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window.formJson = Object.extend([{"form_height":450,"3_text":"Chabad Sparks Holiday Blast - St Kilda","3_subHeader":"","3_headerType":"Default","3_name":"clickTo3","3_qid":3,"3_type":"control_head","3_order":1,"4_text":"\u003cp style=\"text-align:center\"\u003e\u003cfont color=\"#ff00ff\" face=\"Arial, Helvetica Neue, Helvetica, sans-serif\"\u003e\u003cspan style=\"font-size: 22px;\"\u003e\u003cb\u003eDecember 2026 - January 2027\u003c/b\u003e\u003c/span\u003e\u003c/font\u003e\u003c/p\u003e\n\n\u003cp style=\"text-align:center\"\u003e\u003cb\u003e\u003cfont size=\"3\"\u003eGRADES:\u003c/font\u003e\u003c/b\u003e\u003c/p\u003e\n\n\u003cp style=\"text-align:center\"\u003ePrep - Grade 6 (2026 School Year)\u003c/p\u003e\n\n\u003cp style=\"text-align:center\"\u003e\u003cb\u003e\u003cfont size=\"3\"\u003eLOCATION:\u003c/font\u003e\u003c/b\u003e\u003c/p\u003e\n\n\u003cp style=\"text-align:center\"\u003e\u003cspan style=\"font-size:13px\"\u003e1 A\u0026#39;Beckett St, East St. Kilda, 3183\u003c/span\u003e\u003c/p\u003e\n\n\u003cp style=\"text-align:center\"\u003e\u003cb\u003e\u003cfont size=\"3\"\u003eHOURS:\u003c/font\u003e\u003c/b\u003e\u003c/p\u003e\n\n\u003cp style=\"text-align:center\"\u003eMonday to Friday: 9:15 am - 4:00 pm\u003c/p\u003e\n\n\u003cp style=\"text-align:center\"\u003eBefore Care: 8:30 am - 9:15 am\u003c/p\u003e\n\n\u003cp style=\"text-align:center\"\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\n\u003cp style=\"text-align:center\"\u003e\u003cb\u003e\u003cfont size=\"3\"\u003eCOST:\u003c/font\u003e\u003c/b\u003e\u003c/p\u003e\n\n\u003cp style=\"text-align:center\"\u003e$110\u0026nbsp;Per Day\u003cspan style=\"font-size:20px\"\u003e\u003cspan style=\"color:#ff0000\"\u003e \u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n","4_name":"doubleclickTo","4_qid":4,"4_type":"control_text","4_order":2,"5_text":"\u003cp\u003e\u003cspan style=\"background-color:#ccff99;\"\u003eThe Childcare Subsidy (CCS) will be in effect for this day camp. CCS will be based on a family\u0026#39;s combined income, activity test and the service type. Parents need to have a \u003c/span\u003e\u003cspan style=\"background-color:#ccff99;\"\u003eMyGov\u003c/span\u003e\u003cspan style=\"background-color:#ccff99;\"\u003e account which needs to be linked to your \u003c/span\u003e\u003cspan style=\"background-color:#ccff99;\"\u003ecentrelink\u003c/span\u003e\u003cspan style=\"background-color:#ccff99;\"\u003e account for all future payments. If you are unsure if you qualify please be in touch with the family assistance office.\u0026#160;\u003c/span\u003e\u003c/p\u003e\n\n\u003cp\u003e\u003cbr\u003e\n\u003cu\u003e\u003cstrong\u003e\u003cspan style=\"background-color:#ccff99;\"\u003eIMPORTANT: If your child has not attended any overnight or day camps with \u003c/span\u003e\u003cspan style=\"background-color:#ccff99;\"\u003eChabad\u003c/span\u003e\u003cspan style=\"background-color:#ccff99;\"\u003e Youth before please follow the link and \u003c/span\u003e\u003cspan style=\"background-color:#ccff99;\"\u003eenrol\u003c/span\u003e\u003cspan style=\"background-color:#ccff99;\"\u003e at\u0026#160;\u003c/span\u003e\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\n\u003cp\u003e\u003cspan style=\"font-size:11.0pt\"\u003e\u003cspan style=\"font-family:\u0026#34;Calibri\u0026#34;,sans-serif\"\u003e\u003ca href=\"https://chabad-youth.hubworks.com.au/registrations/register\" style=\"font-family:\u0026#34;Times New Roman\u0026#34;,serif; color:#0563c1; text-decoration:underline\"\u003ehttps://chabad-youth.hubworks.com.au/registrations/register\u003c/a\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\n\u003cp\u003e\u003cbr\u003e\n\u003cu\u003e\u003cstrong\u003e\u003cspan style=\"background-color:#ccff99;\"\u003eWe also require a copy of your \u003c/span\u003e\u003cspan style=\"background-color:#ccff99;\"\u003echilds\u003c/span\u003e\u003cspan style=\"background-color:#ccff99;\"\u003e \u003c/span\u003e\u003cspan style=\"background-color:#ccff99;\"\u003eimmunisation\u003c/span\u003e\u003cspan style=\"background-color:#ccff99;\"\u003e record. This is a mandatory requirement before acceptance into our \u003c/span\u003e\u003cspan style=\"background-color:#ccff99;\"\u003eday camp\u003c/span\u003e\u003cspan style=\"background-color:#ccff99;\"\u003e.\u003c/span\u003e\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\n\u003cp\u003e\u003cbr\u003e\n\u003cspan style=\"background-color:#ccff99;\"\u003eFor further information regarding government subsidies please contact Naomi or Ellie on 8595 2083\u0026#160;or email admin@chabadyouth.org. Please note: It is the responsibility of the parent to ensure we have the correct information in order to process your benefits. Your credit card will not be charged until after the benefits have been calculated.\u003c/span\u003e\u003c/p\u003e\n","5_name":"doubleclickTo5","5_qid":5,"5_type":"control_text","5_order":3,"6_text":"Registration Information","6_subHeader":"","6_headerType":"Default","6_name":"clickTo6","6_qid":6,"6_type":"control_head","6_order":4,"7_text":"\u003cp\u003ePlease take care when filling out the form that all information is correct. Incorrect information may result in your child not receiving a place in camp.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eGeneral Information:\u003c/strong\u003e\u003c/p\u003e\n","7_name":"doubleclickTo7","7_qid":7,"7_type":"control_text","7_order":5,"8_text":"Child\u0027s Full Name","8_message":"","8_labelAlign":"Auto","8_required":"Yes","8_prefix":"No","8_suffix":"No","8_middle":"No","8_description":"","8_sublabels":{"prefix":"Prefix","first":"Given Name/s","middle":"Middle Name","last":"Last Name","suffix":"Suffix"},"8_readonly":"No","8_name":"fullName","8_qid":8,"8_type":"control_fullname","8_order":6,"9_text":"Child\u0027s Birth Date","9_message":"","9_labelAlign":"Auto","9_required":"Yes","9_format":"ddmmyyyy","9_yearFrom":"","9_yearTo":"","9_months":[[],[],[],[],[],[],[],[],[],[],[],[]],"9_description":"","9_sublabels":{"month":"Month","day":"Day","year":"Year"},"9_name":"birthDate","9_qid":9,"9_type":"control_birthdate","9_order":7,"10_text":"Child\u0027s Address","10_message":"","10_labelAlign":"Auto","10_required":"Yes","10_selectedCountry":"Australia","10_description":"","10_subfields":"st1|st2|city|state|zip|country","10_sublabels":{"cc_firstName":"First Name","cc_lastName":"Last Name","cc_number":"Credit Card Number","cc_ccv":"Security Code","cc_exp_month":"Expiration Month","cc_exp_year":"Expiration Year","addr_line1":"Street Address","addr_line2":"Street Address Line 2","city":"City","state":"State / Province","postal":"Postal / Zip