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<form class="userform-form" action="" method="post" name="form_5578915" id="5578915" accept-charset="utf-8"><input type="hidden" name="formID" value="5578915" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li id="cid_31" class="form-input-wide"> <div class="form-header-group"><h1 id="header_31" class="form-header">MBHS  Returning Student Registration Form</h1></div> </li><li class="form-line" id="id_121"><div id="cid_121" class="form-input-wide"> <div id="text_121" class="form-html"><p>This form is for <strong>returning students only. </strong>To register new students please <a href="/article.asp?AID=5578902"><span style="background-color:#3498db;">Click Here.</span></a></p>
</div> </div></li><li class="form-line" id="id_32"><div id="cid_32" class="form-input-wide"> <div id="text_32" class="form-html"><p>Welcome! We are currently accepting applications for the 2026-2027 school year. Classes begin on Sunday, Sep. 6. If you have any questions or concerns you would like to discuss with us, please contact us at 347-987-0083.</p>
</div> </div></li><li class="form-line" id="id_96"><div class="form-label-left" id="label_96"><label for="input_96"> How many children are you enrolling in MBHS? </label><label class="label-message" for="input_96"> </label></div><div id="cid_96" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_96_0" name="q96_input96[]" value="1" /><label id="label_input_96_0" for="input_96_0"><span>1</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_97"><div class="form-label-left" id="label_97"><label for="input_97">  </label><label class="label-message" for="input_97"> </label></div><div id="cid_97" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_97_0" name="q97_input97[]" value="2" /><label id="label_input_97_0" for="input_97_0"><span>2</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_34"><div class="form-label-left" id="label_34"><label for="input_34"> Please select the program you would like your child/ren to join.<span class="form-required">*</span> </label><label class="label-message" for="input_34"> </label></div><div id="cid_34" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_34" name="q34_input34"><option value=""></option><option value="Sunday: 10:00 AM - 12:30 PM">Sunday: 10:00 AM - 12:30 PM</option></select> </div></li><li id="cid_55" class="form-input-wide"> <div class="form-header-group"><h2 id="header_55" class="form-header">Family Information</h2></div> </li><li class="form-line" id="id_101"><div class="form-label-left" id="label_101"><label for="input_101"> Parent's name (either parent) </label><label class="label-message" for="input_101"> </label></div><div id="cid_101" 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class="form-sub-label-container"><input class="form-textbox validate[required] form-address-city" type="text" name="q8_address[city]" id="input_8_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_8_city" id="sublabel_8_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q8_address[state]" id="input_8_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_8_state" id="sublabel_8_state">State / Province</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-postal" type="text" name="q8_address[postal]" id="input_8_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_8_postal" id="sublabel_8_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select 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value="Chad">Chad</option><option value="Chile">Chile</option><option value="People's Republic of China">People's Republic of China</option><option value="Republic of China">Republic of China</option><option value="Christmas Island">Christmas Island</option><option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo">Congo</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Cote d'Ivoire">Cote d'Ivoire</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Eswatini">Eswatini</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Polynesia">French Polynesia</option><option value="Gabon">Gabon</option><option value="The Gambia">The Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jersey">Jersey</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="North Korea">North Korea</option><option value="South Korea">South Korea</option><option value="Kosovo">Kosovo</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Laos">Laos</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macau">Macau</option><option value="Macedonia">Macedonia</option><option value="Madagascar">Madagascar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Myanmar">Myanmar</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="Northern Mariana">Northern Mariana</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn Islands">Pitcairn Islands</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Barthelemy">Saint Barthelemy</option><option value="Saint Helena">Saint Helena</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="Somaliland">Somaliland</option><option value="South Africa">South Africa</option><option