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Please specify.\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"areThere\",\"qid\":\"57\",\"subLabel\":\"Prayer requirements, meals, etc.\",\"text\":\"Are there any cultural customs or practices that the child has\\u002Fdoes that SMASH should be aware of?\",\"type\":\"control_textbox\"}]);}, 20); \n<\/script>\n<\/head>\n<body>\n<form class=\"jotform-form\" action=\"https:\/\/submit.jotform.com\/submit\/203066399450862\/\" method=\"post\" name=\"form_203066399450862\" id=\"203066399450862\" accept-charset=\"utf-8\" autocomplete=\"on\">\n  <input type=\"hidden\" name=\"formID\" value=\"203066399450862\" \/>\n  <input type=\"hidden\" id=\"JWTContainer\" value=\"\" \/>\n  <input type=\"hidden\" id=\"cardinalOrderNumber\" value=\"\" \/>\n  <div role=\"main\" class=\"form-all\">\n    <ul class=\"form-section page-section\">\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_5\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_5\" for=\"input_5\">\n          Are you a returning customer?\u00a0\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_5\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_5\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_5_0\" name=\"q5_areYou\" value=\"Yes (Only complete the required fields)\" required=\"\" \/>\n              <label id=\"label_input_5_0\" for=\"input_5_0\"> Yes (Only complete the required fields) <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_5_1\" name=\"q5_areYou\" value=\"No (Please complete the entire form)\" required=\"\" \/>\n              <label id=\"label_input_5_1\" for=\"input_5_1\"> No (Please complete the entire form) <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_32\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_32\" for=\"input_32\">\n          Do you require a WINZ form?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_32\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_32\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_32_0\" name=\"q32_doYou\" value=\"Yes (please make sure you provide your postal address)\" required=\"\" \/>\n              <label id=\"label_input_32_0\" for=\"input_32_0\"> Yes (please make sure you provide your postal address) <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_32_1\" name=\"q32_doYou\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_32_1\" for=\"input_32_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_3\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_3\" for=\"first_3\">\n          1. Child's Name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_3\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"first\">\n              <input type=\"text\" id=\"first_3\" name=\"q3_1Childs[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_3 sublabel_3_first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_3\" id=\"sublabel_3_first\" style=\"min-height:13px\" aria-hidden=\"false\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"last\">\n              <input type=\"text\" id=\"last_3\" name=\"q3_1Childs[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_3 sublabel_3_last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_3\" id=\"sublabel_3_last\" style=\"min-height:13px\" aria-hidden=\"false\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_datetime\" id=\"id_4\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_4\" for=\"day_4\">\n          1. Child's D.O.B.\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_4\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\" class=\"extended notLiteMode\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"day_4\" name=\"q4_1Childs4[day]\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" value=\"\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_4 sublabel_4_day\" \/>\n              <span class=\"date-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"day_4\" id=\"sublabel_4_day\" style=\"min-height:13px\" aria-hidden=\"false\"> Day <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"month_4\" name=\"q4_1Childs4[month]\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" value=\"\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_4 sublabel_4_month\" \/>\n              <span class=\"date-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"month_4\" id=\"sublabel_4_month\" style=\"min-height:13px\" aria-hidden=\"false\"> Month <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"year_4\" name=\"q4_1Childs4[year]\" size=\"4\" data-maxlength=\"4\" data-age=\"\" maxLength=\"4\" value=\"\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_4 sublabel_4_year\" \/>\n              <label class=\"form-sub-label\" for=\"year_4\" id=\"sublabel_4_year\" style=\"min-height:13px\" aria-hidden=\"false\"> Year <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <img class=\"showAutoCalendar newDefaultTheme-dateIcon icon-seperatedMode\" alt=\"Pick a Date\" id=\"input_4_pick\" src=\"https:\/\/cdn.jotfor.ms\/images\/calendar.png\" data-component=\"datetime\" aria-hidden=\"true\" data-allow-time=\"No\" data-version=\"v1\" \/>\n              <label class=\"form-sub-label\" for=\"input_4_pick\" style=\"border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap\" aria-hidden=\"true\"> Date Picker Icon <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_dropdown\" id=\"id_6\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_6\" for=\"input_6\">\n          1. Gender\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_6\" class=\"form-input-wide jf-required\">\n          <select class=\"form-dropdown validate[required]\" id=\"input_6\" name=\"q6_1Gender\" style=\"width:150px\" data-component=\"dropdown\" required=\"\" aria-labelledby=\"label_6\">\n            <option value=\"\">  <\/option>\n            <option value=\"Boy\"> Boy <\/option>\n            <option value=\"Girl\"> Girl <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_divider\" id=\"id_14\">\n        <div id=\"cid_14\" class=\"form-input-wide\">\n          <div data-component=\"divider\" style=\"border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px\">\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_fullname\" id=\"id_7\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_7\" for=\"first_7\"> 2. Child's Name <\/label>\n        <div id=\"cid_7\" class=\"form-input-wide\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"first\">\n              <input type=\"text\" id=\"first_7\" name=\"q7_2Childs[first]\" class=\"form-textbox\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_7 sublabel_7_first\" \/>\n              <label class=\"form-sub-label\" for=\"first_7\" id=\"sublabel_7_first\" style=\"min-height:13px\" aria-hidden=\"false\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"last\">\n              <input type=\"text\" id=\"last_7\" name=\"q7_2Childs[last]\" class=\"form-textbox\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_7 sublabel_7_last\" \/>\n              <label class=\"form-sub-label\" for=\"last_7\" id=\"sublabel_7_last\" style=\"min-height:13px\" aria-hidden=\"false\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_datetime\" id=\"id_8\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_8\" for=\"day_8\"> 2. Child's D.O.B. <\/label>\n        <div id=\"cid_8\" class=\"form-input-wide\">\n          <div data-wrapper-react=\"true\" class=\"extended notLiteMode\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"tel\" class=\"form-textbox validate[limitDate]\" id=\"day_8\" name=\"q8_2Childs8[day]\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" value=\"\" autoComplete=\"off\" aria-labelledby=\"label_8 sublabel_8_day\" \/>\n              <span class=\"date-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"day_8\" id=\"sublabel_8_day\" style=\"min-height:13px\" aria-hidden=\"false\"> Day <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"tel\" class=\"form-textbox validate[limitDate]\" id=\"month_8\" name=\"q8_2Childs8[month]\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" value=\"\" autoComplete=\"off\" aria-labelledby=\"label_8 sublabel_8_month\" \/>\n              <span class=\"date-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"month_8\" id=\"sublabel_8_month\" style=\"min-height:13px\" aria-hidden=\"false\"> Month <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"tel\" class=\"form-textbox validate[limitDate]\" id=\"year_8\" name=\"q8_2Childs8[year]\" size=\"4\" data-maxlength=\"4\" data-age=\"\" maxLength=\"4\" value=\"\" autoComplete=\"off\" aria-labelledby=\"label_8 sublabel_8_year\" \/>\n              <label class=\"form-sub-label\" for=\"year_8\" id=\"sublabel_8_year\" style=\"min-height:13px\" aria-hidden=\"false\"> Year <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <img class=\"showAutoCalendar newDefaultTheme-dateIcon icon-seperatedMode\" alt=\"Pick a Date\" id=\"input_8_pick\" src=\"https:\/\/cdn.jotfor.ms\/images\/calendar.png\" data-component=\"datetime\" aria-hidden=\"true\" data-allow-time=\"No\" data-version=\"v1\" \/>\n              <label class=\"form-sub-label\" for=\"input_8_pick\" style=\"border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap\" aria-hidden=\"true\"> Date Picker Icon <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_9\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_9\" for=\"input_9\"> 2. Gender <\/label>\n        <div id=\"cid_9\" class=\"form-input-wide\">\n          <select class=\"form-dropdown\" id=\"input_9\" name=\"q9_2Gender\" style=\"width:150px\" data-component=\"dropdown\" aria-labelledby=\"label_9\">\n            <option value=\"\">  <\/option>\n            <option value=\"Boy\"> Boy <\/option>\n            <option value=\"Girl\"> Girl <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_divider\" id=\"id_15\">\n        <div id=\"cid_15\" class=\"form-input-wide\">\n          <div data-component=\"divider\" style=\"border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px\">\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_fullname\" id=\"id_10\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_10\" for=\"first_10\"> 3. Child's Name <\/label>\n        <div