Code","country":"Country"},"10_name":"address","10_qid":10,"10_type":"control_address","10_order":8,"12_text":"Child\u0027s School","12_message":"","12_labelAlign":"Auto","12_required":"Yes","12_size":20,"12_validation":"None","12_maxsize":"","12_inputTextMask":"","12_defaultValue":"","12_subLabel":"","12_hint":" ","12_description":"","12_readonly":"No","12_name":"input12","12_qid":12,"12_type":"control_textbox","12_order":9,"13_text":"Child\u0027s Grade (in 2026)","13_message":"","13_labelAlign":"Auto","13_required":"Yes","13_options":"Prep|Year 1|Year 2|Year 3|Year 4|Year 5|Year 6","13_special":"None","13_size":0,"13_width":150,"13_selected":"","13_subLabel":"","13_description":"","13_emptyText":"","13_name":"input13","13_qid":13,"13_type":"control_dropdown","13_order":10,"15_text":"\u003cp\u003e\u003cstrong\u003eDays attending:\u003c/strong\u003e\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003e\u003cspan style=\"background-color:#ffff00;\"\u003ePlease note: \u003c/span\u003e\u003cspan style=\"background-color:#ffff00;\"\u003eEnrolment\u003c/span\u003e\u003cspan style=\"background-color:#ffff00;\"\u003e is for a minimum of 3 days.\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n","15_name":"doubleclickTo15","15_qid":15,"15_type":"control_text","15_order":11,"87_text":"28/9","87_message":"","87_labelAlign":"Auto","87_required":"No","87_options":"Monday, 28 September - Zone Bowling \u0026amp; Arcades","87_special":"None","87_allowOther":"No","87_otherText":"Other","87_calculateOther":"No","87_spreadCols":"1","87_selected":"","87_minSelection":"","87_maxSelection":"","87_description":"","87_name":"input87","87_qid":87,"87_type":"control_checkbox","87_order":12,"87_hidden":"No","88_text":"29/9","88_message":"","88_labelAlign":"Auto","88_required":"No","88_options":"Tuesday, 29 September - Gravity Zone","88_special":"None","88_allowOther":"No","88_otherText":"Other","88_calculateOther":"No","88_spreadCols":"1","88_selected":"","88_minSelection":"","88_maxSelection":"","88_description":"","88_name":"input88","88_qid":88,"88_type":"control_checkbox","88_order":13,"89_text":"30/9","89_message":"","89_labelAlign":"Auto","89_required":"No","89_options":"Wednesday, 30 September - Nerf Wars and awesome STEM crafts","89_special":"None","89_allowOther":"No","89_otherText":"Other","89_calculateOther":"No","89_spreadCols":"1","89_selected":"","89_minSelection":"","89_maxSelection":"","89_description":"","89_name":"input89","89_qid":89,"89_type":"control_checkbox","89_order":14,"90_text":"1/10","90_message":"","90_labelAlign":"Auto","90_required":"No","90_options":"Thursday, 1 October - Royal Melbourne Show","90_special":"None","90_allowOther":"No","90_otherText":"Other","90_calculateOther":"No","90_spreadCols":"1","90_selected":"","90_minSelection":"","90_maxSelection":"","90_description":"","90_name":"input90","90_qid":90,"90_type":"control_checkbox","90_order":15,"18_text":"\u003cp\u003e\u003cstrong\u003ePLEASE READ ALL CANCELLATION POLICIES BELOW, \u003c/strong\u003e\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eBY SUBMITTING YOUR FORM YOU ARE AGREEING TO THE TERMS \u0026amp; CONDITIONS OF OUR POLICIES\u003c/strong\u003e\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003e\u0026#160;\u0026#160;\u0026#160;\u0026#160;\u0026#160;\u0026#160;\u0026#160;\u0026#160;\u0026#160;\u0026#160;\u0026#160;\u0026#160;\u003c/strong\u003e\u0026#160;\u003c/p\u003e\n\n\u003cp\u003e\u003cb\u003e\u003cu\u003eSparks Holiday Blast Cancellation Policy.\u003c/u\u003e\u003c/b\u003e\u003c/p\u003e\n\n\u003cul\u003e\n\t\u003cli\u003e\u003cstrong\u003eBookings will need to have at least three\u0026#160;days selected. \u003c/strong\u003e\u003cstrong\u003ePriority may be given to those applying for the full 4 days.\u003c/strong\u003e\u003c/li\u003e\n\t\u003cli\u003e\u003cstrong\u003eChanges to enrolment\u0026#160;after 48 hours of receiving a confirmation email will incur a\u0026#160;$50 admin fee.\u003c/strong\u003e\u003c/li\u003e\n\t\u003cli\u003e\u003cstrong\u003eAny changes or cancellations to your booking must be sent\u0026#160;via email to \u003ca href=\"mailto:yosef@csparks.org.au\"\u003eyosef@csparks.org.au\u003c/a\u003e.\u003c/strong\u003e\u003c/li\u003e\n\t\u003cli\u003e\u003cb\u003eNo changes to your enrolment after 11th September, 2026. At this point, any cancellations will be charged in full\u003c/b\u003e.\u003c/li\u003e\n\u003c/ul\u003e\n","18_name":"doubleclickTo18","18_qid":18,"18_type":"control_text","18_order":16,"103_text":"I have read and agree to these policies","103_message":"","103_labelAlign":"Auto","103_required":"Yes","103_options":"Yes","103_special":"None","103_size":0,"103_width":150,"103_selected":"","103_subLabel":"","103_description":"","103_emptyText":"","103_name":"input103","103_qid":103,"103_type":"control_dropdown","103_order":17,"19_text":"\u003cp\u003e\u003cstrong\u003e\u003cspan style=\"background-color:#ffff00;\"\u003eChabad\u003c/span\u003e\u003cspan style=\"background-color:#ffff00;\"\u003e Sparks Holiday\u0026#160;Blast \u003c/span\u003e\u003cspan style=\"background-color:#ffff00;\"\u003eT-shirts\u003c/span\u003e\u003cspan style=\"background-color:#ffff00;\"\u003e\u0026#160;are required to be worn by all attendees at all times. T-shirts\u0026#160;can be purchased for\u0026#160;$7 each. Each child requires a \u003c/span\u003e\u003cspan style=\"background-color:#ffff00;\"\u003eT-shirt\u003c/span\u003e\u003cspan style=\"background-color:#ffff00;\"\u003e to attend Holiday Blast.\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n","19_name":"doubleclickTo19","19_qid":19,"19_type":"control_text","19_order":18,"20_text":"","20_message":"","20_labelAlign":"Auto","20_required":"Yes","20_options":"I already have a Chabad Sparks T-shirt|I would like to purchase a Chabad Sparks T-shirt","20_special":"None","20_allowOther":"No","20_otherText":"Other","20_calculateOther":"No","20_spreadCols":"1","20_selected":"","20_minSelection":"","20_maxSelection":"","20_description":"","20_name":"input20","20_qid":20,"20_type":"control_checkbox","20_order":19,"21_text":"How many shirts would you like to purchase?","21_message":"","21_labelAlign":"Auto","21_required":"No","21_options":"1|2|3","21_special":"None","21_size":0,"21_width":150,"21_selected":"","21_subLabel":"","21_description":"","21_emptyText":"","21_name":"input21","21_qid":21,"21_type":"control_dropdown","21_order":20,"22_text":"What size would you like to purchase?","22_message":"","22_labelAlign":"Auto","22_required":"No","22_options":"Size 8|Size 10|Size 12|Size 14","22_special":"None","22_size":0,"22_width":150,"22_selected":"","22_subLabel":"","22_description":"","22_emptyText":"","22_name":"input22","22_qid":22,"22_type":"control_dropdown","22_order":21,"22_pricing":"0|0|0|0","23_text":"Parent 