/*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 i92692414196 = new FrameBuilder("92692414196", 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:white;\n }\n\n .form-all{\n margin:0px auto;\n padding-top:0px;\n width:850px;\n background:white;\n color:black !important;\n font-family:Verdana;\n font-size:12px;\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.initCaptcha('input_110');\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_92692414196\" id=\"92692414196\" accept-charset=\"utf-8\">\n <input type=\"hidden\" name=\"formID\" value=\"92692414196\" \/>\n <div class=\"form-all\">\n <ul class=\"form-section\">\n <li id=\"cid_8\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_8\" class=\"form-header\">\n Our Lady Queen of Angels Church Registration\n <\/h2>\n <div id=\"subHeader_8\" class=\"form-subHeader\">\n Fields with asterisks are required\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_13\">\n <label class=\"form-label-top\" id=\"label_13\" for=\"input_13\">\n Date (mm\/dd\/yyyy):<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_13\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_13\" name=\"q13_datemmddyyyy\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_14\">\n <label class=\"form-label-top\" id=\"label_14\" for=\"input_14\"> For Office Use: <\/label>\n <div id=\"cid_14\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_14\" name=\"q14_forOffice\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_15\">\n <label class=\"form-label-top\" id=\"label_15\" for=\"input_15\"> Area: <\/label>\n <div id=\"cid_15\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_15\" name=\"q15_area\" size=\"20\" maxlength=\"30\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column form-line-column-clear\" id=\"id_16\">\n <label class=\"form-label-top\" id=\"label_16\" for=\"input_16\">\n Last Name:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_16\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_16\" name=\"q16_lastName\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_17\">\n <label class=\"form-label-top\" id=\"label_17\" for=\"input_17\">\n First Name:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_17\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_17\" name=\"q17_firstName\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_19\">\n <label class=\"form-label-top\" id=\"label_19\" for=\"input_19\">\n Title:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_19\" class=\"form-input-wide\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_19_0\" name=\"q19_title[]\" value=\"M\/M\" \/>\n <label for=\"input_19_0\"> M\/M <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_19_1\" name=\"q19_title[]\" value=\"Mr.\" \/>\n <label for=\"input_19_1\"> Mr. <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_19_2\" name=\"q19_title[]\" value=\"Mrs.\" \/>\n <label for=\"input_19_2\"> Mrs. <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_19_3\" name=\"q19_title[]\" value=\"Ms.\" \/>\n <label for=\"input_19_3\"> Ms. <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_19_4\" name=\"q19_title[]\" value=\"Dr.\/Mrs.\" \/>\n <label for=\"input_19_4\"> Dr.\/Mrs. <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column form-line-column-clear\" id=\"id_20\">\n <label class=\"form-label-top\" id=\"label_20\" for=\"input_20\"> Name of Spouse: <\/label>\n <div id=\"cid_20\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_20\" name=\"q20_nameOf\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column form-line-column-clear\" id=\"id_21\">\n <label class=\"form-label-top\" id=\"label_21\" for=\"input_21\">\n Address:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_21\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_21\" name=\"q21_address\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_22\">\n <label class=\"form-label-top\" id=\"label_22\" for=\"input_22\">\n City:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_22\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_22\" name=\"q22_city\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_23\">\n <label class=\"form-label-top\" id=\"label_23\" for=\"input_23\">\n ZIP Code:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_23\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_23\" name=\"q23_zipCode\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column form-line-column-clear\" id=\"id_18\">\n <label class=\"form-label-top\" id=\"label_18\" for=\"input_18\">\n Phone:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_18\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_18\" name=\"q18_phone\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_24\">\n <label class=\"form-label-top\" id=\"label_24\" for=\"input_24\"> Email Address: <\/label>\n <div id=\"cid_24\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_24\" name=\"q24_emailAddress24\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_25\">\n <label class=\"form-label-top\" id=\"label_25\" for=\"input_25\"> Years in Parish: <\/label>\n <div id=\"cid_25\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_25\" name=\"q25_yearsIn\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_26\">\n <label class=\"form-label-top\" id=\"label_26\" for=\"input_26\"> Envelope No.: <\/label>\n <div id=\"cid_26\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_26\" name=\"q26_envelopeNo26\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li id=\"cid_50\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h3 id=\"header_50\" class=\"form-header\">\n Head of Household:\n <\/h3>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column form-line-column-clear\" id=\"id_28\">\n <label class=\"form-label-top\" id=\"label_28\" for=\"input_28\"> First Name: <\/label>\n <div id=\"cid_28\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_28\" name=\"q28_firstName28\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_30\">\n <label class=\"form-label-top\" id=\"label_30\" for=\"input_30\"> Last and Maiden Name: <\/label>\n <div id=\"cid_30\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_30\" name=\"q30_lastAnd30\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_52\">\n <label class=\"form-label-top\" id=\"label_52\" for=\"input_52\"> Male or Female: <\/label>\n <div id=\"cid_52\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_52\" name=\"q52_maleOr31\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_32\">\n <label class=\"form-label-top\" id=\"label_32\" for=\"input_32\"> Marital Status (Church?): <\/label>\n <div id=\"cid_32\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_32\" name=\"q32_maritalStatus32\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_33\">\n <label class=\"form-label-top\" id=\"label_33\" for=\"input_33\"> Date Married: <\/label>\n <div id=\"cid_33\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_33\" name=\"q33_dateMarried33\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column form-line-column-clear\" id=\"id_34\">\n <label class=\"form-label-top\" id=\"label_34\" for=\"input_34\"> Physical Limitations: <\/label>\n <div id=\"cid_34\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_34\" name=\"q34_physicalLimitations34\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_36\">\n <label class=\"form-label-top\" id=\"label_36\" for=\"input_36\">\n Religion:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_36\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_36\" name=\"q36_religion\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_37\">\n <label class=\"form-label-top\" id=\"label_37\" for=\"input_37\"> Language Spoken: <\/label>\n <div id=\"cid_37\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_37\" name=\"q37_languageSpoken37\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_38\">\n <label class=\"form-label-top\" id=\"label_38\" for=\"input_38\"> Occupation: <\/label>\n <div id=\"cid_38\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_38\" name=\"q38_occupation\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_39\">\n <label class=\"form-label-top\" id=\"label_39\" for=\"input_39\"> School Attended\/Attending: <\/label>\n <div id=\"cid_39\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_39\" name=\"q39_schoolAttendedattending\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_40\">\n <label class=\"form-label-top\" id=\"label_40\" for=\"input_40\"> Highest Degree\/Grade: <\/label>\n <div id=\"cid_40\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_40\" name=\"q40_highestDegreegrade40\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_41\">\n <label class=\"form-label-top\" id=\"label_41\" for=\"input_41\"> Years of Religous Ed: <\/label>\n <div id=\"cid_41\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_41\" name=\"q41_yearsOf\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_42\">\n <label class=\"form-label-top\" id=\"label_42\" for=\"input_42\"> Date of Birth (m\/d\/y): <\/label>\n <div id=\"cid_42\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_42\" name=\"q42_dateOf\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_43\">\n <label class=\"form-label-top\" id=\"label_43\" for=\"input_43\">\n Baptized Catholic? Y or N (m\/d\/y):<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_43\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_43\" name=\"q43_baptizedCatholic\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_44\">\n <label class=\"form-label-top\" id=\"label_44\" for=\"input_44\">\n First Communion? Y or N (m\/d\/y):<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_44\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_44\" name=\"q44_firstCommunion44\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_45\">\n <label class=\"form-label-top\" id=\"label_45\" for=\"input_45\">\n Confirmation? Y or N (m\/d\/y):<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_45\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_45\" name=\"q45_confirmationY\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_46\">\n <label class=\"form-label-top\" id=\"label_46\" for=\"input_46\"> Ministries\/Organizations: <\/label>\n <div id=\"cid_46\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_46\" name=\"q46_ministriesorganizations\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_66\">\n <label class=\"form-label-top\" id=\"label_66\" for=\"input_66\"> Church Attendance Reg\/Occas\/Never: <\/label>\n <div id=\"cid_66\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_66\" name=\"q66_churchAttendance66\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li id=\"cid_51\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h3 id=\"header_51\" class=\"form-header\">\n Spouse:\n <\/h3>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_48\">\n <label class=\"form-label-top\" id=\"label_48\" for=\"input_48\"> First Name: <\/label>\n <div id=\"cid_48\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_48\" name=\"q48_firstName48\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_49\">\n <label class=\"form-label-top\" id=\"label_49\" for=\"input_49\"> Last and Maiden Name: <\/label>\n <div