id=\"cid_10\" class=\"form-input-wide\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"first\">\n              <input type=\"text\" id=\"first_10\" name=\"q10_3Childs[first]\" class=\"form-textbox\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_10 sublabel_10_first\" \/>\n              <label class=\"form-sub-label\" for=\"first_10\" id=\"sublabel_10_first\" style=\"min-height:13px\" aria-hidden=\"false\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"last\">\n              <input type=\"text\" id=\"last_10\" name=\"q10_3Childs[last]\" class=\"form-textbox\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_10 sublabel_10_last\" \/>\n              <label class=\"form-sub-label\" for=\"last_10\" id=\"sublabel_10_last\" style=\"min-height:13px\" aria-hidden=\"false\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_datetime\" id=\"id_11\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_11\" for=\"day_11\"> 3. Child's D.O.B. <\/label>\n        <div id=\"cid_11\" class=\"form-input-wide\">\n          <div data-wrapper-react=\"true\" class=\"extended notLiteMode\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"tel\" class=\"form-textbox validate[limitDate]\" id=\"day_11\" name=\"q11_3Childs11[day]\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" value=\"\" autoComplete=\"off\" aria-labelledby=\"label_11 sublabel_11_day\" \/>\n              <span class=\"date-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"day_11\" id=\"sublabel_11_day\" style=\"min-height:13px\" aria-hidden=\"false\"> Day <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"tel\" class=\"form-textbox validate[limitDate]\" id=\"month_11\" name=\"q11_3Childs11[month]\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" value=\"\" autoComplete=\"off\" aria-labelledby=\"label_11 sublabel_11_month\" \/>\n              <span class=\"date-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"month_11\" id=\"sublabel_11_month\" style=\"min-height:13px\" aria-hidden=\"false\"> Month <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"tel\" class=\"form-textbox validate[limitDate]\" id=\"year_11\" name=\"q11_3Childs11[year]\" size=\"4\" data-maxlength=\"4\" data-age=\"\" maxLength=\"4\" value=\"\" autoComplete=\"off\" aria-labelledby=\"label_11 sublabel_11_year\" \/>\n              <label class=\"form-sub-label\" for=\"year_11\" id=\"sublabel_11_year\" style=\"min-height:13px\" aria-hidden=\"false\"> Year <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <img class=\"showAutoCalendar newDefaultTheme-dateIcon icon-seperatedMode\" alt=\"Pick a Date\" id=\"input_11_pick\" src=\"https:\/\/cdn.jotfor.ms\/images\/calendar.png\" data-component=\"datetime\" aria-hidden=\"true\" data-allow-time=\"No\" data-version=\"v1\" \/>\n              <label class=\"form-sub-label\" for=\"input_11_pick\" style=\"border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap\" aria-hidden=\"true\"> Date Picker Icon <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_12\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_12\" for=\"input_12\"> 3. Gender <\/label>\n        <div id=\"cid_12\" class=\"form-input-wide\">\n          <select class=\"form-dropdown\" id=\"input_12\" name=\"q12_3Gender\" style=\"width:150px\" data-component=\"dropdown\" aria-labelledby=\"label_12\">\n            <option value=\"\">  <\/option>\n            <option value=\"Boy\"> Boy <\/option>\n            <option value=\"Girl\"> Girl <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_divider\" id=\"id_16\">\n        <div id=\"cid_16\" class=\"form-input-wide\">\n          <div data-component=\"divider\" style=\"border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px\">\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_17\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-default\">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_17\" class=\"form-header\" data-component=\"header\">\n              Contact Details\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_18\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_18\" for=\"first_18\">\n          Main Contact Name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_18\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"first\">\n              <input type=\"text\" id=\"first_18\" name=\"q18_mainContact18[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_18 sublabel_18_first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_18\" id=\"sublabel_18_first\" style=\"min-height:13px\" aria-hidden=\"false\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"last\">\n              <input type=\"text\" id=\"last_18\" name=\"q18_mainContact18[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_18 sublabel_18_last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_18\" id=\"sublabel_18_last\" style=\"min-height:13px\" aria-hidden=\"false\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_54\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_54\" for=\"input_54\">\n          Relationship to the