/*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 i90521737699 = new FrameBuilder("90521737699", false, "", "\n\n\n\n\nForm<\/title>\n<link href=\"http:\/\/max.jotfor.ms\/min\/g=formCss?3.0.2435\" 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:rgb(241, 241, 241) url(http:\/\/www.jotform.com\/images\/big-back.png) repeat-x;\n }\n\n .form-all{\n margin:0px auto;\n padding-top:0px;\n width:690px;\n background:rgb(241, 241, 241) url(http:\/\/www.jotform.com\/images\/big-back.png) repeat-x;\n color:black !important;\n font-family:Verdana;\n font-size:18px;\n }\n<\/style>\n\n<script src=\"http:\/\/max.jotfor.ms\/min\/g=jotform?3.0.2435\" 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_48', '20');\n JotForm.description('input_53', '20');\n $('input_153').rating({stars:'5', inputClassName:'form-textbox', imagePath:'http:\/\/www.jotform.com\/images\/stars.png', cleanFirst:true, value:''});\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_90521737699\" id=\"90521737699\" accept-charset=\"utf-8\">\n <input type=\"hidden\" name=\"formID\" value=\"90521737699\" \/>\n <div class=\"form-all\">\n <ul class=\"form-section\">\n <li id=\"cid_16\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_16\" class=\"form-header\">\n 2011 Tri-State Fellowship Camp Student Registration\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_15\">\n <div id=\"cid_15\" class=\"form-input-wide\">\n <div id=\"text_15\" class=\"form-html\">\n One name per application.\n <\/div>\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 Camper Name:<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_camperName\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_10\">\n <label class=\"form-label-left\" id=\"label_10\" for=\"input_10\">\n Address:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_10\" class=\"form-input\">\n <textarea id=\"input_10\" class=\"form-textarea validate[required]\" name=\"q10_address\" cols=\"30\" rows=\"2\"><\/textarea>\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 City:<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_city\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_8\">\n <label class=\"form-label-left\" id=\"label_8\" for=\"input_8\">\n State:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_8\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_8\" name=\"q8_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_7\">\n <label class=\"form-label-left\" id=\"label_7\" for=\"input_7\">\n Zip code:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_7\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_7\" name=\"q7_zipCode\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_134\">\n <label class=\"form-label-left\" id=\"label_134\" for=\"input_134\"> Day Phone: <\/label>\n <div id=\"cid_134\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_134\" name=\"q134_dayPhone\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_14\">\n <label class=\"form-label-left\" id=\"label_14\" for=\"input_14\"> Evening Phone: <\/label>\n <div id=\"cid_14\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_14\" name=\"q14_eveningPhone\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_17\">\n <label class=\"form-label-left\" id=\"label_17\" for=\"input_17\"> Cell Phone: <\/label>\n <div id=\"cid_17\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_17\" name=\"q17_cellPhone\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_3\">\n <label class=\"form-label-left\" id=\"label_3\" for=\"input_3\"> Parent's E-mail: <\/label>\n <div id=\"cid_3\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_3\" name=\"q3_parentsEmail\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_18\">\n <label class=\"form-label-left\" id=\"label_18\" for=\"input_18\">\n Emergency Contact:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_18\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_18\" name=\"q18_emergencyContact\" 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 Emergency Contact Phone:<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_emergencyContact45\" 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 Male \/ Female<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_19\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_19\" name=\"q19_male\">\n <option> <\/option>\n <option value=\"Male \"> Male <\/option>\n <option value=\"Female\"> Female <\/option>\n <\/select>\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 Birth Date:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_48\" class=\"form-input\"><span class=\"form-sub-label-container\"><select class=\"form-dropdown validate[required]\" name=\"q48_birthDate[month]\" id=\"input_48_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_48_month\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown validate[required]\" name=\"q48_birthDate[day]\" id=\"input_48_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_48_day\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown validate[required]\" name=\"q48_birthDate[year]\" id=\"input_48_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_48_year\" id=\"sublabel_year\"> Year <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_21\">\n <label class=\"form-label-left\" id=\"label_21\" for=\"input_21\"> Home Church (if applicable) <\/label>\n <div id=\"cid_21\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_21\" name=\"q21_homeChurch\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_154\">\n <label class=\"form-label-left\" id=\"label_154\" for=\"input_154\">\n Grade entering<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_154\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_154\" name=\"q154_gradeEntering\">\n <option> <\/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 <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_33\">\n <div id=\"cid_33\" class=\"form-input-wide\">\n <div id=\"text_33\" class=\"form-html\">\n Cabin mate request only one name may be listed \/ both must request.