1 Full Name","23_message":"","23_labelAlign":"Auto","23_required":"Yes","23_prefix":"No","23_suffix":"No","23_middle":"No","23_description":"","23_sublabels":{"prefix":"Prefix","first":"First Name","middle":"Middle Name","last":"Last Name","suffix":"Suffix"},"23_readonly":"No","23_name":"fullName23","23_qid":23,"23_type":"control_fullname","23_order":22,"24_text":"Parent 1 Phone Number","24_message":"","24_labelAlign":"Auto","24_required":"Yes","24_validation":"None","24_countryCode":"No","24_inputMask":"enable","24_inputMaskValue":"+614########","24_description":"","24_sublabels":{"country":"Country Code","area":"Area Code","phone":"Phone Number","full":"Phone Number"},"24_readonly":"No","24_name":"phoneNumber24","24_qid":24,"24_type":"control_phone","24_order":23,"25_receivesReceipts":"Yes","25_text":"Parent 1 E-mail","25_message":"","25_labelAlign":"Auto","25_required":"Yes","25_size":30,"25_validation":"Email","25_maxsize":"","25_defaultValue":"","25_subLabel":"","25_hint":" ","25_description":"","25_confirmation":"No","25_confirmationHint":"Confirm Email","25_readonly":"No","25_name":"email","25_qid":25,"25_type":"control_email","25_order":24,"26_text":"Parent 2 Full Name","26_message":"","26_labelAlign":"Auto","26_required":"No","26_prefix":"No","26_suffix":"No","26_middle":"No","26_description":"","26_sublabels":{"prefix":"Prefix","first":"First Name","middle":"Middle Name","last":"Last Name","suffix":"Suffix"},"26_readonly":"No","26_name":"fullName26","26_qid":26,"26_type":"control_fullname","26_order":25,"27_text":"Parent 2 Phone Number","27_message":"","27_labelAlign":"Auto","27_required":"No","27_validation":"None","27_countryCode":"No","27_inputMask":"enable","27_inputMaskValue":"+614########","27_description":"","27_sublabels":{"country":"Country Code","area":"Area Code","phone":"Phone Number","full":"Phone Number"},"27_readonly":"No","27_name":"phoneNumber27","27_qid":27,"27_type":"control_phone","27_order":26,"28_receivesReceipts":"No","28_text":"Parent 2 E-mail","28_message":"","28_labelAlign":"Auto","28_required":"No","28_size":30,"28_validation":"Email","28_maxsize":"","28_defaultValue":"","28_subLabel":"","28_hint":" ","28_description":"","28_confirmation":"No","28_confirmationHint":"Confirm Email","28_readonly":"No","28_name":"email28","28_qid":28,"28_type":"control_email","28_order":27,"30_text":"\u003cp\u003e\u003cstrong\u003eEmergency Contact (other than parents)\u003c/strong\u003e\u003c/p\u003e\n","30_name":"doubleclickTo30","30_qid":30,"30_type":"control_text","30_order":28,"29_text":"Emergency Contact Full Name","29_message":"","29_labelAlign":"Auto","29_required":"Yes","29_prefix":"No","29_suffix":"No","29_middle":"No","29_description":"","29_sublabels":{"prefix":"Prefix","first":"First Name","middle":"Middle Name","last":"Last Name","suffix":"Suffix"},"29_readonly":"No","29_name":"fullName29","29_qid":29,"29_type":"control_fullname","29_order":29,"31_text":"Emergency Contact Phone Number","31_message":"","31_labelAlign":"Auto","31_required":"Yes","31_validation":"None","31_countryCode":"No","31_inputMask":"enable","31_inputMaskValue":"+614########","31_description":"","31_sublabels":{"country":"Country Code","area":"Area Code","phone":"Phone Number","full":"Phone Number"},"31_readonly":"No","31_name":"phoneNumber31","31_qid":31,"31_type":"control_phone","31_order":30,"32_text":"Emergency Contact Relationship To Child","32_message":"","32_labelAlign":"Auto","32_required":"Yes","32_size":20,"32_validation":"None","32_maxsize":"","32_inputTextMask":"","32_defaultValue":"","32_subLabel":"","32_hint":" ","32_description":"","32_readonly":"No","32_name":"input32","32_qid":32,"32_type":"control_textbox","32_order":31,"33_text":"\u003ch4\u003e\u003cstrong\u003e\u003cspan style=\"background-color:#ffff00;\"\u003eMedical Information\u003c/span\u003e\u003c/strong\u003e\u003c/h4\u003e\n\n\u003ch5\u003e\u003cspan style=\"background-color:#ffff00;\"\u003eIMPORTANT: WE REQUIRE A COPY OF YOUR CHILD\u0026#39;S \u003c/span\u003e\u003cspan style=\"background-color:#ffff00;\"\u003eIMMUNISATION\u003c/span\u003e\u003cspan style=\"background-color:#ffff00;\"\u003e RECORD PRIOR TO ACCEPTANCE INTO THE CAMP PROGRAM.\u003c/span\u003e\u003c/h5\u003e\n","33_name":"doubleclickTo33","33_qid":33,"33_type":"control_text","33_order":32,"34_text":"Current GP Name","34_message":"","34_labelAlign":"Auto","34_required":"Yes","34_size":20,"34_validation":"None","34_maxsize":"","34_inputTextMask":"","34_defaultValue":"","34_subLabel":"","34_hint":" ","34_description":"","34_readonly":"No","34_name":"input34","34_qid":34,"34_type":"control_textbox","34_order":33,"35_text":"Medicare: Child\u0027s Name on Card","35_message":"","35_labelAlign":"Auto","35_required":"Yes","35_size":20,"35_validation":"None","35_maxsize":"","35_inputTextMask":"","35_defaultValue":"","35_subLabel":"","35_hint":" ","35_description":"","35_readonly":"No","35_name":"input35","35_qid":35,"35_type":"control_textbox","35_order":34,"36_text":"Medicare: Card Number","36_message":"","36_labelAlign":"Auto","36_required":"Yes","36_size":20,"36_validation":"None","36_maxsize":"","36_inputTextMask":"","36_defaultValue":"","36_subLabel":"","36_hint":" ","36_description":"","36_readonly":"No","36_name":"input36","36_qid":36,"36_type":"control_textbox","36_order":35,"37_text":"Medicare: Child\u0027s number on card","37_message":"","37_labelAlign":"Auto","37_required":"Yes","37_options":"1|2|3|4|5|6|7|8","37_special":"None","37_size":0,"37_width":150,"37_selected":"","37_subLabel":"","37_description":"","37_emptyText":"","37_name":"input37","37_qid":37,"37_type":"control_dropdown","37_order":36,"40_text":"Medicare Expiry Date 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All of the relevant details are provided below for your convenience. The service has conducted an Excursion Risk Assessment which is available for your review upon request. For your child to attend, you are required to read this information and complete the Authority for Excursion Form. 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<form class="userform-form" action="" method="post" name="form_7584784" id="7584784" accept-charset="utf-8"><input type="hidden" name="formID" value="7584784" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li id="cid_3" class="form-input-wide"> <div class="form-header-group"><h2 id="header_3" class="form-header">Chabad Sparks Holiday Blast - St Kilda</h2></div> </li><li class="form-line" id="id_4"><div id="cid_4" class="form-input-wide"> <div id="text_4" class="form-html"><p style="text-align:center"><font color="#ff00ff" face="Arial, Helvetica Neue, Helvetica, sans-serif"><span style="font-size: 22px;"><b>December 2026 - January 2027</b></span></font></p>

