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<form class="userform-form" action="" method="post" name="form_7268074" id="7268074" accept-charset="utf-8"><input type="hidden" name="formID" value="7268074" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li class="form-line" id="id_1"><div id="cid_1" class="form-input-wide"> <img alt="" class="form-image" border="0" src="https://w2.chabad.org/media/images/1359/tXpH13595121.jpg" height="1024.1000000000001" width="665" /> </div></li><li id="cid_3" class="form-input-wide"> <div class="form-header-group"><h3 id="header_3" class="form-header">Reservations</h3></div> </li><li class="form-line" id="id_4"><div class="form-label-left" id="label_4"><label for="input_4"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_4"> </label></div><div id="cid_4" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q4_fullName[first]" id="first_4" autocomplete="given-name" />  <label class="form-sub-label" for="first_4" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q4_fullName[last]" id="last_4" autocomplete="family-name" />  <label class="form-sub-label" for="last_4" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_5"><div class="form-label-left" id="label_5"><label for="input_5"> E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_5"> </label></div><div id="cid_5" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_5" name="q5_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_7"><div class="form-label-left" id="label_7"><label for="input_7"> Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_7"> </label></div><div 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class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxselection="2" id="input_15_0" name="q15_input15[]" value="I would like to pay suggested amount of $60 per adult" /><label id="label_input_15_0" for="input_15_0"><span>I would like to pay suggested amount of $60 per adult</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxselection="2" id="input_15_1" name="q15_input15[]" value="I would like to pay cost of $80 per adult" /><label id="label_input_15_1" for="input_15_1"><span>I would like to pay cost of $80 per adult</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxselection="2" id="input_15_2" name="q15_input15[]" value="I would like to co sponsor $250 (includes 2 adults)" /><label id="label_input_15_2" for="input_15_2"><span>I would like to co sponsor $250 (includes 2 adults)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxselection="2" id="input_15_3" name="q15_input15[]" value="I would like to be a Seder sponsor $500 (includes party of 4)" /><label id="label_input_15_3" for="input_15_3"><span>I would like to be a Seder sponsor $500 (includes party of 4)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxselection="2" id="input_15_4" name="q15_input15[]" value="I would like to be a Passover sponsor $1000 (includes party of 6)" /><label id="label_input_15_4" for="input_15_4"><span>I would like to be a Passover sponsor $1000 (includes party of 6)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxselection="2" id="input_15_5" name="q15_input15[]" value="I would like to choose a different amount (nobody will be turned away)" /><label id="label_input_15_5" for="input_15_5"><span>I would like to choose a different amount (nobody will be turned away)</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_24"><div class="form-label-left" id="label_24"><label for="input_24"> Number of Adults<span class="form-required">*</span> </label><label class="label-message" for="input_24"> </label></div><div id="cid_24" class="form-input"> <input type="number" class="form-number-input  form-textbox validate[required]" id="input_24" name="q24_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_25"><div class="form-label-left" id="label_25"><label for="input_25"> Number of Children </label><label class="label-message" for="input_25"> </label></div><div id="cid_25" class="form-input"> <input type="number" class="form-number-input  form-textbox" id="input_25" name="q25_number25" 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_26"><div class="form-label-left" id="label_26"><label for="input_26"> Number of Adults<span class="form-required">*</span> </label><label class="label-message" for="input_26"> </label></div><div id="cid_26" class="form-input"> <input type="number" class="form-number-input  form-textbox validate[required]" id="input_26" name="q26_number26" 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_27"><div class="form-label-left" id="label_27"><label for="input_27"> Number of Children </label><label class="label-message" for="input_27"> </label></div><div id="cid_27" class="form-input"> <input type="number" class="form-number-input  form-textbox" id="input_27" name="q27_number27" 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_28"><div class="form-label-left" id="label_28"><label for="input_28"> Number of Adults<span class="form-required">*</span> </label><label class="label-message" for="input_28"> </label></div><div id="cid_28" class="form-input"> <input type="number" class="form-number-input  form-textbox validate[required]" id="input_28" name="q28_number28" 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_29"><div class="form-label-left" id="label_29"><label for="input_29"> Number of Children </label><label class="label-message" for="input_29"> </label></div><div id="cid_29" class="form-input"> <input type="number" class="form-number-input  form-textbox" id="input_29" name="q29_number29" 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_30"><div