 id="header_17" class="form-header">Child #2 Information</h2></div> </li><li class="form-line" id="id_18"><div class="form-label-left" id="label_18"><label for="input_18"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_18"> </label></div><div id="cid_18" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q18_fullName18[first]" id="first_18" autocomplete="given-name" />  <label class="form-sub-label" for="first_18" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q18_fullName18[last]" id="last_18" autocomplete="family-name" />  <label class="form-sub-label" for="last_18" id="sublabel_last">Last Name</label></span> </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_input19" 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_input19" 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_20"><div class="form-label-left" id="label_20"><label for="input_20"> Birth Date<span class="form-required">*</span> </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"><select autocomplete="nope" class="form-dropdown validate[required]" name="q20_birthDate20[month]" id="input_20_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_20_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q20_birthDate20[day]" id="input_20_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_20_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q20_birthDate20[year]" id="input_20_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_20_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_21"><div class="form-label-left" id="label_21"><label for="input_21"> School Attending<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_input21" size="20" value="" /> </div></li><li class="form-line" id="id_22"><div class="form-label-left" id="label_22"><label for="input_22"> I'd like to sign my child up for<span class="form-required">*</span> </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-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_22_0" name="q22_input22[]" value="Week 1 (June 15- 19) *Only Mini Gan" /><label id="label_input_22_0" for="input_22_0"><span>Week 1 (June 15- 19) *Only Mini Gan</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_22_1" name="q22_input22[]" value="Week 2 (June 22- 26)" /><label id="label_input_22_1" for="input_22_1"><span>Week 2 (June 22- 26)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_22_2" name="q22_input22[]" value="Week 3 (June 29- July 3)" /><label id="label_input_22_2" for="input_22_2"><span>Week 3 (June 29- July 3)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_22_3" name="q22_input22[]" value="Week 4 (July 6- 10)" /><label id="label_input_22_3" for="input_22_3"><span>Week 4 (July 6- 10)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_22_4" name="q22_input22[]" value="Week 5 (July 13-17)" /><label id="label_input_22_4" for="input_22_4"><span>Week 5 (July 13-17)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_22_5" name="q22_input22[]" value="Week 6 (July 20- 24)" /><label id="label_input_22_5" for="input_22_5"><span>Week 6 (July 20- 24)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_22_6" name="q22_input22[]" value="Week 7 (July 27- 31)" /><label id="label_input_22_6" for="input_22_6"><span>Week 7 (July 27- 31)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_22_7" name="q22_input22[]" value="Full Mini Gan Summer (7 Weeks: June 15- July 31)" /><label id="label_input_22_7" for="input_22_7"><span>Full Mini Gan Summer (7 Weeks: June 15- July 31)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_22_8" name="q22_input22[]" value="Full Main Camp Summer (6 Weeks: June 22- July 31)" /><label id="label_input_22_8" for="input_22_8"><span>Full Main Camp Summer (6 Weeks: June 22- July 31)</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_23" class="form-input-wide"> <div class="form-header-group"><h2 id="header_23" class="form-header">Child #3 Information</h2></div> </li><li class="form-line" id="id_24"><div class="form-label-left" id="label_24"><label for="input_24"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_24"> </label></div><div id="cid_24" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q24_fullName24[first]" id="first_24" autocomplete="given-name" />  <label class="form-sub-label" for="first_24" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q24_fullName24[last]" id="last_24" autocomplete="family-name" />  <label class="form-sub-label" for="last_24" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> Gender<span class="form-required">*</span> </label><label class="label-message" for="input_26"> </label></div><div id="cid_26" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_26_0" name="q26_input26" value="Male" /><label id="label_input_26_0" for="input_26_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_26_1" name="q26_input26" value="Female" /><label id="label_input_26_1" for="input_26_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_25"><div class="form-label-left" id="label_25"><label for="input_25"> Birth Date<span class="form-required">*</span> </label><label class="label-message" for="input_25"> </label></div><div id="cid_25" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q25_birthDate25[month]" id="input_25_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_25_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q25_birthDate25[day]" id="input_25_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_25_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q25_birthDate25[year]" id="input_25_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_25_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_33"><div class="form-label-left" id="label_33"><label