/*jslint nomen:false, debug:true, evil:true, vars:false, browser:true, forin:true, undef:false, white:false */ /** * Includes a Form with javascript * @param {Object} formId * @param {Object} initialHeight * @param {Object} iframeCode */ function FrameBuilder (formId, appendTo, initialHeight, iframeCode){ this.formId = formId; this.initialHeight = initialHeight; this.iframeCode = iframeCode; this.frame = null; this.timeInterval= 200; this.appendTo = appendTo || false; // initialize function for object this.init = function(){ this.createFrame(); this.addFrameContent(this.iframeCode); }; // Create the frame this.createFrame = function(){ var htmlCode = "<"+"iframe src=\"\" allowtransparency=\"true\" frameborder=\"0\" name=\""+this.formId+"\" id=\""+this.formId+"\" style=\"width:100%; height:"+this.initialHeight+"px; border:none;\" scrolling=\"no\">"; if(this.appendTo === false){ document.write(htmlCode); }else{ var tmp = document.createElement('div'); tmp.innerHTML = htmlCode; var a = this.appendTo; document.getElementById(a).appendChild(tmp.firstChild); } // also get the frame for future use. this.frame = document.getElementById(this.formId); // set the time on the on load event of the frame this.addEvent(this.frame, 'load', this.bindMethod(this.setTimer, this)); }; // add event function for different browsers this.addEvent = function( obj, type, fn ) { if ( obj.attachEvent ) { obj["e"+type+fn] = fn; obj[type+fn] = function() { obj["e"+type+fn]( window.event ); }; obj.attachEvent( "on"+type, obj[type+fn] ); } else{ obj.addEventListener( type, fn, false ); } }; this.addFrameContent = function (string){ string = string.replace(new RegExp('src\\=\\"[^"]*captcha.php\"><\/scr'+'ipt>', 'gim'), 'src="http://api.recaptcha.net/js/recaptcha_ajax.js"><'+'div id="recaptcha_div"><'+'/div>'+ '<'+'style>#recaptcha_logo{ display:none;} #recaptcha_tagline{display:none;} #recaptcha_table{border:none !important;} .recaptchatable .recaptcha_image_cell, #recaptcha_table{ background-color:transparent !important; } <'+'/style>'+ '<'+'script defer="defer"> window.onload = function(){ Recaptcha.create("6Ld9UAgAAAAAAMon8zjt30tEZiGQZ4IIuWXLt1ky", "recaptcha_div", {theme: "clean",tabindex: 0,callback: function (){'+ 'if (document.getElementById("uword")) { document.getElementById("uword").parentNode.removeChild(document.getElementById("uword")); } if (window["validate"] !== undefined) { if (document.getElementById("recaptcha_response_field")){ document.getElementById("recaptcha_response_field").onblur = function(){ validate(document.getElementById("recaptcha_response_field"), "Required"); } } } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_challenge_field")[0].setAttribute("name", "anum"); } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_response_field")[0].setAttribute("name", "qCap"); }}})'+ ' }<'+'/script>'); string = string.replace(/(type="text\/javascript">)\s+(validate\(\"[^"]*"\);)/, '$1 jTime = setInterval(function(){if("validate" in window){$2clearTimeout(jTime);}}, 1000);'); var frameDocument = (this.frame.contentWindow) ? this.frame.contentWindow : (this.frame.contentDocument.document) ? this.frame.contentDocument.document : this.frame.contentDocument; frameDocument.document.open(); frameDocument.document.write(string); setTimeout( function(){ frameDocument.document.close(); try{ if('JotFormFrameLoaded' in window){ JotFormFrameLoaded(); } }catch(e){} },200); }; this.setTimer = function(){ var self = this; this.interval = setTimeout(function(){self.changeHeight();},this.timeInterval); }; this.changeHeight = function (){ var actualHeight = this.getBodyHeight(); var currentHeight = this.getViewPortHeight(); if(actualHeight === undefined){ this.frame.style.height = "100%"; if(!this.frame.style.minHeight){ this.frame.style.minHeight = "300px"; } }else if (Math.abs(actualHeight - currentHeight) > 18){ this.frame.style.height = (actualHeight)+"px"; } this.setTimer(); }; this.bindMethod = function(method, scope) { return function() { method.apply(scope,arguments); }; }; this.getBodyHeight = function (){ var height; var scrollHeight; var offsetHeight; try{ // Prevent IE from throw errors if (this.frame.contentWindow.document.height){ height = this.frame.contentWindow.document.height; //Emre: to prevent "iframe height" problem (61059) if (this.frame.contentWindow.document.body.scrollHeight){ height = scrollHeight = this.frame.contentWindow.document.body.scrollHeight; } if (this.frame.contentWindow.document.body.offsetHeight){ height = offsetHeight = this.frame.contentWindow.document.body.offsetHeight; } } else if (this.frame.contentWindow.document.body){ if (this.frame.contentWindow.document.body.scrollHeight){ height = scrollHeight = this.frame.contentWindow.document.body.scrollHeight; } if (this.frame.contentWindow.document.body.offsetHeight){ height = offsetHeight = this.frame.contentWindow.document.body.offsetHeight; } if (scrollHeight && offsetHeight){ height = Math.max(scrollHeight, offsetHeight); } } }catch(e){ } return height; }; this.getViewPortHeight = function(){ var height = 0; try{ // Prevent IE from throw errors if (this.frame.contentWindow.window.innerHeight) { height = this.frame.contentWindow.window.innerHeight - 18; } else if ((this.frame.contentWindow.document.documentElement) && (this.frame.contentWindow.document.documentElement.clientHeight)) { height = this.frame.contentWindow.document.documentElement.clientHeight; } else if ((this.frame.contentWindow.document.body) && (this.frame.contentWindow.document.body.clientHeight)) { height = this.frame.contentWindow.document.body.clientHeight; } }catch(e){ } return height; }; this.init(); } FrameBuilder.get = []; var i10821801242 = new FrameBuilder("10821801242", false, "", "\n\n\n\n\nForm<\/title>\n<link href=\"http:\/\/max.jotfor.ms\/min\/g=formCss?3.0.2432\" rel=\"stylesheet\" type=\"text\/css\" \/>\n<style type=\"text\/css\">\n .form-label{\n width:150px !important;\n }\n .form-label-left{\n width:150px !important;\n }\n .form-line{\n padding:5px;\n }\n .form-label-right{\n width:150px !important;\n }\n body, html{\n margin:0;\n padding:0;\n background:white;\n }\n\n .form-all{\n margin:0px auto;\n padding-top:0px;\n width:600px;\n background:white;\n color:black !important;\n font-family:Georgia;\n font-size:14px;\n }\n<\/style>\n\n<script src=\"http:\/\/max.jotfor.ms\/min\/g=jotform?3.0.2432\" type=\"text\/javascript\"><\/script>\n<script type=\"text\/javascript\">\n var jsTime = setInterval(function(){try{\n JotForm.jsForm = true;\n\n JotForm.init(function(){\n JotForm.description('input_19', '20');\n });\n\n clearInterval(jsTime);\n }catch(e){}}, 1000);\n<\/script>\n<\/head>\n<body>\n<form class=\"jotform-form\" action=\"http:\/\/submit.jotform.com\/submit.php\" method=\"post\" name=\"form_10821801242\" id=\"10821801242\" accept-charset=\"utf-8\">\n <input type=\"hidden\" name=\"formID\" value=\"10821801242\" \/>\n <div class=\"form-all\">\n <ul class=\"form-section\">\n <li id=\"cid_55\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_55\" class=\"form-header\">\n Unschool Adventures - Online Application\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_70\">\n <div id=\"cid_70\" class=\"form-input-wide\">\n <div id=\"text_70\" class=\"form-html\">\n To apply for enrollment, please fill out all required boxes in the following form.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_117\">\n <div id=\"cid_117\" class=\"form-input-wide\">\n <div id=\"text_117\" class=\"form-html\">\n After pressing \"Submit\", you will be directed to PayPal to pay the $30 non-refundable application fee. PayPal accepts all major credit cards.