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	HS Returning Student Registration - Neshama - Chabad of Manhattan Beach
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<form class="userform-form" action="" method="post" name="form_6050523" id="6050523" accept-charset="utf-8"><input type="hidden" name="formID" value="6050523" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li class="form-line" id="id_1"><div id="cid_1" class="form-input-wide"> <div id="text_1" class="form-html"><p style="text-align: center;"><span style="font-size: 22px;"><strong>Chabad Hebrew School<br />
<span style="font-size: 20px;">of Manhattan Beach</span></strong><br />
<em><span style="font-size: 18px;">Registration Form</span></em></span><br />
<span style="font-size:16px;">School Year 2026-2027</span></p>

<p style="text-align: center;">We are excited for a new year at Chabad Hebrew School of Manhattan Beach.  </p>

<p style="text-align: center;">This form is for returning students.</p>

<p style="text-align: center;">A separate <a href="/article.asp?AID=4461810">Student Registration Form</a> must be filled out for any siblings joining for the first time.</p>

<p style="text-align: center;">We look forward to another wonderful year of learning and growth with your family!</p>

<p style="text-align: center;">Please fill out ALL fields of this form. If you have any questions or concerns you'd like to discuss with us, please contact Shula 646-413-9092.</p>
</div> </div></li><li class="form-line" id="id_65"><div class="form-label-left" id="label_65"><label for="input_65"> How many children are you registering as returning students?<span class="form-required">*</span> </label><label class="label-message" for="input_65"> </label></div><div id="cid_65" class="form-input"> <input type="number" class="form-number-input  form-textbox validate[required]" id="input_65" name="q65_number65" style="width:60px" size="5" value="1" data-type="input-number" autocomplete="nope" min="1" data-numbermin="1" max="3" data-numbermax="3" /> </div></li><li id="cid_3" class="form-input-wide"> <div class="form-header-group"><h3 id="header_3" class="form-header">STUDENT INFORMATION</h3></div> </li><li class="form-line" id="id_87"><div id="cid_87" class="form-input-wide"> <div id="text_87" class="form-html"><p><span style="font-size:18px;"><strong>Child 1</strong></span></p>
</div> </div></li><li class="form-line" id="id_4"><div class="form-label-left" id="label_4"><label for="input_4"> Full Name - Child 1<span class="form-required">*</span> </label><label class="label-message" for="input_4"> </label></div><div id="cid_4" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q4_fullName[first]" id="first_4" autocomplete="given-name" />  <label class="form-sub-label" for="first_4" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q4_fullName[last]" id="last_4" autocomplete="family-name" />  <label class="form-sub-label" for="last_4" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_9"><div class="form-label-left" id="label_9"><label for="input_9"> Grade Entering<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_input9"><option value=""></option><option value="Pre-K">Pre-K</option><option value="Kindergarten">Kindergarten</option><option value="First">First</option><option value="Second">Second</option><option value="Third">Third</option><option value="Fourth">Fourth</option><option value="Fifth">Fifth</option><option value="Sixth">Sixth</option><option value="Seventh">Seventh</option><option value="Eighth">Eighth</option></select> </div></li><li class="form-line" id="id_67"><div class="form-label-left" id="label_67"><label for="input_67"> Does this student have any allergies?<span class="form-required">*</span> </label><label class="label-message" for="input_67"> </label></div><div id="cid_67" 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_67_0" name="q67_input67" value="Yes" /><label id="label_input_67_0" for="input_67_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_67_1" name="q67_input67" value="No" /><label id="label_input_67_1" for="input_67_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_69"><div class="form-label-left" id="label_69"><label for="input_69"> If yes, please list them:<span class="form-required">*</span> </label><label class="label-message" for="input_69"> </label></div><div id="cid_69" class="form-input"> <textarea id="input_69" class="form-textarea validate[required]" name="q69_input69" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_68"><div class="form-label-left" id="label_68"><label for="input_68"> Does this student have an IEP?<span class="form-required">*</span> </label><label class="label-message" for="input_68"> </label></div><div id="cid_68" 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_68_0" name="q68_input68" value="Yes" /><label id="label_input_68_0" for="input_68_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_68_1" name="q68_input68" value="No" /><label id="label_input_68_1" for="input_68_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_70"><div class="form-label-left" id="label_70"><label for="input_70"> If yes, please explain:<span class="form-required">*</span> </label><label class="label-message" for="input_70"> </label></div><div id="cid_70" class="form-input"> <textarea id="input_70" class="form-textarea validate[required]" name="q70_input70" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_88"><div id="cid_88" class="form-input-wide"> <div id="text_88" class="form-html"><p><span style="font-size:18px;"><strong>Child 2</strong></span></p>