value="South Ossetia">South Ossetia</option><option value="Spain">Spain</option><option value="Sri Lanka">Sri Lanka</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Svalbard">Svalbard</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria">Syria</option><option value="Taiwan">Taiwan</option><option value="Tajikistan">Tajikistan</option><option value="Tanzania">Tanzania</option><option value="Thailand">Thailand</option><option value="Timor-Leste">Timor-Leste</option><option value="Togo">Togo</option><option value="Tokelau">Tokelau</option><option value="Tonga">Tonga</option><option value="Trinidad and Tobago">Trinidad and Tobago</option><option value="Tristan da Cunha">Tristan da Cunha</option><option value="Tunisia">Tunisia</option><option value="Turkey">Turkey</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks and Caicos Islands">Turks and Caicos Islands</option><option value="Tuvalu">Tuvalu</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="United Arab Emirates">United Arab Emirates</option><option value="United Kingdom">United Kingdom</option><option value="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Vatican City">Vatican City</option><option value="Venezuela">Venezuela</option><option value="Vietnam">Vietnam</option><option value="British Virgin Islands">British Virgin Islands</option><option value="US Virgin Islands">US Virgin Islands</option><option value="Wallis and Futuna">Wallis and Futuna</option><option value="Western Sahara">Western Sahara</option><option value="Yemen">Yemen</option><option value="Zambia">Zambia</option><option value="Zimbabwe">Zimbabwe</option><option value="other">Other</option></select>  <label class="form-sub-label" for="input_8_country" id="sublabel_8_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_103"><div class="form-label-left" id="label_103"><label for="input_103"> Please contact me regarding parent volunteering opportunities </label><label class="label-message" for="input_103"> </label></div><div id="cid_103" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_103_0" name="q103_input103[]" value="Yes" /><label id="label_input_103_0" for="input_103_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_103_1" name="q103_input103[]" value="No" /><label id="label_input_103_1" for="input_103_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_11" class="form-input-wide"> <div class="form-header-group"><h3 id="header_11" class="form-header">Student Information</h3></div> </li><li class="form-line" id="id_111"><div class="form-label-left" id="label_111"><label for="input_111"> Is Child 1 a returning student? </label><label class="label-message" for="input_111"> </label></div><div id="cid_111" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_111_0" name="q111_input111[]" value="Yes" /><label id="label_input_111_0" for="input_111_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_111_1" name="q111_input111[]" value="No" /><label id="label_input_111_1" for="input_111_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_1"><div class="form-label-left" id="label_1"><label for="input_1"> Child 1 Name<span class="form-required">*</span> </label><label class="label-message" for="input_1"> </label></div><div id="cid_1" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q1_fullName[first]" id="first_1" autocomplete="given-name" />  <label class="form-sub-label" for="first_1" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q1_fullName[last]" id="last_1" autocomplete="family-name" />  <label class="form-sub-label" for="last_1" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_112"><div class="form-label-left" id="label_112"><label for="input_112"> Child 1 Hebrew Name </label><label class="label-message" for="input_112"> </label></div><div id="cid_112" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_112" name="q112_input112" size="20" value="" /> </div></li><li class="form-line" id="id_113"><div class="form-label-left" id="label_113"><label for="input_113"> Child 1 Gender </label><label class="label-message" for="input_113"> </label></div><div id="cid_113" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_113" name="q113_input113"><option value=""></option><option value="Male">Male</option><option value="Female">Female</option></select> </div></li><li class="form-line" id="id_114"><div class="form-label-left" id="label_114"><label for="input_114"> Child 1 Birth Date </label><label class="label-message" for="input_114"> </label></div><div id="cid_114" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q114_birthDate[month]" id="input_114_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_114_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q114_birthDate[day]" id="input_114_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_114_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q114_birthDate[year]" id="input_114_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_114_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_115"><div class="form-label-left" id="label_115"><label for="input_115"> Child 1 Time of birth (required to