child\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_54\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_54\" name=\"q54_relationshipTo\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_54\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_email\" id=\"id_19\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_19\" for=\"input_19\">\n          Billing e-mail Address\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_19\" class=\"form-input-wide jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <input type=\"email\" id=\"input_19\" name=\"q19_billingEmail\" class=\"form-textbox validate[required, Email]\" size=\"30\" value=\"\" data-component=\"email\" aria-labelledby=\"label_19 sublabel_input_19\" required=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_19\" id=\"sublabel_input_19\" style=\"min-height:13px\" aria-hidden=\"false\"> example@example.com <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_phone\" id=\"id_20\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_20\" for=\"input_20_area\">\n          Primary Phone Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_20\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"areaCode\">\n              <input type=\"tel\" id=\"input_20_area\" name=\"q20_primaryPhone[area]\" class=\"form-textbox validate[required]\" value=\"\" data-component=\"areaCode\" aria-labelledby=\"label_20 sublabel_20_area\" required=\"\" \/>\n              <span class=\"phone-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_20_area\" id=\"sublabel_20_area\" style=\"min-height:13px\" aria-hidden=\"false\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"phone\">\n              <input type=\"tel\" id=\"input_20_phone\" name=\"q20_primaryPhone[phone]\" class=\"form-textbox validate[required]\" value=\"\" data-component=\"phone\" aria-labelledby=\"label_20 sublabel_20_phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_20_phone\" id=\"sublabel_20_phone\" style=\"min-height:13px\" aria-hidden=\"false\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_phone\" id=\"id_21\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_21\" for=\"input_21_area\"> Alternative Phone Number <\/label>\n        <div id=\"cid_21\" class=\"form-input-wide\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"areaCode\">\n              <input type=\"tel\" id=\"input_21_area\" name=\"q21_alternativePhone[area]\" class=\"form-textbox\" value=\"\" data-component=\"areaCode\" aria-labelledby=\"label_21 sublabel_21_area\" \/>\n              <span class=\"phone-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_21_area\" id=\"sublabel_21_area\" style=\"min-height:13px\" aria-hidden=\"false\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"phone\">\n              <input type=\"tel\" id=\"input_21_phone\" name=\"q21_alternativePhone[phone]\" class=\"form-textbox\" value=\"\" data-component=\"phone\" aria-labelledby=\"label_21 sublabel_21_phone\" \/>\n              <label class=\"form-sub-label\" for=\"input_21_phone\" id=\"sublabel_21_phone\" style=\"min-height:13px\" aria-hidden=\"false\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_address\" id=\"id_22\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_22\" for=\"input_22_addr_line1\">\n          Home Address\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_22\" class=\"form-input-wide jf-required\">\n          <div summary=\"\" class=\"form-address-table jsTest-addressField\">\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\">\n              <span class=\"form-address-line form-address-street-line jsTest-address-lineField\">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_22_addr_line1\" name=\"q22_homeAddress[addr_line1]\" class=\"form-textbox validate[required] form-address-line\" value=\"\" data-component=\"address_line_1\" aria-labelledby=\"label_22 sublabel_22_addr_line1\" \/>\n                  <label class=\"form-sub-label\" for=\"input_22_addr_line1\" id=\"sublabel_22_addr_line1\" style=\"min-height:13px\" aria-hidden=\"false\"> Street Address <\/label>\n                <\/span>\n              <\/span>\n            <\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\">\n              <span class=\"form-address-line form-address-street-line jsTest-address-lineField\">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_22_addr_line2\" name=\"q22_homeAddress[addr_line2]\" class=\"form-textbox form-address-line\" value=\"\" data-component=\"address_line_2\" aria-labelledby=\"label_22 sublabel_22_addr_line2\" \/>\n                  <label class=\"form-sub-label\" for=\"input_22_addr_line2\" id=\"sublabel_22_addr_line2\" style=\"min-height:13px\" aria-hidden=\"false\"> Street Address Line 2 <\/label>\n                <\/span>\n              <\/span>\n            <\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\">\n              <span class=\"form-address-line form-address-city-line jsTest-address-lineField \">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_22_city\" name=\"q22_homeAddress[city]\" class=\"form-textbox validate[required] form-address-city\" value=\"\" data-component=\"city\" aria-labelledby=\"label_22 sublabel_22_city\" \/>\n                  <label