<p style="text-align:center"><b><font size="3">GRADES:</font></b></p>

<p style="text-align:center">Prep - Grade 6 (2026 School Year)</p>

<p style="text-align:center"><b><font size="3">LOCATION:</font></b></p>

<p style="text-align:center"><span style="font-size:13px">1 A'Beckett St, East St. Kilda, 3183</span></p>

<p style="text-align:center"><b><font size="3">HOURS:</font></b></p>

<p style="text-align:center">Monday to Friday: 9:15 am - 4:00 pm</p>

<p style="text-align:center">Before Care: 8:30 am - 9:15 am</p>

<p style="text-align:center">  </p>

<p style="text-align:center"><b><font size="3">COST:</font></b></p>

<p style="text-align:center">$110 Per Day<span style="font-size:20px"><span style="color:#ff0000"> </span></span></p>
</div> </div></li><li class="form-line" id="id_5"><div id="cid_5" class="form-input-wide"> <div id="text_5" class="form-html"><p><span style="background-color:#ccff99;">The Childcare Subsidy (CCS) will be in effect for this day camp. CCS will be based on a family's combined income, activity test and the service type. Parents need to have a </span><span style="background-color:#ccff99;">MyGov</span><span style="background-color:#ccff99;"> account which needs to be linked to your </span><span style="background-color:#ccff99;">centrelink</span><span style="background-color:#ccff99;"> account for all future payments. If you are unsure if you qualify please be in touch with the family assistance office. </span></p>

<p><br />
<u><strong><span style="background-color:#ccff99;">IMPORTANT: If your child has not attended any overnight or day camps with </span><span style="background-color:#ccff99;">Chabad</span><span style="background-color:#ccff99;"> Youth before please follow the link and </span><span style="background-color:#ccff99;">enrol</span><span style="background-color:#ccff99;"> at </span></strong></u></p>

<p><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><a href="https://chabad-youth.hubworks.com.au/registrations/register" style="font-family:&quot;Times New Roman&quot;,serif; color:#0563c1; text-decoration:underline">https://chabad-youth.hubworks.com.au/registrations/register</a></span></span></p>

<p><br />
<u><strong><span style="background-color:#ccff99;">We also require a copy of your </span><span style="background-color:#ccff99;">childs</span><span style="background-color:#ccff99;"> </span><span style="background-color:#ccff99;">immunisation</span><span style="background-color:#ccff99;"> record. This is a mandatory requirement before acceptance into our </span><span style="background-color:#ccff99;">day camp</span><span style="background-color:#ccff99;">.</span></strong></u></p>

<p><br />
<span style="background-color:#ccff99;">For further information regarding government subsidies please contact Naomi or Ellie on 8595 2083 or email admin@chabadyouth.org. Please note: It is the responsibility of the parent to ensure we have the correct information in order to process your benefits. Your credit card will not be charged until after the benefits have been calculated.</span></p>
</div> </div></li><li id="cid_6" class="form-input-wide"> <div class="form-header-group"><h2 id="header_6" class="form-header">Registration Information</h2></div> </li><li class="form-line" id="id_7"><div id="cid_7" class="form-input-wide"> <div id="text_7" class="form-html"><p>Please take care when filling out the form that all information is correct. Incorrect information may result in your child not receiving a place in camp.</p>

<p><strong>General Information:</strong></p>
</div> </div></li><li class="form-line" id="id_8"><div class="form-label-left" id="label_8"><label for="input_8"> Child's Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q8_fullName[first]" id="first_8" autocomplete="given-name" />  <label class="form-sub-label" for="first_8" id="sublabel_first">Given Name/s</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q8_fullName[last]" id="last_8" autocomplete="family-name" />  <label class="form-sub-label" for="last_8" 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"> Child's Birth Date<span class="form-required">*</span> </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"><select autocomplete="nope" class="form-dropdown validate[required]" name="q9_birthDate[day]" id="input_9_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_9_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q9_birthDate[month]" id="input_9_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_9_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q9_birthDate[year]" id="input_9_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_9_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_10"><div class="form-label-left" id="label_10"><label for="input_10"> Child's Address<span class="form-required">*</span> </label><label class="label-message" for="input_10"> </label></div><div id="cid_10" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-line" type="text" name="q10_address[addr_line1]" id="input_10_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_10_addr_line1" id="sublabel_10_addr_line1">Street Address</label></span></td></tr><tr><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q10_address[addr_line2]" id="input_10_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_10_addr_line2" id="sublabel_10_addr_line2">Street Address Line 2</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-city" type="text" name="q10_address[city]" id="input_10_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_10_city" id="sublabel_10_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q10_address[state]" id="input_10_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_10_state" id="sublabel_10_state">State / Province</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-postal" type="text" name="q10_address[postal]" id="input_10_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_10_postal" id="sublabel_10_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q10_address[country]" id="input_10_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 selected="selected" 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 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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 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Helena</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="Somaliland">Somaliland</option><option value="South Africa">South Africa</option><option value="South Ossetia">South Ossetia</option><option value="Spain">Spain</option><option value="Sri Lanka">Sri Lanka</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Svalbard">Svalbard</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria">Syria</option><option value="Taiwan">Taiwan</option><option value="Tajikistan">Tajikistan</option><option value="Tanzania">Tanzania</option><option value="Thailand">Thailand</option><option value="Timor-Leste">Timor-Leste</option><option value="Togo">Togo</option><option value="Tokelau">Tokelau</option><option value="Tonga">Tonga</option><option value="Trinidad and Tobago">Trinidad and Tobago</option><option value="Tristan da Cunha">Tristan da Cunha</option><option value="Tunisia">Tunisia</option><option value="Turkey">Turkey</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks and Caicos Islands">Turks and Caicos Islands</option><option value="Tuvalu">Tuvalu</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="United Arab Emirates">United Arab Emirates</option><option value="United Kingdom">United Kingdom</option><option value="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Vatican City">Vatican City</option><option value="Venezuela">Venezuela</option><option value="Vietnam">Vietnam</option><option value="British Virgin Islands">British Virgin Islands</option><option value="US Virgin Islands">US Virgin Islands</option><option value="Wallis and Futuna">Wallis and Futuna</option><option value="Western Sahara">Western Sahara</option><option value="Yemen">Yemen</option><option value="Zambia">Zambia</option><option value="Zimbabwe">Zimbabwe</option><option value="other">Other</option></select>  <label class="form-sub-label" for="input_10_country" id="sublabel_10_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12"> Child's School<span class="form-required">*</span> </label><label class="label-message" for="input_12"> </label></div><div id="cid_12" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_12" name="q12_input12" size="20" value="" /> </div></li><li class="form-line" id="id_13"><div class="form-label-left" id="label_13"><label for="input_13"> Child's Grade (in 2026)<span class="form-required">*</span> </label><label class="label-message" for="input_13"> </label></div><div id="cid_13" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_13" name="q13_input13"><option value=""></option><option value="Prep">Prep</option><option value="Year 1">Year 1</option><option value="Year 2">Year 2</option><option value="Year 3">Year 3</option><option value="Year 4">Year 4</option><option value="Year 5">Year 5</option><option value="Year 6">Year 6</option></select> </div></li><li class="form-line" id="id_15"><div id="cid_15" class="form-input-wide"> <div id="text_15" class="form-html"><p><strong>Days attending:</strong></p>

