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	Register - Chabad of the Delta
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Postdated check should be submitted. If paying by credit card, your card will be charged on December 15th, 2025.\u003c/p\u003e\n","51_name":"doubleclickTo51","51_qid":51,"51_type":"control_text","51_order":36,"27_labelAlign":"Auto","27_text":"Total","27_partialPayEnabled":"No","27_partialPayType":"dollar","27_partialPayMinimum":0,"27_required":"No","27_offsetGiftEnabled":"No","27_offsetGift":3,"27_name":"total27","27_qid":27,"27_type":"control_totalamount","27_order":37,"26_text":"Payment","26_message":"","26_labelAlign":"Auto","26_required":"Yes","26_duplicatable":false,"26_selectedCountry":"United States","26_description":"","26_sublabels":{"cc_firstName":"First Name","cc_lastName":"Last Name","cc_type":"Credit Card Type","cc_number":"Credit Card Number","cc_ccv":"Security Code","cc_nameOnCard":"Name on Card","cc_IdNumber":"Israel Identity Number","cc_exp_month":"Expiration Month","cc_exp_year":"Expiration Year","eCheck_bankName":"Bank Name","eCheck_routingNumber":"Routing Number","eCheck_accountNumber":"Account Number","eCheck_accountType":"Account Type","addr_line1":"Street Address","addr_line2":"Street Address Line 2","city":"City","state":"State / Province","postal":"Postal / Zip Code","country":"Country"},"26_name":"payment26","26_qid":26,"26_type":"control_payform","26_order":38,"26_options":{"currency":"default","creditCard":{"value":"Credit Card","enabled":true,"fields":[{"name":"ccv","value":"CCV","enabled":true},{"name":"nameOnCard","value":"Name on Card","enabled":true},{"name":"billingAddress","value":"Billing Address","enabled":true}],"processorIndex":3,"type":[{"name":"Visa","value":"Visa","enabled":true},{"name":"Mastercard","value":"MasterCard","enabled":true},{"name":"Amex","value":"American Express","enabled":true},{"name":"Discover","value":"Discover","enabled":true}],"payMe":false},"paypal":{"value":"Paypal","enabled":true,"processorIndex":2},"eCheck":{"value":"eCheck","enabled":false},"other":{"value":"Other","enabled":true,"message":"Please make check payable to:\u003cbr /\u003eChabad of the Delta\u003cbr /\u003e2295 Tilton Lane\u003cbr /\u003eBrentwood, CA 94513 ","altText":"Check"}},"52_text":"\u003cp\u003e\u003cstrong\u003ePlease note: Your child is not registered in the Chabad Hebrew School until you receive a confirmation phone call or email.\u003c/strong\u003e\u003c/p\u003e\u003cbr\u003e\u003cp\u003e-Enrollment and acceptance in Chabad Hebrew School is in no way a validation of one\u0026rsquo;s status as a Jew-\u0026nbsp;\u003c/p\u003e","52_name":"doubleclickTo52","52_qid":52,"52_type":"control_text","52_order":39,"50_text":"","50_qid":50,"50_type":"control_text","50_order":40,"50_name":"input50","form_title":"HEBREW SCHOOL REGISTRATION","form_pagetitle":"Form","form_styles":"nova","form_font":"","form_fontsize":"14","form_fontcolor":"","form_optioncolor":"","form_lineSpacing":"12","form_background":"","form_formWidth":"685","form_labelWidth":"150","form_alignment":"Left","form_thankurl":"","form_thanktext":"","form_highlightLine":"Enabled","form_activeRedirect":"default","form_sendpostdata":"No","form_unique":"None","form_uniqueField":"\u003cField Id\u003e","form_status":"Enabled","form_injectCSS":"","form_hideMailEmptyFields":"disable","form_showProgressBar":"disable","form_formStrings":[{"alphabetic":"This field can only contain letters","alphanumeric":"This field can only contain letters and numbers.","confirmClearForm":"Are you sure you want to clear the form?","confirmEmail":"E-mail does not match","email":"Enter a valid e-mail address","generalError":"There are errors on the form. 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<form class="userform-form" action="" method="post" name="form_4066327" id="4066327" accept-charset="utf-8"><input type="hidden" name="formID" value="4066327" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li class="form-line" id="id_53"><div id="cid_53" class="form-input-wide"> <div id="text_53" class="form-html"><p class="Title" style="font-size: 22px; font-family: Georgia; line-height: 1.2; margin-top: 10px; color: rgb(239, 61, 35); border-bottom: 1px dotted rgb(239, 61, 35); font-weight: bold;"><strong>Registration in now open!!</strong></p> <p style="font-size: 10pt; font-family: Verdana, Tahoma, Arial, Helvetica, sans-serif; line-height: 1.2;"> 1) Please fill this form</p> <p style="font-size: 10pt; font-family: Verdana, Tahoma, Arial, Helvetica, sans-serif; line-height: 1.2;"> 2) We will contact you to setup a personal meeting</p> <p style="font-size: 10pt; font-family: Verdana, Tahoma, Arial, Helvetica, sans-serif; line-height: 1.2;"><strong>Please note: Your child is not registered in the Chabad Hebrew School until you receive a confirmation phone call or email.