class=\"form-sub-label\" for=\"input_22_city\" id=\"sublabel_22_city\" style=\"min-height:13px\" aria-hidden=\"false\"> City <\/label>\n                <\/span>\n              <\/span>\n              <span class=\"form-address-line form-address-state-line jsTest-address-lineField \">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_22_state\" name=\"q22_homeAddress[state]\" class=\"form-textbox validate[required] form-address-state\" value=\"\" data-component=\"state\" aria-labelledby=\"label_22 sublabel_22_state\" \/>\n                  <label class=\"form-sub-label\" for=\"input_22_state\" id=\"sublabel_22_state\" style=\"min-height:13px\" aria-hidden=\"false\"> State \/ Province <\/label>\n                <\/span>\n              <\/span>\n            <\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\">\n              <span class=\"form-address-line form-address-zip-line jsTest-address-lineField \">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_22_postal\" name=\"q22_homeAddress[postal]\" class=\"form-textbox form-address-postal\" value=\"\" data-component=\"zip\" aria-labelledby=\"label_22 sublabel_22_postal\" \/>\n                  <label class=\"form-sub-label\" for=\"input_22_postal\" id=\"sublabel_22_postal\" style=\"min-height:13px\" aria-hidden=\"false\"> Postal \/ Zip Code <\/label>\n                <\/span>\n              <\/span>\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_divider\" id=\"id_24\">\n        <div id=\"cid_24\" class=\"form-input-wide\">\n          <div data-component=\"divider\" style=\"border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px\">\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_23\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_23\" for=\"input_23\"> Please tick the days you would like to enrol your child for a FULL DAY HOLIDAY PROGRAMME. <\/label>\n        <div id=\"cid_23\" class=\"form-input-wide\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_23\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_23_0\" name=\"q23_pleaseTick23[]\" value=\"Monday 21st December -\u00a0FULLY BOOKED\" \/>\n              <label id=\"label_input_23_0\" for=\"input_23_0\"> Monday 21st December -\u00a0FULLY BOOKED <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_23_1\" name=\"q23_pleaseTick23[]\" value=\"Tuesday 22nd December -\u00a0FULLY BOOKED\" \/>\n              <label id=\"label_input_23_1\" for=\"input_23_1\"> Tuesday 22nd December -\u00a0FULLY BOOKED <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_23_2\" name=\"q23_pleaseTick23[]\" value=\"Wednesday 23rd December -FULLY BOOKED\" \/>\n              <label id=\"label_input_23_2\" for=\"input_23_2\"> Wednesday 23rd December -FULLY BOOKED <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_divider\" id=\"id_25\">\n        <div id=\"cid_25\" class=\"form-input-wide\">\n          <div data-component=\"divider\" style=\"border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px\">\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_26\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_26\" for=\"input_26\">\n          Does your child have any medical condition that we should be aware of? Please specify.\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_26\" class=\"form-input-wide jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <input type=\"text\" id=\"input_26\" name=\"q26_doesYour\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_26 sublabel_input_26\" required=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_26\" id=\"sublabel_input_26\" style=\"min-height:13px\" aria-hidden=\"false\"> Illness, allergy, medication, etc. <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_56\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_56\" for=\"input_56\">\n          Does your child have any behavioural need that we should be aware of? Please specify.\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_56\" class=\"form-input-wide jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <input type=\"text\" id=\"input_56\" name=\"q56_doesYour56\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_56 sublabel_input_56\" required=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_56\" id=\"sublabel_input_56\" style=\"min-height:13px\" aria-hidden=\"false\"> Anxiety, quick to anger, etc. <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_57\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_57\" for=\"input_57\">\n          Are there any cultural customs or practices that the child has\/does that SMASH should be aware of?