<p><strong><span style="background-color:#ffff00;">Please note: </span><span style="background-color:#ffff00;">Enrolment</span><span style="background-color:#ffff00;"> is for a minimum of 3 days.</span></strong></p>
</div> </div></li><li class="form-line" id="id_87"><div class="form-label-left" id="label_87"><label for="input_87"> 28/9 </label><label class="label-message" for="input_87"> </label></div><div id="cid_87" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_87_0" name="q87_input87[]" value="Monday, 28 September - Zone Bowling &amp; Arcades" /><label id="label_input_87_0" for="input_87_0"><span>Monday, 28 September - Zone Bowling &amp; Arcades</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_88"><div class="form-label-left" id="label_88"><label for="input_88"> 29/9 </label><label class="label-message" for="input_88"> </label></div><div id="cid_88" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_88_0" name="q88_input88[]" value="Tuesday, 29 September - Gravity Zone" /><label id="label_input_88_0" for="input_88_0"><span>Tuesday, 29 September - Gravity Zone</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_89"><div class="form-label-left" id="label_89"><label for="input_89"> 30/9 </label><label class="label-message" for="input_89"> </label></div><div id="cid_89" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_89_0" name="q89_input89[]" value="Wednesday, 30 September - Nerf Wars and awesome STEM crafts" /><label id="label_input_89_0" for="input_89_0"><span>Wednesday, 30 September - Nerf Wars and awesome STEM crafts</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_90"><div class="form-label-left" id="label_90"><label for="input_90"> 1/10 </label><label class="label-message" for="input_90"> </label></div><div id="cid_90" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_90_0" name="q90_input90[]" value="Thursday, 1 October - Royal Melbourne Show" /><label id="label_input_90_0" for="input_90_0"><span>Thursday, 1 October - Royal Melbourne Show</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_18"><div id="cid_18" class="form-input-wide"> <div id="text_18" class="form-html"><p><strong>PLEASE READ ALL CANCELLATION POLICIES BELOW, </strong></p>

<p><strong>BY SUBMITTING YOUR FORM YOU ARE AGREEING TO THE TERMS &amp; CONDITIONS OF OUR POLICIES</strong></p>

<p><strong>            </strong> </p>

<p><b><u>Sparks Holiday Blast Cancellation Policy.</u></b></p>

<ul>
	<li><strong>Bookings will need to have at least three days selected. </strong><strong>Priority may be given to those applying for the full 4 days.</strong></li>
	<li><strong>Changes to enrolment after 48 hours of receiving a confirmation email will incur a $50 admin fee.</strong></li>
	<li><strong>Any changes or cancellations to your booking must be sent via email to <a href="mailto:yosef@csparks.org.au">yosef@csparks.org.au</a>.</strong></li>
	<li><b>No changes to your enrolment after 11th September, 2026. At this point, any cancellations will be charged in full</b>.</li>
</ul>
</div> </div></li><li class="form-line" id="id_103"><div class="form-label-left" id="label_103"><label for="input_103"> I have read and agree to these policies<span class="form-required">*</span> </label><label class="label-message" for="input_103"> </label></div><div id="cid_103" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_103" name="q103_input103"><option value=""></option><option value="Yes">Yes</option></select> </div></li><li class="form-line" id="id_19"><div id="cid_19" class="form-input-wide"> <div id="text_19" class="form-html"><p><strong><span style="background-color:#ffff00;">Chabad</span><span style="background-color:#ffff00;"> Sparks Holiday Blast </span><span style="background-color:#ffff00;">T-shirts</span><span style="background-color:#ffff00;"> are required to be worn by all attendees at all times. T-shirts can be purchased for $7 each. Each child requires a </span><span style="background-color:#ffff00;">T-shirt</span><span style="background-color:#ffff00;"> to attend Holiday Blast.</span></strong></p>
</div> </div></li><li class="form-line" id="id_20"><div class="form-label-left" id="label_20"><label for="input_20"> <span class="form-required">*</span> </label><label class="label-message" for="input_20"> </label></div><div id="cid_20" 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_20_0" name="q20_input20[]" value="I already have a Chabad Sparks T-shirt" /><label id="label_input_20_0" for="input_20_0"><span>I already have a Chabad Sparks T-shirt</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_20_1" name="q20_input20[]" value="I would like to purchase a Chabad Sparks T-shirt" /><label id="label_input_20_1" for="input_20_1"><span>I would like to purchase a Chabad Sparks T-shirt</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_21"><div class="form-label-left" id="label_21"><label for="input_21"> How many shirts would you like to purchase? </label><label class="label-message" for="input_21"> </label></div><div id="cid_21" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_21" name="q21_input21"><option value=""></option><option value="1">1</option><option value="2">2</option><option value="3">3</option></select> </div></li><li class="form-line" id="id_22"><div class="form-label-left" id="label_22"><label for="input_22"> What size would you like to purchase? </label><label class="label-message" for="input_22"> </label></div><div id="cid_22" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_22" name="q22_input22"><option value=""></option><option value="Size 8">Size 8</option><option value="Size 10">Size 10</option><option value="Size 12">Size 12</option><option value="Size 14">Size 14</option></select> </div></li><li class="form-line" id="id_23"><div class="form-label-left" id="label_23"><label for="input_23"> Parent 1 Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_23"> </label></div><div id="cid_23" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q23_fullName23[first]" id="first_23" autocomplete="given-name" />  <label class="form-sub-label" for="first_23" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q23_fullName23[last]" id="last_23" autocomplete="family-name" />  <label class="form-sub-label" for="last_23" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_24"><div class="form-label-left" id="label_24"><label for="input_24"> Parent 1 Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_24"> </label></div><div id="cid_24" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q24_phoneNumber24[full]" id="input_24_full" autocomplete="tel" />  <label class="form-sub-label" for="input_24_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_25"><div class="form-label-left" id="label_25"><label for="input_25"> Parent 1 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_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> Parent 2 Full Name </label><label class="label-message" for="input_26"> </label></div><div id="cid_26" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q26_fullName26[first]" id="first_26" autocomplete="given-name" />  <label class="form-sub-label" for="first_26" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q26_fullName26[last]" id="last_26" autocomplete="family-name" />  <label class="form-sub-label" for="last_26" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_27"><div class="form-label-left" id="label_27"><label for="input_27"> Parent 2 Phone Number </label><label class="label-message" for="input_27"> </label></div><div id="cid_27" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox" type="tel" name="q27_phoneNumber27[full]" id="input_27_full" autocomplete="tel" />  <label class="form-sub-label" for="input_27_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_28"><div class="form-label-left" id="label_28"><label for="input_28"> Parent 2 E-mail </label><label class="label-message" for="input_28"> </label></div><div id="cid_28" class="form-input"> <input type="email" class=" form-textbox validate[Email]" id="input_28" name="q28_email28" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_30"><div id="cid_30" class="form-input-wide"> <div id="text_30" class="form-html"><p><strong>Emergency Contact (other than parents)</strong></p>
</div> </div></li><li class="form-line" id="id_29"><div class="form-label-left" id="label_29"><label for="input_29"> Emergency Contact Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_29"> </label></div><div id="cid_29" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q29_fullName29[first]" id="first_29" autocomplete="given-name" />  <label class="form-sub-label" for="first_29" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q29_fullName29[last]" id="last_29" autocomplete="family-name" />  <label class="form-sub-label" for="last_29" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_31"><div class="form-label-left" id="label_31"><label for="input_31"> Emergency Contact Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_31"> </label></div><div id="cid_31" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q31_phoneNumber31[full]" id="input_31_full" autocomplete="tel" />  <label class="form-sub-label" for="input_31_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_32"><div class="form-label-left" id="label_32"><label for="input_32"> Emergency Contact Relationship To Child<span class="form-required">*</span> </label><label class="label-message" for="input_32"> </label></div><div id="cid_32" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_32" name="q32_input32" size="20" value="" /> </div></li><li class="form-line" id="id_33"><div id="cid_33" class="form-input-wide"> <div id="text_33" class="form-html"><h4><strong><span style="background-color:#ffff00;">Medical Information</span></strong></h4>