class="form-label-left" id="label_30"><label for="input_30"> Number of Adults<span class="form-required">*</span> </label><label class="label-message" for="input_30"> </label></div><div id="cid_30" class="form-input"> <input type="number" class="form-number-input  form-textbox validate[required]" id="input_30" name="q30_number30" 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_31"><div class="form-label-left" id="label_31"><label for="input_31"> Number of Children </label><label class="label-message" for="input_31"> </label></div><div id="cid_31" class="form-input"> <input type="number" class="form-number-input  form-textbox" id="input_31" name="q31_number31" 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_32"><div class="form-label-left" id="label_32"><label for="input_32"> I would like to pay </label><label class="label-message" for="input_32"> </label></div><div id="cid_32" class="form-input"> <div class="form-single-column"><span class="form-radio-item simple-mode"><label id="label_input_32" for="input_32"><span>$</span></label><input type="number" class="form-textbox" id="input_32" name="q32_input32" value="" onkeypress="validateNumber(event)" /></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_23"><div class="form-label-left" id="label_23"><label for="input_23"> Total </label></div><div id="cid_23" class="form-input"> <div id="total_amount">$0.00 </div><div class="form-single-column form-checkbox-item" id="div_offset_gift_23" style="padding-top: 10px">                <input type="checkbox" id="input_23" class="form-checkbox" name="q23_offsetGiftPercent" value="3" />            <label id="label_23" for="input_23">Yes, I'd like to donate the cost of processing this transaction by adding 3%</label>                <input type="hidden" id="hidden_23" name="q23_offsetGiftAmount" />              <div class="clearfix"></div>            </div> </div></li><li class="form-line" id="id_11"><div class="form-label-left" id="label_11"><label for="input_11"> Payment </label><label class="label-message" for="input_11"> </label></div><div id="cid_11" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2" class="form-payment-methods form-multiple-column"><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_11_creditCard" name="q11_payment[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_11_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_11_paypal" name="q11_payment[payment_method]" value="paypal" onclick="BuildSource.paypal(this)" /><label for="input_11_paypal">Paypal</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_11_other" name="q11_payment[payment_method]" value="other" onclick="BuildSource.other(this)" /><label for="input_11_other">Check</label> </span></td></tr><tr class="credit_card hide"><th colspan="2">Credit Card</th></tr><tr class="credit_card hide"><td colspan="2" style="padding:0"><table cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container">  <label class="form-sub-label">We accept Visa, MasterCard, American Express, Discover</label></span><div class="cc-icons"><div class="cc-icon visa-icon"></div><div class="cc-icon mastercard-icon"></div><div class="cc-icon amex-icon"></div><div class="cc-icon discover-icon"></div></div><input type="hidden" name="q11_payment[cc_type]" id="input_11_cc_type" value="" /></td></tr><tr><td><div class="cc-field-wrapper"><span class="form-sub-label-container"><input class="form-textbox form-creditcard js-cc-number validate[visible, creditcard]" type="text" name="q11_payment[cc_number]" id="input_11_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_11_cc_number" id="sublabel_cc_number">Credit Card Number</label></span></div></td><td class="cc_ccv "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q11_payment[cc_ccv]" id="input_11_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_11_cc_ccv" id="sublabel_cc_ccv">Security Code</label></span></td></tr><tr class="credit_card hide"><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q11_payment[cc_exp_month]" id="input_11_cc_exp_month" autocomplete="cc-exp-month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_11_cc_exp_month" id="sublabel_cc_exp_month">Expiration Month</label></span></td><td><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q11_payment[cc_exp_year]" id="input_11_cc_exp_year" autocomplete="cc-exp-year"><option></option><option value="2026">2026</option><option value="2027">2027</option><option value="2028">2028</option><option value="2029">2029</option><option value="2030">2030</option><option value="2031">2031</option><option value="2032">2032</option><option value="2033">2033</option><option value="2034">2034</option><option value="2035">2035</option></select>  <label class="form-sub-label" for="input_11_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="paypal hide"><td colspan="2">Paypal has been selected. Payment will take place on the next page.</td></tr><tr class="other hide"><td colspan="2">Checks can be made payable to:<br />Chabad of Islip<br />49 Union Ave<br />Islip, NY 11751</td></tr></tbody></table> </div></li><li class="form-line" id="id_2"><div id="cid_2" class="form-input-wide"> <div style="text-align: center; text-indent:156px;" class="form-buttons-wrapper button-align-auto"><button id="input_2" type="submit" class="form-submit-button  form-submit-button-none;">Submit</button></div> </div></li><li 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="7268074" /><script type="text/javascript">document.getElementById("si"+"mple"+"_spc").value = "7268074-7268074";</script><div>


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