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_57\" class=\"form-input-wide jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <input type=\"text\" id=\"input_57\" name=\"q57_areThere\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_57 sublabel_input_57\" required=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_57\" id=\"sublabel_input_57\" style=\"min-height:13px\" aria-hidden=\"false\"> Prayer requirements, meals, etc. <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_dropdown\" id=\"id_40\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_40\" for=\"input_40\">\n          Please choose your child's swimming capabilities:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_40\" class=\"form-input-wide jf-required\">\n          <select class=\"form-dropdown validate[required]\" id=\"input_40\" name=\"q40_pleaseChoose\" style=\"width:150px\" data-component=\"dropdown\" required=\"\" aria-labelledby=\"label_40\">\n            <option value=\"\">  <\/option>\n            <option value=\"Can Swim\"> Can Swim <\/option>\n            <option value=\"Can NOT Swim\"> Can NOT Swim <\/option>\n            <option value=\"\">  <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_28\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_28\" for=\"input_28\">\n          Doctor\u2019s Name and Medical Centre\u00a0\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_28\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_28\" name=\"q28_doctorsName\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_28\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_phone\" id=\"id_29\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_29\" for=\"input_29_area\"> Doctor's Phone Number <\/label>\n        <div id=\"cid_29\" class=\"form-input-wide\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"areaCode\">\n              <input type=\"tel\" id=\"input_29_area\" name=\"q29_doctorsPhone[area]\" class=\"form-textbox\" value=\"\" data-component=\"areaCode\" aria-labelledby=\"label_29 sublabel_29_area\" \/>\n              <span class=\"phone-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_29_area\" id=\"sublabel_29_area\" style=\"min-height:13px\" aria-hidden=\"false\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"phone\">\n              <input type=\"tel\" id=\"input_29_phone\" name=\"q29_doctorsPhone[phone]\" class=\"form-textbox\" value=\"\" data-component=\"phone\" aria-labelledby=\"label_29 sublabel_29_phone\" \/>\n              <label class=\"form-sub-label\" for=\"input_29_phone\" id=\"sublabel_29_phone\" style=\"min-height:13px\" aria-hidden=\"false\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_31\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-default\">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_31\" class=\"form-header\" data-component=\"header\">\n              Emergency Contacts other than yourself\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_33\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_33\" for=\"first_33\">\n          Emergency Contact Name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_33\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"first\">\n              <input type=\"text\" id=\"first_33\" name=\"q33_emergencyContact[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_33 sublabel_33_first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_33\" id=\"sublabel_33_first\" style=\"min-height:13px\" aria-hidden=\"false\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"last\">\n              <input type=\"text\" id=\"last_33\" name=\"q33_emergencyContact[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_33 sublabel_33_last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_33\" id=\"sublabel_33_last\" style=\"min-height:13px\" aria-hidden=\"false\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_phone\" id=\"id_34\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_34\" for=\"input_34_area\">\n          Emergency Contact Phone Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_34\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"areaCode\">\n              <input type=\"tel\" id=\"input_34_area\" name=\"q34_emergencyContact34[area]\" class=\"form-textbox validate[required]\" value=\"\" data-component=\"areaCode\" aria-labelledby=\"label_34 sublabel_34_area\" required=\"\" \/>\n              <span class=\"phone-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_34_area\" id=\"sublabel_34_area\" style=\"min-height:13px\" aria-hidden=\"false\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"phone\">\n              <input type=\"tel\" id=\"input_34_phone\" name=\"q34_emergencyContact34[phone]\" class=\"form-textbox validate[required]\" value=\"\" data-component=\"phone\" aria-labelledby=\"label_34 sublabel_34_phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_34_phone\" id=\"sublabel_34_phone\" style=\"min-height:13px\" aria-hidden=\"false\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_fullname\" id=\"id_27\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_27\" for=\"first_27\"> Authority to Collect (other than yourself) <\/label>\n        <div id=\"cid_27\" class=\"form-input-wide\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"first\">\n              <input type=\"text\" id=\"first_27\" name=\"q27_authorityTo27[first]\" class=\"form-textbox\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_27 sublabel_27_first\" \/>\n              <label class=\"form-sub-label\" for=\"first_27\" id=\"sublabel_27_first\" style=\"min-height:13px\" aria-hidden=\"false\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"last\">\n              <input type=\"text\" id=\"last_27\" name=\"q27_authorityTo27[last]\" class=\"form-textbox\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_27 sublabel_27_last\" \/>\n              <label class=\"form-sub-label\" for=\"last_27\" id=\"sublabel_27_last\" style=\"min-height:13px\" aria-hidden=\"false\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_37\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-default\">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_37\" class=\"form-header\" data-component=\"header\">\n              Permission Request\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_48\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_48\" for=\"input_48\">\n          Do you authorize The Smash Club\u00a0to take pictures of your child and use it on our website and\/or promotional materials?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_48\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_48\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_48_0\" name=\"q48_doYou48\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_48_0\" for=\"input_48_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_48_1\" name=\"q48_doYou48\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_48_1\" for=\"input_48_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_49\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_49\" for=\"input_49\">\n          Do you authorize your child to go on day trips with the SMASH staff (please note, if you do NOT authorize SMASH to take your child on trips, you should not enroll your child on a &quot;trip day&quot;)?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_49\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_49\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_49_0\" name=\"q49_doYou49\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_49_0\" for=\"input_49_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_49_1\" name=\"q49_doYou49\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_49_1\" for=\"input_49_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_47\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_47\" for=\"input_47\">\n          PARACETAMOL - I give my permission for this medication to be administered by SMASH staff when required\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_47\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_47\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_47_0\" name=\"q47_paracetamol\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_47_0\" for=\"input_47_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_47_1\" name=\"q47_paracetamol\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_47_1\" for=\"input_47_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_50\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_50\" for=\"input_50\">\n          ARNICA - I give my permission for this medication to be administered by SMASH staff when required\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_50\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_50\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_50_0\" name=\"q50_arnica\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_50_0\" for=\"input_50_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_50_1\" name=\"q50_arnica\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_50_1\" for=\"input_50_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_51\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_51\" for=\"input_51\">\n          I understand that any valuable item taken to SMASH by my child is their own responsibility\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_51\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_51\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_51_0\" name=\"q51_iUnderstand\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_51_0\" for=\"input_51_0\"> Yes <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_52\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_52\" for=\"input_52\">\n          I give permission to my child to be taken from the SMASH Club to SMASH's outdoor play area (Marsden School adventure playground and fields) or other areas within the St Mary's Church grounds. This will be under strict supervision.\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_52\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_52\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_52_0\" name=\"q52_iGive\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_52_0\" for=\"input_52_0\"> Yes <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_53\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_53\" for=\"input_53\">\n          SUN SCREEN - I understand that my child can only go outdoors on a sunny day if sunscreen is applied.