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lessons?","64_message":"","64_labelAlign":"Auto","64_required":"No","64_cols":40,"64_rows":6,"64_validation":"None","64_entryLimit":"None-0","64_maxsize":"","64_defaultValue":"","64_subLabel":"","64_hint":"","64_description":"","64_readonly":"No","64_wysiwyg":"Disable","64_name":"input64","64_qid":64,"64_type":"control_textarea","64_order":47,"68_text":"\u003cp\u003eWe look forward to celebrating this special day with you and your family.\u003c/p\u003e\u003cp\u003eIf you have any questions please feel free to call us at 760-586-6192\u0026#160;\u003c/p\u003e\u003cp\u003e\u003cspan id=\"docs-internal-guid-b5e357f3-7fff-82f0-0377-9834b66bdce2\"\u003e\u003cp dir=\"ltr\"\u003eThe B Mitzvah celebration is faithful to the beauty and authenticity of Jewish tradition and will serve to inspire a young boy or girl to constantly recognize his privilege and responsibility to God, his fellow human beings and himself.\u003c/p\u003e\u003cp dir=\"ltr\"\u003eWe believe that no two children are the same 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<form class="userform-form" action="" method="post" name="form_5164224" id="5164224" accept-charset="utf-8"><input type="hidden" name="formID" value="5164224" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li id="cid_5" class="form-input-wide"> <div class="form-header-group"><h3 id="header_5" class="form-header">Bar/Bat Mitzvah Child Information</h3></div> </li><li class="form-line" id="id_1"><div class="form-label-left" id="label_1"><label for="input_1"> Full 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" type="text" name="q1_fullName[prefix]" size="4" id="prefix_1" autocomplete="honorific-prefix" />  <label class="form-sub-label" for="prefix_1" id="sublabel_prefix">Salutation</label></span><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_4"><div class="form-label-left" id="label_4"><label for="input_4"> Hebrew Name (for Mi Sheberach)<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_fullName4[first]" id="first_4" autocomplete="given-name" />  <label class="form-sub-label" for="first_4" id="sublabel_first">Full Hebrew Name Ben/Bat</label></span><span 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autocomplete="family-name" />  <label class="form-sub-label" for="last_43" id="sublabel_last">Father's Hebrew Name</label></span> </div></li><li class="form-line" id="id_65"><div class="form-label-left" id="label_65"><label for="input_65"> Previous Jewish Education </label><label class="label-message" for="input_65"> </label></div><div id="cid_65" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_65" name="q65_input65" size="20" value="" /> </div></li><li class="form-line" id="id_3"><div class="form-label-left" id="label_3"><label for="input_3"> Birth Date<span class="form-required">*</span> </label><label class="label-message" for="input_3"> </label></div><div id="cid_3" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox validate[required]" id="month_3" name="q3_input3[month]" type="tel" size="2" maxlength="2" value="" />  <label class="form-sub-label" for="month_3" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="noDefault form-textbox validate[required]" id="day_3" name="q3_input3[day]" type="tel" size="2" maxlength="2" value="" />  <label class="form-sub-label" for="day_3" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox validate[required]" id="year_3" name="q3_input3[year]" type="tel" size="4" maxlength="4" value="" />  <label class="form-sub-label" for="year_3" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_3_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_3_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_41"><div class="form-label-left" id="label_41"><label for="input_41"> Time of Birth </label><label class="label-message" for="input_41"> </label></div><div id="cid_41" class="form-input"> <span class="dir_ltr inline_block"><span class="form-sub-label-container"><select class="noDefault form-dropdown" id="input_41_hourSelect" name="q41_input41[hourSelect]"><option></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option></select>  <label class="form-sub-label" for="input_41_hourSelect" id="sublabel_hour">Hour</label></span><span class="form-sub-label-container"><select class="form-dropdown" id="input_41_minuteSelect" name="q41_input41[minuteSelect]"><option></option><option value="00">00</option><option value="10">10</option><option value="20">20</option><option value="30">30</option><option value="40">40</option><option value="50">50</option></select>  <label class="form-sub-label" for="input_41_minuteSelect" id="sublabel_minutes">Minutes</label></span><span class="form-sub-label-container"><select class="form-dropdown" id="input_41_ampm" name="q41_input41[ampm]"><option></option><option selected="selected" value="AM">AM</option><option value="PM">PM</option></select>  <label class="form-sub-label" for="input_41_ampm"><span> </span></label></span></span> </div></li><li class="form-line" id="id_42"><div class="form-label-left" id="label_42"><label for="input_42"> If exact time of birth is unknown, was it morning or evening?