</strong></p> <p style="text-align: left;"><br /> <a href="http://www.JewishDelta.com/Article.asp?AID=4873418" style="display:inline-block;border:0px solid rgb(0, 0, 0);border-radius:20px;padding:12px;background:linear-gradient(to top,rgb(255, 220, 23),rgb(255, 220, 23));color:"><strong>Re-Register</strong></a>                   <a href="http://www.JewishDelta.com/Article.asp?AID=3738498" style="display:inline-block;border:0px solid rgb(0, 0, 0);border-radius:20px;padding:12px;background:linear-gradient(to top,rgb(255, 220, 23),rgb(255, 220, 23));color:"><strong>Dates &amp; Rates</strong></a></p></div> </div></li><li class="form-line" id="id_1"><div class="form-label-left" id="label_1"><label for="input_1"> Child's 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_childsName[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_childsName[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_5"><div class="form-label-left" id="label_5"><label for="input_5"> Hebrew Name<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_hebrewName5" size="20" value="" /> </div></li><li class="form-line" id="id_6"><div class="form-label-left" id="label_6"><label for="input_6"> Birth Date<span class="form-required">*</span> </label><label class="label-message" for="input_6"> </label></div><div id="cid_6" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select class="form-dropdown validate[required]" name="q6_birthDate6[month]" id="input_6_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_6_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" name="q6_birthDate6[day]" id="input_6_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_6_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" name="q6_birthDate6[year]" id="input_6_year"><option></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_6_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_10"><div class="form-label-left" id="label_10"><label for="input_10"> Previous Jewish Education<span class="form-required">*</span> </label><label class="label-message" for="input_10"> If YES where?</label></div><div id="cid_10" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_10" name="q10_previousJewish" size="20" value="" /> </div></li><li class="form-line" id="id_8"><div class="form-label-left" id="label_8"><label for="input_8"> School 2025-2026<span class="form-required">*</span> </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_8" name="q8_school" size="20" value="" /> </div></li><li class="form-line" id="id_9"><div class="form-label-left" id="label_9"><label for="input_9"> Grade entering 2025-2026<span class="form-required">*</span> </label><label class="label-message" for="input_9"> </label></div><div id="cid_9" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_9" name="q9_gradeEntering"><option value=""></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><option value="7th">7th</option><option value="8th">8th</option><option value="9th">9th</option></select> </div></li><li class="form-line" id="id_14"><div class="form-label-left" id="label_14"><label for="input_14"> Address<span class="form-required">*</span> </label><label class="label-message" for="input_14"> </label></div><div id="cid_14" 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="q14_address14[addr_line1]" id="input_14_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_14_addr_line1" id="sublabel_14_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="q14_address14[addr_line2]" id="input_14_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_14_addr_line2" id="sublabel_14_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="q14_address14[city]" id="input_14_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_14_city" id="sublabel_14_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q14_address14[state]" id="input_14_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_14_state" id="sublabel_14_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="q14_address14[postal]" id="input_14_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_14_postal" id="sublabel_14_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q14_address14[country]" id="input_14_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_14_country" id="sublabel_14_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12"> Additional notable Information </label><label class="label-message" for="input_12"> </label></div><div id="cid_12" class="form-input"> <textarea id="input_12" class="form-textarea" name="q12_additionalNotable12" cols="59" rows="6"></textarea> </div></li><li id="cid_25" class="form-input-wide"> <div class="form-header-group"><h2 id="header_25" class="form-header">Parents Information</h2></div> </li><li class="form-line" id="id_3"><div class="form-label-left" id="label_3"><label for="input_3"> Father's Name<span class="form-required">*</span> </label><label class="label-message" for="input_3"> </label></div><div id="cid_3" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q3_fathersName[first]" id="first_3" autocomplete="given-name" />  <label class="form-sub-label" for="first_3" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q3_fathersName[last]" id="last_3" autocomplete="family-name" />  <label class="form-sub-label" for="last_3" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_22"><div class="form-label-left" id="label_22"><label for="input_22"> Father Cell </label><label class="label-message" for="input_22"> </label></div><div id="cid_22" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q22_fatherCell[area]" id="input_22_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_22_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q22_fatherCell[phone]" id="input_22_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_22_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_4"><div