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_51\">\n <label class=\"form-label-left\" id=\"label_51\" for=\"input_51\">\n I am applying for the following trip:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_51\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_51_0\" name=\"q51_iAm\" value=\"Asheville Intensive 2012\" \/>\n <label for=\"input_51_0\"> Asheville Intensive 2012 <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_51_1\" name=\"q51_iAm\" value=\"Sustainable Living 2012\" \/>\n <label for=\"input_51_1\"> Sustainable Living 2012 <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_51_2\" name=\"q51_iAm\" value=\"Writing Retreat 2012\" \/>\n <label for=\"input_51_2\"> Writing Retreat 2012 <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li id=\"cid_93\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_93\" class=\"form-header\">\n Student Information\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_0\">\n <label class=\"form-label-left\" id=\"label_0\" for=\"input_0\">\n Student First Name<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_0\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_0\" name=\"q0_studentFirst\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_1\">\n <label class=\"form-label-left\" id=\"label_1\" for=\"input_1\">\n Student Last Name<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_1\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_1\" name=\"q1_studentLast\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_28\">\n <label class=\"form-label-left\" id=\"label_28\" for=\"input_28\"> Student Nickname <\/label>\n <div id=\"cid_28\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_28\" name=\"q28_studentNickname\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_15\">\n <label class=\"form-label-left\" id=\"label_15\" for=\"input_15\">\n Mailing Address<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_15\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_15\" name=\"q15_mailingAddress\" size=\"35\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_4\">\n <label class=\"form-label-left\" id=\"label_4\" for=\"input_4\">\n City<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_4\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_4\" name=\"q4_city\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_5\">\n <label class=\"form-label-left\" id=\"label_5\" for=\"input_5\"> State <\/label>\n <div id=\"cid_5\" class=\"form-input\">\n <select class=\"form-dropdown\" style=\"width:150px\" id=\"input_5\" name=\"q5_state\">\n <option> <\/option>\n <option value=\"Alabama\"> Alabama <\/option>\n <option value=\"Alaska\"> Alaska <\/option>\n <option value=\"Arizona\"> Arizona <\/option>\n <option value=\"Arkansas\"> Arkansas <\/option>\n <option value=\"California\"> California <\/option>\n <option value=\"Colorado\"> Colorado <\/option>\n <option value=\"Connecticut\"> Connecticut <\/option>\n <option value=\"District of Columbia\"> District of Columbia <\/option>\n <option value=\"Delaware\"> Delaware <\/option>\n <option value=\"Florida\"> Florida <\/option>\n <option value=\"Georgia\"> Georgia <\/option>\n <option value=\"Hawaii\"> Hawaii <\/option>\n <option value=\"Idaho\"> Idaho <\/option>\n <option value=\"Illinois\"> Illinois <\/option>\n <option value=\"Indiana\"> Indiana <\/option>\n <option value=\"Iowa\"> Iowa <\/option>\n <option value=\"Kansas\"> Kansas <\/option>\n <option value=\"Kentucky\"> Kentucky <\/option>\n <option value=\"Louisiana\"> Louisiana <\/option>\n <option value=\"Maine\"> Maine <\/option>\n <option value=\"Maryland\"> Maryland <\/option>\n <option value=\"Massachusetts\"> Massachusetts <\/option>\n <option value=\"Michigan\"> Michigan <\/option>\n <option value=\"Minnesota\"> Minnesota <\/option>\n <option value=\"Mississippi\"> Mississippi <\/option>\n <option value=\"Missouri\"> Missouri <\/option>\n <option value=\"Montana\"> Montana <\/option>\n <option value=\"Nebraska\"> Nebraska <\/option>\n <option value=\"Nevada\"> Nevada <\/option>\n <option value=\"New Hampshire\"> New Hampshire <\/option>\n <option value=\"New Jersey\"> New Jersey <\/option>\n <option value=\"New Mexico\"> New Mexico <\/option>\n <option value=\"New York\"> New York <\/option>\n <option value=\"North Carolina\"> North Carolina <\/option>\n <option value=\"North Dakota\"> North Dakota <\/option>\n <option value=\"Ohio\"> Ohio <\/option>\n <option value=\"Oklahoma\"> Oklahoma <\/option>\n <option value=\"Oregon\"> Oregon <\/option>\n <option value=\"Pennsylvania\"> Pennsylvania <\/option>\n <option value=\"Rhode Island\"> Rhode Island <\/option>\n <option value=\"South Carolina\"> South Carolina <\/option>\n <option value=\"South Dakota\"> South Dakota <\/option>\n <option value=\"Tennessee\"> Tennessee <\/option>\n <option value=\"Texas\"> Texas <\/option>\n <option value=\"Utah\"> Utah <\/option>\n <option value=\"Vermont\"> Vermont <\/option>\n <option value=\"Virginia\"> Virginia <\/option>\n <option value=\"Washington\"> Washington <\/option>\n <option value=\"West Virginia\"> West Virginia <\/option>\n <option value=\"Wisconsin\"> Wisconsin <\/option>\n <option value=\"Wyoming\"> Wyoming <\/option>\n <option value=\"Alberta\"> Alberta <\/option>\n <option value=\"British Columbia\"> British Columbia <\/option>\n <option value=\"Manitoba\"> Manitoba <\/option>\n <option value=\"New Brunswick\"> New Brunswick <\/option>\n <option value=\"Newfoundland\"> Newfoundland <\/option>\n <option value=\"Northwest Territories\"> Northwest Territories <\/option>\n <option value=\"Nova Scotia\"> Nova Scotia <\/option>\n <option value=\"Nunavut\"> Nunavut <\/option>\n <option value=\"Ontario\"> Ontario <\/option>\n <option value=\"Prince Edward Island\"> Prince Edward Island <\/option>\n <option value=\"Quebec\"> Quebec <\/option>\n <option value=\"Saskatchewan\"> Saskatchewan <\/option>\n <option value=\"Yukon\"> Yukon <\/option>\n <option value=\"Alabama\"> Alabama <\/option>\n <option value=\"Alaska\"> Alaska <\/option>\n <option value=\"Arizona\"> Arizona <\/option>\n <option value=\"Arkansas\"> Arkansas <\/option>\n <option value=\"California\"> California <\/option>\n <option value=\"Colorado\"> Colorado <\/option>\n <option value=\"Connecticut\"> Connecticut <\/option>\n <option value=\"District of Columbia\"> District of Columbia <\/option>\n <option value=\"Delaware\"> Delaware <\/option>\n <option value=\"Florida\"> Florida <\/option>\n <option value=\"Georgia\"> Georgia <\/option>\n <option value=\"Hawaii\"> Hawaii <\/option>\n <option value=\"Idaho\"> Idaho <\/option>\n <option value=\"Illinois\"> Illinois <\/option>\n <option value=\"Indiana\"> Indiana <\/option>\n <option value=\"Iowa\"> Iowa <\/option>\n <option value=\"Kansas\"> Kansas <\/option>\n <option value=\"Kentucky\"> Kentucky <\/option>\n <option value=\"Louisiana\"> Louisiana <\/option>\n <option value=\"Maine\"> Maine <\/option>\n <option value=\"Maryland\"> Maryland <\/option>\n <option value=\"Massachusetts\"> Massachusetts <\/option>\n <option value=\"Michigan\"> Michigan <\/option>\n <option value=\"Minnesota\"> Minnesota <\/option>\n <option value=\"Mississippi\"> Mississippi <\/option>\n <option value=\"Missouri\"> Missouri <\/option>\n <option value=\"Montana\"> Montana <\/option>\n <option value=\"Nebraska\"> Nebraska <\/option>\n <option value=\"Nevada\"> Nevada <\/option>\n <option value=\"New Hampshire\"> New Hampshire <\/option>\n <option value=\"New Jersey\"> New Jersey <\/option>\n <option value=\"New Mexico\"> New Mexico <\/option>\n <option value=\"New York\"> New York <\/option>\n <option value=\"North Carolina\"> North Carolina <\/option>\n <option value=\"North Dakota\"> North Dakota <\/option>\n <option value=\"Ohio\"> Ohio <\/option>\n <option value=\"Oklahoma\"> Oklahoma <\/option>\n <option value=\"Oregon\"> Oregon <\/option>\n <option value=\"Pennsylvania\"> Pennsylvania <\/option>\n <option value=\"Rhode Island\"> Rhode Island <\/option>\n <option value=\"South Carolina\"> South Carolina <\/option>\n <option value=\"South Dakota\"> South Dakota <\/option>\n <option value=\"Tennessee\"> Tennessee <\/option>\n <option value=\"Texas\"> Texas <\/option>\n <option