<span class="form-required">*</span> </label><label class="label-message" for="input_42"> </label></div><div id="cid_42" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_42" name="q42_input42" size="20" value="" /> </div></li><li class="form-line" id="id_7"><div class="form-label-left" id="label_7"><label for="input_7"> Jewishness<span class="form-required">*</span> </label><label class="label-message" for="input_7"> </label></div><div id="cid_7" 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_7_0" name="q7_input7" value="From Birth" /><label id="label_input_7_0" for="input_7_0"><span>From Birth</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_7_1" name="q7_input7" value="Convert" /><label id="label_input_7_1" for="input_7_1"><span>Convert</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_7_2" name="q7_input7" value="Not Jewish" /><label id="label_input_7_2" for="input_7_2"><span>Not Jewish</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_8"><div class="form-label-left" id="label_8"><label for="input_8"> Family </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_8_0" name="q8_input8" value="Kohen" /><label id="label_input_8_0" for="input_8_0"><span>Kohen</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_8_1" name="q8_input8" value="Levi" /><label id="label_input_8_1" for="input_8_1"><span>Levi</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_8_2" name="q8_input8" value="Yisroel" /><label id="label_input_8_2" for="input_8_2"><span>Yisroel</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_9"><div class="form-label-left" id="label_9"><label for="input_9"> Cell Number </label><label class="label-message" for="input_9"> </label></div><div id="cid_9" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q9_phoneNumber[area]" id="input_9_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_9_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q9_phoneNumber[phone]" id="input_9_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_9_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li id="cid_13" class="form-input-wide"> <div class="form-header-group"><h3 id="header_13" class="form-header">Parent #1 Information</h3></div> </li><li class="form-line" id="id_48"><div class="form-label-left" id="label_48"><label for="input_48"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_48"> </label></div><div id="cid_48" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" name="q48_fullName48[prefix]" size="4" id="prefix_48" autocomplete="honorific-prefix" />  <label class="form-sub-label" for="prefix_48" id="sublabel_prefix">Salutation</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q48_fullName48[first]" id="first_48" autocomplete="given-name" />  <label class="form-sub-label" for="first_48" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q48_fullName48[last]" id="last_48" autocomplete="family-name" />  <label class="form-sub-label" for="last_48" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_47"><div class="form-label-left" id="label_47"><label for="input_47"> Hebrew Name (for Mi Sheberach) </label><label class="label-message" for="input_47"> </label></div><div id="cid_47" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q47_fullName47[first]" id="first_47" autocomplete="given-name" />  <label class="form-sub-label" for="first_47" id="sublabel_first">Full Hebrew Name Ben/Bat</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q47_fullName47[last]" id="last_47" autocomplete="family-name" />  <label class="form-sub-label" for="last_47" id="sublabel_last">Mother's Hebrew Name</label></span> </div></li><li class="form-line" id="id_45"><div class="form-label-left" id="label_45"><label for="input_45"> Hebrew Name (for Aliyah) </label><label class="label-message" for="input_45"> </label></div><div id="cid_45" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q45_fullName45[first]" id="first_45" autocomplete="given-name" />  <label class="form-sub-label" for="first_45" id="sublabel_first">Full Hebrew Name Ben/Bat</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q45_fullName45[last]" id="last_45" autocomplete="family-name" />  <label class="form-sub-label" for="last_45" id="sublabel_last">Father's Hebrew Name</label></span> </div></li><li class="form-line" id="id_18"><div class="form-label-left" id="label_18"><label for="input_18"> Birth Date </label><label class="label-message" for="input_18"> </label></div><div id="cid_18" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="month_18" name="q18_input18[month]" type="tel" size="2" maxlength="2" value="" />  <label class="form-sub-label" for="month_18" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="noDefault form-textbox" id="day_18" name="q18_input18[day]" type="tel" size="2" maxlength="2" value="" />  <label class="form-sub-label" for="day_18" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="year_18" name="q18_input18[year]" type="tel" size="4" maxlength="4" value="" />  <label class="form-sub-label" for="year_18" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_18_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_18_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_25"><div class="form-label-left" id="label_25"><label for="input_25"> E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_25"> </label></div><div id="cid_25" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_25" name="q25_email25" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_16"><div class="form-label-left" id="label_16"><label for="input_16"> Jewishness<span class="form-required">*</span> </label><label class="label-message" for="input_16"> </label></div><div id="cid_16" 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_16_0" name="q16_input16" value="From Birth" /><label id="label_input_16_0" for="input_16_0"><span>From Birth</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_16_1" name="q16_input16" value="Convert" /><label id="label_input_16_1" for="input_16_1"><span>Convert</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_16_2" name="q16_input16" value="Not Jewish" /><label