id=\"cid_49\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_49\" name=\"q49_lastAnd49\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_53\">\n <label class=\"form-label-top\" id=\"label_53\" for=\"input_53\"> Male or Female: <\/label>\n <div id=\"cid_53\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_53\" name=\"q53_maleOr\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_54\">\n <label class=\"form-label-top\" id=\"label_54\" for=\"input_54\"> Marital Status (Church?): <\/label>\n <div id=\"cid_54\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_54\" name=\"q54_maritalStatus54\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_55\">\n <label class=\"form-label-top\" id=\"label_55\" for=\"input_55\"> Date Married: <\/label>\n <div id=\"cid_55\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_55\" name=\"q55_dateMarried\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column form-line-column-clear\" id=\"id_56\">\n <label class=\"form-label-top\" id=\"label_56\" for=\"input_56\"> Physical Limitations: <\/label>\n <div id=\"cid_56\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_56\" name=\"q56_physicalLimitations\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_57\">\n <label class=\"form-label-top\" id=\"label_57\" for=\"input_57\"> Religion: <\/label>\n <div id=\"cid_57\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_57\" name=\"q57_religion57\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_58\">\n <label class=\"form-label-top\" id=\"label_58\" for=\"input_58\"> Language Spoken: <\/label>\n <div id=\"cid_58\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_58\" name=\"q58_languageSpoken\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_59\">\n <label class=\"form-label-top\" id=\"label_59\" for=\"input_59\"> Occupation: <\/label>\n <div id=\"cid_59\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_59\" name=\"q59_occupation59\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_61\">\n <label class=\"form-label-top\" id=\"label_61\" for=\"input_61\"> School Attended\/Attending: <\/label>\n <div id=\"cid_61\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_61\" name=\"q61_schoolAttendedattending61\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_60\">\n <label class=\"form-label-top\" id=\"label_60\" for=\"input_60\"> Highest Degree\/Grade: <\/label>\n <div id=\"cid_60\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_60\" name=\"q60_highestDegreegrade\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_62\">\n <label class=\"form-label-top\" id=\"label_62\" for=\"input_62\"> Years of Religious Ed: <\/label>\n <div id=\"cid_62\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_62\" name=\"q62_yearsOf62\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_63\">\n <label class=\"form-label-top\" id=\"label_63\" for=\"input_63\"> Date of Birth (m\/d\/y): <\/label>\n <div id=\"cid_63\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_63\" name=\"q63_dateOf63\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_64\">\n <label class=\"form-label-top\" id=\"label_64\" for=\"input_64\"> Baptized Catholic? Y or N (m\/d\/y): <\/label>\n <div id=\"cid_64\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_64\" name=\"q64_baptizedCatholic64\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_65\">\n <label class=\"form-label-top\" id=\"label_65\" for=\"input_65\"> First Communion? Y or N (m\/d\/y): <\/label>\n <div id=\"cid_65\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_65\" name=\"q65_firstCommunion\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_67\">\n <label class=\"form-label-top\" id=\"label_67\" for=\"input_67\"> Confirmation? Y or N (m\/d\/y): <\/label>\n <div id=\"cid_67\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_67\" name=\"q67_confirmationY67\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_68\">\n <label class=\"form-label-top\" id=\"label_68\" for=\"input_68\"> Ministries\/Organizations: <\/label>\n <div id=\"cid_68\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_68\" name=\"q68_ministriesorganizations68\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_69\">\n <label class=\"form-label-top\" id=\"label_69\" for=\"input_69\"> Church Attendance Reg\/Occas\/Never: <\/label>\n <div id=\"cid_69\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_69\" name=\"q69_churchAttendance\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li id=\"cid_70\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h3 id=\"header_70\" class=\"form-header\">\n Other\/Child:\n <\/h3>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_71\">\n <label class=\"form-label-top\" id=\"label_71\" for=\"input_71\"> First Name: <\/label>\n <div id=\"cid_71\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_71\" name=\"q71_firstName71\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_72\">\n <label class=\"form-label-top\" id=\"label_72\" for=\"input_72\"> Last and Maiden Name: <\/label>\n <div id=\"cid_72\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_72\" name=\"q72_lastAnd\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_73\">\n <label class=\"form-label-top\" id=\"label_73\" for=\"input_73\"> Male or Female: <\/label>\n <div id=\"cid_73\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_73\" name=\"q73_maleOr73\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_74\">\n <label class=\"form-label-top\" id=\"label_74\" for=\"input_74\"> Marital Status (Church?): <\/label>\n <div id=\"cid_74\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_74\" name=\"q74_maritalStatus\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_75\">\n <label class=\"form-label-top\" id=\"label_75\" for=\"input_75\"> Date Married: <\/label>\n <div id=\"cid_75\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_75\" name=\"q75_dateMarried75\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column form-line-column-clear\" id=\"id_77\">\n <label class=\"form-label-top\" id=\"label_77\" for=\"input_77\"> Physical Limitations: <\/label>\n <div id=\"cid_77\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_77\" name=\"q77_physicalLimitations76\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_76\">\n <label class=\"form-label-top\" id=\"label_76\" for=\"input_76\"> Religion: <\/label>\n <div id=\"cid_76\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_76\" name=\"q76_religion76\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_78\">\n <label class=\"form-label-top\" id=\"label_78\" for=\"input_78\"> Language Spoken: <\/label>\n <div id=\"cid_78\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_78\" name=\"q78_languageSpoken78\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_79\">\n <label class=\"form-label-top\" id=\"label_79\" for=\"input_79\"> Occupation: <\/label>\n <div id=\"cid_79\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_79\" name=\"q79_occupation79\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_80\">\n <label class=\"form-label-top\" id=\"label_80\" for=\"input_80\"> School Attended\/Attending: <\/label>\n <div id=\"cid_80\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_80\" name=\"q80_schoolAttendedattending80\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_81\">\n <label class=\"form-label-top\" id=\"label_81\" for=\"input_81\"> Highest Degree\/Grade: <\/label>\n <div id=\"cid_81\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_81\" name=\"q81_highestDegreegrade81\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_82\">\n <label class=\"form-label-top\" id=\"label_82\" for=\"input_82\"> Years of Religious Ed: <\/label>\n <div id=\"cid_82\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_82\" name=\"q82_yearsOf82\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_83\">\n <label class=\"form-label-top\" id=\"label_83\" for=\"input_83\"> Date of Birth (m\/d\/y): <\/label>\n <div id=\"cid_83\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_83\" name=\"q83_dateOf83\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_84\">\n <label class=\"form-label-top\" id=\"label_84\" for=\"input_84\"> Baptized Catholic? Y or N (m\/d\/y): <\/label>\n <div id=\"cid_84\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_84\" name=\"q84_baptizedCatholic84\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_85\">\n <label class=\"form-label-top\" id=\"label_85\" for=\"input_85\"> First Communion? Y or N (m\/d\/y): <\/label>\n <div id=\"cid_85\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_85\" name=\"q85_firstCommunion85\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_86\">\n <label class=\"form-label-top\" id=\"label_86\" for=\"input_86\"> Confirmation? Y or N (m\/d\/y): <\/label>\n <div id=\"cid_86\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_86\" name=\"q86_confirmationY86\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_87\">\n <label class=\"form-label-top\" id=\"label_87\" for=\"input_87\"> Ministries\/Organizations: <\/label>\n <div id=\"cid_87\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_87\" name=\"q87_ministriesorganizations87\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_88\">\n <label class=\"form-label-top\" id=\"label_88\" for=\"input_88\"> Church Attendance Reg\/Occas\/Never: <\/label>\n <div id=\"cid_88\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_88\" name=\"q88_churchAttendance88\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li id=\"cid_89\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h3 id=\"header_89\" class=\"form-header\">\n Child:\n <\/h3>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_90\">\n <label class=\"form-label-top\" id=\"label_90\" for=\"input_90\"> First Name: <\/label>\n <div id=\"cid_90\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_90\" name=\"q90_firstName90\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_91\">\n <label class=\"form-label-top\" id=\"label_91\" for=\"input_91\"> Last and Maiden Name: <\/label>\n <div id=\"cid_91\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_91\" name=\"q91_lastAnd91\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_92\">\n <label class=\"form-label-top\" id=\"label_92\" for=\"input_92\"> Male or Female: <\/label>\n <div id=\"cid_92\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_92\" name=\"q92_maleOr92\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_93\">\n <label class=\"form-label-top\" id=\"label_93\" for=\"input_93\"> Marital Status (Church?): <\/label>\n <div id=\"cid_93\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_93\" name=\"q93_maritalStatus93\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_94\">\n <label class=\"form-label-top\" id=\"label_94\" for=\"input_94\"> Date Married: <\/label>\n <div id=\"cid_94\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_94\" name=\"q94_dateMarried94\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column form-line-column-clear\" id=\"id_95\">\n <label class=\"form-label-top\" id=\"label_95\" for=\"input_95\"> Physical Limitations: <\/label>\n <div id=\"cid_95\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_95\" name=\"q95_physicalLimitations95\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_96\">\n <label class=\"form-label-top\" id=\"label_96\" for=\"input_96\"> Religion: <\/label>\n <div id=\"cid_96\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_96\" name=\"q96_religion96\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_97\">\n <label class=\"form-label-top\" id=\"label_97\" for=\"input_97\"> Language Spoken: <\/label>\n <div id=\"cid_97\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_97\" name=\"q97_languageSpoken97\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_98\">\n <label class=\"form-label-top\" id=\"label_98\" for=\"input_98\"> Occupation: <\/label>\n <div id=\"cid_98\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_98\" name=\"q98_occupation98\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_99\">\n <label class=\"form-label-top\" id=\"label_99\" for=\"input_99\"> School Attended\/Attending: <\/label>\n <div id=\"cid_99\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_99\" name=\"q99_schoolAttendedattending99\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_100\">\n <label class=\"form-label-top\" id=\"label_100\" for=\"input_100\"> Highest Degree\/Grade: <\/label>\n <div id=\"cid_100\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_100\" name=\"q100_highestDegreegrade100\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_101\">\n <label class=\"form-label-top\" id=\"label_101\" for=\"input_101\"> Years of Religious Ed: <\/label>\n <div id=\"cid_101\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_101\" name=\"q101_yearsOf101\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_102\">\n <label class=\"form-label-top\" id=\"label_102\" for=\"input_102\"> Date of Birth (m\/d\/y): <\/label>\n <div id=\"cid_102\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_102\" name=\"q102_dateOf102\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_103\">\n <label class=\"form-label-top\" id=\"label_103\" for=\"input_103\"> Baptized Catholic? Y or N (m\/d\/y): <\/label>\n <div id=\"cid_103\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_103\" name=\"q103_baptizedCatholic103\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_104\">\n <label class=\"form-label-top\" id=\"label_104\" for=\"input_104\"> First Communion? Y or N (m\/d\/y): <\/label>\n <div id=\"cid_104\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_104\" name=\"q104_firstCommunion104\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_105\">\n <label class=\"form-label-top\" id=\"label_105\" for=\"input_105\"> Confirmation? Y or N (m\/d\/y): <\/label>\n <div id=\"cid_105\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_105\" name=\"q105_confirmationY105\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_106\">\n <label class=\"form-label-top\" id=\"label_106\" for=\"input_106\"> Ministries\/Organizations: <\/label>\n <div id=\"cid_106\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_106\" name=\"q106_ministriesorganizations106\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_107\">\n <label class=\"form-label-top\" id=\"label_107\" for=\"input_107\"> Church Attendance Reg\/Occas\/Never: <\/label>\n <div id=\"cid_107\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_107\" name=\"q107_churchAttendance107\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li id=\"cid_108\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h3 id=\"header_108\" class=\"form-header\">\n Additional Children:\n <\/h3>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_109\">\n <label class=\"form-label-left\" id=\"label_109\" for=\"input_109\"> Enter information on additional children here: <\/label>\n <div id=\"cid_109\" class=\"form-input\">\n <textarea id=\"input_109\" class=\"form-textarea\" name=\"q109_enterInformation\" cols=\"40\" rows=\"6\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_111\">\n <div id=\"cid_111\" class=\"form-input-wide\">\n <div id=\"text_111\" class=\"form-html\">\n Note: Before clicking the Submit button, enter the Verification text to match the image characters. This will protect you from receiving SPAM from automated programs on the Internet. \n <\/div>\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 Enter the image characters in the space below<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_110\" class=\"form-input\">\n <div class=\"form-captcha\">\n <label for=\"input_110\"> <img alt=\"Captcha - Reload if it's not displayed\" id=\"input_110_captcha\" class=\"form-captcha-image\" style=\"background:url(http:\/\/www.jotform.com\/images\/loader-big.gif) no-repeat center;\" src=\"http:\/\/www.jotform.com\/images\/blank.gif\" width=\"150\" height=\"41\" \/> <\/label>\n <div style=\"white-space:nowrap;\">\n <input type=\"text\" id=\"input_110\" class=\"form-textbox validate[required]\" name=\"captcha\" style=\"width:130px;\" \/>\n <img src=\"http:\/\/www.jotform.com\/images\/reload.png\" alt=\"Reload\" align=\"absmiddle\" style=\"cursor:pointer\" onclick=\"JotForm.reloadCaptcha('input_110');\" \/>\n <input type=\"hidden\" name=\"captcha_id\" id=\"input_110_captcha_id\" value=\"0\">\n <\/div>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_1\">\n <div id=\"cid_1\" class=\"form-input-wide\">\n <div style=\"margin-left:156px\" class=\"form-buttons-wrapper\">\n <button id=\"input_1\" 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=\"92692414196\" \/>\n <script type=\"text\/javascript\">\n document.getElementById(\"si\" + \"mple\" + \"_spc\").value = \"92692414196-92692414196\";\n <\/script>\n<\/form><\/body>\n<\/html>\n");