calculate Jewish birth-day) </label><label class="label-message" for="input_115"> </label></div><div id="cid_115" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_115" name="q115_input115"><option value=""></option><option value="Before Sunset">Before Sunset</option><option value="After Sunset">After Sunset</option></select> </div></li><li class="form-line" id="id_45"><div class="form-label-left" id="label_45"><label for="input_45"> Child 1 Grade Entering<span class="form-required">*</span> </label><label class="label-message" for="input_45"> </label></div><div id="cid_45" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_45" name="q45_input45"><option value=""></option><option value="Pre-K">Pre-K</option><option value="Kindergarten">Kindergarten</option><option value="1st">1st</option><option value="2nd">2nd</option><option value="3rd">3rd</option><option value="4th">4th</option><option value="5th">5th</option><option value="6th">6th</option></select> </div></li><li class="form-line" id="id_122"><div class="form-label-left" id="label_122"><label for="input_122">  </label><label class="label-message" for="input_122"> </label></div><div id="cid_122" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_122_0" name="q122_input122[]" value="6th - 8th Grade" /><label id="label_input_122_0" for="input_122_0"><span>6th - 8th Grade</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_123"><div id="cid_123" class="form-input-wide"> <div id="text_123" class="form-html"><p>For girls/boys in grades 6-8<strong>,</strong> please fill out the <a href="https://www.jewishmillbasin.com/article.asp?AID=5638988">Bar Mitzvah Club form</a> / <a href="https://www.jewishmillbasin.com/article.asp?AID=5653182">Bat Mitzvah Club form</a>.  <br />
Even if registering multiple children, please use this form only for children up to 5th grade. <br />
For older students, use <a href="https://www.jewishmillbasin.com/article.asp?AID=5638988">Bar Mitzvah Club form</a> / <a href="https://www.jewishmillbasin.com/article.asp?AID=5653182">Bat Mitzvah Club form</a>. <br />
Thank you.</p>
</div> </div></li><li class="form-line" id="id_44"><div class="form-label-left" id="label_44"><label for="input_44"> Child 1 School Attending<span class="form-required">*</span> </label><label class="label-message" for="input_44"> </label></div><div id="cid_44" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_44" name="q44_input44" size="20" value="" /> </div></li><li class="form-line" id="id_116"><div class="form-label-left" id="label_116"><label for="input_116"> Is Child 2 a returning student? </label><label class="label-message" for="input_116"> </label></div><div id="cid_116" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_116_0" name="q116_input116[]" value="Yes" /><label id="label_input_116_0" for="input_116_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_116_1" name="q116_input116[]" value="No" /><label id="label_input_116_1" for="input_116_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_50"><div class="form-label-left" id="label_50"><label for="input_50"> Child 2 Name<span class="form-required">*</span> </label><label class="label-message" for="input_50"> </label></div><div id="cid_50" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q50_fullName50[first]" id="first_50" autocomplete="given-name" />  <label class="form-sub-label" for="first_50" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q50_fullName50[last]" id="last_50" autocomplete="family-name" />  <label class="form-sub-label" for="last_50" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_117"><div class="form-label-left" id="label_117"><label for="input_117"> Child 2 Hebrew Name </label><label class="label-message" for="input_117"> </label></div><div id="cid_117" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_117" name="q117_input117" size="20" value="" /> </div></li><li class="form-line" id="id_118"><div class="form-label-left" id="label_118"><label for="input_118"> Child 2 Gender </label><label class="label-message" for="input_118"> </label></div><div id="cid_118" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_118" name="q118_input118"><option value=""></option><option value="Male">Male</option><option value="Female">Female</option></select> </div></li><li class="form-line" id="id_119"><div class="form-label-left" id="label_119"><label for="input_119"> Child 2 Birth Date </label><label class="label-message" for="input_119"> </label></div><div id="cid_119" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q119_birthDate119[month]" id="input_119_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_119_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q119_birthDate119[day]" id="input_119_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_119_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q119_birthDate119[year]" id="input_119_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_119_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_120"><div class="form-label-left" id="label_120"><label for="input_120"> Child 2 Time of birth (required to