value=\"Utah\"> Utah <\/option>\n <option value=\"Vermont\"> Vermont <\/option>\n <option value=\"Virginia\"> Virginia <\/option>\n <option value=\"Washington\"> Washington <\/option>\n <option value=\"West Virginia\"> West Virginia <\/option>\n <option value=\"Wisconsin\"> Wisconsin <\/option>\n <option value=\"Wyoming\"> Wyoming <\/option>\n <option value=\"Alberta\"> Alberta <\/option>\n <option value=\"British Columbia\"> British Columbia <\/option>\n <option value=\"Manitoba\"> Manitoba <\/option>\n <option value=\"New Brunswick\"> New Brunswick <\/option>\n <option value=\"Newfoundland\"> Newfoundland <\/option>\n <option value=\"Northwest Territories\"> Northwest Territories <\/option>\n <option value=\"Nova Scotia\"> Nova Scotia <\/option>\n <option value=\"Nunavut\"> Nunavut <\/option>\n <option value=\"Ontario\"> Ontario <\/option>\n <option value=\"Prince Edward Island\"> Prince Edward Island <\/option>\n <option value=\"Quebec\"> Quebec <\/option>\n <option value=\"Saskatchewan\"> Saskatchewan <\/option>\n <option value=\"Yukon\"> Yukon <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_26\">\n <label class=\"form-label-left\" id=\"label_26\" for=\"input_26\"> (or Canadian Province) <\/label>\n <div id=\"cid_26\" class=\"form-input\">\n <select class=\"form-dropdown\" style=\"width:150px\" id=\"input_26\" name=\"q26_orCanadian\">\n <option> <\/option>\n <option value=\"AB\"> AB <\/option>\n <option value=\"BC\"> BC <\/option>\n <option value=\"MB\"> MB <\/option>\n <option value=\"NB\"> NB <\/option>\n <option value=\"NL\"> NL <\/option>\n <option value=\"NT\"> NT <\/option>\n <option value=\"NS\"> NS <\/option>\n <option value=\"NU\"> NU <\/option>\n <option value=\"ON\"> ON <\/option>\n <option value=\"PE\"> PE <\/option>\n <option value=\"QC\"> QC <\/option>\n <option value=\"SK\"> SK <\/option>\n <option value=\"YT\"> YT <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_16\">\n <label class=\"form-label-left\" id=\"label_16\" for=\"input_16\">\n Zip\/Postal Code<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_16\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_16\" name=\"q16_zippostalCode\" size=\"5\" maxlength=\"12\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_14\">\n <label class=\"form-label-left\" id=\"label_14\" for=\"input_14\">\n Country<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_14\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_14\" name=\"q14_country\">\n <option> <\/option>\n <option value=\"United States\"> United States <\/option>\n <option value=\"Canada\"> Canada <\/option>\n <option value=\"Other\"> Other <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_11\">\n <label class=\"form-label-left\" id=\"label_11\" for=\"input_11\">\n Home Phone<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_11\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_11\" name=\"q11_homePhone\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_21\">\n <label class=\"form-label-left\" id=\"label_21\" for=\"input_21\"> Cell Phone <\/label>\n <div id=\"cid_21\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_21\" name=\"q21_cellPhone\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_2\">\n <label class=\"form-label-left\" id=\"label_2\" for=\"input_2\">\n Student E-mail<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_2\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_2\" name=\"q2_studentEmail\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_19\">\n <label class=\"form-label-left\" id=\"label_19\" for=\"input_19\">\n Birthdate<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_19\" class=\"form-input\"><span class=\"form-sub-label-container\"><select class=\"form-dropdown validate[required]\" name=\"q19_birthdate[month]\" id=\"input_19_month\">\n <option> <\/option>\n <option value=\"January\"> January <\/option>\n <option value=\"February\"> February <\/option>\n <option value=\"March\"> March <\/option>\n <option value=\"April\"> April <\/option>\n <option value=\"May\"> May <\/option>\n <option value=\"June\"> June <\/option>\n <option value=\"July\"> July <\/option>\n <option value=\"August\"> August <\/option>\n <option value=\"September\"> September <\/option>\n <option value=\"October\"> October <\/option>\n <option value=\"November\"> November <\/option>\n <option value=\"December\"> December <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_19_month\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown validate[required]\" name=\"q19_birthdate[day]\" id=\"input_19_day\">\n <option> <\/option>\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <option value=\"11\"> 11 <\/option>\n <option value=\"12\"> 12 <\/option>\n <option value=\"13\"> 13 <\/option>\n <option value=\"14\"> 14 <\/option>\n <option value=\"15\"> 15 <\/option>\n <option value=\"16\"> 16 <\/option>\n <option value=\"17\"> 17 <\/option>\n <option value=\"18\"> 18 <\/option>\n <option value=\"19\"> 19 <\/option>\n <option value=\"20\"> 20 <\/option>\n <option value=\"21\"> 21 <\/option>\n <option value=\"22\"> 22 <\/option>\n <option value=\"23\"> 23 <\/option>\n <option value=\"24\"> 24 <\/option>\n <option value=\"25\"> 25 <\/option>\n <option value=\"26\"> 26 <\/option>\n <option value=\"27\"> 27 <\/option>\n <option value=\"28\"> 28 <\/option>\n <option value=\"29\"> 29 <\/option>\n <option value=\"30\"> 30 <\/option>\n <option value=\"31\"> 31 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_19_day\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown validate[required]\" name=\"q19_birthdate[year]\" id=\"input_19_year\">\n <option> <\/option>\n <option value=\"2016\"> 2016 <\/option>\n <option value=\"2015\"> 2015 <\/option>\n <option value=\"2014\"> 2014 <\/option>\n <option value=\"2013\"> 2013 <\/option>\n <option value=\"2012\"> 2012 <\/option>\n <option value=\"2011\"> 2011 <\/option>\n <option value=\"2010\"> 2010 <\/option>\n <option value=\"2009\"> 2009 <\/option>\n <option value=\"2008\"> 2008 <\/option>\n <option value=\"2007\"> 2007 <\/option>\n <option value=\"2006\"> 2006 <\/option>\n <option value=\"2005\"> 2005 <\/option>\n <option value=\"2004\"> 2004 <\/option>\n <option value=\"2003\"> 2003 <\/option>\n <option value=\"2002\"> 2002 <\/option>\n <option value=\"2001\"> 2001 <\/option>\n <option value=\"2000\"> 2000 <\/option>\n <option value=\"1999\"> 1999 <\/option>\n <option value=\"1998\"> 1998 <\/option>\n <option value=\"1997\"> 1997 <\/option>\n <option value=\"1996\"> 1996 <\/option>\n <option value=\"1995\"> 1995 <\/option>\n <option value=\"1994\"> 1994 <\/option>\n <option value=\"1993\"> 1993 <\/option>\n <option value=\"1992\"> 1992 <\/option>\n <option value=\"1991\"> 1991 <\/option>\n <option value=\"1990\"> 1990 <\/option>\n <option value=\"1989\"> 1989 <\/option>\n <option value=\"1988\"> 1988 <\/option>\n <option value=\"1987\"> 1987 <\/option>\n <option value=\"1986\"> 1986 <\/option>\n <option value=\"1985\"> 1985 <\/option>\n <option value=\"1984\"> 1984 <\/option>\n <option value=\"1983\"> 1983 <\/option>\n <option value=\"1982\"> 1982 <\/option>\n <option value=\"1981\"> 1981 <\/option>\n <option value=\"1980\"> 1980 <\/option>\n <option value=\"1979\"> 1979 <\/option>\n <option value=\"1978\"> 1978 <\/option>\n <option value=\"1977\"> 1977 <\/option>\n <option value=\"1976\"> 1976 <\/option>\n <option value=\"1975\"> 1975 <\/option>\n <option value=\"1974\"> 1974 <\/option>\n <option value=\"1973\"> 1973 <\/option>\n <option value=\"1972\"> 1972 <\/option>\n <option value=\"1971\"> 1971 <\/option>\n <option value=\"1970\"> 1970 <\/option>\n <option value=\"1969\"> 1969 <\/option>\n <option value=\"1968\"> 1968 <\/option>\n <option value=\"1967\"> 1967 <\/option>\n <option value=\"1966\"> 1966 <\/option>\n <option value=\"1965\"> 1965 <\/option>\n <option value=\"1964\"> 1964 <\/option>\n <option value=\"1963\"> 1963 <\/option>\n <option value=\"1962\"> 1962 <\/option>\n <option value=\"1961\"> 1961 <\/option>\n <option value=\"1960\"> 1960 <\/option>\n <option value=\"1959\"> 1959 <\/option>\n <option value=\"1958\"> 1958 <\/option>\n <option value=\"1957\"> 1957 <\/option>\n <option value=\"1956\"> 1956 <\/option>\n <option value=\"1955\"> 1955 <\/option>\n <option value=\"1954\"> 1954 <\/option>\n <option value=\"1953\"> 1953 <\/option>\n <option value=\"1952\"> 1952 <\/option>\n <option value=\"1951\"> 1951 <\/option>\n <option value=\"1950\"> 1950 <\/option>\n <option value=\"1949\"> 1949 <\/option>\n <option value=\"1948\"> 1948 <\/option>\n <option value=\"1947\"> 1947 <\/option>\n <option value=\"1946\"> 1946 <\/option>\n <option value=\"1945\"> 1945 <\/option>\n <option value=\"1944\"> 1944 <\/option>\n <option value=\"1943\"> 1943 <\/option>\n <option value=\"1942\"> 1942 <\/option>\n <option value=\"1941\"> 1941 <\/option>\n <option value=\"1940\"> 1940 <\/option>\n <option value=\"1939\"> 1939 <\/option>\n <option value=\"1938\"> 1938 <\/option>\n <option value=\"1937\"> 1937 <\/option>\n <option value=\"1936\"> 1936 <\/option>\n <option value=\"1935\"> 1935 <\/option>\n <option value=\"1934\"> 1934 <\/option>\n <option value=\"1933\"> 1933 <\/option>\n <option value=\"1932\"> 1932 <\/option>\n <option value=\"1931\"> 1931 <\/option>\n <option value=\"1930\"> 1930 <\/option>\n <option value=\"1929\"> 1929 <\/option>\n <option value=\"1928\"> 1928 <\/option>\n <option value=\"1927\"> 1927 <\/option>\n <option value=\"1926\"> 1926 <\/option>\n <option value=\"1925\"> 1925 <\/option>\n <option value=\"1924\"> 1924 <\/option>\n <option value=\"1923\"> 1923 <\/option>\n <option value=\"1922\"> 1922 <\/option>\n <option value=\"1921\"> 1921 <\/option>\n <option value=\"1920\"> 1920 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_19_year\" id=\"sublabel_year\"> Year <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_118\">\n <label class=\"form-label-left\" id=\"label_118\" for=\"input_118\">\n Age at Start of Trip<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_118\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_118\" name=\"q118_ageAt\" size=\"2\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_121\">\n <label class=\"form-label-left\" id=\"label_121\" for=\"input_121\">\n Passport Status<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_121\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_121_0\" name=\"q121_passportStatus\" value=\"I have a passport valid for 6+ months beyond the trip ending date\" \/>\n <label for=\"input_121_0\"> I have a passport valid for 6+ months beyond the trip ending date <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_121_1\" name=\"q121_passportStatus\" value=\"I do not have a passport or it will expire within 6 months of trip ending date\" \/>\n <label for=\"input_121_1\"> I do not have a passport or it will expire within 6 months of trip ending date <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_121_2\" name=\"q121_passportStatus\" value=\"N\/A - I live in the same country where the program takes place\" \/>\n <label for=\"input_121_2\"> N\/A - I live in the same country where the program takes place <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_122\">\n <label class=\"form-label-left\" id=\"label_122\" for=\"input_122\">\n Country of Citizenship<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_122\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_122\" name=\"q122_countryOf\">\n <option> <\/option>\n <option value=\"United States\"> United States <\/option>\n <option value=\"Canada\"> Canada <\/option>\n <option value=\"Other\"> Other <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_131\">\n <label class=\"form-label-left\" id=\"label_131\" for=\"input_131\">\n Adult T-shirt Size<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_131\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:60px\" id=\"input_131\" name=\"q131_adultTshirt\">\n <option> <\/option>\n <option value=\"XS\"> XS <\/option>\n <option value=\"S\"> S <\/option>\n <option value=\"M\"> M <\/option>\n <option value=\"L\"> L <\/option>\n <option value=\"XL\"> XL <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_94\">\n <div id=\"cid_94\" class=\"form-input-wide\">\n <div id=\"text_94\" class=\"form-html\">\n     \n <\/div>\n <\/div>\n <\/li>\n <li id=\"cid_95\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_95\" class=\"form-header\">\n Primary Guardian Contact Information\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_72\">\n <div id=\"cid_72\" class=\"form-input-wide\">\n <div id=\"text_72\" class=\"form-html\">\n (This parent or guardian with legal custody is our primary contact for enrollment, billing, and emergencies.)\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_30\">\n <label class=\"form-label-left\" id=\"label_30\" for=\"input_30\">\n First Name<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_30\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_30\" name=\"q30_firstName\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_31\">\n <label class=\"form-label-left\" id=\"label_31\" for=\"input_31\">\n Last Name<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_31\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_31\" name=\"q31_lastName\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_39\">\n <label class=\"form-label-left\" id=\"label_39\" for=\"input_39\">\n Daytime Phone<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_39\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_39\" name=\"q39_daytimePhone\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_40\">\n <label class=\"form-label-left\" id=\"label_40\" for=\"input_40\">\n Evening Phone<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_40\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_40\" name=\"q40_eveningPhone\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_123\">\n <label class=\"form-label-left\" id=\"label_123\" for=\"input_123\"> Fax <\/label>\n <div id=\"cid_123\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_123\" name=\"q123_fax\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_41\">\n <label class=\"form-label-left\" id=\"label_41\" for=\"input_41\">\n E-mail<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_41\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_41\" name=\"q41_email\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_81\">\n <label class=\"form-label-left\" id=\"label_81\" for=\"input_81\">\n Relationship (e.g. dad, aunt, guardian)<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_81\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_81\" name=\"q81_relationshipeg\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_35\">\n <div id=\"cid_35\" class=\"form-input-wide\">\n <div id=\"text_35\" class=\"form-html\">\n If address is different from student's address, please fill in below:\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_34\">\n <label class=\"form-label-left\" id=\"label_34\" for=\"input_34\"> Mailing Address <\/label>\n <div id=\"cid_34\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_34\" name=\"q34_mailingAddress34\" size=\"35\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_36\">\n <label class=\"form-label-left\" id=\"label_36\" for=\"input_36\"> City <\/label>\n <div id=\"cid_36\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_36\" name=\"q36_city36\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_37\">\n <label class=\"form-label-left\" id=\"label_37\" for=\"input_37\"> State <\/label>\n <div id=\"cid_37\" class=\"form-input\">\n <select class=\"form-dropdown\" style=\"width:150px\" id=\"input_37\" name=\"q37_state37\">\n <option> <\/option>\n <option value=\"Alabama\"> Alabama <\/option>\n <option value=\"Alaska\"> Alaska <\/option>\n <option value=\"Arizona\"> Arizona <\/option>\n <option value=\"Arkansas\"> Arkansas <\/option>\n <option value=\"California\"> California <\/option>\n <option value=\"Colorado\"> Colorado <\/option>\n <option value=\"Connecticut\"> Connecticut <\/option>\n <option value=\"District of Columbia\"> District of Columbia <\/option>\n <option value=\"Delaware\"> Delaware <\/option>\n <option value=\"Florida\"> Florida <\/option>\n <option value=\"Georgia\"> Georgia <\/option>\n <option value=\"Hawaii\"> Hawaii <\/option>\n <option value=\"Idaho\"> Idaho <\/option>\n <option value=\"Illinois\"> Illinois <\/option>\n <option value=\"Indiana\"> Indiana <\/option>\n <option value=\"Iowa\"> Iowa <\/option>\n <option value=\"Kansas\"> Kansas <\/option>\n <option value=\"Kentucky\"> Kentucky <\/option>\n <option value=\"Louisiana\"> Louisiana <\/option>\n <option value=\"Maine\"> Maine <\/option>\n <option value=\"Maryland\"> Maryland <\/option>\n <option value=\"Massachusetts\"> Massachusetts <\/option>\n <option value=\"Michigan\"> Michigan <\/option>\n <option value=\"Minnesota\"> Minnesota <\/option>\n <option value=\"Mississippi\"> Mississippi <\/option>\n <option value=\"Missouri\"> Missouri <\/option>\n <option value=\"Montana\"> Montana <\/option>\n <option value=\"Nebraska\"> Nebraska <\/option>\n <option value=\"Nevada\"> Nevada <\/option>\n <option value=\"New Hampshire\"> New Hampshire <\/option>\n <option value=\"New Jersey\"> New Jersey <\/option>\n <option value=\"New Mexico\"> New Mexico <\/option>\n <option value=\"New York\"> New York <\/option>\n <option value=\"North Carolina\"> North Carolina <\/option>\n <option value=\"North Dakota\"> North Dakota <\/option>\n <option value=\"Ohio\"> Ohio <\/option>\n <option value=\"Oklahoma\"> Oklahoma <\/option>\n <option value=\"Oregon\"> Oregon <\/option>\n <option value=\"Pennsylvania\"> Pennsylvania <\/option>\n <option value=\"Rhode Island\"> Rhode Island <\/option>\n <option value=\"South Carolina\"> South Carolina <\/option>\n <option value=\"South Dakota\"> South Dakota <\/option>\n <option value=\"Tennessee\"> Tennessee <\/option>\n <option value=\"Texas\"> Texas <\/option>\n <option value=\"Utah\"> Utah <\/option>\n <option value=\"Vermont\"> Vermont <\/option>\n <option value=\"Virginia\"> Virginia <\/option>\n <option value=\"Washington\"> Washington <\/option>\n <option value=\"West Virginia\"> West Virginia <\/option>\n <option value=\"Wisconsin\"> Wisconsin <\/option>\n <option value=\"Wyoming\"> Wyoming <\/option>\n <option value=\"Alberta\"> Alberta <\/option>\n <option value=\"British Columbia\"> British Columbia <\/option>\n <option value=\"Manitoba\"> Manitoba <\/option>\n <option value=\"New Brunswick\"> New Brunswick <\/option>\n <option value=\"Newfoundland\"> Newfoundland <\/option>\n <option value=\"Northwest Territories\"> Northwest Territories <\/option>\n <option value=\"Nova Scotia\"> Nova Scotia <\/option>\n <option value=\"Nunavut\"> Nunavut <\/option>\n <option value=\"Ontario\"> Ontario <\/option>\n <option value=\"Prince Edward Island\"> Prince Edward Island <\/option>\n <option value=\"Quebec\"> Quebec <\/option>\n <option value=\"Saskatchewan\"> Saskatchewan <\/option>\n <option value=\"Yukon\"> Yukon <\/option>\n <option value=\"Alabama\"> Alabama <\/option>\n <option value=\"Alaska\"> Alaska <\/option>\n <option value=\"Arizona\"> Arizona <\/option>\n <option value=\"Arkansas\"> Arkansas <\/option>\n <option value=\"California\"> California <\/option>\n <option value=\"Colorado\"> Colorado <\/option>\n <option value=\"Connecticut\"> Connecticut <\/option>\n <option value=\"District of Columbia\"> District of Columbia <\/option>\n <option value=\"Delaware\"> Delaware <\/option>\n <option value=\"Florida\"> Florida <\/option>\n <option value=\"Georgia\"> Georgia <\/option>\n <option value=\"Hawaii\"> Hawaii <\/option>\n <option value=\"Idaho\"> Idaho <\/option>\n <option value=\"Illinois\"> Illinois <\/option>\n <option value=\"Indiana\"> Indiana <\/option>\n <option value=\"Iowa\"> Iowa <\/option>\n <option value=\"Kansas\"> Kansas <\/option>\n <option value=\"Kentucky\"> Kentucky <\/option>\n <option value=\"Louisiana\"> Louisiana <\/option>\n <option value=\"Maine\"> Maine <\/option>\n <option value=\"Maryland\"> Maryland <\/option>\n <option value=\"Massachusetts\"> Massachusetts <\/option>\n <option value=\"Michigan\"> Michigan <\/option>\n <option value=\"Minnesota\"> Minnesota <\/option>\n <option value=\"Mississippi\"> Mississippi <\/option>\n <option value=\"Missouri\"> Missouri <\/option>\n <option value=\"Montana\"> Montana <\/option>\n <option value=\"Nebraska\"> Nebraska <\/option>\n <option value=\"Nevada\"> Nevada <\/option>\n <option value=\"New Hampshire\"> New Hampshire <\/option>\n <option value=\"New Jersey\"> New Jersey <\/option>\n <option value=\"New Mexico\"> New Mexico <\/option>\n <option value=\"New York\"> New York <\/option>\n <option value=\"North Carolina\"> North Carolina <\/option>\n <option value=\"North Dakota\"> North Dakota <\/option>\n <option value=\"Ohio\"> Ohio <\/option>\n <option value=\"Oklahoma\"> Oklahoma <\/option>\n <option value=\"Oregon\"> Oregon <\/option>\n <option value=\"Pennsylvania\"> Pennsylvania <\/option>\n <option value=\"Rhode Island\"> Rhode Island <\/option>\n <option value=\"South Carolina\"> South Carolina <\/option>\n <option value=\"South Dakota\"> South Dakota <\/option>\n <option value=\"Tennessee\"> Tennessee <\/option>\n <option value=\"Texas\"> Texas <\/option>\n <option value=\"Utah\"> Utah <\/option>\n <option value=\"Vermont\"> Vermont <\/option>\n <option value=\"Virginia\"> Virginia <\/option>\n <option value=\"Washington\"> Washington <\/option>\n <option value=\"West Virginia\"> West Virginia <\/option>\n <option value=\"Wisconsin\"> Wisconsin <\/option>\n <option value=\"Wyoming\"> Wyoming <\/option>\n <option value=\"Alberta\"> Alberta <\/option>\n <option value=\"British Columbia\"> British Columbia <\/option>\n <option value=\"Manitoba\"> Manitoba <\/option>\n <option value=\"New Brunswick\"> New Brunswick <\/option>\n <option value=\"Newfoundland\"> Newfoundland <\/option>\n <option value=\"Northwest Territories\"> Northwest Territories <\/option>\n <option value=\"Nova Scotia\"> Nova Scotia <\/option>\n <option value=\"Nunavut\"> Nunavut <\/option>\n <option value=\"Ontario\"> Ontario <\/option>\n <option value=\"Prince Edward Island\"> Prince Edward Island <\/option>\n <option value=\"Quebec\"> Quebec <\/option>\n <option value=\"Saskatchewan\"> Saskatchewan <\/option>\n <option value=\"Yukon\"> Yukon <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_38\">\n <label class=\"form-label-left\" id=\"label_38\" for=\"input_38\"> (or Canadian Province) <\/label>\n <div id=\"cid_38\" class=\"form-input\">\n <select class=\"form-dropdown\" style=\"width:150px\" id=\"input_38\" name=\"q38_orCanadian38\">\n <option> <\/option>\n <option value=\"AB\"> AB <\/option>\n <option value=\"BC\"> BC <\/option>\n <option value=\"MB\"> MB <\/option>\n <option value=\"NB\"> NB <\/option>\n <option value=\"NL\"> NL <\/option>\n <option value=\"NT\"> NT <\/option>\n <option value=\"NS\"> NS <\/option>\n <option value=\"NU\"> NU <\/option>\n <option value=\"ON\"> ON <\/option>\n <option value=\"PE\"> PE <\/option>\n <option value=\"QC\"> QC <\/option>\n <option value=\"SK\"> SK <\/option>\n <option value=\"YT\"> YT <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_66\">\n <label class=\"form-label-left\" id=\"label_66\" for=\"input_66\"> Zip\/Postal Code <\/label>\n <div id=\"cid_66\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_66\" name=\"q66_zippostalCode66\" size=\"5\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_42\">\n <label class=\"form-label-left\" id=\"label_42\" for=\"input_42\"> Country <\/label>\n <div id=\"cid_42\" class=\"form-input\">\n <select class=\"form-dropdown\" style=\"width:150px\" id=\"input_42\" name=\"q42_country42\">\n <option> <\/option>\n <option value=\"United States\"> United States <\/option>\n <option value=\"Canada\"> Canada <\/option>\n <option value=\"Other\"> Other <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li id=\"cid_97\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_97\" class=\"form-header\">\n Second Guardian Contact Information\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_73\">\n <div id=\"cid_73\" class=\"form-input-wide\">\n <div id=\"text_73\" class=\"form-html\">\n (This parent, guardian, or other adult is our back-up contact for emergencies.)