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</div> </div></li><li class="form-line" id="id_8"><div id="cid_8" class="form-input-wide"> <div style="text-align:center;"><img alt="" class="form-image" border="0" src="https://w2.chabad.org/media/images/1331/MDqi13313700.png" height="844.5500000000001" width="665" /></div> </div></li><li class="form-line" id="id_9"><div class="form-label-left" id="label_9"><label for="input_9"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_9"> </label></div><div id="cid_9" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q9_fullName[first]" id="first_9" autocomplete="given-name" />  <label class="form-sub-label" for="first_9" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q9_fullName[last]" id="last_9" autocomplete="family-name" />  <label 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class="form-sub-label" for="input_11_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q11_phoneNumber[phone]" id="input_11_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_11_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12"> Number of reservations<span class="form-required">*</span> </label><label class="label-message" for="input_12"> $50/adult</label></div><div id="cid_12" class="form-input"> <input type="number" class="form-number-input  form-textbox validate[required]" id="input_12" name="q12_number" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" /> </div></li><li class="form-line" id="id_16"><div class="form-label-left" id="label_16"><label for="input_16"> Number of Children </label><label class="label-message" for="input_16"> 12 and under $25/child</label></div><div id="cid_16" class="form-input"> <input type="number" class="form-number-input  form-textbox" id="input_16" name="q16_number16" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" /> </div></li><li class="form-line" id="id_17"><div class="form-label-left" id="label_17"><label for="input_17"> I would like to be a dinner sponsor for: </label><label class="label-message" for="input_17"> </label></div><div id="cid_17" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_17_0" name="q17_input17[]" value="$100 Shana Tova Sponsor" /><label id="label_input_17_0" for="input_17_0"><span>$100 Shana Tova Sponsor</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_17_1" name="q17_input17[]" value="$180 Lchayim Sponsor" /><label id="label_input_17_1" for="input_17_1"><span>$180 Lchayim Sponsor</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_17_2" name="q17_input17[]" value="$360 Dinner Co Sposnor" /><label id="label_input_17_2" for="input_17_2"><span>$360 Dinner Co Sposnor</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_17_3" name="q17_input17[]" value="$540 Dinner Sponsor" /><label id="label_input_17_3" for="input_17_3"><span>$540 Dinner Sponsor</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox-other form-checkbox validate[other]" name="q17_input17[other]" id="other_17" value="" /><span><input type="number" min="1" 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validate[required, visible]" type="text" name="q14_payment[cc_nameOnCard]" id="input_14_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_14_cc_nameOnCard" id="sublabel_cc_nameOnCard">Name on Card</label></span></td></tr><tr class="credit_card hide"><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q14_payment[cc_exp_month]" id="input_14_cc_exp_month" autocomplete="cc-exp-month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label 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Payment will take place on the next page.</td></tr><tr class="other hide"><td colspan="2">Checks can be made payable to:<br />Chabad of Islip<br />283 Ocean Ave<br />Islip, NY 11751</td></tr></tbody></table> </div></li><li class="form-line" id="id_15"><div class="form-label-left" id="label_15"><label for="input_15"> Total </label></div><div id="cid_15" class="form-input"> <div id="total_amount">$0.00 </div><div class="form-single-column form-checkbox-item" id="div_offset_gift_15" style="padding-top: 10px">		<input type="checkbox" id="input_15" class="form-checkbox" name="q15_offsetGiftPercent" value="3" />		<label id="label_15" for="input_15">Yes, I'd like to donate the cost of processing this transaction by adding 3%</label>		<input type="hidden" id="hidden_15" name="q15_offsetGiftAmount" />		<div class="clearfix"></div>		</div> </div></li><li style="display:none">Should be Empty: <input type="text" name="website" value="" /></li></ul></div><input type="hidden" id="simple_spc" name="simple_spc" value="6974000" /><script type="text/javascript">document.getElementById("si"+"mple"+"_spc").value = "6974000-6974000";</script><div>


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