<h5><span style="background-color:#ffff00;">IMPORTANT: WE REQUIRE A COPY OF YOUR CHILD'S </span><span style="background-color:#ffff00;">IMMUNISATION</span><span style="background-color:#ffff00;"> RECORD PRIOR TO ACCEPTANCE INTO THE CAMP PROGRAM.</span></h5>
</div> </div></li><li class="form-line" id="id_34"><div class="form-label-left" id="label_34"><label for="input_34"> Current GP Name<span class="form-required">*</span> </label><label class="label-message" for="input_34"> </label></div><div id="cid_34" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_34" name="q34_input34" size="20" value="" /> </div></li><li class="form-line" id="id_35"><div class="form-label-left" id="label_35"><label for="input_35"> Medicare: Child's Name on Card<span class="form-required">*</span> </label><label class="label-message" for="input_35"> </label></div><div id="cid_35" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_35" name="q35_input35" size="20" value="" /> </div></li><li class="form-line" id="id_36"><div class="form-label-left" id="label_36"><label for="input_36"> Medicare: Card Number<span class="form-required">*</span> </label><label class="label-message" for="input_36"> </label></div><div id="cid_36" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_36" name="q36_input36" size="20" value="" /> </div></li><li class="form-line" id="id_37"><div class="form-label-left" id="label_37"><label for="input_37"> Medicare: Child's number on card<span class="form-required">*</span> </label><label class="label-message" for="input_37"> </label></div><div id="cid_37" class="form-input"> <select class="form-dropdown validate[required]" style="width:150px" id="input_37" name="q37_input37"><option value=""></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></select> </div></li><li class="form-line" id="id_40"><div class="form-label-left" id="label_40"><label for="input_40"> Medicare Expiry Date (MM/YYYY)<span class="form-required">*</span> </label><label class="label-message" for="input_40"> </label></div><div id="cid_40" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_40" name="q40_input40" size="20" value="" /> </div></li><li class="form-line" id="id_39"><div class="form-label-left" id="label_39"><label for="input_39"> Private Health Care Fund </label><label class="label-message" for="input_39"> </label></div><div id="cid_39" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_39" name="q39_input39" size="20" value="" /> </div></li><li class="form-line" id="id_41"><div class="form-label-left" id="label_41"><label for="input_41"> Private Health Care Number </label><label class="label-message" for="input_41"> </label></div><div id="cid_41" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_41" name="q41_input41" size="20" value="" /> </div></li><li class="form-line" id="id_42"><div class="form-label-left" id="label_42"><label for="input_42"> Current Medication (If not applicable, write n/a)<span class="form-required">*</span> </label><label class="label-message" for="input_42"> </label></div><div id="cid_42" class="form-input"> <textarea id="input_42" class="form-textarea validate[required]" name="q42_input42" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_43"><div class="form-label-left" id="label_43"><label for="input_43"> Allergies (If not applicable, write n/a)<span class="form-required">*</span> </label><label class="label-message" for="input_43"> </label></div><div id="cid_43" class="form-input"> <textarea id="input_43" class="form-textarea validate[required]" name="q43_input43" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_44"><div class="form-label-left" id="label_44"><label for="input_44"> Medical Conditions (If not applicable, write n/a)<span class="form-required">*</span> </label><label class="label-message" for="input_44"> </label></div><div id="cid_44" class="form-input"> <textarea id="input_44" class="form-textarea validate[required]" name="q44_input44" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_45"><div class="form-label-left" id="label_45"><label for="input_45"> Special Remarks </label><label class="label-message" for="input_45"> </label></div><div id="cid_45" class="form-input"> <textarea id="input_45" class="form-textarea" name="q45_input45" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_46"><div id="cid_46" class="form-input-wide"> <div id="text_46" class="form-html"><p><strong><span style="background-color:#ffff00;">General Info: Please remember <u>not to send any products containing nuts.</u></span></strong></p>

<p>Please send a labelled sun hat and labelled water bottle daily</p>
</div> </div></li><li class="form-line" id="id_47"><div id="cid_47" class="form-input-wide"> <div id="text_47" class="form-html"><h4><strong>VACATION CARE AUTHORISATION FORM</strong></h4>

<h5>Collecting your child from the Chabad Youth OSHC premises</h5>

<p>We recommend all children are to be picked up by a Parent or an Authorised Nominee directly from the Chabad Youth OSHC premises. An Authorised Nominee means a person who has been given permission by a parent or family member to collect the child from the education and care service.</p>