\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_44\">\n <label class=\"form-label-left\" id=\"label_44\" for=\"input_44\">\n First Name<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_44\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_44\" name=\"q44_firstName44\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_45\">\n <label class=\"form-label-left\" id=\"label_45\" for=\"input_45\">\n Last Name<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_45\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_45\" name=\"q45_lastName45\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_46\">\n <label class=\"form-label-left\" id=\"label_46\" for=\"input_46\">\n Daytime Phone<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_46\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_46\" name=\"q46_daytimePhone46\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_47\">\n <label class=\"form-label-left\" id=\"label_47\" for=\"input_47\">\n Evening Phone<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_47\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_47\" name=\"q47_eveningPhone47\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_48\">\n <label class=\"form-label-left\" id=\"label_48\" for=\"input_48\">\n E-mail<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_48\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_48\" name=\"q48_email48\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_82\">\n <label class=\"form-label-left\" id=\"label_82\" for=\"input_82\">\n Relationship<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_82\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_82\" name=\"q82_relationship\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_60\">\n <div id=\"cid_60\" class=\"form-input-wide\">\n <div id=\"text_60\" class=\"form-html\">\n If address is different from student's address, please fill in below:\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_61\">\n <label class=\"form-label-left\" id=\"label_61\" for=\"input_61\"> Mailing Address <\/label>\n <div id=\"cid_61\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_61\" name=\"q61_mailingAddress61\" size=\"35\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_62\">\n <label class=\"form-label-left\" id=\"label_62\" for=\"input_62\"> City <\/label>\n <div id=\"cid_62\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_62\" name=\"q62_city62\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_63\">\n <label class=\"form-label-left\" id=\"label_63\" for=\"input_63\"> State <\/label>\n <div id=\"cid_63\" class=\"form-input\">\n <select class=\"form-dropdown\" style=\"width:150px\" id=\"input_63\" name=\"q63_state63\">\n <option> <\/option>\n <option value=\"Alabama\"> Alabama <\/option>\n <option value=\"Alaska\"> Alaska <\/option>\n <option value=\"Arizona\"> Arizona <\/option>\n <option value=\"Arkansas\"> Arkansas <\/option>\n <option value=\"California\"> California <\/option>\n <option value=\"Colorado\"> Colorado <\/option>\n <option value=\"Connecticut\"> Connecticut <\/option>\n <option value=\"District of Columbia\"> District of Columbia <\/option>\n <option value=\"Delaware\"> Delaware <\/option>\n <option value=\"Florida\"> Florida <\/option>\n <option value=\"Georgia\"> Georgia <\/option>\n <option value=\"Hawaii\"> Hawaii <\/option>\n <option value=\"Idaho\"> Idaho <\/option>\n <option value=\"Illinois\"> Illinois <\/option>\n <option value=\"Indiana\"> Indiana <\/option>\n <option value=\"Iowa\"> Iowa <\/option>\n <option value=\"Kansas\"> Kansas <\/option>\n <option value=\"Kentucky\"> Kentucky <\/option>\n <option value=\"Louisiana\"> Louisiana <\/option>\n <option value=\"Maine\"> Maine <\/option>\n <option value=\"Maryland\"> Maryland <\/option>\n <option value=\"Massachusetts\"> Massachusetts <\/option>\n <option value=\"Michigan\"> Michigan <\/option>\n <option value=\"Minnesota\"> Minnesota <\/option>\n <option value=\"Mississippi\"> Mississippi <\/option>\n <option value=\"Missouri\"> Missouri <\/option>\n <option value=\"Montana\"> Montana <\/option>\n <option value=\"Nebraska\"> Nebraska <\/option>\n <option value=\"Nevada\"> Nevada <\/option>\n <option value=\"New Hampshire\"> New Hampshire <\/option>\n <option value=\"New Jersey\"> New Jersey <\/option>\n <option value=\"New Mexico\"> New Mexico <\/option>\n <option value=\"New York\"> New York <\/option>\n <option value=\"North Carolina\"> North Carolina <\/option>\n <option value=\"North Dakota\"> North Dakota <\/option>\n <option value=\"Ohio\"> Ohio <\/option>\n <option value=\"Oklahoma\"> Oklahoma <\/option>\n <option value=\"Oregon\"> Oregon <\/option>\n <option value=\"Pennsylvania\"> Pennsylvania <\/option>\n <option value=\"Rhode Island\"> Rhode Island <\/option>\n <option value=\"South Carolina\"> South Carolina <\/option>\n <option value=\"South Dakota\"> South Dakota <\/option>\n <option value=\"Tennessee\"> Tennessee <\/option>\n <option value=\"Texas\"> Texas <\/option>\n <option value=\"Utah\"> Utah <\/option>\n <option value=\"Vermont\"> Vermont <\/option>\n <option value=\"Virginia\"> Virginia <\/option>\n <option value=\"Washington\"> Washington <\/option>\n <option value=\"West Virginia\"> West Virginia <\/option>\n <option value=\"Wisconsin\"> Wisconsin <\/option>\n <option value=\"Wyoming\"> Wyoming <\/option>\n <option value=\"Alberta\"> Alberta <\/option>\n <option value=\"British Columbia\"> British Columbia <\/option>\n <option value=\"Manitoba\"> Manitoba <\/option>\n <option value=\"New Brunswick\"> New Brunswick <\/option>\n <option value=\"Newfoundland\"> Newfoundland <\/option>\n <option value=\"Northwest Territories\"> Northwest Territories <\/option>\n <option value=\"Nova Scotia\"> Nova Scotia <\/option>\n <option value=\"Nunavut\"> Nunavut <\/option>\n <option value=\"Ontario\"> Ontario <\/option>\n <option value=\"Prince Edward Island\"> Prince Edward Island <\/option>\n <option value=\"Quebec\"> Quebec <\/option>\n <option value=\"Saskatchewan\"> Saskatchewan <\/option>\n <option value=\"Yukon\"> Yukon <\/option>\n <option value=\"Alabama\"> Alabama <\/option>\n <option value=\"Alaska\"> Alaska <\/option>\n <option value=\"Arizona\"> Arizona <\/option>\n <option value=\"Arkansas\"> Arkansas <\/option>\n <option value=\"California\"> California <\/option>\n <option value=\"Colorado\"> Colorado <\/option>\n <option value=\"Connecticut\"> Connecticut <\/option>\n <option value=\"District of Columbia\"> District of Columbia <\/option>\n <option value=\"Delaware\"> Delaware <\/option>\n <option value=\"Florida\"> Florida <\/option>\n <option value=\"Georgia\"> Georgia <\/option>\n <option value=\"Hawaii\"> Hawaii <\/option>\n <option value=\"Idaho\"> Idaho <\/option>\n <option value=\"Illinois\"> Illinois <\/option>\n <option value=\"Indiana\"> Indiana <\/option>\n <option value=\"Iowa\"> Iowa <\/option>\n <option value=\"Kansas\"> Kansas <\/option>\n <option value=\"Kentucky\"> Kentucky <\/option>\n <option value=\"Louisiana\"> Louisiana <\/option>\n <option value=\"Maine\"> Maine <\/option>\n <option value=\"Maryland\"> Maryland <\/option>\n <option value=\"Massachusetts\"> Massachusetts <\/option>\n <option value=\"Michigan\"> Michigan <\/option>\n <option value=\"Minnesota\"> Minnesota <\/option>\n <option value=\"Mississippi\"> Mississippi <\/option>\n <option value=\"Missouri\"> Missouri <\/option>\n <option value=\"Montana\"> Montana <\/option>\n <option value=\"Nebraska\"> Nebraska <\/option>\n <option value=\"Nevada\"> Nevada <\/option>\n <option value=\"New Hampshire\"> New Hampshire <\/option>\n <option value=\"New Jersey\"> New Jersey <\/option>\n <option value=\"New Mexico\"> New Mexico <\/option>\n <option value=\"New York\"> New York <\/option>\n <option value=\"North Carolina\"> North Carolina <\/option>\n <option value=\"North Dakota\"> North Dakota <\/option>\n <option value=\"Ohio\"> Ohio <\/option>\n <option value=\"Oklahoma\"> Oklahoma <\/option>\n <option value=\"Oregon\"> Oregon <\/option>\n <option value=\"Pennsylvania\"> Pennsylvania <\/option>\n <option value=\"Rhode Island\"> Rhode Island <\/option>\n <option value=\"South Carolina\"> South Carolina <\/option>\n <option value=\"South Dakota\"> South Dakota <\/option>\n <option value=\"Tennessee\"> Tennessee <\/option>\n <option value=\"Texas\"> Texas <\/option>\n <option value=\"Utah\"> Utah <\/option>\n <option value=\"Vermont\"> Vermont <\/option>\n <option value=\"Virginia\"> Virginia <\/option>\n <option value=\"Washington\"> Washington <\/option>\n <option value=\"West Virginia\"> West Virginia <\/option>\n <option value=\"Wisconsin\"> Wisconsin <\/option>\n <option value=\"Wyoming\"> Wyoming <\/option>\n <option value=\"Alberta\"> Alberta <\/option>\n <option value=\"British Columbia\"> British Columbia <\/option>\n <option value=\"Manitoba\"> Manitoba <\/option>\n <option value=\"New Brunswick\"> New Brunswick <\/option>\n <option value=\"Newfoundland\"> Newfoundland <\/option>\n <option value=\"Northwest Territories\"> Northwest Territories <\/option>\n <option value=\"Nova Scotia\"> Nova Scotia <\/option>\n <option value=\"Nunavut\"> Nunavut <\/option>\n <option value=\"Ontario\"> Ontario <\/option>\n <option value=\"Prince Edward Island\"> Prince Edward Island <\/option>\n <option value=\"Quebec\"> Quebec <\/option>\n <option value=\"Saskatchewan\"> Saskatchewan <\/option>\n <option value=\"Yukon\"> Yukon <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_64\">\n <label class=\"form-label-left\" id=\"label_64\" for=\"input_64\"> (or Canadian Province) <\/label>\n <div id=\"cid_64\" class=\"form-input\">\n <select class=\"form-dropdown\" style=\"width:150px\" id=\"input_64\" name=\"q64_orCanadian64\">\n <option> <\/option>\n <option value=\"AB\"> AB <\/option>\n <option value=\"BC\"> BC <\/option>\n <option value=\"MB\"> MB <\/option>\n <option value=\"NB\"> NB <\/option>\n <option value=\"NL\"> NL <\/option>\n <option value=\"NT\"> NT <\/option>\n <option value=\"NS\"> NS <\/option>\n <option value=\"NU\"> NU <\/option>\n <option value=\"ON\"> ON <\/option>\n <option value=\"PE\"> PE <\/option>\n <option value=\"QC\"> QC <\/option>\n <option value=\"SK\"> SK <\/option>\n <option value=\"YT\"> YT <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_68\">\n <label class=\"form-label-left\" id=\"label_68\" for=\"input_68\"> Zip\/Postal Code <\/label>\n <div id=\"cid_68\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_68\" name=\"q68_zippostalCode68\" size=\"5\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_65\">\n <label class=\"form-label-left\" id=\"label_65\" for=\"input_65\"> Country <\/label>\n <div id=\"cid_65\" class=\"form-input\">\n <select class=\"form-dropdown\" style=\"width:150px\" id=\"input_65\" name=\"q65_country65\">\n <option> <\/option>\n <option value=\"United States\"> United States <\/option>\n <option value=\"Canada\"> Canada <\/option>\n <option value=\"Other\"> Other <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_98\">\n <div id=\"cid_98\" class=\"form-input-wide\">\n <div id=\"text_98\" class=\"form-html\">\n <\/div>\n <\/div>\n <\/li>\n <li id=\"cid_124\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_124\" class=\"form-header\">\n Personal Reference\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_125\">\n <div id=\"cid_125\" class=\"form-input-wide\">\n <div id=\"text_125\" class=\"form-html\">\n Please provide the name and best contact information for an adult who can comment on the student's character and independence (no family, please).\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_126\">\n <label class=\"form-label-left\" id=\"label_126\" for=\"input_126\">\n Name<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_126\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_126\" name=\"q126_name\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_127\">\n <label class=\"form-label-left\" id=\"label_127\" for=\"input_127\">\n Phone or Email<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_127\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_127\" name=\"q127_phoneOr\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_128\">\n <div id=\"cid_128\" class=\"form-input-wide\">\n <div id=\"text_128\" class=\"form-html\">\n <\/div>\n <\/div>\n <\/li>\n <li id=\"cid_99\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_99\" class=\"form-header\">\n Health Questions\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_77\">\n <label class=\"form-label-left\" id=\"label_77\" for=\"input_77\">\n Is the student, or has the student in the past 24 months been under the care of a physician, psychologist, or psychiatrist? (Ignoring routine check-ups)<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_77\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_77_0\" name=\"q77_isThe\" value=\"Yes\" \/>\n <label for=\"input_77_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_77_1\" name=\"q77_isThe\" value=\"No\" \/>\n <label for=\"input_77_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_78\">\n <label class=\"form-label-left\" id=\"label_78\" for=\"input_78\">\n Is there any information about the student\u2019s physical or mental health that might have some bearing on his or her trip?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_78\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_78_0\" name=\"q78_isThere\" value=\"Yes\" \/>\n <label for=\"input_78_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_78_1\" name=\"q78_isThere\" value=\"No\" \/>\n <label for=\"input_78_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_79\">\n <label class=\"form-label-left\" id=\"label_79\" for=\"input_79\">\n Is the student currently taking any prescribed medications?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_79\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_79_0\" name=\"q79_isThe79\" value=\"Yes\" \/>\n <label for=\"input_79_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_79_1\" name=\"q79_isThe79\" value=\"No\" \/>\n <label for=\"input_79_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_80\">\n <label class=\"form-label-left\" id=\"label_80\" for=\"input_80\"> If \"Yes\" to any of the above questions, please provide a short explanation: <\/label>\n <div id=\"cid_80\" class=\"form-input\">\n <textarea id=\"input_80\" class=\"form-textarea\" name=\"q80_ifyes\" cols=\"40\" rows=\"4\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_83\">\n <label class=\"form-label-left\" id=\"label_83\" for=\"input_83\"> Allergies: <\/label>\n <div id=\"cid_83\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_83\" name=\"q83_allergies83\" size=\"35\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_136\">\n <label class=\"form-label-left\" id=\"label_136\" for=\"input_136\">\n Diet:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_136\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_136\" name=\"q136_diet\">\n <option> <\/option>\n <option value=\"Omnivore\"> Omnivore <\/option>\n <option value=\"Vegetarian\"> Vegetarian <\/option>\n <option value=\"Vegan\"> Vegan <\/option>\n <option value=\"Gluten-Free Omnivore\"> Gluten-Free Omnivore <\/option>\n <option value=\"Gluten-Free Vegetarian\"> Gluten-Free Vegetarian <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_84\">\n <label class=\"form-label-left\" id=\"label_84\" for=\"input_84\"> Specific Dietary Restrictions: <\/label>\n <div id=\"cid_84\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_84\" name=\"q84_specificDietary\" size=\"35\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_100\">\n <div id=\"cid_100\" class=\"form-input-wide\">\n <div id=\"text_100\" class=\"form-html\">\n <\/div>\n <\/div>\n <\/li>\n <li id=\"cid_101\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_101\" class=\"form-header\">\n Student Questions\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_119\">\n <div id=\"cid_119\" class=\"form-input-wide\">\n <div id=\"text_119\" class=\"form-html\">\n <p>\n Please answer the following three questions with 1-2 paragraphs each.