for="input_33"> School Attending<span class="form-required">*</span> </label><label class="label-message" for="input_33"> </label></div><div id="cid_33" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_33" name="q33_input33" size="20" value="" /> </div></li><li class="form-line" id="id_28"><div class="form-label-left" id="label_28"><label for="input_28"> I'd like to sign my child up for<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-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_28_0" name="q28_input28[]" value="Week 1 (June 15- 19) *Only Mini Gan" /><label id="label_input_28_0" for="input_28_0"><span>Week 1 (June 15- 19) *Only Mini Gan</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_28_1" name="q28_input28[]" value="Week 2 (June 22- 26)" /><label id="label_input_28_1" for="input_28_1"><span>Week 2 (June 22- 26)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_28_2" name="q28_input28[]" value="Week 3 (June 29- July 3)" /><label id="label_input_28_2" for="input_28_2"><span>Week 3 (June 29- July 3)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_28_3" name="q28_input28[]" value="Week 4 (July 6- 10)" /><label id="label_input_28_3" for="input_28_3"><span>Week 4 (July 6- 10)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_28_4" name="q28_input28[]" value="Week 5 (July 13- 17)" /><label id="label_input_28_4" for="input_28_4"><span>Week 5 (July 13- 17)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_28_5" name="q28_input28[]" value="Week 6 (July 20- 24)" /><label id="label_input_28_5" for="input_28_5"><span>Week 6 (July 20- 24)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_28_6" name="q28_input28[]" value="Week 7 (July 27- 31)" /><label id="label_input_28_6" for="input_28_6"><span>Week 7 (July 27- 31)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_28_7" name="q28_input28[]" value="Full Mini Gan Summer (7 Weeks: June 15- July 31)" /><label id="label_input_28_7" for="input_28_7"><span>Full Mini Gan Summer (7 Weeks: June 15- July 31)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_28_8" name="q28_input28[]" value="Full Main Camp Summer (6 Weeks: June 22- July 31)" /><label id="label_input_28_8" for="input_28_8"><span>Full Main Camp Summer (6 Weeks: June 22- July 31)</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_29" class="form-input-wide"> <div class="form-header-group"><h2 id="header_29" class="form-header">Child #4 Information</h2></div> </li><li class="form-line" id="id_30"><div class="form-label-left" id="label_30"><label for="input_30"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_30"> </label></div><div id="cid_30" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q30_fullName30[first]" id="first_30" autocomplete="given-name" />  <label class="form-sub-label" for="first_30" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q30_fullName30[last]" id="last_30" autocomplete="family-name" />  <label class="form-sub-label" for="last_30" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_32"><div class="form-label-left" id="label_32"><label for="input_32"> Gender<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_input32" value="Male" /><label id="label_input_32_0" for="input_32_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_32_1" name="q32_input32" value="Female" /><label id="label_input_32_1" for="input_32_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_31"><div class="form-label-left" id="label_31"><label for="input_31"> Birth Date<span class="form-required">*</span> </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"><select autocomplete="nope" class="form-dropdown validate[required]" name="q31_birthDate31[month]" id="input_31_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_31_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q31_birthDate31[day]" id="input_31_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_31_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q31_birthDate31[year]" id="input_31_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_31_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_27"><div class="form-label-left" id="label_27"><label for="input_27"> School Attending<span class="form-required">*</span> </label><label class="label-message" for="input_27"> </label></div><div id="cid_27" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_27" name="q27_input27" size="20" value="" /> </div></li><li class="form-line" id="id_34"><div class="form-label-left" id="label_34"><label for="input_34"> I'd like to sign my child up for<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-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_34_0" name="q34_input34[]" value="Week 1 (June 15- 19) *Only Mini Gan" /><label id="label_input_34_0" for="input_34_0"><span>Week 1 (June 15- 19) *Only Mini Gan</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_34_1" name="q34_input34[]" value="Week 2 (June 22- 26)" /><label id="label_input_34_1" for="input_34_1"><span>Week 2 (June 22- 26)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_34_2" name="q34_input34[]" value="Week 3 (June 29- July 3)" /><label id="label_input_34_2" for="input_34_2"><span>Week 3 (June 29- July 3)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_34_3" name="q34_input34[]" value="Week 4 (July 6- 10)" /><label id="label_input_34_3" for="input_34_3"><span>Week 4 (July 6- 10)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_34_4" name="q34_input34[]" value="Week 5 (July 13- 17)" /><label id="label_input_34_4" for="input_34_4"><span>Week 5 (July 13- 17)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_34_5" name="q34_input34[]" value="Week 6 (July 20- 24)" /><label