id="label_input_16_2" for="input_16_2"><span>Not Jewish</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_17"><div class="form-label-left" id="label_17"><label for="input_17"> Family </label><label class="label-message" for="input_17"> </label></div><div id="cid_17" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_17_0" name="q17_input17" value="Kohen" /><label id="label_input_17_0" for="input_17_0"><span>Kohen</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_17_1" name="q17_input17" value="Levi" /><label id="label_input_17_1" for="input_17_1"><span>Levi</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_17_2" name="q17_input17" value="Yisroel" /><label id="label_input_17_2" for="input_17_2"><span>Yisroel</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_22"><div class="form-label-left" id="label_22"><label for="input_22"> Occupation </label><label class="label-message" for="input_22"> </label></div><div id="cid_22" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_22" name="q22_input22" size="20" value="" /> </div></li><li class="form-line" id="id_19"><div class="form-label-left" id="label_19"><label for="input_19"> Cell Number<span class="form-required">*</span> </label><label class="label-message" for="input_19"> </label></div><div id="cid_19" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q19_phoneNumber19[area]" id="input_19_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_19_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q19_phoneNumber19[phone]" id="input_19_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_19_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_20"><div class="form-label-left" id="label_20"><label for="input_20"> Work Number </label><label class="label-message" for="input_20"> </label></div><div id="cid_20" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q20_phoneNumber20[area]" id="input_20_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_20_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q20_phoneNumber20[phone]" id="input_20_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_20_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_21"><div class="form-label-left" id="label_21"><label for="input_21"> Home Number </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_phoneNumber21[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_phoneNumber21[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 id="cid_44" class="form-input-wide"> <div class="form-header-group"><h3 id="header_44" class="form-header">Parent #2 Information</h3></div> </li><li class="form-line" id="id_46"><div class="form-label-left" id="label_46"><label for="input_46"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_46"> </label></div><div id="cid_46" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" name="q46_fullName46[prefix]" size="4" id="prefix_46" autocomplete="honorific-prefix" />  <label class="form-sub-label" for="prefix_46" id="sublabel_prefix">Salutation</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q46_fullName46[first]" id="first_46" autocomplete="given-name" />  <label class="form-sub-label" for="first_46" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q46_fullName46[last]" id="last_46" autocomplete="family-name" />  <label class="form-sub-label" for="last_46" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_49"><div class="form-label-left" id="label_49"><label for="input_49"> Hebrew Name (for Mi Sheberach) </label><label class="label-message" for="input_49"> </label></div><div id="cid_49" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q49_fullName49[first]" id="first_49" autocomplete="given-name" />  <label class="form-sub-label" for="first_49" id="sublabel_first">Full Hebrew Name Ben/Bat</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q49_fullName49[last]" id="last_49" autocomplete="family-name" />  <label class="form-sub-label" for="last_49" id="sublabel_last">Mother's Hebrew Name</label></span> </div></li><li class="form-line" id="id_50"><div class="form-label-left" id="label_50"><label for="input_50"> Hebrew Name (for Aliyah) </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" 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">Full Hebrew Name Ben/Bat</label></span><span class="form-sub-label-container"><input class="form-textbox" 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">Father's Hebrew Name</label></span> </div></li><li class="form-line" id="id_51"><div class="form-label-left" id="label_51"><label for="input_51"> Birth Date </label><label class="label-message" for="input_51"> </label></div><div id="cid_51" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q51_birthDate[month]" id="input_51_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_51_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q51_birthDate[day]" id="input_51_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_51_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q51_birthDate[year]" id="input_51_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_51_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_52"><div class="form-label-left" id="label_52"><label for="input_52"> Jewishness </label><label class="label-message" for="input_52"> </label></div><div id="cid_52" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_52_0" name="q52_input52" value="From Birth" /><label id="label_input_52_0" for="input_52_0"><span>From Birth</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_52_1" name="q52_input52" value="Convert" /><label id="label_input_52_1" for="input_52_1"><span>Convert</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_52_2" name="q52_input52" value="Not