\n <\/p>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_53\">\n <label class=\"form-label-left\" id=\"label_53\" for=\"input_53\">\n What excites you about this trip, and what do you hope to gain from it?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_53\" class=\"form-input\">\n <textarea id=\"input_53\" class=\"form-textarea validate[required]\" name=\"q53_whatExcites\" cols=\"40\" rows=\"7\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_85\">\n <label class=\"form-label-left\" id=\"label_85\" for=\"input_85\">\n What life experiences have prepared you for the challenge of living away from home for an extended period of time?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_85\" class=\"form-input\">\n <textarea id=\"input_85\" class=\"form-textarea validate[required]\" name=\"q85_whatLife\" cols=\"40\" rows=\"7\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_87\">\n <label class=\"form-label-left\" id=\"label_87\" for=\"input_87\">\n What are your major interests? What do you love to do?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_87\" class=\"form-input\">\n <textarea id=\"input_87\" class=\"form-textarea validate[required]\" name=\"q87_whatAre\" cols=\"40\" rows=\"7\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_132\">\n <label class=\"form-label-left\" id=\"label_132\" for=\"input_132\">\n Choose the term that best describes your teenage education.<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_132\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_132\" name=\"q132_chooseThe\">\n <option> <\/option>\n <option value=\"Unschooler\"> Unschooler <\/option>\n <option value=\"Homeschooler\"> Homeschooler <\/option>\n <option value=\"High School\"> High School <\/option>\n <option value=\"Alternative School\"> Alternative School <\/option>\n <option value=\"Eclectic\/Other\"> Eclectic\/Other <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_134\">\n <label class=\"form-label-left\" id=\"label_134\" for=\"input_134\">\n Can you navigate a small city or airport on your own?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_134\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_134_0\" name=\"q134_canYou\" value=\"Yes\" \/>\n <label for=\"input_134_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_134_1\" name=\"q134_canYou\" value=\"No\" \/>\n <label for=\"input_134_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_135\">\n <label class=\"form-label-left\" id=\"label_135\" for=\"input_135\">\n Can you wake yourself up at a certain time if necessary, and can you keep track of time on your own?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_135\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_135_0\" name=\"q135_canYou135\" value=\"Yes\" \/>\n <label for=\"input_135_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_135_1\" name=\"q135_canYou135\" value=\"No\" \/>\n <label for=\"input_135_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_130\">\n <label class=\"form-label-left\" id=\"label_130\" for=\"input_130\">\n All Unschool Adventure trips are drug, alcohol, and tobacco-free. Do you foresee any problem in complying with this policy?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_130\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_130_0\" name=\"q130_allUnschool\" value=\"Yes\" \/>\n <label for=\"input_130_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_130_1\" name=\"q130_allUnschool\" value=\"No\" \/>\n <label for=\"input_130_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_120\">\n <label class=\"form-label-left\" id=\"label_120\" for=\"input_120\">\n How did you find out about this trip?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_120\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_120\" name=\"q120_howDid120\">\n <option> <\/option>\n <option value=\"Word-of-mouth\"> Word-of-mouth <\/option>\n <option value=\"Not Back to School Camp\"> Not Back to School Camp <\/option>\n <option value=\"Zero Tuition College\"> Zero Tuition College <\/option>\n <option value=\"Conference\"> Conference <\/option>\n <option value=\"Online mailing list\"> Online mailing list <\/option>\n <option value=\"Facebook\"> Facebook <\/option>\n <option value=\"Facebook ad\"> Facebook ad <\/option>\n <option value=\"Google\"> Google <\/option>\n <option value=\"Other search engine\"> Other search engine <\/option>\n <option value=\"Clairvoyance\"> Clairvoyance <\/option>\n <option value=\"Other\"> Other <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_133\">\n <label class=\"form-label-left\" id=\"label_133\" for=\"input_133\"> If you have a coupon code, enter it here: <\/label>\n <div id=\"cid_133\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_133\" name=\"q133_ifYou\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li id=\"cid_139\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_139\" class=\"form-header\">\n Writing Retreat 2012 Only\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_138\">\n <label class=\"form-label-left\" id=\"label_138\" for=\"input_138\"> I am interested in the following worktrade(s): <\/label>\n <div id=\"cid_138\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_138_0\" name=\"q138_iAm138[]\" value=\"Dinner Dishes Gladiator ($400)\" \/>\n <label for=\"input_138_0\"> Dinner Dishes Gladiator ($400) <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_138_1\" name=\"q138_iAm138[]\" value=\"BLS Goddess ($400)\" \/>\n <label for=\"input_138_1\"> BLS Goddess ($400) <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li id=\"cid_107\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_107\" class=\"form-header\">\n Submission\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_114\">\n <div id=\"cid_114\" class=\"form-input-wide\">\n <div id=\"text_114\" class=\"form-html\">\n <p>\n <em>\n Privacy Policy\n <\/em>\n : Unschool Adventures only uses application information for contacting parents\/guardians concerning enrollment, billing, or emergencies. We respect your privacy and do not share information with third parties.\n <\/p>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_115\">\n <div id=\"cid_115\" class=\"form-input-wide\">\n <div id=\"text_115\" class=\"form-html\">\n <p>\n When you are ready to apply, please click \"Submit.\" A copy of your information will be e-mailed to the\n <strong>\n student\n <\/strong>\n and\n <strong>\n primary parent\/guardian\n <\/strong>\n .\n <\/p>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_8\">\n <div id=\"cid_8\" class=\"form-input-wide\">\n <div style=\"margin-left:156px\" class=\"form-buttons-wrapper\">\n <button id=\"input_8\" type=\"submit\" class=\"form-submit-button\">\n Submit\n <\/button>\n <\/div>\n <\/div>\n <\/li>\n <li style=\"display:none\">\n Should be Empty:\n <input type=\"text\" name=\"website\" value=\"\" \/>\n <\/li>\n <\/ul>\n <\/div>\n <input type=\"hidden\" id=\"simple_spc\" name=\"simple_spc\" value=\"10821801242\" \/>\n <script type=\"text\/javascript\">\n document.getElementById(\"si\" + \"mple\" + \"_spc\").value = \"10821801242-10821801242\";\n <\/script>\n<\/form><\/body>\n<\/html>\n");