calculate Jewish birth-day) </label><label class="label-message" for="input_120"> </label></div><div id="cid_120" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_120" name="q120_input120"><option value=""></option><option value="Before Sunset">Before Sunset</option><option value="After Sunset">After Sunset</option></select> </div></li><li class="form-line" id="id_38"><div class="form-label-left" id="label_38"><label for="input_38"> Child 2 Grade Entering<span class="form-required">*</span> </label><label class="label-message" for="input_38"> </label></div><div id="cid_38" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_38" name="q38_input38"><option value=""></option><option value="Pre-K">Pre-K</option><option value="Kindergarten">Kindergarten</option><option value="1st">1st</option><option value="2nd">2nd</option><option value="3rd">3rd</option><option value="4th">4th</option><option value="5th">5th</option><option value="6th">6th</option></select> </div></li><li class="form-line" id="id_125"><div class="form-label-left" id="label_125"><label for="input_125">  </label><label class="label-message" for="input_125"> </label></div><div id="cid_125" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_125_0" name="q125_input125[]" value="6th - 8th Grade" /><label id="label_input_125_0" for="input_125_0"><span>6th - 8th Grade</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_124"><div id="cid_124" class="form-input-wide"> <div id="text_124" class="form-html"><p>For girls/boys in grades 6-8<strong>,</strong> please fill out the <a href="https://www.jewishmillbasin.com/article.asp?AID=5638988">Bar Mitzvah Club form</a> / <a href="https://www.jewishmillbasin.com/article.asp?AID=5653182">Bat Mitzvah Club form</a>.  <br />
Even if registering multiple children, please use this form only for children up to 5th grade. <br />
For older students, use <a href="https://www.jewishmillbasin.com/article.asp?AID=5638988">Bar Mitzvah Club form</a> / <a href="https://www.jewishmillbasin.com/article.asp?AID=5653182">Bat Mitzvah Club form</a>. <br />
Thank you.</p>
</div> </div></li><li class="form-line" id="id_5"><div class="form-label-left" id="label_5"><label for="input_5"> Child 2 School Attending<span class="form-required">*</span> </label><label class="label-message" for="input_5"> </label></div><div id="cid_5" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_5" name="q5_input5" size="20" value="" /> </div></li><li class="form-line" id="id_54"><div class="form-label-left" id="label_54"><label for="input_54"> Are there any allergies or other medical conditions we should be aware of ? (CONFIDENTIAL) </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 class="form-line" id="id_42"><div class="form-label-left" id="label_42"><label for="input_42"> Are there any considerations, such as learning difficulties or disorders, that the teacher should be aware of?  If yes, please describe them and indicate special precautions or care needed (CONFIDENTIAL)<span class="form-required">*</span> </label><label class="label-message" for="input_42"> </label></div><div id="cid_42" class="form-input"> <textarea id="input_42" class="form-textarea validate[required]" name="q42_input42" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_41"><div class="form-label-left" id="label_41"><label for="input_41"> What goals do you have for your child/ren attending Hebrew School ?<span class="form-required">*</span> </label><label class="label-message" for="input_41"> </label></div><div id="cid_41" class="form-input"> <textarea id="input_41" class="form-textarea validate[required]" name="q41_input41" cols="40" rows="6"></textarea> </div></li><li id="cid_67" class="form-input-wide"> <div class="form-header-group"><h2 id="header_67" class="form-header">Emergency Contact</h2></div> </li><li class="form-line" id="id_68"><div id="cid_68" class="form-input-wide"> <div id="text_68" class="form-html"><p>Persons to be contacted in case of an emergency when parents cannot be reached. Please provide two contacts <u><strong>other than the parents.</strong></u></p>
</div> </div></li><li class="form-line" id="id_70"><div class="form-label-left" id="label_70"><label for="input_70"> Emergency Contact 1 Name<span class="form-required">*</span> </label><label class="label-message" for="input_70"> </label></div><div id="cid_70" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q70_fullName70[first]" id="first_70" autocomplete="given-name" />  <label class="form-sub-label" for="first_70" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q70_fullName70[last]" id="last_70" autocomplete="family-name" />  <label class="form-sub-label" for="last_70" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_71"><div class="form-label-left" id="label_71"><label for="input_71"> Emergency Contact 1 Number<span class="form-required">*</span> </label><label class="label-message" for="input_71"> </label></div><div