</div> </div></li><li class="form-line" id="id_75"><div class="form-label-left" id="label_75"><label for="input_75"> Full Name - Child 2<span class="form-required">*</span> </label><label class="label-message" for="input_75"> </label></div><div id="cid_75" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q75_fullName75[first]" id="first_75" autocomplete="given-name" />  <label class="form-sub-label" for="first_75" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q75_fullName75[last]" id="last_75" autocomplete="family-name" />  <label class="form-sub-label" for="last_75" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_76"><div class="form-label-left" id="label_76"><label for="input_76"> Grade Entering<span class="form-required">*</span> </label><label class="label-message" for="input_76"> </label></div><div id="cid_76" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_76" name="q76_input76"><option value=""></option><option value="Pre-K">Pre-K</option><option value="Kindergarten">Kindergarten</option><option value="First">First</option><option value="Second">Second</option><option value="Third">Third</option><option value="Fourth">Fourth</option><option value="Fifth">Fifth</option><option value="Sixth">Sixth</option><option value="Seventh">Seventh</option><option value="Eighth">Eighth</option></select> </div></li><li class="form-line" id="id_77"><div class="form-label-left" id="label_77"><label for="input_77"> Does this student have any allergies?<span class="form-required">*</span> </label><label class="label-message" for="input_77"> </label></div><div id="cid_77" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_77_0" name="q77_input77" value="Yes" /><label id="label_input_77_0" for="input_77_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_77_1" name="q77_input77" value="No" /><label id="label_input_77_1" for="input_77_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_78"><div class="form-label-left" id="label_78"><label for="input_78"> If yes, please list them:<span class="form-required">*</span> </label><label class="label-message" for="input_78"> </label></div><div id="cid_78" class="form-input"> <textarea id="input_78" class="form-textarea validate[required]" name="q78_input78" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_79"><div class="form-label-left" id="label_79"><label for="input_79"> Does this student have an IEP?<span class="form-required">*</span> </label><label class="label-message" for="input_79"> </label></div><div id="cid_79" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_79_0" name="q79_input79" value="Yes" /><label id="label_input_79_0" for="input_79_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_79_1" name="q79_input79" value="No" /><label id="label_input_79_1" for="input_79_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_80"><div class="form-label-left" id="label_80"><label for="input_80"> If yes, please explain:<span class="form-required">*</span> </label><label class="label-message" for="input_80"> </label></div><div id="cid_80" class="form-input"> <textarea id="input_80" class="form-textarea validate[required]" name="q80_input80" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_89"><div id="cid_89" class="form-input-wide"> <div id="text_89" class="form-html"><p><span style="font-size:18px;"><strong>Child 3</strong></span></p>
</div> </div></li><li class="form-line" id="id_81"><div class="form-label-left" id="label_81"><label for="input_81"> Full Name - Child 3<span class="form-required">*</span> </label><label class="label-message" for="input_81"> </label></div><div id="cid_81" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q81_fullName81[first]" id="first_81" autocomplete="given-name" />  <label class="form-sub-label" for="first_81" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q81_fullName81[last]" id="last_81" autocomplete="family-name" />  <label class="form-sub-label" for="last_81" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_82"><div class="form-label-left" id="label_82"><label for="input_82"> Grade Entering<span class="form-required">*</span> </label><label class="label-message" for="input_82"> </label></div><div id="cid_82" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_82" name="q82_input82"><option value=""></option><option value="Pre-K">Pre-K</option><option value="Kindergarten">Kindergarten</option><option value="First">First</option><option value="Second">Second</option><option value="Third">Third</option><option value="Fourth">Fourth</option><option value="Fifth">Fifth</option><option value="Sixth">Sixth</option><option value="Seventh">Seventh</option><option value="Eighth">Eighth</option></select> </div></li><li class="form-line" id="id_83"><div class="form-label-left" id="label_83"><label for="input_83"> Does this student have any allergies?