Jewish" /><label id="label_input_52_2" for="input_52_2"><span>Not Jewish</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_53"><div class="form-label-left" id="label_53"><label for="input_53"> Family </label><label class="label-message" for="input_53"> </label></div><div id="cid_53" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_53_0" name="q53_input53" value="Kohen" /><label id="label_input_53_0" for="input_53_0"><span>Kohen</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_53_1" name="q53_input53" value="Levi" /><label id="label_input_53_1" for="input_53_1"><span>Levi</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_53_2" name="q53_input53" value="Yisroel" /><label id="label_input_53_2" for="input_53_2"><span>Yisroel</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_54"><div class="form-label-left" id="label_54"><label for="input_54"> E-mail </label><label class="label-message" for="input_54"> </label></div><div id="cid_54" class="form-input"> <input type="email" class=" form-textbox validate[Email]" id="input_54" name="q54_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_58"><div class="form-label-left" id="label_58"><label for="input_58"> Occupation </label><label class="label-message" for="input_58"> </label></div><div id="cid_58" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_58" name="q58_input58" size="20" value="" /> </div></li><li class="form-line" id="id_55"><div class="form-label-left" id="label_55"><label for="input_55"> Cell Number </label><label class="label-message" for="input_55"> </label></div><div id="cid_55" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q55_phoneNumber55[area]" id="input_55_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_55_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q55_phoneNumber55[phone]" id="input_55_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_55_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_57"><div class="form-label-left" id="label_57"><label for="input_57"> Work Number </label><label class="label-message" for="input_57"> </label></div><div id="cid_57" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q57_phoneNumber57[area]" id="input_57_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_57_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q57_phoneNumber57[phone]" id="input_57_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_57_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_56"><div class="form-label-left" id="label_56"><label for="input_56"> Home Number </label><label class="label-message" for="input_56"> </label></div><div id="cid_56" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q56_phoneNumber56[area]" id="input_56_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_56_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q56_phoneNumber56[phone]" id="input_56_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_56_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li id="cid_27" class="form-input-wide"> <div class="form-header-group"><h2 id="header_27" class="form-header">Family Information</h2></div> </li><li class="form-line" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> Address<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"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-line" type="text" name="q26_address[addr_line1]" id="input_26_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_26_addr_line1" id="sublabel_26_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="q26_address[addr_line2]" id="input_26_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_26_addr_line2" id="sublabel_26_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="q26_address[city]" id="input_26_city" size="21" autocomplete="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_address[state]" id="input_26_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_26_state" id="sublabel_26_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="q26_address[postal]" id="input_26_postal" size="10" autocomplete="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_address[country]" id="input_26_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_26_country" id="sublabel_26_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_28"><div class="form-label-left" id="label_28"><label for="input_28"> Marital Status </label><label class="label-message" for="input_28"> </label></div><div id="cid_28" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_28" name="q28_input28"><option value=""></option><option value="Single">Single</option><option value="Married">Married</option><option value="Divorced">Divorced</option><option value="Widowed">Widowed</option></select> </div></li><li class="form-line" id="id_29"><div class="form-label-left" id="label_29"><label for="input_29"> Anniversary Date </label><label class="label-message" for="input_29"> </label></div><div id="cid_29" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="month_29" name="q29_input29[month]" type="tel" size="2" maxlength="2" value="" />  <label class="form-sub-label" for="month_29" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="noDefault form-textbox" id="day_29" name="q29_input29[day]" type="tel" size="2" maxlength="2" value="" />  <label class="form-sub-label" for="day_29" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="year_29" name="q29_input29[year]" type="tel" size="4" maxlength="4" value="" />  <label class="form-sub-label" for="year_29" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_29_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_29_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_60"><div