id="cid_71" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q71_phoneNumber71[area]" id="input_71_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_71_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q71_phoneNumber71[phone]" id="input_71_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_71_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_72"><div class="form-label-left" id="label_72"><label for="input_72"> Relationship to child<span class="form-required">*</span> </label><label class="label-message" for="input_72"> </label></div><div id="cid_72" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_72" name="q72_input72" size="20" value="" /> </div></li><li class="form-line" id="id_75"><div class="form-label-left" id="label_75"><label for="input_75"> Emergency Contact 2 Name<span class="form-required">*</span> </label><label class="label-message" for="input_75"> </label></div><div id="cid_75" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q75_fullName75[first]" id="first_75" autocomplete="given-name" />  <label class="form-sub-label" for="first_75" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q75_fullName75[last]" id="last_75" autocomplete="family-name" />  <label class="form-sub-label" for="last_75" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_74"><div class="form-label-left" id="label_74"><label for="input_74"> Emergency Contact 2 Number<span class="form-required">*</span> </label><label class="label-message" for="input_74"> </label></div><div id="cid_74" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q74_phoneNumber74[area]" id="input_74_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_74_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q74_phoneNumber74[phone]" id="input_74_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_74_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_73"><div class="form-label-left" id="label_73"><label for="input_73"> Relationship to child<span class="form-required">*</span> </label><label class="label-message" for="input_73"> </label></div><div id="cid_73" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_73" name="q73_input73" size="20" value="" /> </div></li><li id="cid_19" class="form-input-wide"> <div class="form-header-group"><h3 id="header_19" class="form-header">Payment</h3></div> </li><li class="form-line" id="id_76"><div id="cid_76" class="form-input-wide"> <div id="text_76" class="form-html"><p>Tuition per year: $1200 per child + $75 registration &amp; book fee (non refundable). Tuition should be paid in full by registration unless other arrangements are made with the director.  You can receive a early bird discount of $75 per family until Aug 16.</p>
</div> </div></li><li class="form-line" id="id_79"><div class="form-label-left" id="label_79"><label for="input_79"> Registration Fee<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-multiple-column" data-columns="3"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_79_0" name="q79_input79" value="75" /><label for="input_79_0"><span>$75</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line always-hidden" id="id_104"><div class="form-label-left" id="label_104"><label for="input_104"> I would like a early bird discount </label><label class="label-message" for="input_104"> </label></div><div id="cid_104" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_104_0" name="q104_input104[]" value="$75 off" /><label id="label_input_104_0" for="input_104_0"><span>$75 off</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line always-hidden" id="id_105"><div class="form-label-left" id="label_105"><label for="input_105"> I would like a early bird discount </label><label class="label-message" for="input_105"> </label></div><div id="cid_105" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_105_0" name="q105_input105[]" value="$75 off" /><label id="label_input_105_0" for="input_105_0"><span>$75 off</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_106"><div class="form-label-left" id="label_106"><label for="input_106"> I would like to pay in full today 1 child  </label><label class="label-message" for="input_106"> </label></div><div id="cid_106" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_106_0" name="q106_input106[]" value="early bird pricing $1125" /><label id="label_input_106_0" for="input_106_0"><span>early bird pricing $1125</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_86"><div class="form-label-left" id="label_86"><label for="input_86"> I would like to pay in full today </label><label class="label-message" for="input_86"> </label></div><div id="cid_86" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_86_0" name="q86_input86[]" value="Regular Price 1 child $1200" /><label id="label_input_86_0" for="input_86_0"><span>Regular Price 1 child $1200</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_107"><div class="form-label-left" id="label_107"><label for="input_107"> I would like to pay in full today 2 children </label><label class="label-message" for="input_107"> </label></div><div id="cid_107" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_107_0" name="q107_input107[]" value="early bird price $2325" /><label id="label_input_107_0" for="input_107_0"><span>early bird price $2325</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_98"><div class="form-label-left" id="label_98"><label for="input_98"> I would like to pay in full today. </label><label class="label-message" for="input_98"> </label></div><div id="cid_98" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_98_0" name="q98_input98[]" value="regular price 2 children $2400" /><label id="label_input_98_0" for="input_98_0"><span>regular price 2 children $2400</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_88"><div class="form-label-left" id="label_88"><label for="input_88"> I would like to register today. Please contact me regarding a payment plan or for tuition assistance. </label><label class="label-message" for="input_88"> </label></div><div id="cid_88" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_88_0" name="q88_input88[]" value="Regular Price 1 child $1200" /><label id="label_input_88_0" for="input_88_0"><span>Regular Price 1 child $1200</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_100"><div class="form-label-left" id="label_100"><label for="input_100"> I would like to register today. Please contact me regarding a payment plan or for tuition assistance. </label><label class="label-message" for="input_100"> </label></div><div id="cid_100" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_100_0" name="q100_input100[]" value="regular price 2 children $2400" /><label id="label_input_100_0" for="input_100_0"><span>regular price 2 children $2400</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_108"><div class="form-label-left" id="label_108"><label for="input_108"> Scholarship Fund </label><label class="label-message" for="input_108"> </label></div><div id="cid_108" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_108_0" name="q108_input108[]" value="Yes! I would like to give the gift of a Jewish eduacation to a family in need" /><label id="label_input_108_0" for="input_108_0"><span>Yes! I would like to give the gift of a Jewish eduacation to a family in need</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_109"><div class="form-label-left" id="label_109"><label for="input_109"> Thanks for ensuring a Jewish future for every child! </label><label class="label-message" for="input_109"> </label></div><div id="cid_109" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_109_0" name="q109_input109[]" value="Full Scholarship $1275" /><label id="label_input_109_0" for="input_109_0"><span>Full Scholarship $1275</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_109_1" name="q109_input109[]" value="Half Scholarship $650" /><label id="label_input_109_1" for="input_109_1"><span>Half Scholarship $650</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_109_2" name="q109_input109[]" value="Partial Scholarship $360" /><label id="label_input_109_2" for="input_109_2"><span>Partial Scholarship $360</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox-other form-checkbox validate[other]" name="q109_input109[other]" id="other_109" value="" /><span><input type="number" min="1" onkeypress="validateNumber(event)" class="form-checkbox-other-input form-textbox undefined" name="q109_input109[other][text]" data-otherhint="Other" size="15" id="input_109" disabled="disabled" /></span><br /></span></div> </div></li><li class="form-line" id="id_17"><div class="form-label-left" id="label_17"><label for="input_17"> Total tuition cost for year </label></div><div id="cid_17" class="form-input"> <div id="total_amount">$0.00 </div><br /><div class="clearfix form-single-column top_padding" id="payformWrapper"><label class="form-header form-label-left">I would like to pay today:</label><span class="form-radio-item"><label><input type="radio" class="form-radio validate[partialPayment]" value="full" name="partial" checked="checked" id="input_partial_1" />Full amount</label></span><span class="form-radio-item"><input type="radio" class="form-radio validate[partialPayment]" value="minimum" name="partial" id="input_partial_2" /><label for="input_partial_2"><span>$<span id="payformMin">75.00</span>  minimum</span></label></span><span class="form-radio-item"><label><input type="radio" class="form-other form-radio validate[partialPayment]" value="custom" name="partial" id="other_partial" />$<input type="text" onclick="document.getElementById('other_partial').checked = true" class="form-radio-other-input validate[customPartial]" id="input_partial" name="partialamount" data-otherhint="Other" onkeypress="validateNumber(event)" /> </label></span></div><div class="form-single-column form-checkbox-item" id="div_offset_gift_17" style="padding-top: 10px">              <input type="checkbox" id="input_17" class="form-checkbox" name="q17_offsetGiftPercent" value="3" />            <label id="label_17" for="input_17">Yes, I'd like to donate the cost of processing this transaction by adding 3%</label>                <input type="hidden" id="hidden_17" name="q17_offsetGiftAmount" />              <div class="clearfix"></div>            </div> </div></li><li class="form-line" id="id_29"><div class="form-label-left" id="label_29"><label