class="form-label-left" id="label_4"><label for="input_4"> Mother's Name<span class="form-required">*</span> </label><label class="label-message" for="input_4"> </label></div><div id="cid_4" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q4_mothersName[first]" id="first_4" autocomplete="given-name" />  <label class="form-sub-label" for="first_4" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q4_mothersName[last]" id="last_4" autocomplete="family-name" />  <label class="form-sub-label" for="last_4" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_21"><div class="form-label-left" id="label_21"><label for="input_21"> Mother Cell </label><label class="label-message" for="input_21"> </label></div><div id="cid_21" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q21_motherCell[area]" id="input_21_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_21_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q21_motherCell[phone]" id="input_21_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_21_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_29"><div class="form-label-left" id="label_29"><label for="input_29"> Is the natural mother of the child Jewish?<span class="form-required">*</span> </label><label class="label-message" for="input_29"> </label></div><div id="cid_29" 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_29_0" name="q29_input29" value="Yes" /><label id="label_input_29_0" for="input_29_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_29_1" name="q29_input29" value="No" /><label id="label_input_29_1" for="input_29_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_30"><div class="form-label-left" id="label_30"><label for="input_30"> Have there been any conversions or adoptions in the family?<span class="form-required">*</span> </label><label class="label-message" for="input_30"> </label></div><div id="cid_30" 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_30_0" name="q30_input30" value="Yes" /><label id="label_input_30_0" for="input_30_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_30_1" name="q30_input30" value="No" /><label id="label_input_30_1" for="input_30_1"><span>No</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"> If yes, please explain </label><label class="label-message" for="input_31"> </label></div><div id="cid_31" class="form-input"> <textarea id="input_31" class="form-textarea" name="q31_input31" cols="40" rows="6"></textarea> </div></li><li id="cid_32" class="form-input-wide"> <div class="form-header-group"><h2 id="header_32" class="form-header">Emergency Information</h2></div> </li><li class="form-line" id="id_33"><div class="form-label-left" id="label_33"><label for="input_33"> Emergency Contact Name </label><label class="label-message" for="input_33"> </label></div><div id="cid_33" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q33_fullName[first]" id="first_33" autocomplete="given-name" />  <label class="form-sub-label" for="first_33" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q33_fullName[last]" id="last_33" autocomplete="family-name" />  <label class="form-sub-label" for="last_33" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_34"><div class="form-label-left" id="label_34"><label for="input_34"> Phone Number </label><label class="label-message" for="input_34"> </label></div><div id="cid_34" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q34_phoneNumber[area]" id="input_34_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_34_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q34_phoneNumber[phone]" id="input_34_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_34_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_35"><div class="form-label-left" id="label_35"><label for="input_35"> Relation </label><label class="label-message" for="input_35"> </label></div><div id="cid_35" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_35" name="q35_input35" size="20" value="" /> </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 permanent 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" value="No" /><label id="label_input_36_1" for="input_36_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_37"><div class="form-label-left" id="label_37"><label for="input_37"> Any known allergies (incl. reactions to medications) and any present medical conditions?<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" 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_38"><div class="form-label-left" id="label_38"><label for="input_38">   CONFIDENTIAL: Please list all allergies </label><label class="label-message" for="input_38"> </label></div><div id="cid_38" class="form-input"> <textarea id="input_38" class="form-textarea" name="q38_input38" cols="40" rows="6"></textarea> </div></li><li id="cid_24" class="form-input-wide"> <div class="form-header-group"><h2 id="header_24" class="form-header">Disclaimer</h2></div> </li><li class="form-line" id="id_40"><div id="cid_40" class="form-input-wide"> <div id="text_40" class="form-html"><p><strong>Disclaimer </strong></p><p><b>Accident:</b> As the parent(s) or legal guardian of the above child/ren, I/we authorize any adult acting on behalf of Chabad of the Delta Hebrew School to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad of the Delta Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment.</p>  <p><b>Trips and Outings:</b> I hereby give permission for my child to attend and participate in all trips and outings organized as part of the program by Chabad of the Delta Hebrew School.</p>  <p><b>Privacy:</b> I hereby give permission for my child’s photographs/videos to be used in newsletters, local newspapers, Chabad of the Delta website or for promotion of our program.</p></div> </div></li><li class="form-line" id="id_41"><div class="form-label-left" id="label_41"><label for="input_41"> Digital Signature of Parent or Legal Guardian </label><label class="label-message" for="input_41"> </label></div><div id="cid_41" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_41" name="q41_input41" size="20" value="" /> </div></li><li class="form-line" id="id_43"><div class="form-label-left" id="label_43"><label for="input_43"> Date </label><label class="label-message" for="input_43"> </label></div><div id="cid_43" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select class="form-dropdown" name="q43_birthDate[month]" id="input_43_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_43_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q43_birthDate[day]" id="input_43_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_43_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q43_birthDate[year]" id="input_43_year"><option></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_43_year" id="sublabel_year">Year</label></span></div> </div></li><li id="cid_39" class="form-input-wide"> <div class="form-header-group"><h2 id="header_39" class="form-header">Tuition and Billing</h2></div> </li><li class="form-line" id="id_45"><div id="cid_45" class="form-input-wide"> <div id="text_45" class="form-html"><p><b>Tuition</b></p>

<p><b>Hebrew School Primary Program:</b> $700 (includes Book Fee)</p>
</div> </div></li><li class="form-line" id="id_46"><div id="cid_46" class="form-input-wide"> <div id="text_46" class="form-html"><p><b>Program &amp; Tuition Agreement</b></p><p>I hereby confirm my child’s enrollment in Chabad of the Delta's Hebrew School.</p><p>I represent that I am the custodial parent or legal guardian of the child that I am enrolling and that the information</p><p>I have provided is true and correct.</p><p>I fully understand that this enrollment, as part of my commitment to a long-term Jewish education at Chabad of the Delta, is accepted only on the basis of the full year program, and agree to pay the full annual fees accordingly.</p></div> </div></li><li class="form-line" id="id_47"><div class="form-label-left" id="label_47"><label for="input_47"> Digital Signature of Parent or Legal Guardian </label><label class="label-message" for="input_47"> </label></div><div id="cid_47" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_47" name="q47_input47" size="20" value="" /> </div></li><li class="form-line" id="id_48"><div class="form-label-left" id="label_48"><label for="input_48"> Date </label><label class="label-message" for="input_48"> </label></div><div id="cid_48" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select class="form-dropdown" name="q48_birthDate48[month]" id="input_48_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_48_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q48_birthDate48[day]" id="input_48_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_48_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q48_birthDate48[year]" id="input_48_year"><option></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_48_year" id="sublabel_year">Year</label></span></div> </div></li><li id="cid_44" class="form-input-wide"> <div class="form-header-group"><h2 id="header_44" class="form-header">Payment</h2></div> </li><li class="form-line" id="id_49"><div class="form-label-left" id="label_49"><label for="input_49"> Payment Plan </label><label class="label-message" for="input_49"> </label></div><div id="cid_49" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_49" name="q49_input49"><option value=""></option><option selected="selected" value="Pay in full">Pay in full</option><option value="Two payments">Two payments</option><option value="2nd Semester">2nd Semester</option></select> </div></li><li class="form-line" id="id_51"><div id="cid_51" class="form-input-wide"> <div id="text_51" class="form-html"><p>Payment #1 is due on or before August 15th, 2025 and payment # 2 is due on December 15th, 2025. Postdated check should be submitted. If paying by credit card, your card will be charged on December 15th, 2025.</p>