<span class="form-required">*</span> </label><label class="label-message" for="input_83"> </label></div><div id="cid_83" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_83_0" name="q83_input83" value="Yes" /><label id="label_input_83_0" for="input_83_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_83_1" name="q83_input83" value="No" /><label id="label_input_83_1" for="input_83_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_84"><div class="form-label-left" id="label_84"><label for="input_84"> If yes, please list them:<span class="form-required">*</span> </label><label class="label-message" for="input_84"> </label></div><div id="cid_84" class="form-input"> <textarea id="input_84" class="form-textarea validate[required]" name="q84_input84" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_85"><div class="form-label-left" id="label_85"><label for="input_85"> Does this student have an IEP?<span class="form-required">*</span> </label><label class="label-message" for="input_85"> </label></div><div id="cid_85" 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_85_0" name="q85_input85" value="Yes" /><label id="label_input_85_0" for="input_85_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_85_1" name="q85_input85" value="No" /><label id="label_input_85_1" for="input_85_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_86"><div class="form-label-left" id="label_86"><label for="input_86"> If yes, please explain:<span class="form-required">*</span> </label><label class="label-message" for="input_86"> </label></div><div id="cid_86" class="form-input"> <textarea id="input_86" class="form-textarea validate[required]" name="q86_input86" cols="40" rows="6"></textarea> </div></li><li id="cid_27" class="form-input-wide"> <div class="form-header-group"><h3 id="header_27" class="form-header">OTHER INFORMATION</h3></div> </li><li class="form-line" id="id_30"><div class="form-label-left" id="label_30"><label for="input_30"> Primary email for parent communication:<span class="form-required">*</span> </label><label class="label-message" for="input_30"> </label></div><div id="cid_30" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_30" name="q30_email30" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_90"><div class="form-label-left form-label-hidden" id="label_90"></div><div id="cid_90" 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_90" /><label id="label_input_90" for="input_90">I would like to receive news and updates by email</label></div> </div></li><li class="form-line" id="id_71"><div class="form-label-left" id="label_71"><label for="input_71"> Does either parent have any special skill or resource to offer our children or teachers?<span class="form-required">*</span> </label><label class="label-message" for="input_71"> </label></div><div id="cid_71" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_71_0" name="q71_input71" value="Yes, please contact me to discuss further." /><label id="label_input_71_0" for="input_71_0"><span>Yes, please contact me to discuss further.</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_71_1" name="q71_input71" value="No" /><label id="label_input_71_1" for="input_71_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_72"><div id="cid_72" class="form-input-wide"> <div id="text_72" class="form-html"><p>As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of the Chabad 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, the Chabad Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in the Chabad Hebrew School activities and that these pictures may be used for marketing purposes.</p>
</div> </div></li><li class="form-line" id="id_73"><div class="form-label-left" id="label_73"><label for="input_73"> Confirmation<span class="form-required">*</span> </label><label class="label-message" for="input_73"> </label></div><div id="cid_73" 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_73_0" name="q73_input73[]" value="I Accept" /><label id="label_input_73_0" for="input_73_0"><span>I Accept</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_35"><div class="form-label-left" id="label_35"><label for="input_35"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_35"> </label></div><div id="cid_35" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q35_fullName35[first]" id="first_35" autocomplete="given-name" />  <label class="form-sub-label" for="first_35" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q35_fullName35[last]" id="last_35" autocomplete="family-name" />  <label class="form-sub-label" for="last_35" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_74"><div class="form-label-left" id="label_74"><label for="input_74"> Initials<span class="form-required">*</span> </label><label class="label-message" for="input_74"> </label></div><div id="cid_74" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_74" name="q74_input74" size="20" value="" /> </div></li><li id="cid_54" class="form-input-wide"> <div class="form-header-group"><h3 id="header_54" class="form-header">PAYMENT PLAN</h3></div> </li><li class="form-line" id="id_55"><div id="cid_55" class="form-input-wide"> <div id="text_55" class="form-html"><p><strong>Your application is not complete without a payment plan.</strong></p>

<p><strong><u>COSTS PER CHILD:</u> </strong><br />
<strong>Sundays $900 + Registration and Security Fee: $150</strong></p>