for="input_29"> Payment </label><label class="label-message" for="input_29"> </label></div><div id="cid_29" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2" class="form-payment-methods form-multiple-column"><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_29_creditCard" name="q29_payment[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_29_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_29_eCheck" name="q29_payment[payment_method]" value="eCheck" onclick="BuildSource.eCheck(this)" /><label for="input_29_eCheck">eCheck</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_29_other" name="q29_payment[payment_method]" value="other" onclick="BuildSource.other(this)" /><label for="input_29_other">Zelle or Check</label> </span></td></tr><tr class="credit_card hide"><th colspan="2">Credit Card</th></tr><tr class="credit_card hide"><td colspan="2" style="padding:0"><table cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container">  <label class="form-sub-label">We accept Visa, MasterCard, American Express, Discover</label></span><div class="cc-icons"><div class="cc-icon visa-icon"></div><div class="cc-icon mastercard-icon"></div><div class="cc-icon amex-icon"></div><div class="cc-icon discover-icon"></div></div><input type="hidden" name="q29_payment[cc_type]" id="input_29_cc_type" value="" /></td></tr><tr><td><div class="cc-field-wrapper"><span class="form-sub-label-container"><input class="form-textbox form-creditcard js-cc-number validate[visible, creditcard]" type="text" name="q29_payment[cc_number]" id="input_29_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_29_cc_number" id="sublabel_cc_number">Credit Card Number</label></span></div></td><td class="cc_ccv "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q29_payment[cc_ccv]" id="input_29_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_29_cc_ccv" id="sublabel_cc_ccv">Security Code</label></span></td></tr><tr><td colspan="2" class="cc_name_on_card "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q29_payment[cc_nameOnCard]" id="input_29_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_29_cc_nameOnCard" id="sublabel_cc_nameOnCard">Name on Card</label></span></td></tr><tr class="credit_card hide"><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q29_payment[cc_exp_month]" id="input_29_cc_exp_month" autocomplete="cc-exp-month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_29_cc_exp_month" id="sublabel_cc_exp_month">Expiration Month</label></span></td><td><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q29_payment[cc_exp_year]" id="input_29_cc_exp_year" autocomplete="cc-exp-year"><option></option><option value="2026">2026</option><option value="2027">2027</option><option value="2028">2028</option><option value="2029">2029</option><option value="2030">2030</option><option value="2031">2031</option><option value="2032">2032</option><option value="2033">2033</option><option value="2034">2034</option><option value="2035">2035</option></select>  <label class="form-sub-label" for="input_29_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="e_check hide"><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q29_payment[eCheck_bankName]" id="input_29_eCheck_bankName" size="20" />  <label class="form-sub-label" for="input_29_eCheck_bankName" id="sublabel_eCheck_bankName">Bank Name</label></span></td></tr><tr class="e_check hide"><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q29_payment[eCheck_routingNumber]" id="input_29eCheck_routingNumber" size="20" />  <label class="form-sub-label" for="input_29eCheck_routingNumber" id="sublabel_eCheck_routingNumber">Routing Number</label></span></td></tr><tr class="e_check hide"><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q29_payment[eCheck_accountNumber]" id="input_29eCheck_accountNumber" size="20" />  <label class="form-sub-label" for="input_29eCheck_accountNumber" id="sublabel_eCheck_accountNumber">Account Number</label></span></td></tr><tr class="e_check hide"><td colspan="2"><span class="form-sub-label-container"><select class="form-dropdown no-validation" name="q29_payment[eCheck_accountType]" id="input_29eCheck_accountType"><option value="checking">Checking</option><option value="savings">Savings</option><option value="business">Business</option></select>  <label class="form-sub-label" for="input_29eCheck_accountType" id="sublabel_eCheck_accountType">Account Type</label></span></td></tr><tr class="other hide"><td colspan="2">Please send money through Zelle to info@millbasinhebrewschool.com<br />Please make checks payable to Mill Basin Jewish Center and mail to 2748 Mill ave. apt. 2, Brooklyn, NY 11234 </td></tr><tr class="billing_address hide"><th colspan="2">Billing Address</th></tr><tr class="billing_address hide"><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line" type="text" name="q29_payment[addr_line1]" id="input_29_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_29_addr_line1" id="sublabel_29_addr_line1">Street Address</label></span></td></tr><tr class="billing_address