id="label_input_34_5" for="input_34_5"><span>Week 6 (July 20- 24)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_34_6" name="q34_input34[]" value="Week 7 (July 27- 31)" /><label id="label_input_34_6" for="input_34_6"><span>Week 7 (July 27- 31)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_34_7" name="q34_input34[]" value="Full Mini Gan Summer (7 Weeks: June 15- July 31)" /><label id="label_input_34_7" for="input_34_7"><span>Full Mini Gan Summer (7 Weeks: June 15- July 31)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_34_8" name="q34_input34[]" value="Full Main Camp Summer (6 Weeks: June 22- July 31)" /><label id="label_input_34_8" for="input_34_8"><span>Full Main Camp Summer (6 Weeks: June 22- July 31)</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_35" class="form-input-wide"> <div class="form-header-group"><h2 id="header_35" class="form-header">Health Information</h2></div> </li><li class="form-line" id="id_40"><div class="form-label-left" id="label_40"><label for="input_40"> Is your child taking any medications?<span class="form-required">*</span> </label><label class="label-message" for="input_40"> </label></div><div id="cid_40" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_40_0" name="q40_input40" value="Yes" /><label id="label_input_40_0" for="input_40_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_40_1" name="q40_input40" checked="checked" value="No" /><label id="label_input_40_1" for="input_40_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_41"><div class="form-label-left" id="label_41"><label for="input_41"> Has your child had any major surgeries in the past?<span class="form-required">*</span> </label><label class="label-message" for="input_41"> </label></div><div id="cid_41" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_41_0" name="q41_input41" value="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_input41" checked="checked" 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_38"><div class="form-label-left" id="label_38"><label for="input_38"> Does your child have any allergies?<span class="form-required">*</span> </label><label class="label-message" for="input_38"> </label></div><div id="cid_38" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_38_0" name="q38_input38" value="Yes" /><label id="label_input_38_0" for="input_38_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_38_1" name="q38_input38" checked="checked" value="No" /><label id="label_input_38_1" for="input_38_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_39"><div class="form-label-left" id="label_39"><label for="input_39"> If yes, please provide details </label><label class="label-message" for="input_39"> </label></div><div id="cid_39" class="form-input"> <textarea id="input_39" class="form-textarea" name="q39_input39" cols="40" rows="6"></textarea> </div></li><li id="cid_44" class="form-input-wide"> <div class="form-header-group"><h2 id="header_44" class="form-header">Child #2</h2></div> </li><li class="form-line" id="id_46"><div class="form-label-left" id="label_46"><label for="input_46"> Is your child taking any medications?<span class="form-required">*</span> </label><label class="label-message" for="input_46"> </label></div><div id="cid_46" 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_46_0" name="q46_input46" value="Yes" /><label id="label_input_46_0" for="input_46_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_46_1" name="q46_input46" checked="checked" value="No" /><label id="label_input_46_1" for="input_46_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"> Has your child had any major surgeries in the past?<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_input37" 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_input37" checked="checked" 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 class="form-line" id="id_42"><div class="form-label-left" id="label_42"><label for="input_42"> Does your child have any allergies?<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_input42" 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_input42" checked="checked" 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_43"><div class="form-label-left" id="label_43"><label for="input_43"> If yes, please provide details </label><label class="label-message" for="input_43"> </label></div><div id="cid_43" class="form-input"> <textarea id="input_43" class="form-textarea" name="q43_input43" cols="40" rows="6"></textarea> </div></li><li id="cid_45" class="form-input-wide"> <div class="form-header-group"><h2 id="header_45" class="form-header">Child #3</h2></div> </li><li class="form-line" id="id_51"><div class="form-label-left" id="label_51"><label for="input_51"> Is your child taking any medications?<span class="form-required">*</span> </label><label class="label-message" for="input_51"> </label></div><div id="cid_51" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_51_0" name="q51_input51" value="Yes" /><label id="label_input_51_0" for="input_51_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_51_1" name="q51_input51" checked="checked" value="No" /><label id="label_input_51_1" for="input_51_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_52"><div class="form-label-left" id="label_52"><label for="input_52"> Has your child had any major surgeries in the past?<span class="form-required">*</span> </label><label class="label-message" for="input_52"> </label></div><div id="cid_52" 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_52_0" name="q52_input52" value="Yes" /><label id="label_input_52_0" for="input_52_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_52_1" name="q52_input52" checked="checked" value="No" /><label id="label_input_52_1" for="input_52_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_48"><div class="form-label-left" id="label_48"><label for="input_48"> Does your child have any allergies?