class="form-label-left" id="label_60"><label for="input_60"> Additional Children names and ages </label><label class="label-message" for="input_60"> </label></div><div id="cid_60" class="form-input"> <textarea id="input_60" class="form-textarea" name="q60_input60" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_62"><div class="form-label-left" id="label_62"><label for="input_62"> Synagogue family attends? </label><label class="label-message" for="input_62"> </label></div><div id="cid_62" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_62" name="q62_input62" size="20" value="" /> </div></li><li class="form-line" id="id_61"><div class="form-label-left" id="label_61"><label for="input_61"> Are you interested in any other services in addition to b mitzvah lessons </label><label class="label-message" for="input_61"> </label></div><div id="cid_61" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_61_0" name="q61_input61" value="yes" /><label id="label_input_61_0" for="input_61_0"><span>yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_61_1" name="q61_input61" value="just lessons" /><label id="label_input_61_1" for="input_61_1"><span>just lessons</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_63"><div class="form-label-left" id="label_63"><label for="input_63"> If yes, what else are you interested in? </label><label class="label-message" for="input_63"> </label></div><div id="cid_63" class="form-input"> <textarea id="input_63" class="form-textarea" name="q63_input63" cols="40" rows="6"></textarea> </div></li><li id="cid_59" class="form-input-wide"> <div class="form-header-group"><h2 id="header_59" class="form-header">Goals for Bar/Bat Mitvzah</h2></div> </li><li class="form-line" id="id_67"><div class="form-label-left" id="label_67"><label for="input_67"> What are the goals you have for your child?<span class="form-required">*</span> </label><label class="label-message" for="input_67"> You can click as many as you'd like</label></div><div id="cid_67" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_67_0" name="q67_input67[]" value="learn to read hebrew" /><label id="label_input_67_0" for="input_67_0"><span>learn to read hebrew</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_67_1" name="q67_input67[]" value="learn about jewish heritage" /><label id="label_input_67_1" for="input_67_1"><span>learn about jewish heritage</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_67_2" name="q67_input67[]" value="learn how to put on tefillen" /><label id="label_input_67_2" for="input_67_2"><span>learn how to put on tefillen</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_67_3" name="q67_input67[]" value="learn to read in the torah" /><label id="label_input_67_3" for="input_67_3"><span>learn to read in the torah</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_67_4" name="q67_input67[]" value="learn to read Haftorah" /><label id="label_input_67_4" for="input_67_4"><span>learn to read Haftorah</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_67_5" name="q67_input67[]" value="b-mitzvah speech preparation" /><label id="label_input_67_5" for="input_67_5"><span>b-mitzvah speech preparation</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_67_6" name="q67_input67[]" value="learn to pray from a siddur" /><label id="label_input_67_6" for="input_67_6"><span>learn to pray from a siddur</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_67_7" name="q67_input67[]" value="learn to lead prayer services (be chazzan)" /><label id="label_input_67_7" for="input_67_7"><span>learn to lead prayer services (be chazzan)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox-other form-checkbox validate[required, other]" name="q67_input67[other]" id="other_67" value="" /><span><input type="text" class="form-checkbox-other-input form-textbox form-checkbox validate[required, other]" name="q67_input67[other][text]" data-otherhint="Other" size="15" id="input_67" disabled="disabled" /></span><br /></span></div> </div></li><li class="form-line" id="id_66"><div class="form-label-left" id="label_66"><label for="input_66"> Does your child read hebrew? </label><label class="label-message" for="input_66"> </label></div><div id="cid_66" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_66_0" name="q66_input66" value="yes" /><label id="label_input_66_0" for="input_66_0"><span>yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_66_1" name="q66_input66" value="no" /><label id="label_input_66_1" for="input_66_1"><span>no</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_64"><div class="form-label-left" id="label_64"><label for="input_64"> Please describe any additional goals you have for your child's lessons? </label><label class="label-message" for="input_64"> </label></div><div id="cid_64" class="form-input"> <textarea id="input_64" class="form-textarea" name="q64_input64" cols="40" rows="6"></textarea> </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>We look forward to celebrating this special day with you and your family.</p><p>If you have any questions please feel free to call us at 760-586-6192 </p><p><span id="docs-internal-guid-b5e357f3-7fff-82f0-0377-9834b66bdce2"></span></p><p dir="ltr">The B Mitzvah celebration is faithful to the beauty and authenticity of Jewish tradition and will serve to inspire a young boy or girl to constantly recognize his privilege and responsibility to God, his fellow human beings and himself.