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_26\">\n <label class=\"form-label-left\" id=\"label_26\" for=\"input_26\"> Requested Cabin Mate: <\/label>\n <div id=\"cid_26\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_26\" name=\"q26_requestedCabin\" 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\"> Shirt Size (Youth) <\/label>\n <div id=\"cid_41\" class=\"form-input\">\n <select class=\"form-dropdown\" style=\"width:150px\" id=\"input_41\" name=\"q41_shirtSize\">\n <option> <\/option>\n <option value=\"Small\"> Small <\/option>\n <option value=\"Medium\"> Medium <\/option>\n <option value=\"Large\"> Large <\/option>\n <option value=\"Extra Large\"> Extra Large <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_42\">\n <label class=\"form-label-left\" id=\"label_42\" for=\"input_42\"> Shirt Size (Adult) <\/label>\n <div id=\"cid_42\" class=\"form-input\">\n <select class=\"form-dropdown\" style=\"width:150px\" id=\"input_42\" name=\"q42_shirtSize42\">\n <option> <\/option>\n <option value=\"Small\"> Small <\/option>\n <option value=\"Medium\"> Medium <\/option>\n <option value=\"Large\"> Large <\/option>\n <option value=\"X Large\"> X Large <\/option>\n <option value=\"XX Large\"> XX Large <\/option>\n <option value=\"XXX Large\"> XXX Large <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li id=\"cid_36\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_36\" class=\"form-header\">\n Payment Options\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_37\">\n <div id=\"cid_37\" class=\"form-input-wide\">\n <div id=\"text_37\" class=\"form-html\">\n <p>\n Camp registration is $190.00 for Junior Campers and $225.00 for Senior Students. This includes all activities for the week, plus a Camp T-Shirt. Senior Camp price includes a rafting trip.\n <\/p>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_43\">\n <div id=\"cid_43\" class=\"form-input-wide\">\n <div id=\"text_43\" class=\"form-html\">\n <p>\n An early bird discount of $25.00 will be given if the registration is postmarked on or before May 31st, 2011\n <\/p>\n <\/div>\n <\/div>\n <\/li>\n <li id=\"cid_143\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_143\" class=\"form-header\">\n PLEASE NOTE: FOR YOUR APPLICATION TO BE COUNTED FOR THE EARLY BIRD DISCOUNT YOUR PAYMENT MUST BE POSTMARKED ON OR BEFORE MAY 31ST 2011.\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_46\">\n <div id=\"cid_46\" class=\"form-input-wide\">\n <div id=\"text_46\" class=\"form-html\">\n <p>\n Any registration postmarked on or after June 1st, 2011 can not be guaranteed a t-shirt.\n <\/p>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_47\">\n <div id=\"cid_47\" class=\"form-input-wide\">\n <div id=\"text_47\" class=\"form-html\">\n Walk-ins are more than welcome, but may not receive a t-shirt.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_138\">\n <div id=\"cid_138\" class=\"form-input-wide\">\n <div id=\"text_138\" class=\"form-html\">\n Make Checks payable to \"Tri-State Fellowship Camp\" and mail to:\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_140\">\n <div id=\"cid_140\" class=\"form-input-wide\">\n <div id=\"text_140\" class=\"form-html\">\n <p class=\"MsoNormal\" style=\"text-align: left;\">\n Tri-State Fellowship Camp\n <\/p>\n <p class=\"MsoNormal\" style=\"text-align: left;\">\n Camp Registrar: Ray Shank\n <\/p>\n <p class=\"MsoNormal\" style=\"text-align: left;\">\n P.O. Box 213\n <\/p>\n <p class=\"MsoNormal\" style=\"text-align: left;\">\n Dayton OH 45415\n <\/p>\n <\/div>\n <\/div>\n <\/li>\n <li id=\"cid_132\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_132\" class=\"form-header\">\n Medical Information\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_51\">\n <div id=\"cid_51\" class=\"form-input-wide\">\n <div id=\"text_51\" class=\"form-html\">\n *** ALL medications will be given to the Camp Nurse upon arrival. The Camp Nurse will distribute the medicine as prescribed.***\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_52\">\n <label class=\"form-label-left\" id=\"label_52\" for=\"input_52\">\n Camper Name:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_52\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_52\" name=\"q52_camperName52\" size=\"20\" maxlength=\"100\" \/>\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 Birth Date:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_53\" class=\"form-input\"><span class=\"form-sub-label-container\"><select class=\"form-dropdown validate[required]\" name=\"q53_birthDate53[month]\" id=\"input_53_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_53_month\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown validate[required]\" name=\"q53_birthDate53[day]\" id=\"input_53_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_53_day\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown validate[required]\" name=\"q53_birthDate53[year]\" id=\"input_53_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_53_year\" id=\"sublabel_year\"> Year <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_54\">\n <label class=\"form-label-left\" id=\"label_54\" for=\"input_54\">\n Insurance Company Name:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_54\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_54\" name=\"q54_insuranceCompany\" size=\"20\" maxlength=\"100\" \/>\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 Insurance Account Number:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_135\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_135\" name=\"q135_insuranceAccount\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_56\">\n <label class=\"form-label-left\" id=\"label_56\" for=\"input_56\"> Mother's\/Guardian Name: <\/label>\n <div id=\"cid_56\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_56\" name=\"q56_mothersguardianName\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_57\">\n <label class=\"form-label-left\" id=\"label_57\" for=\"input_57\"> Mother's Day Phone: <\/label>\n <div id=\"cid_57\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_57\" name=\"q57_mothersDay\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_58\">\n <label class=\"form-label-left\" id=\"label_58\" for=\"input_58\"> Mother's Evening Phone: <\/label>\n <div id=\"cid_58\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_58\" name=\"q58_mothersEvening\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_59\">\n <label