<span class="form-required">*</span> </label><label class="label-message" for="input_48"> </label></div><div id="cid_48" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_48_0" name="q48_input48" value="Yes" /><label id="label_input_48_0" for="input_48_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_48_1" name="q48_input48" checked="checked" value="No" /><label id="label_input_48_1" for="input_48_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_49"><div class="form-label-left" id="label_49"><label for="input_49"> If yes, please provide details </label><label class="label-message" for="input_49"> </label></div><div id="cid_49" class="form-input"> <textarea id="input_49" class="form-textarea" name="q49_input49" cols="40" rows="6"></textarea> </div></li><li id="cid_50" class="form-input-wide"> <div class="form-header-group"><h2 id="header_50" class="form-header">Child #4</h2></div> </li><li class="form-line" id="id_36"><div class="form-label-left" id="label_36"><label for="input_36"> Is your child taking any medications?<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_input36" 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_input36" checked="checked" 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_47"><div class="form-label-left" id="label_47"><label for="input_47"> Has your child had any major surgeries in the past?<span class="form-required">*</span> </label><label class="label-message" for="input_47"> </label></div><div id="cid_47" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_47_0" name="q47_input47" value="Yes" /><label id="label_input_47_0" for="input_47_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_47_1" name="q47_input47" checked="checked" value="No" /><label id="label_input_47_1" for="input_47_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_53"><div class="form-label-left" id="label_53"><label for="input_53"> Does your child have any allergies?<span class="form-required">*</span> </label><label class="label-message" for="input_53"> </label></div><div id="cid_53" 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_53_0" name="q53_input53" value="Yes" /><label id="label_input_53_0" for="input_53_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_53_1" name="q53_input53" checked="checked" value="No" /><label id="label_input_53_1" for="input_53_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_54"><div class="form-label-left" id="label_54"><label for="input_54"> If yes, please provide details </label><label class="label-message" for="input_54"> </label></div><div id="cid_54" class="form-input"> <textarea id="input_54" class="form-textarea" name="q54_input54" cols="40" rows="6"></textarea> </div></li><li id="cid_55" class="form-input-wide"> <div class="form-header-group"><h2 id="header_55" class="form-header">Pediatrician Information</h2></div> </li><li class="form-line" id="id_56"><div class="form-label-left" id="label_56"><label for="input_56"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_56"> </label></div><div id="cid_56" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q56_fullName56[first]" id="first_56" autocomplete="given-name" />  <label class="form-sub-label" for="first_56" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q56_fullName56[last]" id="last_56" autocomplete="family-name" />  <label class="form-sub-label" for="last_56" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_57"><div class="form-label-left" id="label_57"><label for="input_57"> Address<span class="form-required">*</span> </label><label class="label-message" for="input_57"> </label></div><div id="cid_57" 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="q57_address57[addr_line1]" id="input_57_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_57_addr_line1" id="sublabel_57_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="q57_address57[addr_line2]" id="input_57_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_57_addr_line2" id="sublabel_57_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="q57_address57[city]" id="input_57_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_57_city" id="sublabel_57_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q57_address57[state]" id="input_57_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_57_state" id="sublabel_57_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="q57_address57[postal]" id="input_57_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_57_postal" id="sublabel_57_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q57_address57[country]" id="input_57_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_57_country" id="sublabel_57_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_58"><div class="form-label-left" id="label_58"><label for="input_58"> Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_58"> </label></div><div id="cid_58" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q58_phoneNumber58[full]" id="input_58_full" autocomplete="tel" />  <label class="form-sub-label" for="input_58_full"><span> </span></label></span></div> </div></li><li id="cid_59" class="form-input-wide"> <div class="form-header-group"><h2 id="header_59" class="form-header">Waivers</h2></div> </li><li class="form-line" id="id_60"><div class="form-label-left" id="label_60"><label for="input_60"> <span class="form-required">*</span> </label><label class="label-message" for="input_60"> </label></div><div id="cid_60" 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_60_0" name="q60_input60[]" value="The health history that I have provided is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations." /><label id="label_input_60_0" for="input_60_0"><span>The health history that I have provided is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations.</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"> <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-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_61_0" name="q61_input61[]" value="If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a 'need to know' basis with camp staff. I give permission to print this information. In addition, camp has permission to obtain a copy of my child's health record from providers who treat my child and these providers may talk with the program's staff about my child's health status." /><label id="label_input_61_0" for="input_61_0"><span>If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a 'need to know' basis with camp staff. I give permission to print this information. In addition, camp has permission to obtain a copy of my child's health record from providers who treat my child and these providers may talk with the program's staff about my child's health status.</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_62" class="form-input-wide"> <div class="form-header-group"><h2 id="header_62" class="form-header">Emergency Contacts</h2></div> </li><li class="form-line" id="id_63"><div id="cid_63" class="form-input-wide"> <div id="text_63" class="form-html"><p><em>Contact 1</em></p>
</div> </div></li><li class="form-line" id="id_64"><div class="form-label-left" id="label_64"><label for="input_64"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_64"> </label></div><div id="cid_64" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q64_fullName64[first]" id="first_64" autocomplete="given-name" />  <label class="form-sub-label" for="first_64" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q64_fullName64[last]" id="last_64" autocomplete="family-name" />  <label class="form-sub-label" for="last_64" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_65"><div class="form-label-left" id="label_65"><label for="input_65"> Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_65"> </label></div><div id="cid_65" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q65_phoneNumber65[full]" id="input_65_full" autocomplete="tel" />  <label class="form-sub-label" for="input_65_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_68"><div id="cid_68" class="form-input-wide"> <div id="text_68" class="form-html"><p><em>Contact 2</em></p>
</div> </div></li><li class="form-line" id="id_66"><div class="form-label-left" id="label_66"><label for="input_66"> Full Name </label><label class="label-message" for="input_66"> </label></div><div id="cid_66" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q66_fullName66[first]" id="first_66" autocomplete="given-name" />  <label class="form-sub-label" for="first_66" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q66_fullName66[last]" id="last_66" autocomplete="family-name" />  <label class="form-sub-label" for="last_66" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_67"><div class="form-label-left" id="label_67"><label for="input_67"> Phone Number </label><label class="label-message" for="input_67"> </label></div><div id="cid_67" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox" type="tel" name="q67_phoneNumber67[full]" id="input_67_full" autocomplete="tel" />  <label class="form-sub-label" for="input_67_full"><span> </span></label></span></div> </div></li><li id="cid_69" class="form-input-wide"> <div class="form-header-group"><h2 id="header_69" class="form-header">Terms, Conditions, and Waivers</h2></div> </li><li class="form-line" id="id_70"><div id="cid_70" class="form-input-wide"> <div id="text_70" class="form-html"><p>Please read this information and agreement carefully before registering to Camp Gan Israel. By submitting your registration, you are agreeing to the following terms, conditions, and waivers.</p>
</div> </div></li><li class="form-line" id="id_71"><div class="form-label-left" id="label_71"><label for="input_71"> Please check off the boxes<span class="form-required">*</span> </label><label class="label-message" for="input_71"> </label></div><div id="cid_71" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_71_0" name="q71_input71[]" value="Health Guidelines- I agree to follow all the health guidelines in place at camp this summer including checking my child's temperature before coming to camp each morning and not brining them in if they are displaying a fever, vomiting, diarrhea or other flu symptoms; or after traveling out of the area or being aroound someone who may have the virus. I understand that all children may be subjected to a health screening before entering camp each morning including an electronic temperature check, and they will be sent home if a fever is found" /><label id="label_input_71_0" for="input_71_0"><span>Health Guidelines- I agree to follow all the health guidelines in place at camp this summer including checking my child's temperature before coming to camp each morning and not brining them in if they are displaying a fever, vomiting, diarrhea or other flu symptoms; or after traveling out of the area or being aroound someone who may have the virus. I understand that all children may be subjected to a health screening before entering camp each morning including an electronic temperature check, and they will be sent home if a fever is found</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_77"><div class="form-label-left" id="label_77"><label for="input_77"> <span class="form-required">*</span> </label><label class="label-message" for="input_77"> </label></div><div id="cid_77" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_77_0" name="q77_input77[]" value="Parental Consent- Parental consent for participation in all activities of Camp Gan Israel is fully implied." /><label id="label_input_77_0" for="input_77_0"><span>Parental Consent- Parental consent for participation in all activities of Camp Gan Israel is fully implied.