<p>If you would like for your child to walk home by themselves, or to a location to be picked up, in accordance with Regulation 99(4)(b), they will need to be signed out by a Chabad Youth OSHC staff member and/or volunteer before exiting the premises.</p>
</div> </div></li><li class="form-line" id="id_48"><div class="form-label-left" id="label_48"><label for="input_48"> Please tick all that apply:<span class="form-required">*</span> </label><label class="label-message" for="input_48"> </label></div><div id="cid_48" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_48_0" name="q48_input48[]" value="I'll be picking my child up directly from the VAC premises." /><label id="label_input_48_0" for="input_48_0"><span>I'll be picking my child up directly from the VAC premises.</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_48_1" name="q48_input48[]" value="I give permission for my child to leave the premises by themselves and to be signed out by a Chabad Youth OSHC staff member and/or volunteer" /><label id="label_input_48_1" for="input_48_1"><span>I give permission for my child to leave the premises by themselves and to be signed out by a Chabad Youth OSHC staff member and/or volunteer</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_48_2" name="q48_input48[]" value="I nominate the following people as my Authorised Nominee(s), please include any siblings that may collect your child. (Please list nominees below)" /><label id="label_input_48_2" for="input_48_2"><span>I nominate the following people as my Authorised Nominee(s), please include any siblings that may collect your child. (Please list nominees below)</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_49"><div id="cid_49" class="form-input-wide"> <div id="text_49" class="form-html"><p>Authorised Nominees:</p>
</div> </div></li><li class="form-line" id="id_50"><div class="form-label-left" id="label_50"><label for="input_50"> Authorised Nominee 1 Full Name </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">First Name</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">Last Name</label></span> </div></li><li class="form-line" id="id_51"><div class="form-label-left" id="label_51"><label for="input_51"> Authorised Nominee 1 Phone Number </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"><input data-type="mask-number" class="mask-phone-number form-textbox" type="tel" name="q51_phoneNumber51[full]" id="input_51_full" autocomplete="tel" />  <label class="form-sub-label" for="input_51_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_52"><div class="form-label-left" id="label_52"><label for="input_52"> Authorised Nominee 1 Address </label><label class="label-message" for="input_52"> </label></div><div id="cid_52" 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 form-address-line" type="text" name="q52_address52[addr_line1]" id="input_52_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_52_addr_line1" id="sublabel_52_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="q52_address52[addr_line2]" id="input_52_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_52_addr_line2" id="sublabel_52_addr_line2">Street Address Line 2</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q52_address52[city]" id="input_52_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_52_city" id="sublabel_52_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q52_address52[state]" id="input_52_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_52_state" id="sublabel_52_state">State / Province</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q52_address52[postal]" id="input_52_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_52_postal" id="sublabel_52_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q52_address52[country]" id="input_52_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 selected="selected" 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_52_country" id="sublabel_52_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_56"><div class="form-label-left" id="label_56"><label for="input_56"> Authorised Nominee 1 Relationship to Child </label><label class="label-message" for="input_56"> </label></div><div id="cid_56" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_56" name="q56_input56" size="20" value="" /> </div></li><li class="form-line" id="id_53"><div class="form-label-left" id="label_53"><label for="input_53"> Authorised Nominee 2 Full Name </label><label class="label-message" for="input_53"> </label></div><div id="cid_53" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q53_fullName53[first]" id="first_53" autocomplete="given-name" />  <label class="form-sub-label" for="first_53" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q53_fullName53[last]" id="last_53" autocomplete="family-name" />  <label class="form-sub-label" for="last_53" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_54"><div class="form-label-left" id="label_54"><label for="input_54"> Authorised Nominee 2 Phone Number </label><label class="label-message" for="input_54"> </label></div><div id="cid_54" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox" type="tel" name="q54_phoneNumber54[full]" id="input_54_full" autocomplete="tel" />  <label class="form-sub-label" for="input_54_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_55"><div class="form-label-left" id="label_55"><label for="input_55"> Authorised Nominee 2 Address </label><label class="label-message" for="input_55"> </label></div><div id="cid_55" 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 form-address-line" type="text" name="q55_address55[addr_line1]" id="input_55_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_55_addr_line1" id="sublabel_55_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="q55_address55[addr_line2]" id="input_55_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_55_addr_line2" id="sublabel_55_addr_line2">Street Address Line 2</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q55_address55[city]" id="input_55_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_55_city" id="sublabel_55_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q55_address55[state]" id="input_55_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_55_state" id="sublabel_55_state">State / Province</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q55_address55[postal]" id="input_55_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_55_postal" id="sublabel_55_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q55_address55[country]" id="input_55_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 selected="selected" 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_55_country" id="sublabel_55_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_57"><div class="form-label-left" id="label_57"><label for="input_57"> Authorised Nominee 2  Relationship to Child </label><label class="label-message" for="input_57"> </label></div><div id="cid_57" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_57" name="q57_input57" size="20" value="" /> </div></li><li class="form-line" id="id_58"><div class="form-label-left" id="label_58"><label for="input_58"> Authorised Nominee 3 Full Name </label><label class="label-message" for="input_58"> </label></div><div id="cid_58" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q58_fullName58[first]" id="first_58" autocomplete="given-name" />  <label class="form-sub-label" for="first_58" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q58_fullName58[last]" id="last_58" autocomplete="family-name" />  <label class="form-sub-label" for="last_58" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_59"><div class="form-label-left" id="label_59"><label for="input_59"> Authorised Nominee 3 Phone Number </label><label class="label-message" for="input_59"> </label></div><div id="cid_59" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox" type="tel" name="q59_phoneNumber59[full]" id="input_59_full" autocomplete="tel" />  <label class="form-sub-label" for="input_59_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_60"><div class="form-label-left" id="label_60"><label for="input_60"> Authorised Nominee 3 Address </label><label class="label-message" for="input_60"> </label></div><div id="cid_60" 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 form-address-line" type="text" name="q60_address60[addr_line1]" id="input_60_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_60_addr_line1" id="sublabel_60_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="q60_address60[addr_line2]" id="input_60_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_60_addr_line2" id="sublabel_60_addr_line2">Street Address Line 2</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q60_address60[city]" id="input_60_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_60_city" id="sublabel_60_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q60_address60[state]" id="input_60_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_60_state" id="sublabel_60_state">State / Province</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q60_address60[postal]" id="input_60_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_60_postal" id="sublabel_60_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q60_address60[country]" id="input_60_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 selected="selected" 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_60_country" id="sublabel_60_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_61"><div class="form-label-left" id="label_61"><label for="input_61"> Authorised Nominee 3 Relationship to Child </label><label class="label-message" for="input_61"> </label></div><div id="cid_61" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_61" name="q61_input61" size="20" value="" /> </div></li><li class="form-line" id="id_62"><div class="form-label-left" id="label_62"><label for="input_62"> <span class="form-required">*</span> </label><label class="label-message" for="input_62"> </label></div><div id="cid_62" 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_62_0" name="q62_input62[]" value="I hereby authorise a Chabad Youth OSHC staff member and/or volunteer to obtain any medical care necessary for my child, including from a medical practitioner, hospital or ambulance service. I understand that transportation to receive medical care may include an ambulance and I agree to pay for any costs involved with seeking medical care for my child. I understand that in the case of an emergency of significant illness or injury attempts will be made to contact myself or an authorised nominee, as soon as practical" /><label id="label_input_62_0" for="input_62_0"><span>I hereby authorise a Chabad Youth OSHC staff member and/or volunteer to obtain any medical care necessary for my child, including from a medical practitioner, hospital or ambulance service. I understand that transportation to receive medical care may include an ambulance and I agree to pay for any costs involved with seeking medical care for my child. I understand that in the case of an emergency of significant illness or injury attempts will be made to contact myself or an authorised nominee, as soon as practical</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"> I hereby authorise Chabad Youth OSHC staff and/or volunteers to photograph my child and use the photographs for the following purposes: </label><label class="label-message" for="input_63"> </label></div><div id="cid_63" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_63_0" name="q63_input63[]" value="Yes, Educational Pruposes" /><label id="label_input_63_0" for="input_63_0"><span>Yes, Educational Pruposes</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_63_1" name="q63_input63[]" value="Yes, Promotional Purposes" /><label id="label_input_63_1" for="input_63_1"><span>Yes, Promotional Purposes</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_63_2" name="q63_input63[]" value="Yes, Social Media" /><label id="label_input_63_2" for="input_63_2"><span>Yes, Social Media</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"> <span class="form-required">*</span> </label><label class="label-message" for="input_64"> </label></div><div id="cid_64" 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_64_0" name="q64_input64[]" value="I hereby acknowledge that I have read, understood and agree to the terms outlined in the Family Handbook (copies available on this website)" /><label id="label_input_64_0" for="input_64_0"><span>I hereby acknowledge that I have read, understood and agree to the terms outlined in the Family Handbook (copies available on this website)</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_65"><div class="form-label-left" id="label_65"><label for="input_65"> <span class="form-required">*</span> </label><label class="label-message" for="input_65"> </label></div><div id="cid_65" 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_65_0" name="q65_input65[]" value="I will provide Chabad Youth OSHC and/or volunteers with documentation regarding any medical conditions for my child and attached the relevant and up to date Medical Management Plans and my child's participation is dependant on this." /><label id="label_input_65_0" for="input_65_0"><span>I will provide Chabad Youth OSHC and/or volunteers with documentation regarding any medical conditions for my child and attached the relevant and up to date Medical Management Plans and my child's participation is dependant on this.</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_66"><div class="form-label-left" id="label_66"><label for="input_66"> <span class="form-required">*</span> </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-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_66_0" name="q66_input66[]" value="I understand that if my child has a Medical Management Plan I will be required to complete a Risk Minimisation Form and a Communication Plan in consultation with Chabad Youth staff and/or volunteers." /><label id="label_input_66_0" for="input_66_0"><span>I understand that if my child has a Medical Management Plan I will be required to complete a Risk Minimisation Form and a Communication Plan in consultation with Chabad Youth staff and/or volunteers.</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_68"><div class="form-label-left" id="label_68"><label for="input_68"> I give permission for my child to have a band aid administered<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-checkbox-item clear-left"><input type="checkbox" class="form-checkbox 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-checkbox-item clear-left"><input type="checkbox" class="form-checkbox 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_69"><div class="form-label-left" id="label_69"><label for="input_69"> I give permission for my child to have sunscreen applied<span class="form-required">*</span> </label><label class="label-message" for="input_69"> </label></div><div id="cid_69" 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_69_0" name="q69_input69[]" value="Yes" /><label id="label_input_69_0" for="input_69_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_69_1" name="q69_input69[]" value="No" /><label id="label_input_69_1" for="input_69_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"> The approved provider of the program has sighted my child's health record<span class="form-required">*</span> </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-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_70_0" name="q70_input70[]" value="Yes" /><label id="label_input_70_0" for="input_70_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_70_1" name="q70_input70[]" value="No" /><label id="label_input_70_1" for="input_70_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_71"><div id="cid_71" class="form-input-wide"> <div id="text_71" class="form-html"><h4><strong>Authorisation for Excursion Form:</strong></h4>