class=\"form-label-left\" id=\"label_59\" for=\"input_59\"> Mother's Cell Phone: <\/label>\n <div id=\"cid_59\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_59\" name=\"q59_mothersCell\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_60\">\n <label class=\"form-label-left\" id=\"label_60\" for=\"input_60\"> Father's\/ Guardian Name: <\/label>\n <div id=\"cid_60\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_60\" name=\"q60_fathersGuardian\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_61\">\n <label class=\"form-label-left\" id=\"label_61\" for=\"input_61\"> Father's Day Phone: <\/label>\n <div id=\"cid_61\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_61\" name=\"q61_fathersDay\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_64\">\n <label class=\"form-label-left\" id=\"label_64\" for=\"input_64\"> Father's Evening Phone: <\/label>\n <div id=\"cid_64\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_64\" name=\"q64_fathersEvening\" size=\"20\" 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\"> Father's Cell Phone: <\/label>\n <div id=\"cid_65\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_65\" name=\"q65_fathersCell\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_66\">\n <div id=\"cid_66\" class=\"form-input-wide\">\n <div id=\"text_66\" class=\"form-html\">\n Person to contact in case of accident or emergency, if parents not available.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_67\">\n <label class=\"form-label-left\" id=\"label_67\" for=\"input_67\">\n Contact Name:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_67\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_67\" name=\"q67_contactName\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_68\">\n <label class=\"form-label-left\" id=\"label_68\" for=\"input_68\">\n Contact Number:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_68\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_68\" name=\"q68_contactNumber\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_69\">\n <label class=\"form-label-left\" id=\"label_69\" for=\"input_69\">\n Doctor's Name:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_69\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_69\" name=\"q69_doctorsName\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_70\">\n <label class=\"form-label-left\" id=\"label_70\" for=\"input_70\">\n Doctor's Phone:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_70\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_70\" name=\"q70_doctorsPhone\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_71\">\n <label class=\"form-label-left\" id=\"label_71\" for=\"input_71\">\n Dentist's Name:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_71\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_71\" name=\"q71_dentistsName\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_72\">\n <label class=\"form-label-left\" id=\"label_72\" for=\"input_72\">\n Dentist's Phone:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_72\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_72\" name=\"q72_dentistsPhone\" size=\"20\" maxlength=\"100\" \/>\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 Please choose the appropriate response below pertaining to your child. There will be room to add information at the end.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_75\">\n <label class=\"form-label-left\" id=\"label_75\" for=\"input_75\">\n Previous history of concussions<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_75\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_75\" name=\"q75_previousHistory\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_111\">\n <label class=\"form-label-left\" id=\"label_111\" for=\"input_111\">\n Epilepitic<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_111\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_111\" name=\"q111_epilepitic\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_110\">\n <label class=\"form-label-left\" id=\"label_110\" for=\"input_110\">\n Wears glasses<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_110\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_110\" name=\"q110_wearsGlasses\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_109\">\n <label class=\"form-label-left\" id=\"label_109\" for=\"input_109\">\n Are lenses shatterproof<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_109\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_109\" name=\"q109_areLenses\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_108\">\n <label class=\"form-label-left\" id=\"label_108\" for=\"input_108\">\n Wears contact lenses<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_108\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_108\" name=\"q108_wearsContact\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_107\">\n <label class=\"form-label-left\" id=\"label_107\" for=\"input_107\">\n Wears dental appliance<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_107\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_107\" name=\"q107_wearsDental\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_106\">\n <label class=\"form-label-left\" id=\"label_106\" for=\"input_106\">\n Hearing problem<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_106\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_106\" name=\"q106_hearingProblem\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_105\">\n <label class=\"form-label-left\" id=\"label_105\" for=\"input_105\">\n Asthma<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_105\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_105\" name=\"q105_asthma\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_104\">\n <label class=\"form-label-left\" id=\"label_104\" for=\"input_104\">\n MRSA in last 6 months<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_104\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_104\" name=\"q104_mrsaIn\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_103\">\n <label class=\"form-label-left\" id=\"label_103\" for=\"input_103\">\n Diabetic<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_103\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_103\" name=\"q103_diabetic\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_102\">\n <label class=\"form-label-left\" id=\"label_102\" for=\"input_102\">\n Heart condition<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_102\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_102\" name=\"q102_heartCondition\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_101\">\n <label class=\"form-label-left\" id=\"label_101\" for=\"input_101\">\n Fainting episodes during exercise<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_101\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_101\" name=\"q101_faintingEpisodes\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_100\">\n <label class=\"form-label-left\" id=\"label_100\" for=\"input_100\">\n Trouble breathing during exercise<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_100\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_100\" name=\"q100_troubleBreathing\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_99\">\n <label class=\"form-label-left\" id=\"label_99\" for=\"input_99\">\n Medication<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_99\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_99\" name=\"q99_medication\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_98\">\n <label class=\"form-label-left\" id=\"label_98\" for=\"input_98\">\n Allergies<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_98\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_98\" name=\"q98_allergies\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_97\">\n <label class=\"form-label-left\" id=\"label_97\" for=\"input_97\">\n Wears a medic alert bracelet\/necklace<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_97\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_97\" name=\"q97_wearsA\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_96\">\n <label class=\"form-label-left\" id=\"label_96\" for=\"input_96\">\n Surgery in the last year<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_96\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_96\" name=\"q96_surgeryIn\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_94\">\n <label class=\"form-label-left\" id=\"label_94\" for=\"input_94\">\n Has been in hospital in the last year<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_94\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_94\" name=\"q94_hasBeen\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_95\">\n <label class=\"form-label-left\" id=\"label_95\" for=\"input_95\">\n Has had injuries requiring medical attention in the past year<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_95\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_95\" name=\"q95_hasHad\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_93\">\n <label class=\"form-label-left\" id=\"label_93\" for=\"input_93\">\n Presently injured<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_93\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_93\" name=\"q93_presentlyInjured\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_112\">\n <div id=\"cid_112\" class=\"form-input-wide\">\n <div id=\"text_112\" class=\"form-html\">\n If you answered \"Yes\" to any of the questions above please provide more details below.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_114\">\n <label class=\"form-label-left\" id=\"label_114\" for=\"input_114\"> <\/label>\n <div id=\"cid_114\" class=\"form-input\">\n <textarea id=\"input_114\" class=\"form-textarea\" name=\"q114_114\" cols=\"40\" rows=\"30\"><\/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\"> Allergy <\/label>\n <div id=\"cid_83\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_83\" name=\"q83_allergy\" size=\"50\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_113\">\n <label class=\"form-label-left\" id=\"label_113\" for=\"input_113\"> Reaction <\/label>\n <div id=\"cid_113\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_113\" name=\"q113_reaction\" size=\"50\" 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\"> Allergy <\/label>\n <div id=\"cid_82\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_82\" name=\"q82_allergy82\" size=\"50\" 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\"> Reaction <\/label>\n <div id=\"cid_81\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_81\" name=\"q81_reaction81\" size=\"50\" maxlength=\"100\" \/>\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 Please list any medical conditions, food sensitivities or other allergies.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_115\">\n <label class=\"form-label-left\" id=\"label_115\" for=\"input_115\"> .... <\/label>\n <div id=\"cid_115\" class=\"form-input\">\n <textarea id=\"input_115\" class=\"form-textarea\" name=\"q115_115\" cols=\"40\" rows=\"30\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_119\">\n <label class=\"form-label-left\" id=\"label_119\" for=\"input_119\"> Recent Injuries <\/label>\n <div id=\"cid_119\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_119\" name=\"q119_recentInjuries\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_76\">\n <label class=\"form-label-left\" id=\"label_76\" for=\"input_76\">\n Last Tetanus Shot<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_76\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_76\" name=\"q76_lastTetanus\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_153\">\n <label class=\"form-label-left\" id=\"label_153\" for=\"input_153\"> Click to edit <\/label>\n <div id=\"cid_153\" class=\"form-input\">\n <div id=\"input_153\" name=\"q153_clickTo\">\n <select name=\"q153_clickTo\">\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 <\/select>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_152\">\n <div id=\"cid_152\" class=\"form-input-wide\">\n <div style=\"margin-left:156px\" class=\"form-buttons-wrapper\">\n <button id=\"input_152\" type=\"submit\" class=\"form-submit-button\">\n Submit Form\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=\"90521737699\" \/>\n <script type=\"text\/javascript\">\n document.getElementById(\"si\" + \"mple\" + \"_spc\").value = \"90521737699-90521737699\";\n <\/script>\n<\/form><\/body>\n<\/html>\n");