</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_78"><div class="form-label-left" id="label_78"><label for="input_78"> <span class="form-required">*</span> </label><label class="label-message" for="input_78"> </label></div><div id="cid_78" 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_78_0" name="q78_input78[]" value="Payments and Cancellations- All camp registrations require a scheduled payment plan to be confirmed. Without a payment schedule registrations are not saved and your place is not confirmed. Refund policy: Camp Gan Israel offers complete refunds of all fees up until one week before your program start date minus a $75 cancellation fee. To cancel a session please contact our office. Other cancellations: no refunds available from 7 days before program start date. Please note: We are unable to offer any refunds for illness of a camper that prevents him/​her from attending our program. If Camp Gan Israel is forced to cancel or temporarily close a program due to an infection, Camp Gan Israel will offer a full refund for unused days (prorated) to all campers affected. Only those campers (and siblings) who are directly affected by the closure will be offered a refund." /><label id="label_input_78_0" for="input_78_0"><span>Payments and Cancellations- All camp registrations require a scheduled payment plan to be confirmed. Without a payment schedule registrations are not saved and your place is not confirmed. Refund policy: Camp Gan Israel offers complete refunds of all fees up until one week before your program start date minus a $75 cancellation fee. To cancel a session please contact our office. Other cancellations: no refunds available from 7 days before program start date. Please note: We are unable to offer any refunds for illness of a camper that prevents him/​her from attending our program. If Camp Gan Israel is forced to cancel or temporarily close a program due to an infection, Camp Gan Israel will offer a full refund for unused days (prorated) to all campers affected. Only those campers (and siblings) who are directly affected by the closure will be offered a refund.</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_79"><div class="form-label-left" id="label_79"><label for="input_79"> <span class="form-required">*</span> </label><label class="label-message" for="input_79"> </label></div><div id="cid_79" 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_79_0" name="q79_input79[]" value="Dismissal of a Camper- Camp Gan Israel reserves the right to dismiss at its sole discretion, any camper whose condition, conduct, influence or behavior is deemed unsatisfactory or detrimental to the best interests of the camp or fellow campers, or who violates camp rules and regulations, in which case no refunds will be made." /><label id="label_input_79_0" for="input_79_0"><span>Dismissal of a Camper- Camp Gan Israel reserves the right to dismiss at its sole discretion, any camper whose condition, conduct, influence or behavior is deemed unsatisfactory or detrimental to the best interests of the camp or fellow campers, or who violates camp rules and regulations, in which case no refunds will be made.</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_80"><div class="form-label-left" id="label_80"><label for="input_80"> <span class="form-required">*</span> </label><label class="label-message" for="input_80"> </label></div><div id="cid_80" 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_80_0" name="q80_input80[]" value="Medical Care- In the event of an emergency, serious illness, or accident, Camp Gan Israel has permission to arrange for any necessary first-aid or care by a licensed physician for any children attending camp. Every effort will be made to contact the parent/​guardian and emergency contacts first. Should it be necessary for the well being of the camper to utilize outside medical or dental services all expenses involved will be paid for by the parent. Parents are required to notify CGI in a timely manner of any infectious diseases or infestations asquired by a camper during their participation of camp." /><label id="label_input_80_0" for="input_80_0"><span>Medical Care- In the event of an emergency, serious illness, or accident, Camp Gan Israel has permission to arrange for any necessary first-aid or care by a licensed physician for any children attending camp. Every effort will be made to contact the parent/​guardian and emergency contacts first. Should it be necessary for the well being of the camper to utilize outside medical or dental services all expenses involved will be paid for by the parent. Parents are required to notify CGI in a timely manner of any infectious diseases or infestations asquired by a camper during their participation of camp.</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_81"><div class="form-label-left" id="label_81"><label for="input_81"> <span class="form-required">*</span> </label><label class="label-message" for="input_81"> </label></div><div id="cid_81" 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_81_0" name="q81_input81[]" value="Images Etc.