<p>Our service has organised an excursion for your child to attend. All of the relevant details are provided below for your convenience. The service has conducted an Excursion Risk Assessment which is available for your review upon request. For your child to attend, you are required to read this information and complete the Authority for Excursion Form. To complete this Form, you must be listed on the child’s enrolment record as either their parent or an Authorised Nominee.</p>
</div> </div></li><li class="form-line" id="id_72"><div class="form-label-left" id="label_72"><label for="input_72"> Child's Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_72"> </label></div><div id="cid_72" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q72_fullName72[first]" id="first_72" autocomplete="given-name" />  <label class="form-sub-label" for="first_72" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q72_fullName72[last]" id="last_72" autocomplete="family-name" />  <label class="form-sub-label" for="last_72" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_73"><div id="cid_73" class="form-input-wide"> <div id="text_73" class="form-html"><h1><b>Excursion Information:</b></h1>

<p><strong>Mode of transport for all excursions: Charter bus. All buses are fitted with seat belts.</strong></p>

<p><strong>Educator ratio for all excursions will be at least 1:15.</strong></p>

<p><strong>28 September – Timezone &amp; Zone Bowling Southland (Westfield, Level 3/1239 Nepean Hwy, Cheltenham VIC 3192)</strong> each way 15 minutes, off-site time 2.5 hours. Activity: Campers will have the opportunity to participate in ten-pin bowling and arcade games. Expected number of participants: 45 campers, 3 staff, 6 volunteers.</p>

<p><strong>29 September – Gravity Zone (25 Oliphant Way, Seaford VIC 3198)</strong> each way 40 minutes, off-site time 3 hours 10 minutes. Activity: Campers will have the opportunity to participate in trampolining activities. Expected number of participants: 45 campers, 3 staff, 6 volunteers.</p>

<p><strong>30 September – Nerf Wars and Awesome STEM Crafts (Incursion)</strong> Activity: Campers will have the opportunity to participate in a Nerf Wars experience and hands-on STEM craft activities at the service. Expected number of participants: 45 campers, 3 staff, 6 volunteers.</p>

<p><strong>1 October – Royal Melbourne Show (Epsom Rd, Ascot Vale VIC 3032)</strong> each way 30 minutes, off-site time 5 hours. Activity: Campers will have the opportunity to participate in a variety of educational, agricultural, cultural and recreational activities throughout the Royal Melbourne Show. Expected number of participants: 45 campers, 3 staff, 6 volunteers.</p>

<p><strong>Reason for excursions:</strong> Excursions during vacation care provide children with opportunities to develop an understanding of belonging to groups and communities and to learn to interact with others with care, empathy and respect. Excursions create engaging learning environments that encourage physical activity, social development and the exploration of new experiences.</p>

<p><strong>Transportation details (to and from):</strong> The most convenient and safest route, as determined by the bus driver at the time. Children attending excursions will travel by private charter bus. A Google Maps route is available in the relevant risk assessments.</p>

<p><strong>Staff-to-child ratio:</strong> Up to 45 children with 3 staff and 6 volunteers.</p>

<p><strong>The period the child will be away from the service premises:</strong> See individual briefs above.</p>

<h4>Authority for my child to attend the excursion:</h4>
</div> </div></li><li class="form-line" id="id_74"><div class="form-label-left" id="label_74"><label for="input_74"> Parent Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_74"> </label></div><div id="cid_74" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q74_fullName74[first]" id="first_74" autocomplete="given-name" />  <label class="form-sub-label" for="first_74" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q74_fullName74[last]" id="last_74" autocomplete="family-name" />  <label class="form-sub-label" for="last_74" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_75"><div class="form-label-left" id="label_75"><label for="input_75"> Relationship to Child<span class="form-required">*</span> </label><label class="label-message" for="input_75"> </label></div><div id="cid_75" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_75" name="q75_input75" size="20" value="" /> </div></li><li class="form-line" id="id_76"><div class="form-label-left" id="label_76"><label for="input_76"> <span class="form-required">*</span> </label><label class="label-message" for="input_76"> </label></div><div id="cid_76" 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_76_0" name="q76_input76[]" value="By submitting this form, I agree to and understand the following:" /><label id="label_input_76_0" for="input_76_0"><span>By submitting this form, I agree to and understand the following:</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_77"><div id="cid_77" class="form-input-wide"> <div id="text_77" class="form-html"><ul>
	<li>My child has my permission to attend the excursions listed.</li>
	<li>I am listed on the child’s Enrolment Form as a Parent or Authorised Nominee.</li>
	<li>I have read all of the details provided by the service and understand that I can access the Excursion Risk Assessment at the service.</li>
	<li>I understand that all written policies and procedures for transporting children are available at the Chabad Youth office and on our website. </li>
	<li>The contact details, including all emergency contact details, listed on my child’s Enrolment Form are up-to-date.</li>
</ul>
</div> </div></li><li class="form-line" id="id_98"><div class="form-label-left" id="label_98"><label for="input_98"> <span class="form-required">*</span> </label><label class="label-message" for="input_98"> </label></div><div id="cid_98" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_98_0" name="q98_input98[]" value="I confirm my child's suitability to participate in the activities." /><label id="label_input_98_0" for="input_98_0"><span>I confirm my child's suitability to participate in the activities.</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_78"><div id="cid_78" class="form-input-wide"> <div id="text_78" class="form-html"><h1><big><strong>Payment Information</strong></big></h1>

<p><strong>Cost:</strong> $110 per day</p>

<p><strong>Please note that the Child Care Subsidy (CCS) does not apply to absences at the beginning or end of a Vacation Care program. Parents will be responsible for the full fee in these circumstances.</strong></p>

<p>Payment details are <strong>not</strong> being collected through this enrolment format this time.</p>

<p>After submitting your enrolment, you will receive a separate secure form to provide your credit card details and complete the required payment authorisation.</p>

<p>Government subsidies may apply, and fees will be processed after any applicable Child Care Subsidy deductions have been calculated.</p>

<p>Please note that your child's place cannot be confirmed until payment information and the required payment authorisations have been completed.</p>
</div> </div></li><li class="form-line" id="id_80"><div id="cid_80" class="form-input-wide"> <div id="text_80" class="form-html"><h3><strong>Before you submit:</strong></h3>

<h4>1. Have you answered all the questions in full?</h4>

<h4>2. Does your child have a hubworks profile? If you are unsure, check with the office.</h4>

<h4>3. We cannot accept children into our program if we do not have a copy of their immunisation record. If the centre does not have a copy, please send it to <a href="mailto:cyadmin@chabadyouth.org">cyadmin@chabadyouth.org</a> ASAP.</h4>
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