</div> </div></li><li class="form-line" id="id_27"><div class="form-label-left" id="label_27"><label for="input_27"> Total </label></div><div id="cid_27" class="form-input"> <div id="total_amount">$700.00 </div> </div></li><li class="form-line" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> Payment<span class="form-required">*</span> </label><label class="label-message" for="input_26"> </label></div><div id="cid_26" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2" class="form-payment-methods form-multiple-column"><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_26_creditCard" name="q26_payment26[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_26_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_26_paypal" name="q26_payment26[payment_method]" value="paypal" onclick="BuildSource.paypal(this)" /><label for="input_26_paypal">Paypal</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_26_other" name="q26_payment26[payment_method]" value="other" onclick="BuildSource.other(this)" /><label for="input_26_other">Check</label> </span></td></tr><tr class="credit_card hide"><th colspan="2">Credit Card</th></tr><tr class="credit_card hide"><td colspan="2" style="padding:0"><table cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container">  <label class="form-sub-label">We accept Visa, MasterCard, American Express, Discover</label></span><div class="cc-icons"><div class="cc-icon visa-icon"></div><div class="cc-icon mastercard-icon"></div><div class="cc-icon amex-icon"></div><div class="cc-icon discover-icon"></div></div><input type="hidden" name="q26_payment26[cc_type]" id="input_26_cc_type" value="" /></td></tr><tr><td><div class="cc-field-wrapper"><span class="form-sub-label-container"><input class="form-textbox form-creditcard js-cc-number validate[required, visible, creditcard]" type="text" name="q26_payment26[cc_number]" id="input_26_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_26_cc_number" id="sublabel_cc_number">Credit Card Number</label></span></div></td><td class="cc_ccv "><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q26_payment26[cc_ccv]" id="input_26_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_26_cc_ccv" id="sublabel_cc_ccv">Security Code</label></span></td></tr><tr><td colspan="2" class="cc_name_on_card "><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q26_payment26[cc_nameOnCard]" id="input_26_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_26_cc_nameOnCard" id="sublabel_cc_nameOnCard">Name on Card</label></span></td></tr><tr class="credit_card hide"><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q26_payment26[cc_exp_month]" id="input_26_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_26_cc_exp_month" id="sublabel_cc_exp_month">Expiration Month</label></span></td><td><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q26_payment26[cc_exp_year]" id="input_26_cc_exp_year" autocomplete="cc-exp-year"><option></option><option value="2025">2025</option><option value="2026">2026</option><option value="2027">2027</option><option value="2028">2028</option><option value="2029">2029</option><option value="2030">2030</option><option value="2031">2031</option><option value="2032">2032</option><option value="2033">2033</option><option value="2034">2034</option></select>  <label class="form-sub-label" for="input_26_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="paypal hide"><td colspan="2">Paypal has been selected. Payment will take place on the next page.</td></tr><tr class="other hide"><td colspan="2">Please make check payable to:<br />Chabad of the Delta<br />2295 Tilton Lane<br />Brentwood, CA 94513 </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 validate[required] form-address-line" type="text" name="q26_payment26[addr_line1]" id="input_26_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_26_addr_line1" id="sublabel_26_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 validate[required] form-address-city" type="text" name="q26_payment26[city]" id="input_26_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_26_city" id="sublabel_26_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q26_payment26[state]" id="input_26_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_26_state" id="sublabel_26_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 validate[required] form-address-postal" type="text" name="q26_payment26[postal]" id="input_26_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_26_postal" id="sublabel_26_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q26_payment26[country]" id="input_26_country" autocomplete="billing country-name"><option value="" selected="selected">Please Select</option><option selected="selected" value="United States">United States</option><option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="The Bahamas">The Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Brazil">Brazil</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burundi">Burundi</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cape Verde">Cape Verde</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="People's Republic of China">People's Republic of China</option><option value="Republic of China">Republic of China</option><option value="Christmas Island">Christmas Island</option><option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo">Congo</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Cote d'Ivoire">Cote d'Ivoire</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Eswatini">Eswatini</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Polynesia">French Polynesia</option><option value="Gabon">Gabon</option><option value="The Gambia">The Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jersey">Jersey</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="North Korea">North Korea</option><option value="South Korea">South Korea</option><option value="Kosovo">Kosovo</option><option 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