</p><p dir="ltr">We believe that no two children are the same nor are any two families the same. We therefore strive to personalize this event to make it most meaningful, enjoyable and inspiring one for your family. We celebrate each child's individual strengths by tailor-making each B Mitzvah to fit the unique needs of the child</p><p dir="ltr">Our goal is to instill in each child the meaning and relevance behind what it is they are doing, so the experience is engaging and relevant to their lives in today's modern world.</p><p dir="ltr">The B Mitzvah is much more than a ceremony, it is about who we are. Our focus is on experiencing the joy and depth of being Jewish. The ceremony is only one part of that. The training and preparation for the B Mitzvah reflects that as well. The child is taught the meaning of what it means to be Jewish and is given time to ask and reflect on his becoming a B Mitzvah with the Rabbis and teachers he studies with.</p><p dir="ltr">It is not just about the destination. The journey should be meaningful and enjoyable as well. We want your child to always remember their B Mitzvah and the training that preceded it, as a joyous and memorable learning experience.</p><br /> <p></p><p>*it is always helpful for our records to have any and all paperwork you have on file including and not limited to:</p><p>Conversion documents</p><p>Jewish marriage documents from parents or grandparents</p><p>Pictures of family tombstones</p><p>Letters from previous rabbis </p><p>Please email to chabadencinitas@gmail.com </p></div> </div></li><li class="form-line" id="id_24"><div class="form-label-left form-label-hidden" id="label_24"></div><div id="cid_24" 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_24" /><label id="label_input_24" for="input_24">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:156px;" 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 class="form-line" id="id_70"><div class="form-label-left" id="label_70"><label for="input_70"> Payment for lessons </label><label class="label-message" for="input_70"> </label></div><div id="cid_70" class="form-input"> <div class="form-single-column"><span class="form-radio-item simple-mode"><label id="label_input_70" for="input_70"><span>$</span></label><input type="number" class="form-textbox" id="input_70" name="q70_input70" value="" onkeypress="validateNumber(event)" /></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_72"><div class="form-label-left form-label-hidden" id="label_72"></div><div id="cid_72" class="form-input"> <div class="form-single-column form-checkbox-item">		<input type="checkbox" id="input_72" class="form-checkbox" name="q72_paymentrecurrence" value="Monthly" />		<label id="label_72" for="input_72">Yes, I'd like to make this a monthly recurring payment.</label>		<div class="clearfix"></div>		</div> </div></li><li class="form-line" id="id_71"><div class="form-label-left" id="label_71"><label for="input_71"> Payment </label><label class="label-message" for="input_71"> </label></div><div id="cid_71" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2" class="form-payment-methods form-multiple-column"></td></tr><tr class="credit_card "><th colspan="2">Credit Card</th></tr><tr class="credit_card "><td colspan="2" style="padding:0"><table cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container">  <label class="form-sub-label">We accept Visa, MasterCard, American Express, Discover</label></span><div class="cc-icons"><div class="cc-icon visa-icon"></div><div class="cc-icon mastercard-icon"></div><div class="cc-icon amex-icon"></div><div class="cc-icon discover-icon"></div></div><input type="hidden" name="q71_payment[cc_type]" id="input_71_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="q71_payment[cc_number]" id="input_71_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_71_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="q71_payment[cc_ccv]" id="input_71_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_71_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="q71_payment[cc_nameOnCard]" id="input_71_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_71_cc_nameOnCard" id="sublabel_cc_nameOnCard">Name on Card</label></span></td></tr><tr class="credit_card "><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q71_payment[cc_exp_month]" id="input_71_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_71_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="q71_payment[cc_exp_year]" id="input_71_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_71_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="billing_address "><th colspan="2">Billing Address</th></tr><tr class="billing_address "><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line" type="text" name="q71_payment[addr_line1]" id="input_71_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_71_addr_line1" id="sublabel_71_addr_line1">Street Address</label></span></td></tr><tr class="billing_address "><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q71_payment[city]" id="input_71_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_71_city" id="sublabel_71_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q71_payment[state]" id="input_71_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_71_state" id="sublabel_71_state">State / Province</label></span></td></tr><tr class="billing_address "><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q71_payment[postal]" id="input_71_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_71_postal" id="sublabel_71_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q71_payment[country]" id="input_71_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 value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option 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