\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_53\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_53\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_53_0\" name=\"q53_sunScreen\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_53_0\" for=\"input_53_0\"> Yes <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_45\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-default\">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_45\" class=\"form-header\" data-component=\"header\">\n              Privacy Act 1993:\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_44\">\n        <div id=\"cid_44\" class=\"form-input-wide\">\n          <div id=\"text_44\" class=\"form-html\" data-component=\"text\">\n            <p>The information that you have supplied is necessary for the safe and effective operation of the OSCAR programme. All personal information requested will be archieved for 5 years after\u00a0your child\u2019s time in the programme and destroyed after that. You are welcome to review information pertaining to your child\u2019s enrolment at any time.<\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_42\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-default\">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_42\" class=\"form-header\" data-component=\"header\">\n              Parent Contract\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_41\">\n        <div id=\"cid_41\" class=\"form-input-wide\">\n          <div id=\"text_41\" class=\"form-html\" data-component=\"text\">\n            <p>Before submitting this form, please read our Terms &amp; Conditions.<\/p>\n            <p><a href=\"http:\/\/thesmashclub.org.nz\/holiday-programme-terms-conditions\/\" target=\"_blank\" rel=\"nofollow\">SMASH Holiday Programme Terms &amp; Conditions<\/a><\/p>\n            <p>I agree and acknowledge that:<\/p>\n            <p>I have read, understood and agree with the Terms &amp; Conditions.<\/p>\n            <p>The supervisor has my permission to arrange any necessary urgent medical treatment at my cost.<\/p>\n            <p>I will notify the office\u00a0of any changes to enrolment information in a timely fashion.<\/p>\n            <p>I agree to pay fees as stipulated in the fees policy.<\/p>\n            <p>All care will be taken to provide supervision of children attending the programme in accordance with The SMASH Club\u00a0Policies &amp;\u00a0Procedures (available on site or under request).<\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_43\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_43\" for=\"input_43\">\n          Agreement\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_43\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_43\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_43_0\" name=\"q43_agreement\" value=\"By ticking this box I confirm that I agree with all specified above, including the cancellation fees&#x27; policies.\" required=\"\" \/>\n              <label id=\"label_input_43_0\" for=\"input_43_0\"> By ticking this box I confirm that I agree with all specified above, including the cancellation fees' policies. <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_dropdown\" id=\"id_46\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_46\" for=\"input_46\">\n          We would like to know how you heard about us:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_46\" class=\"form-input-wide jf-required\">\n          <select class=\"form-dropdown validate[required]\" id=\"input_46\" name=\"q46_weWould\" style=\"width:150px\" data-component=\"dropdown\" required=\"\" aria-labelledby=\"label_46\">\n            <option value=\"\">  <\/option>\n            <option value=\"School\"> School <\/option>\n            <option value=\"St Mary&#x27;s ECC\"> St Mary&#x27;s ECC <\/option>\n            <option value=\"St Mary&#x27;s Church\"> St Mary&#x27;s Church <\/option>\n            <option value=\"Returning Client\"> Returning Client <\/option>\n            <option value=\"Friend\"> Friend <\/option>\n            <option value=\"Advertising\"> Advertising <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_button\" id=\"id_2\">\n        <div id=\"cid_2\" class=\"form-input-wide\">\n          <div style=\"margin-left:156px\" data-align=\"auto\" class=\"form-buttons-wrapper form-buttons-auto   jsTest-button-wrapperField\">\n            <button id=\"input_2\" type=\"submit\" class=\"form-submit-button submit-button jf-form-buttons jsTest-submitField\" data-component=\"button\" data-content=\"\">\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  <script>\n  JotForm.showJotFormPowered = \"0\";\n  <\/script>\n  <script>\n  JotForm.poweredByText = \"Powered by JotForm\";\n  <\/script>\n  <input type=\"hidden\" class=\"simple_spc\" id=\"simple_spc\" name=\"simple_spc\" value=\"203066399450862\" \/>\n  <script type=\"text\/javascript\">\n  var all_spc = document.querySelectorAll(\"form[id='203066399450862'] .si\" + \"mple\" + \"_spc\");\nfor (var i = 0; i < all_spc.length; i++)\n{\n  all_spc[i].value = \"203066399450862-203066399450862\";\n}\n  <\/script>\n<\/form><\/body>\n<\/html>\n","December Holidays 2020",Array);(function(){window.handleIFrameMessage=function(e){if(!e.data||!e.data.split)return;var args=e.data.split(":");if(args[2]!="203066399450862"){return;}
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