hide"><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q29_payment[city]" id="input_29_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_29_city" id="sublabel_29_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q29_payment[state]" id="input_29_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_29_state" id="sublabel_29_state">State / Province</label></span></td></tr><tr class="billing_address hide"><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q29_payment[postal]" id="input_29_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_29_postal" id="sublabel_29_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q29_payment[country]" id="input_29_country" autocomplete="billing country-name"><option value="" selected="selected">Please Select</option><option value="United States">United States</option><option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="The Bahamas">The Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Brazil">Brazil</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burundi">Burundi</option><option 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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_29_country" id="sublabel_29_country">Country</label></span></td></tr></tbody></table> </div></li><li id="cid_89" class="form-input-wide"> <div class="form-header-group"><h2 id="header_89" class="form-header">Parental Consent</h2></div> </li><li class="form-line" id="id_90"><div id="cid_90" class="form-input-wide"> <div id="text_90" class="form-html"><p>AUTHORIZATION</p><p>As the parent (s) or legal guardian of the above child/ren, I / we authorize any adult acting on behalf of Mill Basin Hebrew School to hospitalize or secure treatment for my / our child/ren. I / we further agree to pay all charges for that care or treatment. It is understood that if time and circumstances reasonably permit, Mill Basin Hebrew School personnel will try, but are not required, to communicate with me/us prior to such treatment. I/we hereby give permission for my/our child/ren to participate in all school activities, join in class and school trips on and beyond school properties and allow my/our child/ren to be photographed while participating in Hebrew School activities, and that these pictures may be used for marketing purposes. I/we also understand that all liability and costs resulting from damage to property and/or personal injury caused or attributable to my/our child/ren will be my/our responsibility and I/we agree to fully indemnify and save Mill Basin Hebrew School and its associates, teachers and agents harmless there from. I/we consent to Mill Basin Hebrew School’s use of our personal information and of our child/ren at its discretion in pursuit of school activities.</p></div> </div></li><li class="form-line" id="id_91"><div class="form-label-left" id="label_91"><label for="input_91"> <span class="form-required">*</span> </label><label class="label-message" for="input_91"> </label></div><div id="cid_91" 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_91_0" name="q91_input91" value="I agree to the above" /><label id="label_input_91_0" for="input_91_0"><span>I agree to the above</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_93"><div class="form-label-left" id="label_93"><label for="input_93"> Parent Signature<span class="form-required">*</span> </label><label class="label-message" for="input_93"> </label></div><div id="cid_93" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_93" name="q93_input93" size="20" value="" /> </div></li><li class="form-line" id="id_94"><div class="form-label-left" id="label_94"><label for="input_94"> Do you have any questions, concerns, or suggestions for this coming Hebrew school year? </label><label class="label-message" for="input_94"> </label></div><div id="cid_94" class="form-input"> <textarea id="input_94" class="form-textarea" name="q94_input94" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_95"><div id="cid_95" class="form-input-wide"> <div id="text_95" class="form-html"><p><strong><em>Looking forward to seeing your child at MBHS!</em></strong></p></div> </div></li><li class="form-line" id="id_59"><div class="form-label-left form-label-hidden" id="label_59"></div><div id="cid_59" class="form-input"> <div class="form-single-column form-checkbox-item"><input name="optin" value="true" type="checkbox" checked="checked" class="form-checkbox" id="input_59" /><label id="label_input_59" for="input_59">I would like to receive news and updates by email</label></div> </div></li><li class="form-line" id="id_2"><div id="cid_2" class="form-input-wide"> <div style="text-align: center; text-indent:172px;" class="form-buttons-wrapper button-align-auto"><button id="input_2" type="submit" class="form-submit-button  form-submit-button-none;">Submit</button></div> </div></li><li style="display:none">Should be Empty: <input type="text" name="website" value="" /></li></ul></div><input type="hidden" id="simple_spc" name="simple_spc" value="5578915" /><script type="text/javascript">document.getElementById("si"+"mple"+"_spc").value = "5578915-5578915";</script><div>


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