</div> </div></li><li class="form-line" id="id_64"><div class="form-label-left" id="label_64"><label for="input_64"> Tuition<span class="form-required">*</span> </label><label class="label-message" for="input_64"> Child 1</label></div><div id="cid_64" 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_64_0" name="q64_input64" value="Sundays 10:30am-12:30pm - $900+$150" /><label id="label_input_64_0" for="input_64_0"><span>Sundays 10:30am-12:30pm - $900+$150</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_94"><div class="form-label-left" id="label_94"><label for="input_94"> Tuition<span class="form-required">*</span> </label><label class="label-message" for="input_94"> Child 2</label></div><div id="cid_94" 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_94_0" name="q94_input94" value="Sundays 10:30am-12:30pm - $900+$150" /><label id="label_input_94_0" for="input_94_0"><span>Sundays 10:30am-12:30pm - $900+$150</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_93"><div class="form-label-left" id="label_93"><label for="input_93"> Tuition<span class="form-required">*</span> </label><label class="label-message" for="input_93"> Child 3</label></div><div id="cid_93" 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_93_0" name="q93_input93" value="Sundays 10:30am-12:30pm - $900+$150" /><label id="label_input_93_0" for="input_93_0"><span>Sundays 10:30am-12:30pm - $900+$150</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_92"><div id="cid_92" class="form-input-wide"> <div id="text_92" class="form-html"><p><em>Optional: I'm aware that there are students on scholarship. I'd like to contribute this additional amount towards the tuition of a fellow student in need.</em></p>
</div> </div></li><li class="form-line" id="id_91"><div class="form-label-left" id="label_91"><label for="input_91"> Amount </label><label class="label-message" for="input_91"> </label></div><div id="cid_91" class="form-input"> <input type="number" class="form-number-input  form-textbox" id="input_91" name="q91_number" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" /> </div></li><li class="form-line" id="id_56"><div class="form-label-left" id="label_56"><label for="input_56"> Payment type<span class="form-required">*</span> </label><label class="label-message" for="input_56"> </label></div><div id="cid_56" 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_56_creditCard" name="q56_payment[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_56_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_56_other" name="q56_payment[payment_method]" value="other" onclick="BuildSource.other(this)" /><label for="input_56_other">Cash or Check</label> </span></td></tr><tr class="credit_card hide"><th colspan="2">Credit Card</th></tr><tr class="credit_card hide"><td colspan="2" style="padding:0"><table cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container">  <label class="form-sub-label">We accept Visa, MasterCard, American Express, Discover</label></span><div class="cc-icons"><div class="cc-icon visa-icon"></div><div class="cc-icon mastercard-icon"></div><div class="cc-icon amex-icon"></div><div class="cc-icon discover-icon"></div></div><input type="hidden" name="q56_payment[cc_type]" id="input_56_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="q56_payment[cc_number]" id="input_56_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_56_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="q56_payment[cc_ccv]" id="input_56_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_56_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="q56_payment[cc_nameOnCard]" id="input_56_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_56_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="q56_payment[cc_exp_month]" id="input_56_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_56_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="q56_payment[cc_exp_year]" id="input_56_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_56_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="other hide"><td colspan="2">Checks should be made payable to Neshama.</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="q56_payment[addr_line1]" id="input_56_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_56_addr_line1" id="sublabel_56_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="q56_payment[city]" id="input_56_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_56_city" id="sublabel_56_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q56_payment[state]" id="input_56_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_56_state" id="sublabel_56_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="q56_payment[postal]" id="input_56_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_56_postal" id="sublabel_56_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q56_payment[country]" id="input_56_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 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_56_country" id="sublabel_56_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_58"><div class="form-label-left" id="label_58"><label for="input_58"> Total </label></div><div id="cid_58" class="form-input"> <div id="total_amount">$0.00 </div> </div></li><li class="form-line" id="id_59"><div class="form-label-left" id="label_59"><label for="input_59"> Confirmation<span class="form-required">*</span> </label><label class="label-message" for="input_59"> </label></div><div id="cid_59" class="form-input"> <div 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