- Permission is hereby given for Camp Gan Israel to use in promoting the camp and in other ventures directly relating to the camp including the Camp Gan Israel Facebook page (i) digital, photographic, video, and audio images or likenesses of camper, and (ii) statements, articles, names, music, art, photographs, audio recordings, films and videos creataed by camper or originating from camp or from a camp- related activity." /><label id="label_input_81_0" for="input_81_0"><span>Images Etc.- Permission is hereby given for Camp Gan Israel to use in promoting the camp and in other ventures directly relating to the camp including the Camp Gan Israel Facebook page (i) digital, photographic, video, and audio images or likenesses of camper, and (ii) statements, articles, names, music, art, photographs, audio recordings, films and videos creataed by camper or originating from camp or from a camp- related activity.</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_82"><div class="form-label-left" id="label_82"><label for="input_82"> <span class="form-required">*</span> </label><label class="label-message" for="input_82"> </label></div><div id="cid_82" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_82_0" name="q82_input82[]" value="Indemnify and Hold Harmless- I agree to indemnify and hold harmless Camp Gan Israel and its officers, employees, volunteers, or assigns from any liability concerning my child's involvement in camp, and further agree that the use of any premises during the program is made at my own risk. By signing this agreement, I certify that I have legal capacity to act as the parent/​guardian of the named minor. I further understand that the terms of this agreement are legally binding and certified that I am signing this agreement after having carefully read it of my own free will." /><label id="label_input_82_0" for="input_82_0"><span>Indemnify and Hold Harmless- I agree to indemnify and hold harmless Camp Gan Israel and its officers, employees, volunteers, or assigns from any liability concerning my child's involvement in camp, and further agree that the use of any premises during the program is made at my own risk. By signing this agreement, I certify that I have legal capacity to act as the parent/​guardian of the named minor. I further understand that the terms of this agreement are legally binding and certified that I am signing this agreement after having carefully read it of my own free will.</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_72" class="form-input-wide"> <div class="form-header-group"><h2 id="header_72" class="form-header">Payment</h2></div> </li><li class="form-line" id="id_73"><div id="cid_73" class="form-input-wide"> <div id="text_73" class="form-html"><p><em>A $100 Registration fee per family and one week's payment per child is required now. The remainder will be charged before camp starts.</em></p>

<p>By providing your card information, you allow Chabad Lubavitch of Weston Inc to charge your card for future payments in accordance with their terms.</p>
</div> </div></li><li class="form-line" id="id_75"><div class="form-label-left" id="label_75"><label for="input_75"> <span class="form-required">*</span> </label><label class="label-message" for="input_75"> </label></div><div id="cid_75" 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_75_0" name="q75_input75[]" value="I agree to save my card for future transactions." /><label id="label_input_75_0" for="input_75_0"><span>I agree to save my card for future transactions.</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_74"><div class="form-label-left" id="label_74"><label for="input_74"> Payment </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" class="form-payment-methods form-multiple-column"></td></tr><tr class="credit_card "><th colspan="2">Credit Card</th></tr><tr class="credit_card "><td colspan="2" style="padding:0"><table cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container">  <label class="form-sub-label">We accept Visa, MasterCard, American Express, Discover</label></span><div class="cc-icons"><div class="cc-icon visa-icon"></div><div class="cc-icon mastercard-icon"></div><div class="cc-icon amex-icon"></div><div class="cc-icon discover-icon"></div></div><input type="hidden" name="q74_payment[cc_type]" id="input_74_cc_type" value="" /></td></tr><tr><td><div class="cc-field-wrapper"><span class="form-sub-label-container"><input class="form-textbox form-creditcard js-cc-number validate[visible, creditcard]" type="text" name="q74_payment[cc_number]" id="input_74_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_74_cc_number" id="sublabel_cc_number">Credit Card Number</label></span></div></td><td class="cc_ccv "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q74_payment[cc_ccv]" id="input_74_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_74_cc_ccv" id="sublabel_cc_ccv">Security Code</label></span></td></tr><tr><td colspan="2" class="cc_name_on_card "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q74_payment[cc_nameOnCard]" id="input_74_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_74_cc_nameOnCard" id="sublabel_cc_nameOnCard">Name on Card</label></span></td></tr><tr class="credit_card "><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q74_payment[cc_exp_month]" id="input_74_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_74_cc_exp_month" id="sublabel_cc_exp_month">Expiration Month</label></span></td><td><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q74_payment[cc_exp_year]" id="input_74_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 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